University of Michigan School of Public Health Risk Science Center Blog

Mind the Scienge Gap: Beach Bums! Gastrointestinal Distress from Sand?

by Shara Evans on February 22, 2012

This article is Cross Posted from Mind the Science Gap. Under the guidance of the Risk Science Center’s director Andrew Maynard, for ten weeks between January and April 2012, Ten Masters of Public Health students from the University of Michigan will post weekly articles, translating complex sciences into accessible science communication for a broad audience.

Colleen Davis is a second-year Human Nutrition and Dietetics Masters of Public Health student at the University of Michigan, and she holds a B.S. degree in Biology from Hillsdale College. Her interests include all things nutrition–everything from clinical dietetics to food and nutrition policy.

Winter break officially starts next week, but my mind is already at the beach. I’m ready to relax by the water and trade in my textbooks for a stack of magazines. After reading this study, however, I’m inclined to keep my hands out of the sand.

A research study published in Epidemiology last month investigated the relationship between sand-contact activities and enteric illness. Enteric illness refers to intestinal infections acquired by contact with bacteria-contaminated sources such as food, or by contact with contaminated feces or vomit. The effects of enteric illness run on a continuum from mild gastrointestinal discomfort to severe GI complications and diarrheal disease that can cause death. The study in Epidemiology found a positive relationship between engaging in sand-contact activities and the development of enteric illness from pathogens associated with fecal contamination.

The impetus to conduct this research resulted from previous studies that confirmed the presence fecal matter and the associated enteric pathogens such as E. coli in beach sand. Water quality of beaches is a hot topic in research, but sand quality doesn’t receive as much attention. Since beach-goers are likely to spend time on, well, the beach, further research in this area was certainly justified.

The researchers analyzed data from the 2007 trials of the National Epidemiological and Environmental Assessment of Recreational Water Study, which took place at 2 recreational beach sites, one at Mobile Bay in Fairhope, Alabama and the other at Greenwich Bay in Warwick, Rhode Island. Beachgoers were questioned at each site as they left the waterfront about their sand-contact activities. They were asked to report all varieties of contact with sand, including digging and playing in the sand, swimming, building sandcastles, and being buried in the sand. Participants were also asked if they washed their hands before eating or drinking on the beach, and researchers inquired if beachgoers had consumed raw or undercooked food in the past three days. On the same day, researchers collected sand samples from each beach site (144 samples total) and tested for the presence of enteric pathogens known to cause gastrointestinal stress.

Ten to twelve days later, a member of each beach-going group was interviewed regarding his or her group’s gastrointestinal health after visiting the beach. Specifically, researchers asked the group representative if he or she or any of the members of the group experienced vomiting, diarrhea, cramps, or general gastrointestinal distress in the time following the beach outing. Participants were again asked about their consumption of raw or undercooked foods in the time since visiting the beach. A total of 4948 beachgoers fully participated in the research study.

The results? Playing in the sand could be hazardous to your health. A positive association was found between digging and being buried in the sand and enteric illness at both beach sites. Specifically, enteric-illness causing pathogens Enterococcus and Bacteroidales were found in the sand samples.

The results cast a small cloud over my upcoming beach getaway, but knowledge is power. The spread of enteric illness can be prevented by thorough hand-washing and sanitation practices that can easily be applied at the beach. I’ll toss a bar of soap into my beach bag and pass on the full-body sand application.

Tagged as: enteric illness, Exposure, Mind the Science Gap, Sand, sun, vacation

{ 0 comments }

RSC Member Shobita Parthasarathy’s Influential Book Now Out In Paperback

by Shara Evans on February 20, 2012

Shobita Parthasarathy is an Associate Professor at University of Michigan’s Ford School of Public Policy. She is also a member of the Risk Science Center and sits on our Internal Advisory Board. Dr. Parthasarathy is currently on sabbatical as a Visiting Scholar at the American Bar Foundation.

Building Genetic Medicine: Breast Cancer, Technology, and the Comparative Politics of Health Care.

Shobita Parthasarathy’s first book, which has influenced legal and policy debates about genetic testing and patenting, has been released in paperback by MIT Press. Building Genetic Medicine: Breast Cancer, Technology, and the Comparative Politics of Health Care compares the development of genetic testing for breast and ovarian cancer in the United States and the United Kingdom. It demonstrates how national approaches to health care, to patient advocacy, and to commercializing scientific work led to different understandings of risk and disease, the rights and responsibilities of users, and even the role of the test itself in the two countries.

The book’s findings have influenced an ongoing federal lawsuit by breast cancer patients, scientists, and physicians (led by the American Civil Liberties Union) against Myriad Genetics, the US company who owns the genes linked to breast and ovarian cancer (known as the BRCA genes). Based on the book, Parthasarathy submitted an expert declaration that disputed Myriad’s claim that it was the sole inventor of the BRCA genes. She also described Myriad Genetics’ aggressive strategy to use its patent rights to shut down other BRCA gene testing services in the United States, and the implications of the company’s eventual monopoly for users. In sum, the declaration disputed the idea that patents are necessary for research and development and that they are beneficial for society. In his March 2010 judgment against Myriad Genetics, NY District Court Robert Sweet cited Parthasarathy’s declaration extensively when he ruled that genes are “products of nature” and therefore unpatentable. While an appeals court overturned the decision, the Supreme Court is now considering the case. Parthasarathy has also testified about the book’s findings to the Secretary’s Advisory Committee on Genetics, Health, and Society (US Department of Health and Human Services), the Dutch Medical Biotechnology Commission, Austrian Genome Research Program, and individual staff members of the US Congress.

You can find the paperback version of Dr. Parthasarathy ‘s book on amazon here.

Tagged as: news, parthasarathy, publication, RSC members

{ 0 comments }

Mind the Science Gap: Why Don’t More Kids Get Flu Shots?

by Shara Evans on February 16, 2012

This article was written by Drew Heyding. Drew is an MPH student in the Epidemiology department, his background is clinical medicine, having practiced internal medicine at Harlem Hospital before coming to the University of Michigan for additional training in preventive medicine.

As a parent, I don’t look forward to long winters of runny noses and respiratory infections. I’ve come to terms with the fact that my kids are very skilled at picking up every cold and stomach bug going around. I know that when flu season comes around, they are vulnerable and so I make sure they get their vaccines.

The American Academy of Pediatrics and the Advisory Committee on Immunization Practices recommend that all children aged 6 months to 19 years receive the yearly seasonal flu vaccine. Yet less than half of American children in this age group have been vaccinated during each of the last two flu seasons. Why don’t more kids get the flu shot?

Katherine Harmon, an associate editor for Scientific American, covers some common misconceptions that result in vaccine hesitancy in her blog. Because parents and caregivers are typically responsible for decisions on their child’s vaccinations, it’s not surprising that the reasons adults and children don’t get flu shots are similar.

Let’s consider these misconceptions in the context of children and the flu vaccine:

* Flu shots are for older people, my kids are not in a high risk group

In fact, an average of 20,000 children under the age of 5 are hospitalized because of flu complications every year.

* It’s not serious, it’s just the flu

Between 2003-2004 and 2010-2011, pediatric deaths due to flu reported to the Centers for Disease Control and Prevention (CDC) ranged from 46 to 153 per year. During 2009-2010, when swine (H1N1) flu emerged, the number was even higher.

http://www.cdc.gov/flu/weekly/

* When my kids get the flu shot, they still get the flu

The flu (or influenza) is a contagious illness caused by a group of viruses. Flu can show up as a fever, cough, runny nose and sore throat. Vomiting and diarrhea can also occur and are more common in children. But kids with the flu may only have some of these symptoms, and to complicate matters we see these same symptoms in kids without the flu. So although it’s easy to think otherwise, most of the coughs, colds and GI bugs that come up every winter are not the flu.

* The flu shot will give my kids the flu

Flu vaccines given by injection (the classic flu shot) are made from killed virus. It is impossible to catch the flu from these inactivated virus vaccines. Older children may receive a nose spray vaccine that is made from a weakened virus. The severe symptoms caused by live flu cannot be caused by this type of live attenuated virus vaccine.

* There are dangerous ingredients in the flu shot

Thimerosal (a mercury–based preservative used in vaccines) is sometimes identified as a safety concern, in particular related to autism. No studies have found an association with autism, and no other significant side effects have been linked to thimerosal over decades of use. (In fact, as thimerosal use has decreased in the Unites States, autism rates have increased.) Flu vaccine side effects are rare and mild with the most common being pain and redness at the injection site, aches, and a low-grade fever.

These misconceptions make parents less likely to vaccinate their kids. In the case of the flu shot, it does appear that knowledge is power. One study of parents surveyed in a hospital ER and clinic found that vaccine acceptance was higher among those who:

were knowledgeable about flu symptoms in children
knew that flu in children can lead to hospitalization
knew that flu vaccine does not cause the flu

Vaccination rates in children are increasing but coverage rates of less than 50 percent leave a great deal of room for improvement. We need to do better. As reported by ABC News, a study of pediatric flu deaths in 2010 found that more than three quarters of the 115 children who died from flu were not vaccinated.

It’s not too late in the flu season to get your shot. A recent CDC update tells us that “while influenza activity in the United States remains relatively low for the week ending December 31, there are early indications in FluView that flu season may be getting underway”.

How can health care providers and parents work together to make sure that appropriate information is conveyed effectively? It seems unacceptable in our age of information that the straightforward facts on flu in kids should remain a mystery to those in control of vaccination choices.

Perhaps part of the problem is that there is so much information, a parent can’t sort out the good from the bad. A helpful place to start is the CDC, where step 1 to fighting the flu is getting a vaccine. And if your kids need a little extra motivation to visit the nurse or doctor, maybe, like my daughter, they’re partial to Sid the Science Kid.

Tagged as: children's health, influenza, Mind the Science, pediatrics, vaccination safety, vaccinations

{ 0 comments }

Mind the Science Gap: The Science Influencing the CDC Panel Recommendation for the HPV Vaccine for Boys

by Shara Evans on February 15, 2012

This article was written by Suzy OGawa, She is currently a second year at the University of Michigan School of Public Health in the Health Management and Policy department and will graduate in April 2012 with a Master in Health Services Administration. In June she will be moving to Grand Rapids to start an Administrative Fellowship with a regional health system.

————

In October 2011, a CDC Panel recommended that the HPV4 (Gardasil) vaccine be included in the course of vaccines (routine use) given to young men and boys starting as early as age 9 with full vaccination by age 11 or 12. This follows the Panel’s 2006 recommendation that girls aged 11 or 12 should receive the vaccine.

What is HPV?

Human Papillomavirus (HPV) is a prevalent sexually transmitted disease. There are 40 different strains of HPV that infect both men and women. Often people will contract HPV without ever knowing because HPV can be asymptomatic. This makes HPV easily transmittable, as those who are asymptomatic do not seek treatment and unknowingly pass it on to their sexual partners. Most people’s immune systems will get rid of HPV without any medical treatment, however, some HPV types can cause serious disease, including disfigurement and cancer.

Image: © Pasieka/Science Photo Library/Corbis Human papilloma virus (HPV), colored transmission electron micrograph (TEM).

The Problem

There is sufficient evidence to say that certain types of HPV (16, 18) show carcinogenicity in the cervix, vagina, vulva, anus, penis, oropharynx and oral cavity. There is also limited evidence showing carcinogenicity in the larynx and skin periungal. Other types of HPV have sufficient evidence for carcinogenicity in the cervix only. In 2007, 697,024 cases of HPV-related cancer in females were reported and 758,587 cases cancer were reported in males. 96% of cervical cancer, 64% of vaginal cancer, 51% of vulvar cancer and 93% of anal cancer is caused by HPV. The majority of these cancers are caused by HPV types 16 and 18. The following chart shows new cases of HPV-associated cancers between 2004 and 2007.

Estimate HPV and HPV 16/18-Associated Cancers, Both Sexes, 2004-2007
		Estimated
Site	Avg annual number of cases	HPV associated	HPV 16/18 associated
Cervix	11,845	11,370	9,000
Vagina	714	460	400
Vulva	3,062	1,560	1,350
Anus & Rectum (W)	2,977	2,770	2,590
Oropharynx (W)	2,306	1,450	1,380
Total (Females)	20,903	17,610	14,720
Penis	1,000	360	310
Anus & Rectum (M)	1,618	1,500	1,410
Oropharynx (M)	8,936	5,630	5,360
Total (Males)	11,553	7,490	7,080
*http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb11/11-2-hpv-rela-cancer.pdf

The HPV4 Vaccine (Gardasil)

In June of 2006, HPV4 (Gardasil) was recommended for girls aged 11 to 12. Gardasil is effective against HPV types 6, 11, 16 and 18 or the most prevalent strains of HPV that cause cancer. The recommendation was and is controversial mainly for two reasons. One, the vaccine is expensive. To be fully vaccinated, one must receive three shots at $130 a stick. Today, these shots are typically covered by both public and private insurance, however, back in 2006 they were out-of-pocket costs to the patient. The shots are to be given over a 6-month period prior to the patient becoming sexually active. This leads to the second controversy which is that young girls are receiving a vaccine to protect them against a sexually transmitted disease. The proponents of this controversy are those that want to keep sex and/or the discussion of sex away from their kids. Some have said, perhaps facetiously, that this vaccine will encourage kids to have sex and therefore it shouldn’t be given to young girls. Of course the argument against this is that the vaccine needs to be given before the girls are sexually active to ensure maximum efficacy. Other controversies have arisen, mostly due to inaccurate information, including the misunderstanding that the vaccine a mandate. It is a recommendation.

The HPV4 Vaccine for Boys

October of 2011 brought the impending recommendation of Gardasil for boys (11 or 12) and young men (13-21). HPV is linked to anal, penile and oropharyngeal cancers in males and is commonly asymptomatic in males allowing it to be unknowingly transmitted to their sexual partners. Gardasil was permissively recommended for boys in the prevention of genital warts (2009) and then for anal cancer (Dec, 2010). The current recommendation puts Gardasil in the routine recommended vaccine schedule for boys, and while genital warts and anal cancer were important considerations, the protection against the large amount of HPV-associated oral cancers was sufficient in itself to include it in the vaccine schedule.

The gap between the recommendation for girls and boys was a result of the initial human clinical study including only girls. The current recommendation is based on vaccine efficacy, vaccine safety, estimates of disease and cancer resulting from HPV, cost-effectiveness, and programmatic considerations. The Panel took into consideration the likely additional benefit that vaccinated males would have on females, given the reduced spread of the disease. However, they ultimately concluded that the prevalence of HPV-associated diseases in males was alone sufficient to recommend the vaccine.

The Science Behind The Recommendation

In a phase III efficacy trial, Gardasil had high efficacy for the prevention of genital warts (a main symptom of HPV and precancerous lesions) in 4,055 males ages 16-26. The study population was seronegative before the first dose, meaning the males had not come into contact with HPV. Gardasil was 89.3% effective for the prevention of HPV 6-, 11-, 16- and 18-related genital warts for those study participants who received all three vaccine doses. There was still a 68.1% efficacy for those with at least 1 dose, regardless of baseline serology. It is important to note that the study population, while serology was initially determined, does not note sexual activity between vaccine dosage and therefore the efficacy could be higher amongst those who are sexually inactive up through the third vaccine dose. Furthermore the immune response of the trial’s subjects showed high seroconversion for all four HPV types, or in other words the vaccine was causing an immune response.

The recommendation for both males and females said that the vaccine should be completed at age 11 or 12 in order to be effective. This age was determined based on the need for the vaccine to be administered prior to sexual exposure to HPV. The Panel determined that 11 or 12 predates most young male’s and female’s sexual activity.

Adverse events related to the HPV4 vaccine are mild or moderate and are mostly related to injection-site reactions. Headaches and fever were also common in the study population, however they were also common in the control group. And no, mental retardation is not an adverse effect of Gardasil.

Cost-effectiveness was determined to be $20,000-$40,000 per quality-adjusted life year (QALY) in the favorable scenario and $75,000 to >$250,000 per QALY in the less favorable scenario. This cost-effectiveness decreases as the age of vaccination increases. While no hard and fast $ per QALY number has been determined as a cutoff for any CDC recommendation, it is useful in understanding alternatives, for example, whether to recommend vaccination at age 11 or 18. The cost-effectiveness study concluded that the HPV vaccination might be cost-effective, particularly in populations with low female HPV vaccination coverage. However, they also concluded that the most efficient strategy would involve increasing female vaccination coverage, rather than instituting male vaccination programs. This conclusion, however, should not be viewed in isolation, as it only takes into account dollar values per QALY and does not include things such as equity.

The Panel concluded that the vaccination of men against HPV would directly reduce HPV-related cancers in males, and in conjunction with female HPV vaccinations would reduce HPV transmission, and therefore, through herd immunity, reduce cancers in females. Furthermore, they determined that the vaccine was potentially cost-effective, although it may not be those most monetarily efficient strategy.

*Edits were made and an image was removed after publishing.

References:

Ahmed F, Temte JL, Campos-Outcalt D, Schünemann HJ; ACIP Evidence Based Recommendations Work Group (EBRWG). Methods for developing evidence-based recommendations by the Advisory Committee on Immunization Practices (ACIP) of the U.S. Centers for Disease Control and Prevention (CDC). Vaccine 2011;29:9171–6.
CDC. FDA licensure of quadrivalent human papillomavirus vaccine (HPV4, Gardasil) for use in males and guidance from the Advisory Committee on Immunization Practices (ACIP). MMWR 2010;59:630–2.
Gillison ML, Chaturvedi AK, Lowy DR. HPV Prophylactic vaccines and the potential prevention of noncervical cancers in both men and women. Cancer 2008;113(10 Suppl):3036–46.
Hu D, Goldie S. The economic burden of noncervical human papillomavirus disease in the United States. Am J Obstet Gynecol 2008;198:500–7.
Kjaer SK, Sigurdsson K, Iversen OE, et al. A pooled analysis of continued prophylactic efficacy of quadrivalent human papillomavirus (types 6/11/16/18) vaccine against high-grade cervical and external genital lesions. Cancer Prev Res (Phila) 2009;2:868–78.
Ferris D. A long-term extension study of Gardasil in adolescents. O-18.05. Proceedings of the 27th International Papillomavirus Conference and Clinical Workshop, September 17–22, 2011, Berlin, Germany.
Gee J, Naleway A, Shui I, et al. Monitoring the safety of quadrivalent human papillomavirus vaccine: Findings from the Vaccine Safety Datalink. Vaccine 2011;29;8279–84.
Velicer C. Post-licensure safety study of quadrivalent human papillomavirus vaccine among 189,629 females. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Presentation before the Advisory Committee on Immunization Practices (ACIP), October 25, 2011. Available at http://www.cdc.gov/VACCINes/recs/acip/downloads/mtg-slides-oct11/03-HPV-CVelicer.pdf . Accessed November 21, 2011.
Brisson M, Van de Velde N, Boily MC. Economic evaluation of human papillomavirus vaccination in developed countries. Public Health Genomics 2009;12:343–51.
Kim JJ, Goldie SJ. Cost effectiveness analysis of including boys in a human papillomavirus vaccination programme in the United States. BMJ 2009;339:b3884.
Elbasha EH, Dasbach EJ. Impact of vaccinating boys and men against HPV in the United States. Vaccine 2010;28:6858–67.
Chesson HW, Ekwueme DU, Saraiya M, Dunne EF, Markowitz LE. The cost-effectiveness of male HPV vaccination in the United States. Vaccine 2011;29:8443–50.
Chesson HW. HPV vaccine cost-effectiveness: updates and review. Presentation before the Advisory Committee on Immunization Practices (ACIP), June 22, 2011. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-jun11/07-5-hpv-cost-effect.pdf . Accessed January 15, 2012.

Tagged as: Cancer, CDC Panel Recommendation, Controversy, HPV, HPV Vaccine, Human Papillomavirus, Mind the Science Gap, Sexually Transmitted Disease, STD, Vaccination, Vaccine

{ 0 comments }

Planned Parenthood (lowercase): The Cure for Poverty

by Mark Stewart on February 4, 2012

“There is a cure for poverty. It is a rudimentary one, it does work, though. It works everywhere, and for the same reason. It’s colloquially called ‘the empowerment of women.’ It’s the only thing that does work. If you allow women control over their cycle of reproduction, so that they are not chained by their husbands or by village custom to annual animal-type pregnancies, early death, disease, and so on. If you will free them from that, give them some basic health of that sort—and if you are generous enough to throw in, perhaps, a handful of seeds and a bit of credit—the whole floor, culturally, socially, medically, economically of that village will rise. It works every time.”

—Christopher Hitchens, in a debate with William Dembski at Prestonwood Baptist Church in Plano, Texas

This is not a political rant. This has nothing to do with religion or individual beliefs. This post has to do with science. By that, I mean what has humankind been able to learn about our universe and world, what can be demonstrated, what can be shown.

: 2007 Susan G. Komen St. Louise Race For The Cure. Source: WildChild1976. Used under CC

I have long been an admirer of Christopher Hitchens. However, as the Risk Science blog is focused on health issues, I could never think of a way to involve him in any of my posts. Furthermore, I was worried that his atheism, his political views, his opinions of various sacred cows, or his career as an iconoclast and contrarian would anger people causing them not to listen to what I had to say. But, I am now grateful that the recent conflict between the Susan G. Komen Foundation and Planned Parenthood allows me to quote him. I am also glad to have the opportunity to lay out some of my observations and conclusions that I have come to regarding various ills of our societies around the world. And, I now have the opportunity to demonstrate what humankind has learned about contraceptives and abortion.

“The cure for poverty around the world is the empowerment and emancipation of women.” If Christopher Hitchens’s word is not enough for you, even the United Nations feel that the empowerment of women is what leads to development. They have listed the empowerment of women as a necessity to reach their Millennium Development goals. And, in my time in the United States Peace Corps in Cameroon where I worked to combat HIV, I would agree wholeheartedly with their assessment. When women have control over their bodies and minds, when women are educated, the society benefits. Women are still the primary caregivers and early educators of their children. If they are able to determine “when” and “how many,” the next generation will be better cared for and better educated. And on and on the generations will pass. “When you teach women, you teach the nation.”

If this is still not enough to convince you, I have one more arrow in my quiver. In the middle of last month, a Lancet article was electronically published in advance of the journal publication. It was an examination of the last 15 years of abortion around the world. I would like to quote an excerpt from this article. It follows.

“We found that the proportion of women living under liberal abortion laws is inversely associated with the abortion rate in the sub-regions of the world. Other studies have found that abortion incidence is inversely associated with the level of contraceptive use, especially where fertility rates are holding steady, and there is a positive correlation between unmet need for contraception and abortion levels.”

In other words, what humankind has learned, what can be demonstrated, what can be shown, is that when abortion and contraception is legally available, abortions are less frequent and contraception is used more effectively. Furthermore, the researchers discovered something else. “Our findings show that the substantial decline in the abortion rate observed between 1995 and 2003 has tapered off, and the proportion of abortions that are unsafe has increased since 1995, such that nearly half of all abortions worldwide were unsafe in 2008.” They relate these findings to changes in laws around the world that make abortion illegal and contraceptives less easily available.

Thus, when contraceptives are available,the evidence suggests that abortions are less frequent, and the ones that do occur are carried out safely. The previous sentence could be one of the sentences of a mission statement of Planned Parenthood. And, oh by the way, according to Planned Parenthood’s Annual Report, 35% of their funding goes to contraceptives, and only 3% goes to abortion services. Also, Planned Parenthood offers health services to women with low incomes who often have no other sources for medical care, cancer and STD screenings, or reproductive services.

Thus, it seems the opponents of abortion who pressured the Susan G. Komen Foundation to sever its ties with Planned Parenthood ended up working towards increasing the number of abortions. Furthermore, as Susan G. Komen board members realized, cutting ties with Planned Parenthood leads to cutting ties with the health of poor women. Thankfully, advocates for women made a massive push to make sure this was understood. They were successful. The mistake was corrected. Thanks be to humankind.

Citations

Sedgh G, Singh S, Shah IH, Ahman E, Henshaw SK, Bankole A. Induced abortion: incidence and trends worldwide from 1995 to 2008. Lancet. 2012 Jan 18. (Epub ahead of print)

Planned Parenthood Annual Report

Tagged as: Abortion, Breast Cancer, Planned Parenhood, Susan G Komen, Women empowerment

{ 0 comments }

Infrasounds, Annoyance and Anecdotes: The Debate over Wind Turbine Safety

by Lindsay Ward on January 31, 2012

The controversy over adverse health effects from wind turbine installations is an interesting one: both sides of the debate present compelling scientific evidence in favor of their particular perspective on the issue. A recent entry on the New York Times’ Green blog describes metastudies carried out by the state EPA branches of Massachusetts and Oregon, both concluding that the weight of scientific evidence indicates that direct wind turbine-related illness events are insignificant at present and unlikely to present a substantial risk with their increasing installation.

This is in stark contrast to the ideas presented by the group Save Western NY, an organization comprised of residents of Wethersfeld, a small New York town, who believe that the proposed 67-70 wind turbines in their region will be detrimental to the town and its surroundings from economic, environmental, and health perspectives. Their website’s “Health Concerns” page primarily cites newspaper articles quoting local doctors who say they’ve seen an uptick in the mild neurological disturbances, headaches, palpitations and dizziness commonly seen in vibro-acoustic disease (VAD). VAD is most prevalent in occupational contexts such as construction, where workers are likely to use loud, vibrating tools such as jackhammers or sand-blasters for hours on end. While this sounds like anecdotal information that wouldn’t hold water in any serious scientific context, I’m more interested in exploring the different tactics taken by these two organizations (The New York Times’ blog and Save Western NY) in their attempts to inform the public about the risks of wind turbine farms.

Wind Turbine by Petr Kratochvil

A study published in Environmental Health in September of last year set out to examine the difference between scientific and popular depictions of the risks presented by wind turbines in the residential setting. The authors filtered thousands of results containing keywords like “wind turbines”, “health problem”, “annoyance”, and others into a pool of fifteen relevant pieces of peer-reviewed literature. At the same time, they identified half a dozen studies that are referenced the most often in popular contexts, all of which were carried out by individuals or groups with scientific credentials but never published in peer-reviewed contexts. These studies presented results in a more anecdotal way and were not likely to contain descriptive or regression-based statistics.

The authors of this meta-study found that both scientific and more anecdotal studies were very likely to describe problems of annoyance with the presence of wind turbines. However, a particularly interesting pattern notable in the scientific studies was that annoyance and self-reported health effects were more strongly correlated with subjective characteristics like opinions that wind turbines were ugly or intrusive, or in individuals who had high sensitivity to noise in the first place. Actual noise coming from the wind turbines didn’t relate as directly to these negative outcomes or opinions. Popular literature tended to strictly attribute increasing annoyance and behavioral or health effects to decreasing distance from the base of the turbines.

Taken together, this evidence indicates that proponents of wind-generated energy have an uphill battle to face: additional study on the exact health effects of infrasound and flickering from wind turbines is certainly necessary until clear relationships and consensus are reached. But even more importantly, campaigns touting this alternative source of energy have failed to win over the hearts of citizens in affected neighborhoods or regions. Until the public image of this new technology improves, logistical and political barriers will stand taller and more obnoxious than the turbines themselves.

References:

NYTimes Green blog: http://green.blogs.nytimes.com/2012/01/18/wind-turbines-and-health-hazards/

Save Western NY: http://www.savewesternny.org/health.html

Env Health paper: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3179699/?tool=pubmed

Image Credit: http://www.publicdomainpictures.net/view-image.php?image=137&picture=wind-turbine

Tagged as: Energy, Regulation, Risk Perception, wind turbines

{ 0 comments }

National Academy publishes new nanomaterials risk research strategy

by Andrew Maynard on January 26, 2012

Cross posted from 2020 Science

The US National Academy of Science today published its long-awaited Research Strategy for Environmental, Health, and Safety Aspects of Engineered Nanomaterials. I won’t comment extensively on the report as I was a member of the committee that wrote it. But I did want to highlight a number of aspects of it that I think are particularly noteworthy:

Great progress so far, but it’s time to change gears. Something we grappled with as a committee was what the value of yet another research strategy was going to be. After all, it wasn’t so long ago that the US federal government published a well received strategy of its own. A key driver behind our strategy was a sense that the past decade has been one of defining the challenges we face as the field of nanotechnology develops, while the next decade will require more focus as an ever greater number of nanotechnology-enabled products hit the market. In other words, from a research perspective it’s time to change gears, building on past work but focusing on rapidly emerging challenges.

Combining life cycle and value chain in a single framework for approaching nanomaterial risk research. As a committee, we spent considerable time developing a conceptual framework for approaching research addressing the health and environmental impacts of engineered nanomaterials. What we ended up using was a combination of value chain – ranging from raw materials to intermediate products to final products – and material/product life cycle at each stage of the value chain. This effectively allows risk hot spots to be identified at each point of a material and product’s development, use and disposal cycle.

Principles, not definitions. Rather than rely on a single definition of engineered nanomaterial to guide risk-related research, we incorporated a set of principles into our conceptual framework to help identify materials of concern from an environment, health and safety impact perspective. These build on the principles proposed by myself, Martin Philbert and David Warheit in a toxicology review published last year. From the National Academies report:

…the present committee focuses on a set of principles in lieu of definitions to help identify nanomaterials and associated processes on which research is needed to ensure the responsible development and use of the materials. The principles were adopted in part because of concern about the use of rigid definitions of ENMs that drive EHS research and risk-based decisions … The principles are technology-independent and can therefore be used as a long-term driver of nanomaterial risk research. They help in identifying materials that require closer scrutiny regarding risk irrespective of whether they are established, emerging, or experimental ENMs. The principles are built on three concepts: emergent risk, plausibility, and severity; …

Emergent risk, as described here, refers to the likelihood that a new material will cause harm in ways that are not apparent, assessable, or manageable with current risk-assessment and risk-management approaches. Examples of emergent risk include the ability of some nanoscale particles to penetrate to biologically relevant areas that are inaccessible to larger particles, the failure of some established toxicity assays to indicate accurately the hazard posed by some nanomaterials, scalable behavior that is not captured by conventional hazard assessments (such as behavior that scales with surface area, not mass), and the possibility of abrupt changes in the nature of material-biologic interactions associated with specific length scales. Identifying emergent risk depends on new research that assesses a novel material’s behavior and potential to cause harm.

Emergent risk is defined in terms of the potential of a material to cause harm in unanticipated or poorly understood ways rather than being based solely on its physical structure or physicochemical properties. Thus, it is not bound by rigid definitions of nanotechnology or nanomaterials. Instead, the principle of emergence enables ENMs that present unanticipated risks to human health and the environment to be distinguished from materials that probably do not. It also removes considerable confusion over how nanoscale atoms, molecules, and internal material structures should be considered from a risk perspective, by focusing on behavior rather than size.

Many of the ENMs of concern in recent years have shown a potential to lead to emergent risks and would be tagged under this principle and thus require further investigation. But the concept also allows more complex nanomaterials to be considered—those in the early stages of development or yet to be developed. These include active and self-assembling nanomaterials. The principle does raise the question of how “emergence” is identified, being by definition something that did not exist previously. However the committee recognized that in many cases it is possible to combine and to interpret existing data in ways that indicate the possible emergence of new risks. For example, some research has suggested that surface area is an important factor that affects the toxic potency of some ENMs; ENMs that have high specific surface area and are poorly soluble might pose an emergent risk.

Plausibility refers in qualitative terms to the science-based likelihood that a new material, product, or process will present a risk to humans or the environment. It combines the possible hazard associated with a material and the potential for exposure or release to occur. Plausibility also refers to the likelihood that a particular technology will be developed and commercialized and thus lead to emergent risks. For example, the self-replicating nanobots envisaged by some writers in the field of nanotechnology might legitimately be considered an emergent risk; if it occurs, the risk would lie outside the bounds of conventional risk assessment. But this scenario is not plausible, clearly lying more appropriately in the realm of science fiction than in science. The principle of plausibility can act as a crude but important filter to distinguish between speculative risks and credible risks.

The principle of severity refers to the extent and magnitude of harm that might result from a poorly managed nanomaterial. It also helps to capture the reduction in harm that may result from research on the identification, assessment, and management of emergent risk. The principle offers a qualitative reality check that helps to guard against extensive research efforts that are unlikely to have a substantial effect on human health or environmental protection. It also helps to ensure that research that has the potential to make an important difference is identified and supported.

Together, those three broad principles provide a basis for developing an informed strategy for selecting materials that have the greatest potential to present risks. They can be used to separate new materials that raise safety concerns from materials that, although they may be novel from an application perspective, do not present undetected, unexpected, or enhanced risks. They contribute to providing a framework for guiding a prioritized risk-research agenda. In this respect, the principles were used by the committee as it considered the pressing risk challenges presented by ENMs.

Maintaining current research and development funding levels. As a committee, we felt that the current US federal government of ~$120 million into environment, health and safety-specific nanotechnology research was reasonable, especially given the current economic climate. However, we did recommend that, as knowledge develops and commercialization of products using nanomaterials increases, funded research is aligned with areas and priorities identified within the strategy.

Developing cross-cutting activities. There were five areas where the committee felt that further funding was needed to ensure the value of nano-risk research was fully realized. Each of these cuts across areas of research, and provides the means to maximize the benefit of the science being supported. From the report:

Informatics: $5 million per year in new funding for the next 5 years should be used to support the development of robust informatics systems and tools for managing and using information on the EHS effects of ENMs. The committee concluded that developing robust and responsive informatics systems for ENM EHS information was critical to guiding future strategic research, and translating research into actionable intelligence. This includes maximizing the value of research that is EHS-relevant but not necessarily EHS-specific, such as studies conducted during the development of new therapeutics. Based on experiences from other areas of research, investment in informatics of the order of $15 million is needed to make substantial progress in a complex and data rich field. However, within the constraints of nanotechnology R&D, the committee concluded that the modest investment proposed would at least allow initial informatics systems to be developed and facilitate planning for the long-term.

Instrumentation: $10 million per year in new funding for the next 5 years should be invested in translating existing measurement and characterization techniques into platforms that are accessible and relevant to EHS research and in developing new EHS- specific measurement and characterization techniques for assessing ENMs under a variety of conditions. The committee recognized that the proposed budget is insufficient for substantial research into developing new nanoscale characterization techniques— especially considering the cost of high-end instruments such as analytic electron microscopes—in excess of $2 million per instrument. However, the proposed budget was considered adequate to support the translation of techniques developed or deployed in other fields for the EHS characterization of ENMs.

Materials: Investment is needed in developing benchmark ENMs over the next 5 years, a long-standing need that has attracted little funding to date. The scope of funding needed depends in part on the development of public-private partnerships. However, to assure that funding is available to address this critical gap, the committee recommends that $3-5 million per year be invested initially in developing and distributing benchmark ENMs. While more funds could be expended on developing a library of materials, this amount will assure that the most critically needed materials are developed. These materials will enable systematic investigation of their behavior and mechanisms of action in environmental and biologic systems. The availability of such materials will allow benchmarking of studies among research groups and research activities. The committee further recommends that activities around materials development be supported by public- private partnerships. Such partnerships would also help to assure that relevant materials are being assessed.

Sources: $2 million per year in new funding for the next 5 years should be invested in characterizing sources of ENM release and exposure throughout the value chain and life cycle of products. The committee considered that this was both an adequate and reasonable budget to support a comprehensive inventory of ENM sources.

Networks: $2 million per year in new funding for the next 5 years should be invested in developing integrated researcher and stakeholder networks that facilitate the sharing of information and the translation of knowledge to effective use. The networks should allow participation of representatives of industry and international research programs and are a needed complement to the informatics infrastructure. They would also facilitate dialogue around the development of a dynamic library of materials. The committee concluded that research and stakeholder networks are critical to realizing the value of federally funded ENM EHS research and considered this to be an area where a relatively small amount of additional funding would have a high impact—both in the development of research strategies and in the translation and use of research findings. Given the current absence of such networks, the proposed budget was considered adequate.

Authority and accountability. In our report, we talk quite a bit about the need for an entity within the federal government to take the lead in implementing a risk research strategy. While the US National Nanotechnology Initiative have done a great job coordinating interagency activities, we felt that there is only so far coordination without authority can go if socially and economically important research is to be conducted in a timely and relevant manner. What this “entity” might look like – we left that to the federal government to chew over.

There’s a lot more to the report – including (as you would expect) a broad assessment of research areas that need attention if the science of nanomaterial human health and environmental impacts is to continue to develop effectively.

This is the first of two reports- the second is due in around 18 months, and will look at progress toward implementing a relevant and effective research strategy.

The National Academies report “A Research Strategy for Environmental, Health, and Safety Aspects of Engineered Nanomaterials” can be downloaded here.

{ 1 comment }

Mind the Science Gap – Helping science students connect with a non-science audience

by Andrew Maynard on January 21, 2012

Cross-posted from the Scientific American Incubator blog:

Studying for a Masters degree in Public Health prepares you for many things. But it doesn’t necessarily give you hands-on experience of how to take complex information and translate it into something others can understand and use. Yet as an increasing array of public health issues hit the headlines, from fungicide residues in orange juice to the safe development of new technologies, this is exactly where public health professionals need to be developing their skills. And it’s not only in the public domain: the ability to translate complex science into actionable intelligence is more important now than ever in supporting policy makers and business leaders make decisions that are grounded in evidence rather than speculation.

These were just some of the drivers behind a new course I have just started teaching at the University of Michigan School of Public Health that built around science blogging. OK, so maybe I wanted to have a little fun with the students as well. But my experiences with the blog 2020 Science have taught me that the discipline of writing a science-based blog for a broad audience is invaluable for developing highly transferrable communication skills. And it’s not just me. Emailing with the scientist, author and blogger Sheryl Kirshenbaum about the course, she admitted “blogging taught me how to effectively communicate with broad audiences”. (Sheryl also added that she’s also learned a great deal from many wonderful editors – to which I can only add “me too!”).

The new course throws ten Masters of Public Health students in at the deep end by challenging each of them to publish ten posts over ten weeks on the blog Mind The Science Gap – and to respond to the comments they receive. As this is a science blog, each post will be based around published health-related research. The challenge for the writers will be to translate this into a science-grounded piece that is relevant and accessible to a broad audience.

The key objective here is to develop new skills through experience. And for this, I am encouraging as many people as possible to comment on the posts. As any science blogger will tell you, even simple comments like “I liked this” or “this was confusing” are extremely helpful in understanding what works and what doesn’t. But I am also hoping readers will look beyond the educational aspects of the exercise, and engage with the students on the subjects they are writing about. This is where I suspect the experience will become most empowering.

There’s another aspect of the course that intrigues me. Rather naively, I started this exercise imagining a series of impersonal posts that focused on intellectually interesting but emotionally ambivalent scientific studies. What I forgot is that public health matters to people. And so it’s going to be tough for our bloggers to separate what they write about from their passions – and those of their readers. In fact I’m not even sure that such a separation would be appropriate – for communication to be relevant, it needs to go beyond the numbers. But how do you effectively combine science with a desire to make the world a better place in a blog? I try to achieve this on my own blog, but I must admit don’t have any easy answers here. So as the Mind The Science Gap students develop their skills, I’m going to be doing some learning of my own as I watch how they respond to this particular challenge.

At the end of the day, Mind The Science Gap is about teaching the next generation of public health professionals how to connect more effectively with non-specialist and non-technical audiences – whether they are managers, clients, policy makers or members of the public. It isn’t about creating a new wave of science bloggers. But in the process, I like to think that some of the participants will get the blogging bug. Whether they do or not, I’m looking forward to ten weeks of engaging, entertaining and hopefully challenging posts from ten talented students.

Tagged as: Mind the Science Gap

{ 1 comment }

Identification of Environmental Survival Factors For A. baumannii and Risk Assessment of Exposure

by Shara Evans on January 19, 2012

The following post is by Christine Greene, one of our 2011 Risk Science Fellows, Christine has an MPH and is a Doctoral Pre-candidate in the Department of Environmental Health Science. You can read the abstract of her research project here.

Most people have not heard of Acinetobacter baumannii. A. baumannii is an emerging nosocomial pathogen that has developed resistance to most antibiotics. It is historically an environmental pathogen that has found a way to establish itself in the hospital environment, becoming an opportunistic human pathogen over the past 10 or so years. This multi-drug resistant (MDR) microorganism is now endemic in most hospitals around the globe.

It sounds scary, but the truth is, it is largely pathogenic only in those who are critically ill with a high morbidity/mortality rate largely within this population of people. By critically ill, I am referring to those who have certain risk factors such as longer intensive care unit (ICU) hospitalization, having ventilator-associated pneumonia or use invasive medical devices, neutropenia (low neutrophil counts in the blood), immunosuppression and chronic disease that make them easy targets for this opportunistic pathogen. Therefore, for most of us, we don’t have too much to worry about at this moment.

My research is concerned with how this pathogen, A. baumannii, is able to survive in the hospital environment in the first place. Having a long history of being a microbe of the environment, it is able to cleverly escape our tightest infection control practices. We know that this particular genus is capable of forming biofilms. Since biofilms provide a protective environment within which the bacteria can thrive, I suspect that biofilm formation is one of the reasons why A. baumannii can survive in the hospital despite the use of antiseptics and strict infection control regimens. To investigate the environmental survival of A. baumannii, my research involves testing the ability for this pathogen to grow and persist on various hospital surfaces such as stainless steel, ceramic and plastics as well as the effectiveness of commonly used hospital disinfectants in biofilm removal. Ultimately, biofilm formation capacity, surface type, duration of survival and resistance patterns along with other important data will be used to construct a mathematical model to evaluate the transmission of A. baumannii in hospitals and to assess exposure risk to patients in this environment. I also expect that this study will provide the data needed to develop appropriate infection control procedures that are more focused and strategic for targeting A. baumannii, thus reducing exposure and providing a more cost-effective method of control. Last, but not least, this study would bring more attention to environmental risks in infection transmission and control.

The Risk Science Center summer research fellowship provided me the opportunity to get started with this research as early as the second semester of my PhD program and I was able to make efficient use of my time during the duration of the fellowship. Moreover, having received this award and having begun the research, I found I was well positioned to receive future fellowships. In fact, I was awarded the Fall 2011 IPID Training Grant through the Department of Epidemiology which will provide the means for me to continue my work. I am very grateful to the Risk Science Center for seeing the value of my proposal and for giving me the opportunity and help I needed to get started with this research. Thank you UMRSC!!

Tagged as: Biofilms, hospitals, infection control, Nosocomial infections, RSC Fellows, transmission

{ 1 comment }

Going to Pot: A dangerous concoction of science journals, media and publicity

by Mark Stewart on January 13, 2012

Since the cold of the winter months have come upon us once again (Every year?), I have been inundated with the second-hand marijuana smoke of my neighbor. Let me try to explain. The house where I live has a forced-air central heating system through which all of the apartments are connected. I have returned to my home sanctuary on several occasions to a diaphanous zephyr of cannabis permeating everything. I don’t know what kind of clambake (Do people still use this term? I lived in Co-op houses in Ann Arbor in the late 1990s, so it may be passé now.) session he was undergoing, but the amount of smoke in my apartment was extreme. After at least four sessions of this, I left a note on his door. I do not fear confrontations, but I have found in my life experiences with people who are high (I lived in Co-op houses in Ann Arbor!) that they are not the best negotiators.

Regardless, the gaseous assaults of chemical warfare on my home and body soon stopped. But, it turns out I needn’t have worried. Apparently, according to a new study published in the Journal of the American Medical Association, marijuana smoking does not have a negative effect on lung function. Or, at least that is was the blogosphere is telling me.

What? How can this be? We have been told for years of the dangers of marijuana smoking. That it harms the lungs as tobacco does. That the only reason it isn’t quite as bad is that tobacco smokers smoke 20+ cigarettes a day, whereas marijuana smokers might light a bowl or bong a couple of times a week. This is what we have been told. Have we been lied to again?

As you might expect, the blogosphere has been buzzing with new posts. Most of the reports have titles like, “Pot Smoking Better for Your Lungs than Cigarettes: Study Finds.” But at least one, on the august New York Times Blog, has the title “Marijuana Smoking Does Not Harm Lungs, Study Finds.” Oh, dear. Please allow me to offer my expertise in reading science journals to elucidate what the report actually claims to have demonstrated and/or discovered.

The study, a twenty-year longitudinal analysis of more than 5000 study participants, focused on only two components of lung function: forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1). FVC is the volume of air that one can forcibly blow out after a full inspiration. FEV1 is the volume of air that one can forcibly blow out in one second after a full inspiration. These measures give an indication of the strength and flexibility of the lungs in conjunction with the diaphragm. They are statistics of lung function, used commonly in asthma and cystic fibrosis patients. In other words, they are something that we can measure that gives us an idea about a certain aspect of how a person’s lungs are functioning. These are two components of a field focused on the “measurement of breath” known as spirometry.

The study, however, does not claim that no lung damage occurs through the smoking of marijuana. “Prior studies of marijuana smokers have demonstrated consistent evidence of airway mucosal injury and inflammation as well as increase respiratory symptoms such as cough, phlegm production, and wheeze, similar to that seen in tobacco smokers.” Furthermore, according to the study, the results they found regarding FVC and FEV1 (no change or slight improvement) actually decrease beyond seven “joint-years” (one joint or bowl a day for seven years). That is, long-term and/or high level chronic use of marijuana does diminish the lungs’ ability to hold and expel air. This means that if you smoked pot a few times a week back in college, you do not need to worry about FVC or FEV1 (if you were worried before). If, however, you have been smoking a joint or two a day since the 1960s, you might have a reason for why it seems really hard to climb stairs or blow up your granddaughter’s party balloons.

In the end, however, there are a lot more effects of smoking marijuana than just lung elasticity. The most important ones might be in cognition, memory, ambition, and sex drive, rather than in lung damage. If you are curious, the National Institutes of Health lists many of the known effects of marijuana smoking. Personally, I enjoy my lungs, breathing, my abilities in cognition and memory, and sex. I enjoy them more than getting high. If others make a different decision, that is their business. Please, just make sure to crack a window.

Citations

Pletcher MJ, Vittinghoff E, Kalhan R, Richman J, Safford M, Sidney M, Sidney S, Lin F, Kertesz S. Association between marijuana exposure and pulmonary function over 20 years. JAMA. 2012 Jan 11; 307(2): 173-81.

The cannabis leaf image was taken from American Medical Marijuana Society website.

{ 0 comments }

Fungicides in orange juice – quick facts

January 12, 2012

On December 28, the US Food and Drug Administration learned that a juice company had detected very low levels of the pesticide carbendazim in some of its products – specifically orange juice concentrate – and those of its competitors. While both FDA and the US Environmental Protection Agency have stressed that the reported levels do [...]

Read the full article →

2012 World Economic Forum Global Risk Report and its relevance to public health

January 11, 2012

The World Economic Forum Global Risks Report is one of the most authoritative annual assessments of emerging issues surrounding risk currently produced. Now in its seventh edition, the 2012 report launched today draws on over 460 experts* from industry, government, academia and civil society to provide insight into 50 global risks across five categories, within [...]

Read the full article →

Scientific Triumph Meets Political Nightmare: H5N1 Raises Issues of Fear and Free Speech

January 10, 2012

As 2011 drew to a close, controversy was brewing in the offices of some of the most prominent scientific journals in the field: both Science and Nature received manuscripts in the last quarter of the year describing research on the highly-pathogenic influenza virus A subtype H5N1. This virus is historically very highly lethal, but barely transmitted [...]

Read the full article →

2012 Risk Science Summer Fellows announced

January 9, 2012

Each year the University of Michigan Risk Science Center awards a small number of fellowships to support research students in their research over the summer. This year the standard of the applications was exceptionally high – the highest I’ve seen. It was exciting to see such a high caliber of risk-related research amongst School of [...]

Read the full article →

A decade after anthrax, scary white powders still arrive by mail

January 7, 2012

Five people died in the anthrax mailings of 2001. Since then, anyone receiving mail containing white powder, or a “suspicious package” of any kind, is automatically on high alert. At the Florida state attorney’s office in West Palm Beach on Wednesday, three employees felt ill after an envelope in the mailroom released a white powdery [...]

Read the full article →

Spare a comment – student science writers need your help!

January 5, 2012

In a little over a week, ten of my University of Michigan Masters of Public Health students will embark on an intensive science blogging course – and they need your help! Every week for ten weeks, each student will take a recent scientific publication or emerging area of scientific interest, and write a public blog [...]

Read the full article →

The Quiet Emergency of Hazardous Medical Waste in Developing Countries

December 24, 2011

This past semester, I set my second year Masters of Public Health students a deceptively simple task: Write an opinion piece for a lay audience on a topic related to environmental health sciences and public health. Deceptive, as anyone who has attempted to write an op ed will tell you, it’s fiendishly difficult to find [...]

Read the full article →

Other People’s Children – How Scientific Illiteracy and Political Maneuvering are Hurting the Globe, Public Health, and You

December 24, 2011

Read the full article →

Noise: New risks; old hazards?

December 22, 2011

Much of the attention of the Risk Science Center faculty is focused, appropriately, on new and emerging technologies and their potential impacts on human health. However, as important and intriguing as these emerging issues are, it’s important to acknowledge that there are many existing hazards that we have known about for years, decades, and even [...]

Read the full article →