FIGURE 5-1 The three types of biomarkers.

NOTE: The three categories of biomarkers are biomarkers of exposure, biomarkers of effect, and biomarkers of susceptibility. The boxes represent the different steps in the progression from exposures to a health outcome. The solid arrows depict the rate of change from one stage to the next; the time of progression from one stage to the next is highly variable. The nested ovals represent the areas where biomarkers of exposure, effects, and susceptibility may be found and show their overlapping nature (adapted from Committee on Biological Markers of the National Research Council, 1987).

fetal alcohol syndrome). In general, biomarkers of exposure are nearer in time to the exposure (i.e., they are designed to detect exposure rather than the effect of exposure), while biomarkers of effect are generally nearer in time to the outcome (i.e., they are designed to detect the effect of exposure or the effect on health). The time course of moving from exposure to outcome is not continuous. For example, an internal dose can occur quickly after an acute exposure, while a biological effect may take decades (e.g., exposure to radioactive material and the development of thyroid cancer or exposure to asbestos and lung cancer). Biomarkers of susceptibility can mark increased vulnerability at any of the steps between exposure and outcome.

Biological factors that influence health, such as genotypes for functionally important genetic polymorphisms, variations in gene expression, and biochemical measures that reflect body stores or internal doses of environmental exposures, are useful biomarkers. Thus, the concept of biomarkers provides an organizational framework for considering existing indicators and the potential influence of the biological environment. We use this framework in considering current assessments of biological influences, as well as assessment gaps. Identification and



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