Effect of an Arsenic Mitigation Program on Arsenic Exposure in American Indian Communities: A Cluster Randomized Controlled Trial of the Community-Led Strong Heart Water Study Program

BACKGROUND

Chronic arsenic exposure has been associated with an increased risk of cardiovascular disease; diabetes; cancers of the lung, pancreas and prostate; and all-cause mortality in American Indian communities in the Strong Heart Study.

OBJECTIVE

The Strong Heart Water Study (SHWS) designed and evaluated a multilevel, community-led arsenic mitigation program to reduce arsenic exposure among private well users in partnership with Northern Great Plains American Indian Nations.

METHODS

A cluster randomized controlled trial (cRCT) was conducted to evaluate the effectiveness of the SHWS arsenic mitigation program over a 2-y period on a) urinary arsenic, and b) reported use of arsenic-safe water for drinking and cooking. The cRCT compared the installation of a point-of-use arsenic filter and a mobile Health (mHealth) program (3 phone calls; SHWS mHealth and Filter arm) to a more intensive program, which included this same program plus three home visits (3 phone calls and 3 home visits; SHWS Intensive arm).

RESULTS

A 47% reduction in urinary arsenic [geometric mean  ( GM ) = 13.2  to  7.0 μ g / g creatinine] was observed from baseline to the final follow-up when both study arms were combined. By treatment arm, the reduction in urinary arsenic from baseline to the final follow-up visit was 55% in the mHealth and Filter arm (GM = 14.6  to  6.55 μ g / g creatinine) and 30% in the Intensive arm (GM = 11.2  to  7.82 μ g / g creatinine). There was no significant difference in urinary arsenic levels by treatment arm at the final follow-up visit comparing the Intensive vs. mHealth and Filter arms: GM ratio of 1.21 (95% confidence interval: 0.77, 1.90). In both arms combined, exclusive use of arsenic-safe water from baseline to the final follow-up visit significantly increased for water used for cooking (17% to 53%) and drinking (12% to 46%).

DISCUSSION

Delivery of the interventions for the community-led SHWS arsenic mitigation program, including the installation of a point-of-use arsenic filter and a mHealth program on the use of arsenic-safe water (calls only, no home visits), resulted in a significant reduction in urinary arsenic and increases in reported use of arsenic-safe water for drinking and cooking during the 2-y study period. These results demonstrate that the installation of an arsenic filter and phone calls from a mHealth program presents a promising approach to reduce water arsenic exposure among private well users. https://doi.org/10.1289/EHP12548.

Association of a Housing Mobility Program With Childhood Asthma Symptoms and Exacerbations

Importance

Structural racism has been implicated in the disproportionally high asthma morbidity experienced by children living in disadvantaged, urban neighborhoods. Current approaches designed to reduce asthma triggers have modest impact.

Objective

To examine whether participation in a housing mobility program that provided housing vouchers and assistance moving to low-poverty neighborhoods was associated with reduced asthma morbidity among children and to explore potential mediating factors.

Design, Setting, and Participants

Cohort study of 123 children aged 5 to 17 years with persistent asthma whose families participated in the Baltimore Regional Housing Partnership housing mobility program from 2016 to 2020. Children were matched to 115 children enrolled in the Urban Environment and Childhood Asthma (URECA) birth cohort using propensity scores.

Exposure

Moving to a low-poverty neighborhood.

Main Outcomes

Caregiver-reported asthma exacerbations and symptoms.

Results

Among 123 children enrolled in the program, median age was 8.4 years, 58 (47.2%) were female, and 120 (97.6%) were Black. Prior to moving, 89 of 110 children (81%) lived in a high-poverty census tract (>20% of families below the poverty line); after moving, only 1 of 106 children with after-move data (0.9%) lived in a high-poverty tract. Among this cohort, 15.1% (SD, 35.8) had at least 1 exacerbation per 3-month period prior to moving vs 8.5% (SD, 28.0) after moving, an adjusted difference of -6.8 percentage points (95% CI, -11.9% to -1.7%; P = .009). Maximum symptom days in the past 2 weeks were 5.1 (SD, 5.0) before moving and 2.7 (SD, 3.8) after moving, an adjusted difference of -2.37 days (95% CI, -3.14 to -1.59; P < .001). Results remained significant in propensity score-matched analyses with URECA data. Measures of stress, including social cohesion, neighborhood safety, and urban stress, all improved with moving and were estimated to mediate between 29% and 35% of the association between moving and asthma exacerbations.

Conclusions and Relevance

Children with asthma whose families participated in a program that helped them move into low-poverty neighborhoods experienced significant improvements in asthma symptom days and exacerbations. This study adds to the limited evidence suggesting that programs to counter housing discrimination can reduce childhood asthma morbidity.

Behavioral determinants of arsenic-safe water use among Great Plains Indian Nation private well users: results from the Community-Led Strong Heart Water Study Arsenic Mitigation Program

BACKGROUND

The objective of this study was to evaluate the behavioral determinants associated with exclusive use of arsenic-safe water in the community-led Strong Heart Water Study (SHWS) arsenic mitigation program.

METHODS

The SHWS is a randomized controlled trial of a community-led arsenic mitigation program designed to reduce arsenic exposure among private well users in American Indian Great Plains communities. All households received point-of-use (POU) arsenic filters installed at baseline and were followed for 2 years. Behavioral determinants selected were those targeted during the development of the SHWS program, and were assessed at baseline and follow-up.

RESULTS

Among participants, exclusive use of arsenic-safe water for drinking and cooking at follow-up was associated with higher self-efficacy for accessing local resources to learn about arsenic (OR: 5.19, 95% CI: 1.48-18.21) and higher self-efficacy to resolve challenges related to arsenic in water using local resources (OR: 3.11, 95% CI: 1.11-8.71). Higher commitment to use the POU arsenic filter faucet at baseline was also a significant predictor of exclusive arsenic-safe water use for drinking (OR: 32.57, 95% CI: 1.42-746.70) and cooking (OR: 15.90, 95% CI: 1.33-189.52) at follow-up. From baseline to follow-up, the SHWS program significantly increased perceived vulnerability to arsenic exposure, self-efficacy, descriptive norms, and injunctive norms. Changing one's arsenic filter cartridge after installation was associated with higher self-efficacy to obtain arsenic-safe water for drinking (OR: 6.22, 95% CI: 1.33-29.07) and cooking (OR: 10.65, 95% CI: 2.48-45.68) and higher perceived vulnerability of personal health effects (OR: 7.79, 95% CI: 1.17-51.98) from drinking arsenic-unsafe water.

CONCLUSIONS

The community-led SHWS program conducted a theory-driven approach for intervention development and evaluation that allowed for behavioral determinants to be identified that were associated with the use of arsenic safe water and changing one's arsenic filter cartridge. These results demonstrate that theory-driven, context-specific formative research can influence behavior change interventions to reduce water arsenic exposure. The SHWS can serve as a model for the design of theory-driven intervention approaches that engage communities to reduce arsenic exposure.

TRIAL REGISTRATION

The SHWS is registered with ClinicalTrials.gov (Identifier: NCT03725592).

Indoor environmental exposures and obstructive lung disease phenotypes among children with asthma living in poor urban neighborhoods

BACKGROUND

Air trapping is an obstructive phenotype that has been associated with more severe and unstable asthma in children. Air trapping has been defined using pre- and postbronchodilator spirometry. The causes of air trapping are not completely understood. It is possible that environmental exposures could be implicated in air trapping in children with asthma.

OBJECTIVE

We investigated the association between indoor exposures and air trapping in urban children with asthma.

METHODS

Children with asthma aged 5 to 17 years living in Baltimore and enrolled onto the Environmental Control as Add-on Therapy for Childhood Asthma study were evaluated for air trapping using spirometry. Aeroallergen sensitization was assessed at baseline, and spirometry was performed at 0, 3, and 6 months. Air trapping was defined as an FVC z score of less than -1.64 or a change in FVC with bronchodilation of ≥10% predicted. Logistic normal random effects models were used to evaluate associations of air trapping and indoor exposures.

RESULTS

Airborne and bedroom floor mouse allergen concentrations were associated with air trapping but not airflow limitation (odds ratio 1.19, 95% confidence interval 1.02-1.37, P = .02 per 2-fold increase in airborne mouse allergen; odds ratio 1.23, 95% confidence interval 1.07-1.41, P = .003 per 2-fold increase in bedroom floor mouse allergen). Other indoor exposures (cockroach, cat, dog, dust mite, particulate matter, and nicotine) were not associated with air trapping or airflow limitation.

CONCLUSION

Mouse allergen exposure, but not other indoor exposure, was associated with air trapping in urban children with asthma.

Evaluation of a water arsenic filter in a participatory intervention to reduce arsenic exposure in American Indian communities: The Strong Heart Water Study

Many rural populations, including American Indian communities, that use private wells from groundwater for their source of drinking and cooking water are disproportionately exposed to elevated levels of arsenic. However, programs aimed at reducing arsenic in American Indian communities are limited. The Strong Heart Water Study (SHWS) is a randomized controlled trial aimed at reducing arsenic exposure among private well users in American Indian Northern Great Plains communities. The community-led SHWS program installed point-of-use (POU) arsenic filters in the kitchen sink of households, and health promoters delivered arsenic health communication programs. In this study we evaluated the efficacy of these POU arsenic filters in removing arsenic during the two-year installation period. Participants were randomized into two arms. In the first arm households received a POU arsenic filter, and 3 calls promoting filter use (SHWS mobile health (mHealth) & filter arm). The second arm received the same filter and phone calls, and 3 in-person home visits and 3 Facebook messages (SHWS intensive arm) for program delivery. Temporal variability in water arsenic concentrations from the main kitchen faucet was also evaluated. A total of 283 water samples were collected from 50 households with private wells from groundwater (139 filter and 144 kitchen faucet samples). Ninety-three percent of households followed after baseline had filter faucet water arsenic concentrations below the arsenic maximum contaminant level of 10 μg/L at the final visit during our 2 year study period with no difference between study arms (98 % in the intensive arm vs. 94 % in the mHealth & filter arm). No significant temporal variation in kitchen arsenic concentration was observed over the study period (intraclass correlation coefficient = 0.99). This study demonstrates that POU arsenic filters installed for the community participatory SHWS program were effective in reducing water arsenic concentration in study households in both arms, even with delivery of the POU arsenic filter and mHealth program only. Furthermore, we observed limited temporal variability of water arsenic concentrations from kitchen faucet samples collected over time from private wells in our study setting.

Assessing Residential Exposure to Microbes from Industrial Hog Operations in Rural North Carolina: Methods and Lessons Learned

BACKGROUND

Recent advances in molecular source tracking make answering questions from residents regarding their exposure to microbial contaminants from industrial hog operations (IHOs) possible. Associations between residential distance to IHOs and exposure can be addressed by measuring livestock-associated (Staphylococcus aureus) and pig-specific bacteria in the air, on household surfaces, and in participants' nasal and saliva swabs.

OBJECTIVES

Here we assess the mechanics, feasibility, capacity-building, and lessons learned during a pilot study employing this novel technology in community-based participatory research of bacterial exposure and human health.

METHODS

Together, our team of academics and community members designed a field- and laboratory-based pilot study. Air samples, surface and human swabs, and questionnaires from households at varying distances from IHOs were collected. Data were assessed for completeness and quality by two independent reviewers. These metrics were defined as: missingness (completeness), incorrect data type (validity), out of range (validity), and outliers (accuracy).

LESSONS LEARNED

While critical field equipment was obtained, and knowledge exchange occurred, leading to an increased capacity for future work, after review, 38 of 49 households were deemed eligible for inclusion in the study. Of eligible participants, 98% of required electronic survey questions were complete and 100% were valid; an improvement over prior work which employed paper surveys. While all human microbial and air samples were collected from eligible households (n = 231), (5%) of environmental swabs were reported missing.

CONCLUSIONS

Using community-appropriate sampling protocols, a pilot study of residential exposure to bacteria from IHOs was completed. While high-quality data was collected from those eligible, we learned the necessity of early and continual data review.

The Effect of Floor Height on Secondhand Smoke Transfer in Multiunit Housing

Secondhand smoke (SHS) exposure remains a major public health concern in the United States. Homes have become the primary source of SHS exposure, with elevated risks for residents of multiunit housing. Though this differential risk is well-documented, little is known about whether SHS exposure varies by floor height. The aim of this study was to examine whether SHS accumulates in higher floors of multiunit housing. Using validated passive nicotine sampling monitors, we sampled air nicotine concentrations on multiple floors of 21 high-rise (>15 floors) buildings in New York City. Within the buildings, measurements were collected in three locations: non-smoking individual apartments, hallways and stairwells. Measurements were collected in two winter and two summer waves to account for potential seasonality effects. We analyzed the percent of filters with detectable nicotine and quantified nicotine concentration (µg/m3). Higher floor levels were positively associated with both airborne nicotine measures, with some variation by location and season observed. In winter, the trends were statistically significant in apartments (floors ≤7: 0.022 µg/m3; floors 8−14: 0.026 µg/m3; floors ≥15: 0.029 µg/m3; p = 0.011) and stairwells (floors ≤7: 0.18 µg/m3; floors 8−14: 0.19 µg/m3; floors ≥15: 0.59 µg/m3; p = 0.006). These findings can inform interventions to mitigate the SHS exposure of residents in multiunit housing.

Protecting Children From Tobacco Smoke Exposure: A Randomized Controlled Trial of Project Zero Exposure

INTRODUCTION

Young children are vulnerable to harm from tobacco smoke exposure (TSE). This study assessed the effect of Project Zero Exposure-an intervention program designed to help parents protect children from TSE-on children's exposure.

METHODS

Randomized controlled trial of a home-based, theory-driven intervention. Parents of young children (<8 y) in families with a smoking parent were eligible. The intervention included feedback on child TSE (hair nicotine), and home air quality (PM2.5), with motivational interviewing. Families were randomized to: intervention group (IG, N = 69), regular control group (RCG, N = 70), or to a secondary enhanced control group, (ECG, N = 20). Child hair samples were taken at baseline and follow-up. We report on child TSE in the IG versus RCG at six months.

RESULTS

Most enrolled families completed the trial (IG: 98.6%[68/69], RCG: 97.1%[68/70]). Log hair nicotine (LHN [ng/mg]) decreased in both the IG (Baseline: -1.78 ± 1.91, Follow-up: -2.82 ± 1.87, p = .003) and RCG (Baseline: -1.79 ± 1.54, Follow-up: -2.85 ± 1.73, p = .002), but did not differ between groups at study end (p = .635). Three of five parentally-reported outcomes showed improvement over time in the IG, and one in the RCG. Among IG participants, 90% found hair nicotine feedback useful.

CONCLUSIONS

No difference between the intervention and control groups was found on the objective biomarker, LHN. Child TSE decreased during the trial in intervention and control groups. Trial participation, which included hair nicotine monitoring, may have contributed to decreasing exposure in both groups. Concurrent control group improvements may partially explain lack of proven intervention benefit. Biomarker monitoring warrants further investigation for reduction of child TSE.

IMPLICATIONS

Project Zero Exposure is an intervention program designed to help parents protect their children from TSE. Results from the randomized controlled trial of the program showed no difference between groups at study end, but a clear and substantial reduction in child exposure to tobacco smoke from beginning to end of the trial, in both intervention and control groups. Biomarker monitoring, a key element of the trial, was used with all participants. Biomarker monitoring of child exposure to tobacco smoke may help parents become aware of their child's exposure and better protect them, and should be explored as a means to reduce child TSE. Clinical Trial Registration: NCT02867241.

Spatial relationship between well water arsenic and uranium in Northern Plains native lands

Arsenic and uranium in unregulated private wells affect many rural populations across the US. The distribution of these contaminants in the private wells of most American Indian communities is poorly characterized, and seldom studied together. Here, we evaluate the association between drinking water arsenic and uranium levels in wells (n = 441) from three tribal regions in North Dakota and South Dakota participating in the Strong Heart Water Study. Groundwater contamination was extensive; 29% and 7% of wells exceeded maximum contaminant levels for arsenic and uranium respectively. 81% of wells had both arsenic and uranium concentrations at one-tenth of their human-health benchmark (arsenic, 1 μg/L; uranium 3 μg/L). Well arsenic and uranium concentrations were uncorrelated (rs = 0.06); however, there appeared to be a spatial correlation of wells co-contaminated by arsenic and uranium associated with flow along a geologic contact. These findings indicate the importance of measuring multiple metals in well water, and to understand underlying hydrogeological conditions. The underlying mechanisms for the prevalence of arsenic and uranium across Northern Plains Tribal Lands in the US, and in particular the occurrence of both elevated arsenic and uranium in drinking water wells in this region, demands further study.

Modeling residential indoor concentrations of PM2.5 , NO2 , NOx , and secondhand smoke in the Subpopulations and Intermediate Outcome Measures in COPD (SPIROMICS) Air study

Increased outdoor concentrations of fine particulate matter (PM_2.5 ) and oxides of nitrogen (NO₂ , NO_x ) are associated with respiratory and cardiovascular morbidity in adults and children. However, people spend most of their time indoors and this is particularly true for individuals with chronic obstructive pulmonary disease (COPD). Both outdoor and indoor air pollution may accelerate lung function loss in individuals with COPD, but it is not feasible to measure indoor pollutant concentrations in all participants in large cohort studies. We aimed to understand indoor exposures in a cohort of adults (SPIROMICS Air, the SubPopulations and Intermediate Outcome Measures in COPD Study of Air pollution). We developed models for the entire cohort based on monitoring in a subset of homes, to predict mean 2-week-measured concentrations of PM_2.5 , NO₂ , NO_x , and nicotine, using home and behavioral questionnaire responses available in the full cohort. Models incorporating socioeconomic, meteorological, behavioral, and residential information together explained about 60% of the variation in indoor concentration of each pollutant. Cross-validated R² for best indoor prediction models ranged from 0.43 (NO_x ) to 0.51 (NO₂ ). Models based on questionnaire responses and estimated outdoor concentrations successfully explained most variation in indoor PM_2.5 , NO₂ , NO_x , and nicotine concentrations.

Inorganic arsenic induces sex-dependent pathological hypertrophy in the heart

Arsenic exposure though drinking water is widespread and well associated with adverse cardiovascular outcomes, yet the pathophysiological mechanisms by which iAS induces these effects are largely unknown. Recently, an epidemiological study in an American population with a low burden of cardiovascular risk factors found that iAS exposure was associated with altered left ventricular geometry. Considering the possibility that iAS directly induces cardiac remodeling independently of hypertension, we investigated the impact of an environmentally relevant iAS exposure on the structure and function of male and female hearts. Adult male and female C56BL/6J mice were exposed to 615 μg/L iAS for 8 wk. Males exhibited increased systolic blood pressure via tail cuff photoplethysmography, left ventricular wall thickening via transthoracic echocardiography, and increased plasma atrial natriuretic peptide via enzyme immunoassay. RT-qPCR revealed increased myocardial RNA transcripts of Acta1, Myh7, and Nppa and decreased Myh6, providing evidence of pathological hypertrophy in the male heart. Similar changes were not detected in females, and nitric oxide-dependent mechanisms of cardioprotection in the heart appeared to remain intact. Further investigation found that Rcan1 was upregulated in male hearts and that iAS activated NFAT in HEK-293 cells via luciferase assay. Interestingly, iAS induced similar hypertrophic gene expression changes in neonatal rat ventricular myocytes, which were blocked by calcineurin inhibition, suggesting that iAS may induce pathological cardiac hypertrophy in part by targeting the calcineurin-NFAT pathway. As such, these results highlight iAS exposure as an independent cardiovascular risk factor and provide biological impetus for its removal from human consumption.NEW & NOTEWORTHY This investigation provides the first mechanistic link between an environmentally relevant dose of inorganic arsenic (iAS) and pathological hypertrophy in the heart. By demonstrating that iAS exposure may cause pathological cardiac hypertrophy not only by increasing systolic blood pressure but also by potentially activating calcineurin-nuclear factor of activated T cells and inducing fetal gene expression, these results provide novel mechanistic insight into the theat of iAS exposure to the heart, which is necessary to identify targets for medical and public health intervention.

Early Cardiovascular Risk in E-cigarette Users: the Potential Role of Metals

PURPOSE OF REVIEW

Electronic cigarettes (e-cigs) are a source of metals. Epidemiologic and experimental evidence support that metals are toxic to the cardiovascular system. Little is known, however, about the role that e-cig metals may play as toxicants for the possible cardiovascular effects of e-cig use. The goal of this narrative review is to summarize the evidence on e-cig use and metal exposure and on e-cig use and cardiovascular toxicity and discuss the research needs.

RECENT FINDINGS

In vitro studies show cytotoxicity and increased oxidative stress in myocardial cells and vascular endothelial cells exposed to e-liquids and e-cig aerosols, with effects partially reversed with antioxidant treatment. There is some evidence that the heating coil plays a role in cell toxicity. Mice exposed to e-cigs for several weeks showed higher levels of oxidative stress, inflammation, platelet activation, and thrombogenesis. Cross-over clinical experiments show e-cig use alters nitric oxide-mediated flow-mediated dilation, endothelial progenitor cells, and arterial stiffness. Cross-sectional evidence from large nationally representative samples in the USA support that e-cig use is associated with self-reported myocardial infarction. Smaller studies found associations of e-cig use with higher oxidized low-density protein and heart variability compared to healthy controls. Numerous studies have measured elevated levels of toxic metals in e-cig aerosols including lead, nickel, chromium, and manganese. Arsenic has been measured in some e-liquids. Several of these metals are well known to be cardiotoxic. Numerous studies show that e-cigs are a source of cardiotoxic metals. Experimental studies (in vitro, in vivo, and clinical studies) show acute toxicity of e-cigs to the vascular system. Studies of long-term toxicity in animals and humans are missing. Longitudinal studies with repeated measures of metal exposure and subclinical cardiovascular outcomes (e.g., coronary artery calcification) could contribute to determine the long-term cardiovascular effects of e-cigs and the potential role of metals in those effects.

Evaluation of Secondhand Smoke Exposure in New York City Public Housing After Implementation of the 2018 Federal Smoke-Free Housing Policy

IMPORTANCE

Secondhand smoke (SHS) exposure is associated with many health conditions in children and adults. Millions of individuals in the US are currently exposed to SHS in their homes.

OBJECTIVE

To investigate whether a federal ban on smoking in public housing settings was associated with a decrease in indoor SHS levels in New York City public housing developments 12 months after the policy's implementation.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study tracked indoor air quality longitudinally from April 2018 to September 2019 and used difference-in-differences analysis to examine SHS exposure before vs after implementation of the 2018 federal smoke-free housing (SFH) policy in 10 New York City Housing Authority (NYCHA) buildings vs 11 matched low-income buildings not subject to the SFH policy (ie, Section 8 buildings).

EXPOSURES

Federal SFH policy implementation, beginning July 30, 2018.

MAIN OUTCOMES AND MEASURES

Comparison of nicotine concentration levels from passive, bisulfate-coated filters before vs 12 months after implementation of the federal SFH policy. Secondary outcomes included changes in particulate matter less than 2.5 μm in diameter, measured with low-cost particle monitors, and counts of cigarette butts in common areas.

RESULTS

Air quality was measured repeatedly in a total of 153 NYCHA and 110 Section 8 nonsmoking households as well as in 91 stairwells and hallways. Before the SFH policy implementation, air nicotine was detectable in 19 of 20 stairwells (95.0%) in NYCHA buildings and 15 of 19 stairwells (78.9%) in Section 8 buildings (P = .19) and in 17 of 19 hallways (89.5%) in NYCHA buildings and 14 of 23 hallways (60.9%) in Section 8 buildings (P = .004). Nicotine was detected less frequently inside nonsmoking apartments overall (26 of 263 [9.9%]) but more frequently in NYCHA apartments (20 of 153 [13.1%]) than in Section 8 apartments (6 of 110 [5.5%]) (P = .04). One year after policy implementation, there was no differential change over time in nicotine concentrations measured in stairwells (DID, 0.03 μg/m3; 95% CI, -0.99 to 1.06 μg/m3) or inside nonsmoking households (DID, -0.04 μg/m3; 95% CI, -0.24 to 0.15 μg/m3). Larger decreases in nicotine concentration were found in NYCHA hallways than in Section 8 hallways (DID, -0.43 μg/m3; 95% CI, -1.26 to 0.40 μg/m3).

CONCLUSIONS AND RELEVANCE

The findings suggest that there was no differential change in SHS in NYCHA buildings 12 months after SFH policy implementation. Additional support may be needed to ensure adherence to SFH policies.

Dose-dependent detoxication of the airborne pollutant benzene in a randomized trial of broccoli sprout beverage in Qidong, China

BACKGROUND

Airborne pollutants have collectively been classified as a known human carcinogen and, more broadly, affect the health of hundreds of millions of people worldwide. Benzene is a frequent component of air pollution, and strategies to protect individuals against unavoidable exposure to this and other airborne carcinogens could improve the public's health. Earlier clinical trials in Qidong, China, demonstrated efficacy in enhancing the detoxication of benzene using a broccoli sprout beverage.

OBJECTIVES

A randomized, placebo-controlled, multidose trial of a broccoli sprout beverage was designed to determine the lowest effective concentration that enhances benzene detoxication adjudged by enhanced excretion of the urinary biomarker, S-phenylmercapturic acid (SPMA).

METHODS

Following informed consent, 170 subjects were randomly assigned in 5 blocks of 34 each to drink either a placebo beverage (n = 55) or 1 of 3 graded concentrations of a broccoli sprout beverage [full (n = 25), one-half (n = 35), and one-fifth (n = 55)] for 10 consecutive days. Concentrations of SPMA arising through induced benzene conjugation with glutathione were quantified by MS in sequential 12-h overnight urine collections during the intervention.

RESULTS

MS was also used to quantify urinary sulforaphane metabolites in each dosing regimen that resulted in a median 24-h urinary output of 24.6, 10.3, and 4.3 µmol, respectively, confirming a dose-dependent de-escalation of the inducing principle within the beverage. A statistically significant increase in benzene mercapturic acids in urine was found for the high-dose group (+63.2%) during the 10-d period. The one-half dose (+11.3%) and one-fifth dose groups (-6.4%) were not significantly different from placebo controls.

CONCLUSIONS

An intervention with a broccoli sprout beverage enhanced the detoxication of benzene, an important airborne pollutant, when dosed at a concentration evoking a urinary elimination of ∼25 µmol sulforaphane metabolites per day, and it portends a practical and frugal population-based strategy to attenuate associated long-term health risks of air pollution. This trial was registered at clinicaltrials.gov as NCT02656420.

Waterpipe tobacco smoke: Characterization of toxicants and exposure biomarkers in a cross-sectional study of waterpipe employees

INTRODUCTION

Few studies have comprehensively characterized toxic chemicals related to waterpipe use and secondhand waterpipe exposure. This cross-sectional study investigated biomarkers of toxicants associated with waterpipe use and passive waterpipe exposure among employees at waterpipe venues.

METHOD

We collected urine specimens from employees in waterpipe venues from Istanbul, Turkey and Moscow, Russia, and identified waterpipe and cigarette smoking status based on self-report. The final sample included 110 employees. Biomarkers of exposure to sixty chemicals (metals, volatile organic compounds (VOCs), polycyclic aromatic hydrocarbons (PAHs), nicotine, and heterocyclic aromatic amines (HCAAs)) were quantified in the participants' urine.

RESULTS

Participants who reported using waterpipe had higher urinary manganese (geometric mean ratio (GMR): 2.42, 95% confidence interval (CI): 1.16, 5.07) than never/former waterpipe or cigarette smokers. Being exposed to more hours of secondhand smoke from waterpipes was associated with higher concentrations of cobalt (GMR: 1.38, 95% CI: 1.10, 1.75). Participants involved in lighting waterpipes had higher urinary cobalt (GMR: 1.43, 95% CI: 1.10, 1.86), cesium (GMR: 1.21, 95% CI: 1.00, 1.48), molybdenum (GMR: 1.45, 95% CI: 1.08, 1.93), 1-hydroxypyrene (GMR: 1.36, 95% CI: 1.03, 1.80), and several VOC metabolites.

CONCLUSION

Waterpipe tobacco users and nonsmoking employees of waterpipe venues had higher urinary concentrations of several toxic metals including manganese and cobalt as well as of VOCs, in a distinct signature compared to cigarette smoke. Employees involved in lighting waterpipes may have higher exposure to multiple toxic chemicals compared to other employees.

Indoor air quality in inner-city schools and its associations with building characteristics and environmental factors

Indoor concentrations of fine particulate matter (PM_2.5), nitrogen dioxide (NO₂), and carbon monoxide (CO) were measured across 16 urban public schools in three different seasons. Exceedance of the WHO guidelines for indoor air was observed, mainly for the hourly average NO₂ concentrations. Seasonal variability was statistically significant for indoor NO₂ and CO concentrations, with higher exposures in fall and winter. An extensive list of potential factors at the outdoor environment, school, and room level that may explain the variability in indoor exposure was examined. Factors with significant contributions to indoor exposure were mostly related to the outdoor pollution sources. This is evidenced by the strong associations between indoor concentration of CO and NO₂ and factors including outdoor PM_2.5 and NO₂ concentrations, including length of the nearby roads and the number of nearby industrial facilities. Additionally, we found that poor conditions of the buildings (a prevalent phenomenon in the studied urban area), including physical defects and lack of proper ventilation, contributed to poor air quality in schools. The results suggest that improving building conditions and facilities as well as a consideration of the school surroundings may improve indoor air quality in schools.

Inorganic arsenic exposure induces sex-disparate effects and exacerbates ischemia-reperfusion injury in the female heart

Arsenic is a common contaminant in drinking water throughout the world, and recent studies support a link between inorganic arsenic (iAS) exposure and ischemic heart disease in men and women. Female hearts exhibit an estrogen-dependent reduction in susceptibility to myocardial ischemic injury compared with males, and as such, female hearts may be more susceptible to the endocrine-disrupting effects of iAS exposure. However, iAS exposure and susceptibility to ischemic heart injury have not been examined in mechanistic studies. Male and female mice (8 wk) were exposed to environmentally relevant concentrations of sodium arsenite (0, 10, 100, and 1,000 parts/billion) via drinking water for 4 wk. Pre- and postexposure echocardiography was performed, and postexposure plasma was collected for 17β-estradiol measurement. Hearts were excised and subjected to ischemia-reperfusion (I/R) injury via Langendorff perfusion. Exposure to 1,000 parts/billion iAS led to sex-disparate effects, such that I/R injury was exacerbated in female hearts but unexpectedly attenuated in males. Assessment of echocardiographic parameters revealed statistically significant structural remodeling in iAS-treated female hearts with no change in function; males showed no change. Plasma 17β-estradiol levels were not significantly altered by iAS in male or female mice versus nontreated controls. Although total eNOS protein levels did not change in whole heart homogenates from iAS-treated male or female mice, eNOS phosphorylation (Ser¹¹⁷⁷) was significantly elevated in iAS-treated male hearts. These results suggest that iAS exposure can induce sex-disparate effects and modulate susceptibility to ischemic heart injury by targeting distinct sex-dependent pathways. NEW & NOTEWORTHY This is the first mechanistic study examining iAS exposure on myocardial ischemia-reperfusion injury in male and female mice. Following iAS exposure, ischemia-reperfusion injury was exacerbated in female hearts but attenuated in males. iAS treatment induced statistically significant cardiac remodeling in females, with no change in males. iAS treatment also enhanced phosphorylated eNOS levels at Ser¹¹⁷⁷, but only in male hearts. These results suggest that iAS alters susceptibility to myocardial I/R injury through distinct sex-dependent pathways.

Arsenic in groundwater in private wells in rural North Dakota and South Dakota: Water quality assessment for an intervention trial

Elevated exposure to arsenic disproportionately affects populations relying on private well water in the United States (US). This includes many American Indian (AI) communities where naturally occurring arsenic is often above 10 µg/L, the current US Environmental Protection Agency safety standard. The Strong Heart Water Study is a randomized controlled trial aiming to reduce arsenic exposure to private well water users in AI communities in North Dakota and South Dakota. In preparation for this intervention, 371 households were included in a community water arsenic testing program to identify households with arsenic ≥10 µg/L by inductively coupled plasma mass spectrometry (ICP-MS). Arsenic ≥10 µg/L was found in 97/371 (26.1%) households; median water arsenic concentration was 6.3 µg/L, ranging from <1-198 µg/L. Silica was identified as a water quality parameter that could impact the efficacy of arsenic removal devices to be installed. A low-range field rapid arsenic testing kit evaluated in a small number of households was found to have low accuracy; therefore, not an option for the screening of affected households in this setting. In a pilot study of the effectiveness of a point-of-use adsorptive media water filtration device for arsenic removal, all devices installed removed arsenic below 1 µg/L at both installation and 9 months post-installation. This study identified a relatively high burden of arsenic in AI study communities as well as an effective water filtration device to reduce arsenic in these communities. The long-term efficacy of a community based arsenic mitigation program in reducing arsenic exposure and preventing arsenic related disease is being tested as part of the Strong Heart Water Study.

Maternal exposure to PM2.5 in south Texas, a pilot study

In this study, we characterized personal exposure to fine particulate matter (PM_2.5), black carbon (BC), and nicotine in pregnant women in Hidalgo County, where the hospitalization rates of childhood asthma are the highest in the state of Texas. The measurements were conducted over three non-consecutive sampling days for 17 participants in their third trimester. Measurements were partitioned into four microenvironments, i.e., Residential, Vehicular, Commercial, and Other, on the basis of GPS coordinates and temperature and humidity measurements. The daily average PM_2.5 mass concentration was 24.2 (standard deviation=22.0) μg/m³, with the highest daily mass concentration reaching 126.0μg/m³. The daily average BC concentration was 1.44 (SD=0.82) μg/m³, ranging from 0.5 to 5.4μg/m³. Hair nicotine concentrations were all near the detection level (i.e., 49.2pg/mg), indicating that the participants were not routinely exposed to tobacco smoke. The Residential microenvironment contributed dominantly to the mass concentration since the participants chiefly remained at home and cooking activities contributed significantly to the total PM_2.5. When compared to an ambient monitoring station, the person-specific PM_2.5 was frequently more than double the ambient measurement (10.4μg/m³ overall), revealing that even in regions where ambient concentrations are below national standards, individuals may be still be exposed to elevated PM_2.5 mass concentrations.

The feasibility of an air purifier and secondhand smoke education intervention in homes of inner city pregnant women and infants living with a smoker

OBJECTIVES

Secondhand smoke (SHS) and other air pollutants adversely affect the health of pregnant women and infants. A feasibility study aimed at reducing air pollution in homes of pregnant women or infants living with a smoker was completed.

METHODS

In collaboration with the Baltimore City Health Department, women ≥ 18 years of age and either pregnant nonsmokers, or post-partum (any smoking status) with an infant age 0-12 months were recruited. Homes had at least one smoker. Intervention included two air purifiers and secondhand smoke education. Outcomes included feasibility, change in fine particulate matter (PM_2.5), air nicotine, and salivary cotinine pre- and post-intervention.

RESULTS

Fifty women were enrolled (mean age 27 years, 92% African American, 71% single, 94% Medicaid eligible, 34% reported smoking) and 86% completed the study. Of the 50 women, 32 had infants and 18 were pregnant at time of enrollment. Post- intervention, 70% of participants reported smokers were less likely to smoke indoors, and 77% had at least one air purifier turned on at the final visit. Participant satisfaction was high (91%) and 98% would recommend air purifiers. Indoor PM_2.5 was significantly decreased (P < 0.001). Salivary cotinine was significantly decreased for non-smoking women (P < 0.01) but not infants, and no significant change in air nicotine occurred (P = 0.6).

CONCLUSIONS

Air purifiers with SHS education is a feasible intervention in homes of women and infants. These data demonstrate reduction in indoor PM_2.5 and salivary cotinine in non-smoking adults. Air purifiers are not an alternative for smoking cessation and a home/ car smoking ban. Smoking cessation should be strongly encouraged for all pregnant women, and nonsmoking mothers with infants should be counseled to completely avoid SHS exposure. This study provides support for a future intervention evaluating clinical endpoints.

Protecting Young Children From Tobacco Smoke Exposure: A Pilot Study of Project Zero Exposure

BACKGROUND

Tobacco smoke exposure (TSE) harms children, who are often "captive smokers" in their own homes. Project Zero Exposure is a parent-oriented, theory-based intervention designed to reduce child TSE. This paper reports on findings from the pilot study, which was conducted in Israel from 2013 to 2014.

METHODS

The intervention consisted of motivational interviews, child biomarker and home air quality feedback, a Web site, a video, and self-help materials. The primary outcome was child TSE as measured by hair nicotine. Secondary outcome measures were air nicotine and particulate matter, parental reports of TSE, parental smoking behavior, and TSE child protection. A single-group pre- and posttest design was used.

RESULTS

Twenty-six of the 29 recruited families completed the study. The intervention was feasible to implement and acceptable to participants. Among the 17 children with reliable hair samples at baseline and follow-up, log hair nicotine dropped significantly after the intervention (P = .04), hair nicotine levels decreased in 64.7% of children, and reductions to levels of nonexposed children were observed in 35.3% of children. The number of cigarettes smoked by parents (P = .001) and parent-reported child TSE declined (P = .01). Logistical issues arose with measurement of all objective measures, including air nicotine, which did not decline; home air particulate matter; and hair nicotine.

CONCLUSIONS

A program based on motivational interviewing and demonstrating TSE and contamination to parents in a concrete and easily understandable way is a promising approach to protect children from TSE. Further research is needed to enhance current methods of measurement and assess promising interventions.

A direct method for e-cigarette aerosol sample collection

E-cigarette use is increasing in populations around the world. Recent evidence has shown that the aerosol produced by e-cigarettes can contain a variety of toxicants. Published studies characterizing toxicants in e-cigarette aerosol have relied on filters, impingers or sorbent tubes, which are methods that require diluting or extracting the sample in a solution during collection. We have developed a collection system that directly condenses e-cigarette aerosol samples for chemical and toxicological analyses. The collection system consists of several cut pipette tips connected with short pieces of tubing. The pipette tip-based collection system can be connected to a peristaltic pump, a vacuum pump, or directly to an e-cigarette user for the e-cigarette aerosol to flow through the system. The pipette tip-based system condenses the aerosol produced by the e-cigarette and collects a liquid sample that is ready for analysis without the need of intermediate extraction solutions. We tested a total of 20 e-cigarettes from 5 different brands commercially available in Maryland. The pipette tip-based collection system condensed between 0.23 and 0.53mL of post-vaped e-liquid after 150 puffs. The proposed method is highly adaptable, can be used during field work and in experimental settings, and allows collecting aerosol samples from a wide variety of e-cigarette devices, yielding a condensate of the likely exact substance that is being delivered to the lungs.

Secondhand hookah smoke: an occupational hazard for hookah bar employees

BACKGROUND

Despite the increasing popularity of hookah bars, there is a lack of research assessing the health effects of hookah smoke among employees. This study investigated indoor air quality in hookah bars and the health effects of secondhand hookah smoke on hookah bar workers.

METHODS

Air samples were collected during the work shift of 10 workers in hookah bars in New York City (NYC). Air measurements of fine particulate matter (PM_2.5), fine black carbon (BC_2.5), carbon monoxide (CO), and nicotine were collected during each work shift. Blood pressure and heart rate, markers of active smoking and secondhand smoke exposure (exhaled CO and saliva cotinine levels), and selected inflammatory cytokines in blood (ineterleukin (IL)-1b, IL-6, IL-8, interferon γ (IFN-γ), tumour necrosis factor (TNF-α)) were assessed in workers immediately prior to and immediately after their work shift.

RESULTS

The PM_2.5 (gravimetric) and BC_2.5 concentrations in indoor air varied greatly among the work shifts with mean levels of 363.8 µg/m³ and 2.2 µg/m³, respectively. The mean CO level was 12.9 ppm with a peak value of 22.5 ppm CO observed in one hookah bar. While heart rate was elevated by 6 bpm after occupational exposure, this change was not statistically significant. Levels of inflammatory cytokines in blood were all increased at postshift compared to preshift testing with IFN-Υ increasing from 0.85 (0.13) to 1.6 (0.25) (mean (standard error of the mean; SEM)) pg/mL (p<0.01). Exhaled CO levels were significantly elevated after the work shift with 2 of 10 workers having values >90 ppm exhaled CO.

CONCLUSIONS

These results demonstrate that hookah bars have elevated concentrations of indoor air pollutants that appear to cause adverse health effects in employees. These data indicate the need for further research and a marked need for better air quality monitoring and policies in such establishments to improve the indoor air quality for workers and patrons.

Hyperoxaluric nephrolithiasis is a complication of Roux-en-Y gastric bypass surgery

Roux-en-Y bypass surgery is the most common bariatric procedure currently performed in the United States for medically complicated obesity. Although this leads to a marked and sustained weight loss, we have identified an increasing number of patients with episodes of nephrolithiasis afterwards. We describe a case series of 60 patients seen at Mayo Clinic-Rochester that developed nephrolithiasis after Roux-en-Y gastric bypass (RYGB), including a subset of 31 patients who had undergone metabolic evaluation in the Mayo Stone Clinic. The mean body mass index of the patients before procedure was 57 kg/m(2) with a mean decrease of 20 kg/m(2) at the time of the stone event, which averaged 2.2 years post-procedure. When analyzed, calcium oxalate stones were found in 19 and mixed calcium oxalate/uric acid stones in two patients. Hyperoxaluria was a prevalent factor even in patients without a prior history of nephrolithiasis, and usually presented more than 6 months after the procedure. Calcium oxalate supersaturation, however, was equally high in patients less than 6 months post-procedure due to lower urine volumes. In a small random sampling of patients undergoing this bypass procedure, hyperoxaluria was rare preoperatively but common 12 months after surgery. We conclude that hyperoxaluria is a potential complicating factor of RYGB surgery manifested as a risk for calcium oxalate stones.

Airborne multidrug-resistant bacteria isolated from a concentrated swine feeding operation

The use of nontherapeutic levels of antibiotics in swine production can select for antibiotic resistance in commensal and pathogenic bacteria in swine. As a result, retail pork products, as well as surface and groundwaters contaminated with swine waste, have been shown to be sources of human exposure to antibiotic-resistant bacteria. However, it is unclear whether the air within swine operations also serves as a source of exposure to antibiotic-resistant bacterial pathogens. To investigate this issue, we sampled the air within a concentrated swine feeding operation with an all-glass impinger. Samples were analyzed using a method for the isolation of Enterococcus. A total of 137 presumptive Enterococcus isolates were identified to species level using standard biochemical tests and analyzed for resistance to erythromycin, clindamycin, virginiamycin, tetracycline, and vancomycin using the agar dilution method. Thirty-four percent of the isolates were confirmed as Enterococcus, 32% were identified as coagulase-negative staphylococci, and 33% were identified as viridans group streptococci. Regardless of bacterial species, 98% of the isolates expressed high-level resistance to at least two antibiotics commonly used in swine production. None of the isolates were resistant to vancomycin, an antibiotic that has never been approved for use in livestock in the United States. In conclusion, high-level multidrug-resistant Enterococcus, coagulase-negative staphylococci, and viridans group streptococci were detected in the air of a concentrated swine feeding operation. These findings suggest that the inhalation of air from these facilities may serve as an exposure pathway for the transfer of multidrug-resistant bacterial pathogens from swine to humans.

Airborne multidrug-resistant bacteria isolated from a concentrated swine feeding operation

The use of nontherapeutic levels of antibiotics in swine production can select for antibiotic resistance in commensal and pathogenic bacteria in swine. As a result, retail pork products, as well as surface and groundwaters contaminated with swine waste, have been shown to be sources of human exposure to antibiotic-resistant bacteria. However, it is unclear whether the air within swine operations also serves as a source of exposure to antibiotic-resistant bacterial pathogens. To investigate this issue, we sampled the air within a concentrated swine feeding operation with an all-glass impinger. Samples were analyzed using a method for the isolation of Enterococcus. A total of 137 presumptive Enterococcus isolates were identified to species level using standard biochemical tests and analyzed for resistance to erythromycin, clindamycin, virginiamycin, tetracycline, and vancomycin using the agar dilution method. Thirty-four percent of the isolates were confirmed as Enterococcus, 32% were identified as coagulase-negative staphylococci, and 33% were identified as viridans group streptococci. Regardless of bacterial species, 98% of the isolates expressed high-level resistance to at least two antibiotics commonly used in swine production. None of the isolates were resistant to vancomycin, an antibiotic that has never been approved for use in livestock in the United States. In conclusion, high-level multidrug-resistant Enterococcus, coagulase-negative staphylococci, and viridans group streptococci were detected in the air of a concentrated swine feeding operation. These findings suggest that the inhalation of air from these facilities may serve as an exposure pathway for the transfer of multidrug-resistant bacterial pathogens from swine to humans.

Immunofluorescent localization of an androgen-dependent isoenzyme of prostatic acid phosphatase in rat ventral prostate

Isoenzymes of rat ventral prostate (RVP) acid phosphatase were isolated and partially purified by ultracentrifugation, Sephadex G-100 column chromatography, and isoelectric focusing. Antisera were raised to the isoenzymes of prostatic acid phosphatase by immunization of New Zealand white rabbits. Rabbit antisera reacting specifically to homologous but not heterologous isoenzymes of acid phosphatase were then reacted with a variety of tissues using indirect immunofluorescence. The tissues included prostate, spleen, bone marrow, liver, kidney, salivary gland complex, small intestine, and adrenal glands. An antiserum against a RVP acid phosphatase isoenzyme with a pI of 4.5 (A-PAP) localized acid phosphatase only in the supranuclear region of rat ventral prostate epithelial cells, and did not react with acid phosphatase in any of the other organs tested. A-PAP did not localize acid phosphatase in the ventral prostate from rats 14 days after castration. A-PAP did localize acid phosphatase in the ventral prostate from castrated animals that were treated with testosterone. These results indicate the A-PAP localized an androgen-dependent isoenzyme of acid phosphatase in RVP epithelial cells that may be secretory in nature. This antiserum should prove to be an ideal marker for studies involving hormonal regulation of prostatic epithelial function in vivo and in vitro.

Ultrastructural localization of in vivo-bound complement in bullous pemphigoid

Antihuman complement component C3 labeled with horseradish peroxidase was used to reveal the ultrastructural localization of complement in two cases of bullous pemphigoid. The complement deposits were shown to be exclusively located in the space between the plasma membrane of the basal cells and the basal lamina. This corresponds exactly to the ultrastructural localization of immunoglobulins in bullous pemphigoid.

Ultrastructural localization of in vivo bound immunoglobulins in bullous pemphigoid--a preliminary report

The ultrastructural location of in vivo bound immunoglobulins in a case of bullous pemphigoid was determined by coupling peroxidase to antihuman gamma globulin. Immunoglobulin deposits were found exclusively in the space between the basal cells and the basal lamina. The location of the immunoglobulin in bullous pemphigoid thus differs from that in lupus erythematosus where immunoglobulins are found mainly below the basal lamina.