What’s Next?

ATSDR's mission is to protect communities from harmful health effects that could result from exposure to hazardous substances. Foundational principles of ATSDR's work are health equity, environmental justice, and engaging and involving the communities who are expressing concern as a key part of the environmental public health process. The following strategies, resources, and tools highlight ATSDR's initiatives to advance health equity and environmental justice.

CORE Health Equity Science and Intervention Strategy

People who live and work in economically and socially marginalized settings continue to bear disproportionate effects of hazardous environmental exposures. ATSDR is broadening the reach of its equity and justice efforts by aligning with CDC's inaugural CORE Health Equity Science and Intervention Strategy. During 2021–2023, ATSDR's CORE goals will help communities and public health professionals address environmental health inequities by developing tools and data that empower them to identify and evaluate related factors. These tools include a comprehensive Environmental Justice Index (EJI) and an educational module on incorporating health equity into the public health assessment process.

Public Health Assessment Health Equity Module

ATSDR's health assessors and regional offices evaluate community exposures and provide actionable information to marginalized communities. For example, ATSDR's Region 10 is working with American Indian and Alaska Native tribes on five health consultations to evaluate exposures from drinking water or traditional and subsistence use on or near contaminated sites. ATSDR's Health Equity Module (HEM) will be the latest addition to its Public Health Assessment Guidance Manual. The HEM will guide public health professionals on how to evaluate health equity across the spectrum of public health assessments. HEM will outline a process for identifying sites with health equity or environmental justice concerns and provide guidance geared toward evaluating the unique needs of environmental justice communities.

Environmental Justice Index (EJI)

In partnership with the Department of Health and Human Services' Office of Environmental Justice, ATSDR's GRASP program and NCEH, released the Environmental Justice Index (EJI), the first national, place-based tool designed to measure the cumulative impacts of environmental burden through the lens of human health and health equity.

The EJI builds off existing environmental justice indexes to provide a single environmental justice score for local communities across the United States so that public health officials can identify and map areas most at risk for the health impacts of environmental burden.

The EJI delivers a single score for each community so that public health officials can identify and map areas most at risk for the health impacts of environmental burden. Social factors such as poverty, race, and ethnicity, along with pre-existing health conditions, may increase these health impacts. This tool helps public health officials prioritize action for those communities most at need. Individuals and community-based organizations, public health officials at local state and federal levels, scientists, and researchers can use the EJI to:

• Identify areas that may require special attention or additional action to improve health and health equity
• Educate and inform the public about their community
• Analyze the unique, local factors driving cumulative impacts on health to inform policy decision-making
• Establish meaningful goals and measure progress towards environmental justice and health equity

APPLETREE

ATSDR's Partnership to Promote Localized Efforts to Reduce Environmental Exposure (APPLETREE) program is also supporting environmental justice and health equity efforts. ATSDR is working with APPLETREE participants to promote environmental justice and health equity through work at the regional and local levels, in alignment with Justice40, a whole-of-government approach to expand investments in environmental justice, toxic waste remediation, and other areas.

Toxicological Profiles and PEHSUs

ATSDR also works to provide the best available science and information about environmental contaminants, which often disproportionately affect communities at greater social and economic risk. ATSDR's Toxicological Profiles continue to provide state-of-the-science information to healthcare and public health professionals who are addressing exposure concerns in these communities. The Pediatric Environmental Health Specialty Units (PEHSU) network supported by ATSDR continues to advise parents and healthcare providers about how to protect and care for children potentially exposed to harmful chemicals.

In 2022, ATSDR looks forward to grantees continuing work on the Per- and Polyfluoroalkyl (PFAS) Multi-site Study, completing data collection for the PFAS expanded environmental exposure investigation, and releasing the individual community reports and the final report for the PFAS exposure assessments. Findings will help us learn more about health effects of PFAS exposure from PFAS-contaminated drinking water and other sources in differing populations. Findings also will help people better understand their risk for health effects associated with PFAS exposure.

PFAS Multi-site Study

The Multi-site Study (MSS) is designed to discover more about the relationship between PFAS exposure and health outcomes among differing populations and levels of PFAS exposure in communities across eight states exposed to PFAS-contaminated drinking water. This information will provide a better scientific understanding about the relationships between PFAS exposure and certain health outcomes and will help people across the nation understand their risk for health effects. ATSDR aims to enroll 2,100 children and 7,000 adults from the participating sites.

Data collection will focus on findings related to immune response, lipid metabolism, kidney function, thyroid disease, liver disease, glycemic parameters, and diabetes. After all data are collected and analyzed, each participant will receive their own test results, enabling them to learn more about their own exposure and health and potential next steps. An aggregate report evaluating data across all MSS study sites also will be released to inform public health practitioners about how PFAS affects human health.

PFAS Exposure Assessment Releases

In 2022, ATSDR and CDC will complete the remaining PFAS exposure assessments (EAs) in communities near current or former military bases known to have had PFAS in their drinking water.

The primary goal of these assessments is to provide information to community residents about levels of PFAS in their bodies and how they can reduce exposure. The information also may be used to inform future studies evaluating the effects of PFAS exposure on human health. The first EA was released in November 2021 for the City of Westfield in Hampden County, Massachusetts, near Barnes Air National Guard Base. The remaining exposure assessments and a final report evaluating data across all EA sites will be released in 2022.

PFAS Environmental Sampling

People can be exposed to PFAS through both drinking water and non-drinking water sources. In 2022, ATSDR and the Environmental Protection Agency (EPA) will investigate the potential for human exposure to PFAS from environmental sources other than drinking water. ATSDR will evaluate potential PFAS exposure inside the home by collecting samples from indoor air, indoor dust, and wet wipes for analyses. ATSDR also will evaluate potential exposure to PFAS from outdoor sources by sampling soil at residences and outdoor air in the community. In addition, participants will wear a silicone wristband that will be analyzed for any PFAS exposure the person might encounter during daily activities. Samples of locally grown produce also will be analyzed to evaluate PFAS concentrations that might contribute to dietary exposure.

The PFAS environmental sampling will occur at two PFAS EA sites, Hampden County, Massachusetts, and New Castle County, Delaware. Households who participated in these two EAs will be invited to participate in the environmental sampling. ATSDR anticipates recruiting approximately 30% of households from each EA, for a total of 80 households from Hampden County and 40 households from New Castle County.

What are PFAS?

PFAS are manufactured chemicals that have been used since the 1940s. Some products, such as food packaging materials, water- and stain-repellent fabrics and carpets, firefighting foam, and some cosmetics, may still contain PFAS. PFAS are a public health concern because they can stay in people's bodies for a long time and have been linked to harmful health effects in humans.

2022 will be a year of strategic alignment for ATSDR data. In collaboration with CDC, ATSDR is focused on solidifying and advancing its data strategy toward a new future state of connected, adaptable, and sustainable response ready systems and data that help to more effectively and efficiently respond to the evolving public health needs related to environmental contaminants.

The Camp Lejeune Cancer Incidence Study is one of the largest studies of this type conducted in the United States. The study uses data linkages with state and federal cancer registries — a process of matching information from different sources about the same person to form a new dataset ― to obtain individual-level cancer information.

The Camp Lejeune Cancer Incidence Study includes a total of 536,601 Marines, Navy personnel, and civilian workers. Those include Marines and Navy personnel who were stationed at U.S. Marine Corps Base Camp Lejeune, New River Air Station adjacent to Camp Lejeune, or Camp Pendleton at any time from April 1975 through September 1987. The civilian workers include those who worked at Camp Lejeune or Camp Pendleton at any time from October 1972 through December 1987.

This is one of the largest cancer incidence studies conducted in the United States, using data linkages from cancer registries in all 50 states, the District of Columbia, Puerto Rico, the Pacific Islands, and the U.S. Department of Veterans Affairs.

From the 1950s through the mid-1980s, drinking water at Camp Lejeune in North Carolina was contaminated with trichloroethylene, tetrachloroethylene, vinyl chloride, and benzene. The contaminants were in drinking water of family housing, barracks, officers' quarters, and non-residential buildings on the base. The heavily contaminated drinking water supply wells were shut down by February 1985.

In 2014, ATSDR initiated a retrospective cohort cancer incidence study of Marines and civilian employees at Camp Lejeune. The study was designed to include comparison cohorts of Marines and civilian workers unexposed to contaminated drinking water who were stationed at Camp Pendleton. ATSDR convened an expert panel meeting in the summer of 2014 to help guide the process for carrying out the study. In addition to cancer incidence data, this study is also evaluating cause of death information. The purpose of this study is to follow up on the findings from a mortality study of Marines and civilian employees at Camp Lejeune that was published in 2014.

During 2015, ATSDR prepared a draft study protocol that was reviewed by an expert panel and four independent peer reviewers. In December 2015, the Camp Lejeune Cancer Incidence Study received approval from the CDC Institutional Review Board to proceed.

In 2016, work began to complete the approval process for each registry in the nation. After 4 years of dedicated effort, data linkages were conducted in the fall and winter of 2020–2021. After manual review to verify the data linkage matches, ATSDR received the cancer incidence data in the spring of 2021.

ATSDR is conducting extensive data analyses of the cancer incidence and mortality data for the cohorts of Marines and plans to draft reports of the cancer incidence study and mortality studies of the Marines and civilians.