4
Researching a Broad Range of Health Outcomes

Health outcomes of interest to environmental epidemiologists range from well-characterized diseases, such as cancer, to syndromes or constellations of clinical measures of physiologic or neurobehavioral function. Changes in these health outcomes can indicate that environmental factors are involved. However, not all relations between health end points and environmental exposures have been recognized. In order to identify changes in chronic diseases, the expected or baseline rates of diseases need to be determined, as has already been done for cancer. This is difficult because case definitions for many chronic diseases and syndromes are not uniform or well defined, registries and codings are not consistent, many demographic variables may influence the outcome, and time trends may not be reliable.

Many environmental toxins, acting either independently or in combination with other agents, may affect several organ systems. We consider problems in defining and studying a variety of health end points, especially those not associated with cancer. We identify gaps in current knowledge, suggest several noncancer end points that require additional research, and highlight some of those research opportunities. Finally, we discuss biologic markers for these end points and considerations of special populations at risk.

A comprehensive assessment of the evolving literature on health outcomes that may be associated with environmental exposures is beyond the scope of this study. Readers are referred to reports from the National Research Council on some of these health outcomes (NRC, 1989a,b, 1991, 1992a,b,c, 1993).



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--> 4 Researching a Broad Range of Health Outcomes Health outcomes of interest to environmental epidemiologists range from well-characterized diseases, such as cancer, to syndromes or constellations of clinical measures of physiologic or neurobehavioral function. Changes in these health outcomes can indicate that environmental factors are involved. However, not all relations between health end points and environmental exposures have been recognized. In order to identify changes in chronic diseases, the expected or baseline rates of diseases need to be determined, as has already been done for cancer. This is difficult because case definitions for many chronic diseases and syndromes are not uniform or well defined, registries and codings are not consistent, many demographic variables may influence the outcome, and time trends may not be reliable. Many environmental toxins, acting either independently or in combination with other agents, may affect several organ systems. We consider problems in defining and studying a variety of health end points, especially those not associated with cancer. We identify gaps in current knowledge, suggest several noncancer end points that require additional research, and highlight some of those research opportunities. Finally, we discuss biologic markers for these end points and considerations of special populations at risk. A comprehensive assessment of the evolving literature on health outcomes that may be associated with environmental exposures is beyond the scope of this study. Readers are referred to reports from the National Research Council on some of these health outcomes (NRC, 1989a,b, 1991, 1992a,b,c, 1993).

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--> Most environmental epidemiology has been concerned with relatively few health outcomes, such as the neurologic and mental outcomes associated with lead and methyl mercury, respiratory disease associated with air pollution, and malignant neoplasms associated with exposures to various chemical agents in the environment. However, there is increasing evidence that a much broader array of health outcomes—such as neurologic, respiratory, and reproductive end points—may also be associated with environmental exposures. Examples of the environmental associations that have been investigated are a link between congenital malformations and trichloroethylene in drinking water, increased hospitalization of children and adults for asthma associated with air pollution, and the neurologic consequences of exposures to lead and solvents in the environment (NRC, 1991). The factors causing many noncancer outcomes, the underlying mechanisms of causation, and relative contributions of the various causal agents have not been clearly delineated. Further, an individual or community may experience more than one health outcome. Persons may be exposed to multiple chemicals (sometimes from the same source), each producing different outcome events, or a single chemical can be responsible for different outcomes in the same or different individuals. Research into many outcomes potentially related to environmental exposure is at an early stage of development. In part, this is because there has been little effort to measure the incidence and prevalence of many chronic diseases. It is difficult to identify, monitor, and study populations at risk. Finally, more-refined measures of disease that can be applied to groups of persons are needed. This chapter provides a brief overview of health outcomes that have been associated with environmental exposure. We also review outcomes for which evidence from toxicologic or occupational studies suggests associations with environmental exposure, but where current environmental-epidemiologic data are inadequate to provide definitive information about risk. Respiratory Outcomes A diverse and growing literature characterizes the effects of air pollution on human health. Progress over past decades has elucidated the link of an array of respiratory outcomes to air pollution. Adverse effects on the respiratory tract of air pollutants such as ozone or airborne particles are highly nonspecific and not easily detected clinically. Nevertheless, for many common diseases, even small relative risks (RRs) may translate into significant numbers of cases of disease because of the large size of the exposed population.

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--> For example, studies of the effects on animals of long-term exposure to ozone at concentrations similar to those seen in some US cities showed chronic lung damage that increased monotonically with cumulative dose; there was no evidence of a threshold (American Thoracic Society, 1996a). If similar effects also occur in humans, a substantial proportion of the population in the United States is exposed every summer to ozone concentrations that may produce chronic lung damage. Analyses of data in 8 cities have detected associations of airborne particles with small increases in the risk of mortality (Schwartz, 1991). In a community study, the closing of a steel mill for a year was associated with more than a 40% decrease in hospital admissions for asthma in children; the next year the mill reopened, and hospitalization rates rose to their previous level (Pope 1989, 1991). Another recent study found that rates of acute bronchitis in children were about twice as high in a town with particle concentrations at the US air-quality standard as they were in a community with near background concentrations; intermediate communities had intermediate rates (Dockery et al., 1989). Braun-Fahrlander et al. (1992) found major changes in respiratory symptoms among schoolchildren at concentrations commonly seen in the US urban population. Acute Health Effects Acute health effects of air pollution have long been established, although primarily by studies at concentrations of pollutants far higher than those now typical in developed countries. Recently, however, exposure to air pollution has been associated with acute outcomes—such as reversible reductions in lung function, increased respiratory symptoms and illness, emergency-room visits and increased hospitalization, and deaths from respiratory and cardiovascular diseases—at exposure levels far lower than those at which earlier data were collected. These are discussed briefly below in order of increasing severity. Several recent reports provide more-complete treatments of the evidence on acute health effects (Dockery and Pope, 1994; American Thoracic Society, 1996b). Exercising volunteers exposed to ozone at concentrations below current air-quality standards show reversible decrements in lung function (McDonnell et al., 1985). Studies of ozone-exposed children in summer camps (Spektor et al., 1988; Lioy et al., 1985) have found that they have similar responses at even lower levels, at least in the summer months, when they are outdoors during much of the day. Smaller but still significant effects of ozone on lung function have been reported in schoolchildren during the school year, when outdoor activity is less (Kinney et al., 1989). Studies of lavage fluid from the lungs of volunteers have also provided evidence of inflammatory processes in the lung following ozone

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--> exposure (American Thoracic Society, 1996a). Short-duration exposures of asthmatics to SO2 also reduce lung function; in the protocols, delivering the gas during exercise increases the amount of SO2 received (American Thoracic Society, 1996b). Short periods of moderately elevated particle concentrations have been associated with pulmonary-function deficits (Dassen et al., 1986; Brunekreef et al., 1991). Subsequent studies that have examined daily time series, rather than episodes, have also associated ambient PM10 concentrations with short-term variation in peak expiratory flow rate at concentrations below current national ambient-air quality standards (Pope and Dockery, 1992; Pope et al., 1991). Daily symptom incidence and duration of respiratory illness have been linked to exposure to airborne particles. Supporting evidence includes results from the Six Cities Study conducted by Harvard investigators (Schwartz et al., 1989), in which particle concentrations never exceeded 75% of the current air-quality standard. In this study, daily diary responses concerning respiratory symptoms were significantly associated with particle concentrations. Similar findings come from Switzerland (Braun-Fahrlander et al., 1992) and Provo, Utah (Pope and Dockery, 1992; Pope et al., 1991). Acid-aerosol exposure has been associated with increased symptoms in a diary study of asthmatics (Ostro et al., 1991). For several of the respiratory symptoms, the odds ratios from Utah, the Six Cities Study, and Switzerland are similar. Exposure to airborne particles has been associated with increased rates of bronchitis in children (Dockery et al., 1989) at concentrations below current standards and also with increased rates of croup attacks in children (Schwartz et al., 1991). These effects do not appear to be limited to children. For example, Ostro and Rothschild (1989) have reported an association between airborne particles and ozone and respiratory illness severe enough to restrict activity in adults. A meta-analysis has reported a significant association between NO2 exposure and respiratory illness in children (Hasselblad et al., 1992). Bates and Sizto (1987) reported that exposures to both ozone and sulfate were associated with increased incidences of hospitalization for respiratory illness in Ontario. Pope (1989), as mentioned above, found sharp changes in hospitalization rates for children when a steel mill closed and then reopened. Hospital admissions were also increased in the German smog episode of 1985 (Wichmann et al., 1989) at a time of sharp increases in both total suspended particles and SO2. Sunyer et al. (1991) reported that airborne particles and SO2 were associated with hospitalization for respiratory illness in Barcelona, Spain. Hospital emergency-room visits were associated with sulfates and SO2 in a study in Vancouver, Canada (Bates et al., 1990), and respirable particles were associated with hospital

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--> emergency-room visits in Israel (Gross et al., 1984). Schwartz et al. (1993) reported that inhalable-particle concentrations that never exceeded the current air-quality standards were associated with increased emergency-room visits for asthma. Studies have associated airborne particles with increased mortality (Dockery and Pope, 1994; American Thoracic Society., 1996b). Those studies have shown similar patterns of disease in areas with different mean temperatures and climatic conditions and in areas with air-pollution peaks in both winter and summer. Other studies have used somewhat different methods, so their estimates of effect size are not directly comparable. However, Fairley (1990) and Schwartz and Marcus (1990) both reported that optical measures of airborne particles were associated with daily mortality. Qualitatively, the effect-size estimates as assessed by the regression coefficients seemed similar. In contrast, Hatzakis et al. (1986) reported that mortality in Athens, Greece, was primarily associated with SO2 and not with particulate matter, though data for the winter season alone (Katsounnayi et al., 1990) showed a principal association with particulate matter. Kinney and Ozkaynak (1991) have reported associations of both ozone and airport visibility (as a proxy for particles) with daily mortality in Los Angeles, Calif. The ozone association was stronger in that study. Chronic Effects of Air Pollution Spektor et al. (1991) have reported that long-term exposure of children to particulate air pollution was associated with impaired lung function. Data from the NHANES II survey (Schwartz, 1989) showed that chronic exposure to particles or ozone was associated with lower lung function in children; the ozone effect was stronger. Chestnut et al. (1991) have reported that long-term TSP exposure was associated with lung-function decrements in adults. Some studies have associated differences in long-term exposure to air pollution with increased rates of chronic respiratory illness. For example, Euler et al. (1987, 1988) have reported that an index of cumulative exposure to TSP was associated with increased rates of chronic bronchitis in a cohort of Seventh-Day Adventists in California. The association remained when ozone exposure was also examined. A weaker association was found with ozone exposure. Detels et al. (1987) have reported differences in respiratory health among communities exposed to different levels of air pollution in the Los Angeles area. Several studies (e.g., Lave and Seskin, 1977; Chappie and Lave, 1982; Lipfert, 1980; Ozkaynak et al., 1986) have sought to associate long-term differences in air-pollution concentrations with differences in age-adjusted

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--> mortality rates across major urban areas. These studies have applied regression methods to data from multiple locations. Such studies are constrained by the difficulty of adequately controlling for potential confounding effects of other risk factors, such as smoking; this problem is avoided by time-series analyses within a single urban area. In general, research methods have improved over time, though much uncertainty remains. The magnitude of the excess mortality suggested by these studies is somewhat larger than that suggested by acute studies of daily mortality. Studies have also been directed at specific diseases, for example, lung cancer. Archer (1990) examined deaths from lung cancer and other respiratory illnesses in 2 heavily populated valleys in Utah. Mortality rates were essentially identical in the 1940s and early 1950s. However, a steel mill was opened in one of these areas in the late 1950s. By the 1960s, a trend toward higher lung cancer and respiratory mortality was evident in this valley, and the trend was quite pronounced in the 1970s and 1980s. Neurologic Outcomes Neurologic and neurobehavioral changes can result from effects of agents on autonomic, peripheral, and central components of the nervous system. Thus, neurotoxins can have a wide range of effects, including changes in motor and sensory function or behavior, central nervous system damage, and cognitive, memory, and developmental changes. The effects on the autonomic system are primarily biochemical. Chronic exposures may affect the peripheral nervous system; even minor damage to myelin can affect nerve conduction velocities. Since the nervous system has only a modest capacity to regenerate, subtle damage can have serious and long-lasting effects (Tilson and Mitchell, 1992). Neurotoxic effects may be acute, chronic, or delayed. Time relationships may be more complicated for some neurotoxic exposures. For example, solvent exposure just before testing may interfere with performance tests for chronic neurotoxic effects (Melius and Schulte, 1981). Thus, the study design should use the proper exposure time range and the proper response time range for the situation being evaluated, e.g., chronic effects in a chronically exposed population. The full range of neurologic and behavioral effects of a toxic substance is rarely known (Xintaras et al., 1979). During recent decades, increasing attention has been paid to subtle behavioral changes that may occur at doses of agents lower than those causing physical signs and symptoms (Gochfeld et al., 1991; Tilson and Mitchell, 1992). These changes may occur after inapparent and chronic exposures, and they may lead to functional impairment that would otherwise be subclinical. Such impairments, unnoticeable in an individual, can have a substantial impact on the population. For example, Needleman et

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--> al. (1982) has estimated that a downward shift in IQ of 4 points would double the proportion of children with IQ less than 80. Environmental exposures have been suggested for such diseases as parkinsonism, amyotrophic lateral sclerosis, Alzheimer's disease, and several peripheral neuropathies (Tanner et al., 1987; Ngim and Devathasan, 1989; Kalfakis et al., 1991; Bos et al., 1991; McLachlan et al., 1991). Improved means to evaluate more-subtle neurobehavioral and neurophysiologic effects (Valciukas and Lilis, 1980; Xintaras et al., 1979) have led to major advances in assessing neurotoxic effects. These methods are often specific for certain types of neurobehavioral effects, e.g., visual versus auditory memory. Hence, a careful selection of tests is required for field surveys. Consideration must also be given to possible confounders, such as age, alcohol intake, and education. Sometimes a battery of tests may be needed to screen workers for the effects of a neurotoxic substance. Such a battery should be specific enough to measure functions related to known effects of the substance and heterogeneous enough to cover a variety of neurobehavioral functions. Neurologic and behavioral effects have been assessed for exposures to some indoor air pollutants. Otto et al. (1992) exposed 66 healthy young male subjects with no history of chemical sensitivity to air, to clean air, and to a complex mixture of volatile organic compounds (VOCs). Participants reported more fatigue and mental confusion after exposure to the organic compounds. However, performance on 13 neurobehavioral tests was not affected. In another part of the study, eye and throat irritation, headache, and drowsiness increased or showed no evidence of adaptation during exposure, even though the intensity of odors decreased by 30% (Hudnell et al., 1992). The investigators concluded that these results indicate that irritation intensity and other symptoms are not related in a simple way to odor intensity. The findings suggest that the symptoms may not be a psychosomatic response to the detection of an unpleasant odor and that environmental odor pollution may affect neurobehavior. Instead, subthreshold levels of VOCs may interact additively and stimulate trigeminal nerve receptors. Many nonspecific-symptom clusters have an odor component. Noxious environmental odors might trigger symptoms by a variety of physiologic mechanisms, including exacerbation of underlying medical conditions, innate odor aversions or aversive conditioning, stress-induced illness, and possible phenomenal reactions. Whereas relatively consistent patterns of subjective symptoms have been reported among individuals who live near environmental odor sources, documentation of objective correlates to such symptoms would require the development of new research tools. An example of a common environmental neurotoxicant that produces a variety of chronic effects is lead. Lead has been known to cause serious

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--> cognitive damage to children since the pioneering work of Byers and Lord (1943). Historically, assessment of the neuropsychologic effects of lead has been hampered by inadequate markers of exposure; i.e., blood lead is a short-term marker, and levels may return to normal after exposure has ended (Needleman, 1986), even though subjects' past exposures have caused persistent physiologic effects. One approach to the exposure-assessment issue is use of lead in shed deciduous teeth as a marker of past exposures. In a cohort study, first- and second-grade students who were considered asymptomatic for lead were classified by dentin lead levels and then evaluated with a battery of neuropsychologic tests (Needleman et al., 1979). Children with high dentin lead scored significantly less well on the Wechsler Intelligence Scale for Children (revised), on 3 measures of auditory speech processing, and on a measure of attention (Needleman et al., 1982). The authors concluded that lead, at doses below those that produce clinical symptoms, is associated with impaired neurobehavioral functioning (Needleman, 1986). Although recent studies have found negative associations between blood lead concentrations and the full-scale intelligence quotient (IQ), not all have been statistically significant after control for some potential confounders (Needleman et al., 1979; Fulton et al., 1987; Hatzakis et al., 1987; Fergusson et al., 1988; Yule et al., 1981; Lansdown et al., 1986; Schroeder et al., 1985; Hawk et al., 1986; Bellinger et al., 1987). These studies are supported by studies in animals. In primates, Rice and Wiles (1979) found learning and attention-deficit disorders. Studies in rodents have shown cognitive disorders and interference with the dopaminergic system in the brain (Cory-Schlecta et al., 1981). Inhibition of long-term potentiation in the hippocampal region by lead (Munoz et al., 1988) has also been demonstrated in rats at moderate blood lead levels, which is again consistent with learning disorders. Meta-analyses of the human data have reported evidence for the association (Needleman and Gatsonis, 1990; Schwartz et al., 1985). These associations may or may not indicate a cause-effect relation (see discussion in NRC, 1993). Several lessons may be drawn from these studies. First, a toxicant may have numerous neurologic effects, though it may be difficult to measure real but subtle behavioral changes. Second, markers of neurotoxic effect are often obtained simultaneously with markers of dose, making it difficult to discern the temporal or pathologic sequence of exposure, dose, and response. Third, neurotoxicant-induced alterations of neurobehavioral, neurophysiologic, and neurochemical function are believed to precede morphologic evidence of toxicity and to be more sensitive. However, functional indicators can be compromised by the adaptive capacity of the individual, especially with moderate to low levels of exposure. If the function of the nervous system is viewed as an adaptive process, it is

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--> logical to predict that at sufficiently high exposures the functional reserve of the individual will be depleted and performance will deteriorate (Tilson and Mitchell, 1983; Bleeker and Agnew, 1987). This implies a threshold at the individual level. However, if person-to-person variations in biologic effect are great, the overall group effect of exposure may have no detectable threshold and individual dose-response relationships may be lost because of influences by genetics, age, sex, prior experience, overall health, and adaptive capacities. Reproductive and Developmental Outcomes The term reproductive and developmental toxicity refers to maternal, paternal, pregnancy, and fetal effects. The exposure of pregnant women to drugs or other toxicants has long been recognized to produce adverse pregnancy outcomes, and effects on both males and females of exposures before conception have also been reported. Fecundity Fecundity (biologic capacity to have a child, whether or not one does so) may be affected by several mechanisms, including decreased fertility (reproductive capacity expressed as number of liveborn children) of either partner or the desire to have children. A report that exposure to the pesticide dibromochloropropane affected the fecundity of exposed men (Whorton et al., 1977) spurred studies of more-subtle indicators to determine whether other chemicals may also adversely affect male reproductive capacity. Epidemiologic reports have linked paternal occupational exposures to adverse pregnancy outcomes (Davis et al., 1992). Data from the National Toxicology Program indicate that chemicals affecting the fecundity of male rodents usually affect the fecundity of the female as well. Research to assess the fecundity and fertility of women exposed to potential toxicants is growing. Assessment of the effects of potential toxicants on male fecundity is conducted primarily through endocrine and semen analyses. The basic methods (Schrader et al., 1987, 1992) attempt to evaluate effects on the neuroendocrine system, testes, and accessory sex glands. Hormone levels are used to assess the neuroendocrine system. Sperm count, morphology, and morphometry are used to assess testicular function. Sperm-cell function, including motility and viability, and semen biochemistry are useful in evaluating accessory sex gland function. Well-designed human field studies are needed to evaluate the many chemicals in our environment. Better laboratory methods are needed to assess semen, genetic damage in the sperm, and sexual function. Research

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--> is also needed in recruitment strategies to increase participation rates in field studies, thus decreasing potential bias. Research is needed to understand the implications of animal data for human risk. Gaps in knowledge about fecundity are even larger for females than for males. Data from well-designed human studies of potential exposures are needed. Data on the ''normal" values and their interindividual and intraindividual variations are needed for designing future studies. Most early studies of women and reproductive toxicity were centered around adverse outcomes of pregnancy, with little interest in the women's fecundity. The data reported by the National Toxicology Program's Continuous Breeding Protocol indicated that many toxicants being tested were affecting female rat fecundity. New methods are now being assessed to detect neuroendocrine function, biochemical changes, and ovulation in humans (Hughes, 1988; Wright et al., 1992). Research needs include the development of practical, noninvasive methods for field studies of exposed humans, including better epidemiologic methods for the recruitment and study of human populations. Further research should address female sexual function, accessory sex organs, and genetic damage to the ova. Pregnancy Outcomes Adverse pregnancy outcomes include miscarriage and low birthweight, as well as malformations and functional abnormalities. Most of the findings on chemicals causing adverse pregnancy outcomes have been established in animal studies. Two major exceptions illustrate that human fetuses are at risk from chemical exposures: the therapeutic use of thalidomide (McBride, 1961) and environmental exposures to mercury in Minamata Bay, Japan (Koos and Longo, 1976). A few noninvasive laboratory methods are useful for the assessment of adverse effects on human pregnancies. Recently developed "ultra-sensitive" assays of human chorionic gonadotropin can detect pregnancy losses around the time of the first postconception menstrual cycle, and studies using this technology may provide insight into early pregnancy loss due to environmental exposures (NRC, 1989a). Birth Defects and Developmental Effects Developmental effects, including birth defects, have been studied as possible effects of toxic pollutants from point sources. This is because such effects can be readily monitored with either existing surveillance systems or special studies and because they have shorter latency periods than

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--> cancer. Some of the studies evaluating exposures that might increase the risk of birth defects, congenital anomalies, and low birthweight were reviewed in volume 1 (NRC, 1991). One of these sets of studies, performed by the California Department of Health Services (CDHS), was updated in a special issue of Epidemiology (Swan et al., 1992; Deane et al., 1992; Zierler, 1992). CDHS investigated cardiac defects among babies born in Santa Clara County in 1981 to September 1, 1982. The investigators compared the rates of cardiac defects in the study area (suspected of water contamination) with the rates for the rest of the county. Investigators found an increased risk of cardiac defects in the study area (RR = 2.6, p = 0.01). The results could not be due to recall bias, because the information is documented by charts. However, the investigators also compared the times when the birth defects occurred with when the water contamination occurred and concluded that the timing could not link them. Investigators mention other possible exposures, such as air contaminants and other contaminants in the water, that might have increased the rates of cardiac defects. In a second study, CDHS compared the Los Paseos census tract, which received water from one contaminated well, with a control census tract that had demographic characteristics similar to those of Los Paseos. Women who had been pregnant in 1980 and/or 1981 were contacted by mail, telephone, or home visit and interviewed to determine rates of spontaneous abortion, congenital anomalies, and low birthweight, as well as various risk factors. After adjustment for confounding variables, the Las Paseos spontaneous abortion rate was 2.3 times that in the control community (odds ratio, OR = 2.3, 95% confidence interval, CI = , 1.3-4.2). Drinking tap water was also found to be associated with spontaneous abortions in both the control area and case area. The congenital anomaly rate was 3 times that of the control area (OR = 3.1, 95% CI = 1.1-10.4). However, the authors commented that the observed pattern is not consistent with a single teratogen, but rather with several teratogens affecting the fetus at different times during gestation. They did not find any low birthweight babies in the Los Paseos area. Tests for chemicals in the control area did not show chemical contamination. The investigators concluded that the exposure data were insufficient to determine whether the leak into the contaminated well was a cause of the increased rates of spontaneous abortions and congenital malformations. The relation between environmental exposures and birth defects remains important but difficult to study. An innovative study from New York state used existing data to detect some associations between congenital malformations (all types pooled) and residential proximity to hazardous-waste sites (Geschwind et al., 1992). This study examined unusu-

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--> cific control populations that are adequately characterized in such variables as age, race, sex, geographic region, socioeconomic status, nutritional status, life style, and sexual habits. The selection of immunologic markers to be used in a battery of tests to define exposure requires careful study. A battery of immunologic markers for assessing exposure might be quite different from one used to assess toxicity. Conversely, there may be value in developing a single battery that is less than optimal for specific tests but is familiar, as well as widely known and widely used. If the battery is to be comprehensive, it is often useful to employ some nonimmunologic markers as well. For example, the determination of a covalently bound DNA adduct, coupled with some measure of immunoreactivity, might provide a useful measure of exposure and immunologic response. Since the immune system generally has some degree of functional reserve capacity, it is not likely that gross indicators, such as cell counts, will be useful as early indicators of exposure (Bick, 1985). One purpose of individual exposure assessment is to identify members of a possibly exposed population who are actually exposed. The normal range of some immunologic parameters in humans includes extensive interindividual and intraindividual variability. In a 14-month study of healthy individuals between 21 and 70 years of age, the coefficient of variation for 13 of 16 immunologic parameters was greater than 30% (Dorey and Zighelboim, 1980). However, for all the parameters measured in a short period, intraindividual variability was significantly less than interindividual variability. The interindividual variability was due, in general, to subjects who consistently exhibited functional levels and cell numbers that were significantly higher or lower than the population mean. No significant correlation was found between age and most of the immunologic parameters examined, though this does not rule out significant age-related changes in other immune end points. Animal studies have shown age-related changes in immunity (Bick, 1985). Large intraindividual coefficients of variation determined for various immunologic parameters do not preclude the use of such markers to assess exposure or effect. In industrial and environmental exposure measurements, it is not unusual to find coefficients of variation as high as those found with immunologic parameters. Some implications of large coefficients of variation in immunologic markers that may be used to define exposure are that large samples must be used to reduce random variation, comparisons between exposed and nonexposed persons might involve stratification or adjustment for populations whose results significantly deviate from the mean, and construct validity must be established for multiple markers to ensure that confounders are distributed similarly between exposed and nonexposed groups.

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--> In summary, immunologic markers of exposure can be used in several ways to distinguish exposed from nonexposed individuals and to distinguish among those with different levels of exposure within exposed groups. The use of immunologic markers should be considered in the context of other information, such as exposure history or environmental or breathing-zone measurements. The use of biologic markers may need consideration during the design of a study, during implementation, and during the interpretation of results. However, before any study, the investigator should ask what benefit biologic markers might provide over exposure assessment by ambient personal or environmental monitoring. If this question cannot be answered in a convincing way, biologic markers should not be used in environmental-epidemiologic research. Susceptible Populations The frequency of many diseases is likely to increase in certain population groups. For example, an increasingly large proportion of the population is over age 65 (Cooper et al., 1991). Older persons have an increased vulnerability to many stresses. Whether and to what extent an elderly person is more susceptible to the toxic effects of potentially hazardous compounds from the environment is largely unknown. Elderly individuals may be at increased risk from toxicant exposure because of age-related changes in the body's protective mechanisms (NRCb, 1989). Older persons have had a long period of exposure to chemicals, more time for latent adverse effects to manifest themselves, and more time for cumulative effects to emerge. The role of aging in environmental toxicity has been a subject of extensive research. In aged populations, 2 classes of adverse effects may exist: those caused by aging alone and those caused by interactions between aging and toxic agents (Williams et al., 1987). It may not be possible to discern with confidence the health decrements from these. A problem, then, is the identification of experimental approaches that will give insight into the relation between age and toxicity (NRC, 1989b). A major impediment to understanding the role of environmental agents in the aging process is the paucity of reliable and valid biomarkers of aging per se (Reff and Schneider, 1982; Ingram, 1988; McClearn, 1988). Harrison (1988) suggested 4 criteria for determining whether a particular physiologic assay may be useful as a biomarker of aging in an individual organism: the results should change significantly with age, the changes should be repeatable in the same individual, assays of independent physiologic parameters should give similar estimates of age for the same individual, and the degree of aging as determined by the assays should correlate with subsequent longevity.

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--> Children also have heightened sensitivity to many environmentally induced diseases. The susceptible period of childhood can be viewed as beginning with influences on the sperm and egg and, hence, on preconception parental exposure and life styles, continuing with the impacts on embryos and fetuses, and including the particular susceptibility of neonates and infants. Research is needed to catalog environmental factors that influence each of these stages (NRC, 1989b). The immature enzymatic detoxification systems of embryos, fetuses, and neonates put them at increased risk of the effects of pharmacologic and environmental substances that pass through the placenta, such as heavy metals, PCBs, and immunogens. Information is scanty about racial and ethnic differences in susceptibility to disease, though these also merit careful consideration. Lead poisoning affects children of all races but occurs with especially high frequency in inner-city African Americans. Other diseases also occur more commonly among different ethnic groups and reflect genetic, nutritional, and environmental factors that need to be systematically evaluated. Personal choice of life style, such as smoking or use of alcoholic beverages, and personal exposures, such as use of medication, may change susceptibility. The recent and rapid increase in knowledge about molecular biology and genetics has identified, at the gene or molecular level, an increased number of susceptible groups. These have implications for research and for societal response to environmental hazards. The key to future epidemiologic research is the linkage of susceptibility markers to exposures and outcomes in ways that will answer questions about why, in similarly exposed groups, some people develop disease and others do not. Susceptibility markers can be used to differentiate subgroups of populations in order to identify risks. The ability to distinguish sensitive subgroups in populations has legal, ethical, and social implications that need to be assessed in detail. For example, labeling individuals as susceptible has been alleged to have effects on psychosocial status and function, job security, property values, obtaining insurance, and finding a mate (Ashford et al., 1990). Recent evidence that each human has, on average, 5-10 genetic abnormalities may diminish the social and psychologic impact of knowing about a specific abnormality in a specific person. Recommendations The types, nature, and extent of environmental influences on humans are unclear. Substantial evidence associates air-pollution exposure with some respiratory outcomes. The toxicities of lead are increasingly well understood. The rate of environment-related risks of other outcomes is

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--> less well understood, and further work is necessary to delineate environmental risks. Researchers should use a range of strategies to study possible relations of health outcomes to environmental exposures. These strategies include the following: Agencies concerned with the prevention of disease and the promotion of health should make a deliberate effort to identify diseases and syndromes that appear to be increasing or to have an important impact on public health. Specific causes of death and illness, as well as such functional afflictions as impaired vision and effects on reproductive health, need to be considered. Nomenclature and case definitions should be standardized for these diseases and syndromes. When time trends reveal recent shifts in disease patterns, researchers should explore possible etiologic explanations. Health-information databases should be designed to facilitate linkage to exposure information and other relevant factors, and vice versa, so that analyses can be extended from local patterns to relations with possible causal factors Researchers should search for and study cohorts with exposures to toxicants that might be associated with specific health outcomes in order to test hypotheses about association. Whenever possible, high-exposure populations and those with a range of exposures should be selected Opportunities should be exploited to add environmental assessments to existing research on end points where there is a potential environmental risk. This could be a cost-effective approach to epidemiology. Broad evaluations of symptom prevalence and disease history should be a part of selected environmental investigations, and findings that suggest effects on specific organ systems should be followed with more-focused studies. Tools to identify susceptible subpopulations need substantial further development and should be used to identify associations of exposures with specific effects. A broad range of criteria-such as age, race, metabolic phenotypes, and socioeconomic status-should be used. Data gaps exist in reproductive epidemiology, and we urge renewed research focus on this field. Important data gaps occur in the study of pregnancy, including early pregnancy loss, and extrapolations from animal studies have generally not been validated in humans. Data gaps also exist on male-mediated adverse pregnancy outcomes. An important research need is the development of measures and tools to identify toxic effects on fecundity. Longitudinal studies should be conducted to assess the significance of biologic markers and preclinical effects suggestive of disease, including their use in calculating and assessing past exposures. Biologic markers need to be validated for specificity for exposure

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--> and health outcome. Many of the markers that have been identified and characterized in the laboratory have not been specifically tied to chemical, biologic, or physical exposures. Validation of these will strengthen the ability of environmental epidemiology to discern relations between exposure and disease. Research is needed to identify additional direct and indirect markers of exposure and disease. Environmental exposure to some substances is now routinely monitored. The planning of such monitoring should incorporate factors that will increase its utility for epidemiologic studies. References American Thoracic Society, Committee of the Environmental and Occupational Health Assembly: R. Bascom, P.A. Bromberg, D.A. Costa, R. Devlin, D.W. Dockery, M.W. Frampton, W. Lambert, J. M. Samet, F. E. Speizer, and M. Utell. 1996a. Health effects of outdoor air pollution. Part 2. Am. J. Resp. Crit. Care Med. 153: 477-498. American Thoracic Society, Committee of the Environmental and Occupational Health Assembly: R. Bascom, P.A. Bromberg, D.A. Costa, R. Devlin, D.W. Dockery, M.W. Frampton, W. Lambert, J. M. Samet, F. E. Speizer, and M. Utell. 1996b. Health effects of outdoor air pollution. Part 1. Am. J. Resp. Crit. Care Med. 153: 3-50. Ashford, N.A., C.J. Spadafor, D.B. Hattis, and C.C. Caldart. 1990. Monitoring the Worker for Exposure and Disease: Scientific, Legal, and Ethical Considerations in the Use of Biomarkers. Baltimore: Johns Hopkins University Press. 224 pp. Archer, V.E. 1990. Air pollution and fatal lung disease in three Utah counties. Arch. Environ. Health 45:325-334. Axelson, O. 1991. Cancer and combined exposures to occupational and environmental factors. Rec. Res. Cancer Res. 122:60-70. Bates, D.V., and R. Sizto. 1987. Hospital admissions and air pollutants in Southern Ontario: the acid summer haze effect. Environ. Res. 43:317-331. Bates, D.V., M. Baker-Anderson, and R. Sizto. 1990. Asthma attack periodicity: a study of hospital emergency visits in Vancouver. Environ. Res. 51:51-70. Bellinger, D., A. Leviton, C. Waternaux, H. Needleman, and M. Rabinowitz. 1987. Longitudinal analyses of prenatal leads exposure and early cognitive development. N. Engl. J. Med. 316:1037-1043. Bernard A., J.P. Buchet, H. Roels, P. Masson, and R. Lauwerys. 1979. Renal excretion of proteins and enzymes in workers exposed to cadmium. Eur. J. Clin. Invest. 9:11-22. Biagini, R.E., W.J. Moorman, T.R. Lewis, and I.L. Bernstein. 1986. Ozone enhancement of platinum asthma in a primate model. Am. Rev. Respir. Dis. 134:719-725. Bick, P.H. 1985. The immune system: organization and function. Pp. 1-10 in J. Dean, M.I. Luster, A.E. Munson, and H. Amos, eds. Immunotoxicology and Immunopharmacology. New York: Raven. Bleeker, M.L., and J. Agnew. 1987. The assessment of the dose-response relationship for low-level exposure to neurotoxicants in man. Pp. 508-515 in V. Foa, E.A. Emmett, M. Maroni, and A. Colombi, eds. Occupational and Environmental Chemical Hazards: Cellular and Biochemical Indices for Monitoring Toxicity. Chichester: Ellis Horwood. Bos, P.M., G. de Mik, and P.C. Bragt. 1991. Critical review of the toxicity of methyl n-butyl ketone: risk from occupational exposure. Am. J. Ind. Med. 20:175-194. Braun-Fahrlander, C., U. Ackermann-Liebrich, J. Schwartz, H.P. Gnehm, M. Rutishauser, and H.U. Wanner. 1992. Air pollution and respiratory symptoms in preschool children. Am. Rev. Respir. Dis. 145:42-47.

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