National Center for Environmental Health

1. Chemical and Allergy Food SafetyCDC PerspectiveThomas Sinks, PhDDeputy Director NCEH/ATSDRCenters for Disease Control and Prevention National Center for Environmental Health Agency for Toxic Substances and Disease Registry The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and do not represent any agency determination or policy.

2. Different strategies are necessary to prevent disease from infectious agents, toxins, chemicals, and allergens in our food. National Center for Environmental Health Agency for Toxic Substances and Disease Registry

3. Different prevention strategies are needed to prevent disease from infectious, chemical, and allergic agents in food Latency Effect Food Severity variable Diagnosis is agent specific Reportable condition Risk = infectious dose A few dozen organism or toxins hours Acute poisoning, neuro-, or chronic disease. Not reportable Chronic outcomes are not exposure specific Risk = cumulative dose 100’s of chemicals days, weeks, years Non-specific reaction Defined constellation of responses Not reportable Risk = susceptibility A handful of allergens minutes

4. Food Safety – Risks from Chemicals and Allergens • NCEH/ATSDR Data and Resources • National Report on Human Exposure to Environmental Chemicals • National Poison Control Center Data Base • ATSDR Minimal Risk Levels • Community Site Assessments • Food Allergies National Center for Environmental Health Agency for Toxic Substances and Disease Registry

5. National Report on Human Exposure to Environmental Chemicals • NCEH lab measurement of chemicals in human blood and urine • NHANES samples linkable to health effect and dietary data • 4th National Report • 228 chemicals in blood and urine • Approximately 25,000 people • Nationally representative sample • Years: 1999 – 2008 National Center for Environmental Health Agency for Toxic Substances and Disease Registry

6. Distribution of urinary arsenic (µg/L)U.S. population 2007-2008* • Difference in toxicity between inorganic and organic As. • Inorganic As occurs in water and food. • 66% of inorganic arsenic is from foods (vegetables, fruit juices, rice, ET0H, grain** ) • 10% of total As in food is inorganic.** • Need inorganic HBGVs for foods. *Fourth National Report on Human Exposure to Environmental Chemicals, Updated tables, February 2012; ** Xue et al., EHP March 2010 National Center for Environmental Health Agency for Toxic Substances and Disease Registry

7. National Report on Human Exposure to Environmental Chemicals Strengths and Limitations re Food Safety • Represent population-based urine and blood concentrations to hundreds of chemicals by gender, race, age, and calendar time. • Limited relative source contribution calculations are possible. • Few measured chemicals are exclusively food contaminants. • Food is one of several exposure pathways for many, perhaps most, of the chemicals. • Few measurements can be directly linked to health outcomes. • Most HBGV do not use [blood or urine]. The largest contributor to Cd body burdens is smoking. National Center for Environmental Health Agency for Toxic Substances and Disease Registry

8. National Chemical Event Surveillance Using the AAPCC National Poison Center Data System • CDC uses the NPDS to conduct 24/7 public health surveillance for early detection and situational awareness of a chemical, radiological and biologic (e.g.; plague, anthrax) exposures & illness • NPCD covers calls and reports to poison control centers across the US • Real-time data collected every 15 minutes • A mathematical algorithm monitors the database to identify excursions from baseline using defined syndromes. • 11,061 excursions were reviewed or investigated in 2011 • 194 notifications were made to state /federal agencies. • Situational awareness • Japan tsunami and Fukushima nuclear event • Deepwater Horizon Oil spill The largest number of calls to poison control centers was due to KI. National Center for Environmental Health Agency for Toxic Substances and Disease Registry

9. Foodborne Illness Identified through the National Poison Control Center Data Base • 2008 through 2011: 112 automatic alerts related to puffer fish associated illness were evaluated. • 48 suspect cases of puffer fish associated illness were identified. • 3 significant public health events occurred involving 13 of these cases. • October 2011: FDA and CDC collaborated in an investigation of scombrotoxin poisoning involving 2 people consuming Tuna from a fast food restaurant in Ohio. • 20 additional reported exposures in 7 other states were identified using this database. National Center for Environmental Health Agency for Toxic Substances and Disease Registry

10. National Poison Control Center Database Strengths and Limitations re Food Safety Strengths • 24/7 coverage of acute poisonings and exposures • Entire United States • Immediate data access • Established syndromic algorithms and baselines • Flexibility to examine emerging issues • Limitations • Reports do not equal patients - a mixture of calls from the public and calls from clinicians attending to patients. • Passive surveillance -dependent upon contacts with poison control centers. • Chronic illnesses not included

11. ATSDR Resources Relevant to Chemical Food SafetyNon-cancer Health Based Guidance Values Minimal Risk Levels (MRLs) - an estimate of daily human exposure to a substance [mg/kg/day] that is likely to be without non-carcinogenic health effects during a specified duration of exposure based on ATSDR evaluations. ATSDR uses the no observed adverse effect level/uncertainty factor (NOAEL/UF) approach. MRLs are set below levels that, based on current information, might cause adverse health effects in the people most sensitive to such substance-induced effects. Environmental Media Evaluation Guides (EMEGs)EMEGs are estimated contaminant concentrations that are not expected to result in adverse non-carcinogenic health effects based on ATSDR evaluation. EMEGs are based on HBGVs and conservative assumptions about intake rate, exposure frequency, duration, and body weight. We do not have default values for intakes of specific foods so food EMEGs would be developed on a case by case basis. 172 Tox Profiles MRLs 122 Acute: 1 to 14 days 164 Intermediate: 15 to 364 days 111 Chronic: 1 year +

12. Community-based health assessments and consultations • Local issues with local stakeholders • 90% are not listed on the NPL – many are petition requests • In 2011; ATSDR produced: • 382 technical assists • 124 health consultations • 41 health assessments health guidance value exposure pathway [hazardous substance]

13. The Food Pathway in ATSDR Final Public Health Assessments with a Public Health Hazard Finding (2008-2010) • 18 sites • Foods: fish (18), shellfish (1), waterfowl (1), frogs & turtles (1) • States: AK, CA, CT, GA, ID, MA, MI, NC, NH, TN, TX, & WA • Chemicals: Hg (7), dioxins (3), PCBs (4), lead (3), cadmium (2), arsenic (2), heptachlor, dieldrin, DDT, aldrin , toxaphene, zinc, uranium, strontium, nickel, manganese, & aluminum

14. Food Allergies • Trend: Food allergy (FA) appears to be increasing over time. (Boyce, et al., 2010) • Comorbidity: Children with FA are 2-4x more likely to have other allergic conditions and asthma than children without FA. Children with coexisting FA and asthma may be more likely to experience anaphylactic reactions to foods and be at a higher risk of death. (Bock, et al., 2007 & Colver, et al., 2005) • Mortality: An estimated 150-200 people die of food-induced anaphylaxis per year. (Sampson, 2003) National Center for Environmental Health Agency for Toxic Substances and Disease Registry

15. Is there a need for a public health approach to food allergies? “Despite the risk of severe allergic reactions and even death, there is no current treatment for FA: the disease can only be managed by allergen avoidance or treatment of symptoms.” -Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-Sponsored Expert Panel (2010) GAPS • Leading expert guidance does not sufficiently address the management of persons with FA outside of clinical care settings or related public health policy issues. • Significant gaps exist in practice (e.g., addressing FA in the restaurant, home, and retail environments), policy (e.g., local, state, and federal FA policy), surveillance, and economic analysis. National Center for Environmental Health Agency for Toxic Substances and Disease Registry

16. Food Allergens: CDC Activities CDC School Health Guidelines requirements under Food Safety Modernization Act: • (i) develop [voluntary] guidelines … to develop plans for individuals to manage the risk of food allergy and anaphylaxis in schools and early childhood education programs; and • (ii) make such guidelines available to local educational agencies, schools, early childhood education programs … to be implemented on a voluntary basis only. Other proposals (not–funded): • Surveillance and Burden • Add anaphylaxis to Poison Control Center reporting • NCHS healthcare utilization data analysis • Practice: • Environmental Health Specialists Network (EHS-Net) Restaurant Allergen Study to collect descriptive data on restaurant knowledge, attitudes, policies, and practices concerning food allergens. National Center for Environmental Health Agency for Toxic Substances and Disease Registry

17. Different strategies are necessary to prevent disease from infectious agents, toxins, chemicals, and allergens in our food. National Center for Environmental Health Agency for Toxic Substances and Disease Registry