This chapter provides an overview of the legal issues relating to public health surveillance. It discusses the general legal authorities for public health surveillance set forth in constitutional, statutory, and regulatory laws; legal milestones in the evolution of public health surveillance and disease control in the United States; and legal issues related to the collection, analysis, and dissemination of surveillance data for public health practice and research activities. In addition, the chapter presents information about new surveillance challenges beyond traditional infectious disease models, including the influence of bioterrorism preparedness on surveillance activities.

National fish consumption advisories that are based solely on assessment of risk of exposure to contaminants without consideration of consumption benefits result in overly restrictive advice that discourages eating fish even in areas where such advice is unwarranted. In fact, generic fish advisories may have adverse public health consequences because of decreased fish consumption and substitution of foods that are less healthy. Public health is on the threshold of a new era for determining actual exposures to environmental contaminants, owing to technological advances in analytical chemistry. It is now possible to target fish consumption advice to specific at-risk populations by evaluating individual contaminant exposures and health risk factors. Because of the current epidemic of nutritionally linked disease, such as obesity, diabetes, and cardiovascular disease, general recommendations for limiting fish consumption are ill conceived and potentially dangerous.

Vol. 113, No. 10 PerspectivesOpen AccessRisk-Based Consumption of Dioxin-Contaminated Farmed Salmon John P. Middaugh, Scott M. Arnold, and Lori A. Verbrugge John P. Middaugh Alaska Division of Public Health, Anchorage, Alaska, E-mail: Search for more papers by this author Email the corresponding author at [email protected] , Scott M. Arnold Alaska Division of Public Health, Anchorage, Alaska, E-mail: Search for more papers by this author Email the corresponding author at [email protected] , and Lori A. Verbrugge Alaska Division of Public Health, Anchorage, Alaska, E-mail: Search for more papers by this author Email the corresponding author at [email protected] Published:1 October 2005https://doi.org/10.1289/ehp.113-a655Cited by:1AboutSectionsPDF ToolsDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InReddit In their article, “Risk-Based Consumption Advice for Farmed Atlantic and Wild Pacific Salmon Contaminated with Dioxins and Dioxin-like Compounds,” Foran et al. (2005) present recommendations for consumption of salmon containing dioxin-like compounds (DLCs) based on three risk assessment approaches.Relying strictly on risk assessment to develop fish consumption advice has many shortcomings and may actually do more harm than good (Arnold et al. 2005; Egeland and Middaugh 1997). Risk assessment is only part of the risk management process when developing fish consumption advice [U.S. Environmental Protection Agency (EPA) 1996]. Other factors need to be considered when developing fish consumption advice, such as the nutritional and health benefits of consuming fish and the cultural, societal, and economic impacts of reduced fish consumption (U.S. EPA 1996). Ignoring these factors may place an undue burden on a local population by removing a relatively inexpensive protein source that would likely be replaced by a less healthy substitute (Arnold et al. 2005; Egeland and Middaugh 1997). Decisions to limit fish consumption should only be made at the local level because local public health officials are most aware of the local aforementioned impacts and the actual concentration of contaminants in locally caught fish [Arctic Monitoring and Assessment Programme (AMAP) 2002; Arnold et al. 2005; Hites et al. 2004].In addition to measuring contaminant concentrations in fish, human biomonitoring is a very useful tool to measure actual levels of contaminant exposure in targeted “at-risk” populations rather than relying solely on calculated estimates of exposure. Biomonitoring should ideally be performed in any identified at-risk population to verify that a problem actually exists before advising people to reduce fish consumption. This is especially true in populations that rely on locally caught fish as their primary protein source and that have few inexpensive healthy alternatives. Fortunately, recent evidence suggests that the average concentration of DLCs in the general U.S. population is declining (U.S. EPA 2000).Two aspects of this study’s (Foran et al. 2005) methodology are problematic because they lead to inappropriately conservative estimates of health risk. First, the majority of people in the United States do not eat salmon skin, and as the authors noted, cooking has been shown to reduce DLCs in fish tissue. Because DLCs partition to fatty tissues including skin, measuring DLCs in raw fish with the skin on will overestimate the amount of exposure to DLCs and overestimate the consumption risks. Second, when assessing health risks posed by salmon consumption, Foran et al. (2005) estimated the number of meals of salmon per month that would limit dioxin intake to 20% above the U.S. average “background” adult intake level of 65 pg toxic equivalents (TEQ)/day. This approach ignores the fact that the background rate incorporates both freshwater and saltwater fish consumption (U.S. EPA 2000). In effect, Foran et al. (2005) double counted dioxin exposure through fish consumption. They also ignored the fact that a person who chooses not to consume a salmon meal would likely substitute another protein source that also contains trace quantities of DLCs.ReferencesArctic Monitoring and Assessment Programme (AMAP) 2002. Arctic Pollution 2002. Oslo, Norway:Arctic Monitoring and Assessment Programme. Available: http://www.amap.no./ [accessed 18 May 2005]. Google ScholarArnold SM, Lynn TV, Verbrugge LA, Middaugh JP. 2005. Human biomonitoring to optimize fish consumption advice: reducing uncertainty when evaluating benefits and risks. Am J Public Health 95(3):393-39715727965. Crossref, Medline, Google ScholarEgeland GM, Middaugh JP. 1997. Balancing fish consumption benefits with mercury exposure. Science 278:1904-19059417640. Crossref, Medline, Google ScholarForan JA, Carpenter DO, Hamilton MC, Knuth BA, Schwager SJ. 2005. Risk-based consumption advice for farmed Atlantic and wild Pacific salmon contaminated with dioxins and dioxin-like compounds. Environ Health Perspect 113:552-55615866762. Link, Google ScholarHites RA, Foran JA, Carpenter DO, Hamilton MC, Knuth BA, Schwager SJ. 2004. Global assessment of organic contaminants in farmed salmon. Science 303:226-22914716013. Crossref, Medline, Google ScholarU.S. EPA 1996. Guidance for assessing chemical contaminant data for use in fish advisories. Volume 3. Overview of risk management. Washington, DC:U.S. Environmental Protection Agency. Available: http://www.epa.gov/ost/fishadvice/vol3/doc3ndx.html [accessed 18 May 2005]. Google ScholarU.S. EPA 2000. Draft Dioxin Reassessment. Washington, DC:U.S. Environmental Protection Agency. Available: http://cfpub.epa.gov/ncea/cfm/part3.cfm?ActType=default [accessed 18 May 2005]. Google ScholarFiguresReferencesRelatedDetailsCited by Halldorsson T (2012) Dietary Exposures to Persistent Organic Pollutants and Fetal Growth Handbook of Growth and Growth Monitoring in Health and Disease, 10.1007/978-1-4419-1795-9_152, (2559-2578), . Vol. 113, No. 10 October 2005Metrics About Article Metrics Publication History Originally published1 October 2005Published in print1 October 2005 Financial disclosuresPDF download License information EHP is an open-access journal published with support from the National Institute of Environmental Health Sciences, National Institutes of Health. All content is public domain unless otherwise noted. Note to readers with disabilities EHP strives to ensure that all journal content is accessible to all readers. However, some figures and Supplemental Material published in EHP articles may not conform to 508 standards due to the complexity of the information being presented. 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BACKGROUNDVibrio parahaemolyticus, the leading cause of seafood-associated gastroenteritis in the United States, typically is associated with the consumption of raw oysters gathered from warm-water estuaries. We describe a recognized outbreak of V. parahaemolyticus infection associated with the consumption of seafood from Alaska.METHODSAfter we received reports of the occurrence of gastroenteritis on a cruise ship, we conducted a retrospective cohort study among passengers, as well as active surveillance throughout Alaska to identify additional cases, and an environmental study to identify sources of V. parahaemolyticus and contributors to the outbreak.RESULTSOf 189 passengers, 132 ( 70 percent) were interviewed; 22 of the interviewees ( 17 percent) met our case definition of gastroenteritis. In our multiple logistic-regression analysis, consumption of raw oysters was the only significant predictor of illness; the attack rate among people who consumed oysters was 29 percent. Active surveillance identified a total of 62 patients with gastroenteritis. V. parahaemolyticus serotype O6: K18 was isolated from the majority of patients tested and from environmental samples of oysters. Patterns on pulsed-field gel electrophoresis were highly related across clinical and oyster isolates. All oysters associated with the outbreak were harvested when mean daily water temperatures exceeded 15.0 degrees C ( the theorized threshold for the risk of V. parahaemolyticus illness from the consumption of raw oysters). Since 1997, mean water temperatures in July and August at the implicated oyster farm increased 0.21 degrees C per year (P< 0.001 by linear regression); 2004 was the only year during which mean daily temperatures in July and August at the shellfish farm did not drop below 15.0 degrees C.CONCLUSIONSThis investigation extends by 1000 km the northernmost documented source of oysters that caused illness due to V. parahaemolyticus. Rising temperatures of ocean water seem to have contributed to one of the largest known outbreaks of V. parahaemolyticus in the United States.

A measles outbreak occurred among a highly vaccinated population in Alaska during 1998, providing an opportunity to determine the incremental efficacy of >or=2 doses of measles-containing vaccine (MCV) compared with 1 dose. Of 33 confirmed case patients identified, 31 had been vaccinated with 1 dose of MCV, 1 had received 2 doses, and vaccination status was unknown in 1 case. Seventy percent of cases were school-associated; 58% of cases occurred in 2 high schools. Of 3679 students attending the 2 schools, 50.4% and 45.5% had received >or=2 doses of MCV before measles introduction at the schools. The relative risk of developing measles among persons vaccinated with >or=2 doses of MCV compared with 1 dose was 0.06 (95% confidence interval, 0.01-0.44; P<.001), yielding an estimated incremental vaccine efficacy of 94.1% (95% confidence interval, 55.9%-99.2%; P<.001). Rapid implementation of a mandatory second-dose MCV requirement probably limited the extent of this outbreak.

We report an outbreak of botulism that occurred in July 2002 in a group of 12 Alaskan Yu'pik Eskimos who ate blubber and skin from a beached beluga whale. Botulism death rates among Alaska Natives have declined in the last 20 years, yet incidence has increased.

We document an echovirus 18 meningitis outbreak occurring at a remote overnight children's camp in Alaska. The outbreak involved 26% of 113 camp residents, was associated with building overcrowding and occurred in a camp with a contaminated drinking water source. Lack of specific children's camp regulations and failure to implement and enforce existing regulations may have contributed to the outbreak.

Considerable interest exists in characterizing the extent of changes in methylmercury exposures from preindustrial to modern-day times. Hair is often preserved over centuries and has been useful in determining the extent of dietary trace metal exposures, particularly methylmercury. We examined 16 human hair samples taken from human hair bundles buried in the soil of the Karluk One Archaeological site located near the current Karluk village on the Kodiak Archipelago of Alaska. Hair samples were analyzed for total mercury, methylmercury, selenium, and cadmium. The mean total mercury level was 1.33 ppm (SD = 1.09). The mean methylmercury level, however, was considerably lower than the total mercury concentration: the mean methylmercury level was 0.03 ppm (SD = 0.02). The mean cadmium level was 0.15 ppm (SD = 0.14) and the mean selenium level was 5.22 ppm (SD = 5.73). While the concentration of total mercury in the Karluk hair samples is comparable to those observed in ancient hair from other locations, direct methylmercury quantization demonstrated that methylmercury levels were less than 2% of the total mercury in these hair samples. Because the hair was subjected to a variety of environmental influences over the centuries, the possibility of degradation of methylmercury in the hair over the last 400 to 800 years cannot be ruled out. The use of hair from remains found in more protected frozen or dry environments may provide the best evidence for the extent of preindustrial exposures to methylmercury and other trace metals.

OBJECTIVES: The prevalence and characteristics of fetal alcohol syndrome cases and the usefulness of various data sources in surveillance were examined in Alaska to guide prevention and future surveillance efforts. METHODS: Sixteen data sources in Alaska were used to identify children with fetal alcohol syndrome. Medical charts were reviewed to verify cases, and records were reviewed to provide descriptive data. RESULTS: Fetal alcohol syndrome rates varied markedly by birth year and race, with the highest prevalence (4.1 per 1000 live births) found among Alaska Natives born between 1985 and 1988. Screening and referral programs to diagnostic clinics identified 70% of all recorded cases. The intervention program for children 0 to 3 years of age detected 29% of age-appropriate cases, and Medicaid data identified 11% of all cases; birth certificates detected only 9% of the age-appropriate cases. CONCLUSIONS: Our findings indicate a high prevalence of fetal alcohol syndrome in Alaska and illustrate that reliance on any one data source would lead to underestimates of the extent of fetal alcohol syndrome in a population.

The Youth Risk Behavior Survey (YRBS) is a national school-based survey used to monitor health risk behaviors that contribute to the leading causes of mortality, morbidity, and social problems among youth and adults in the United States. Both high school and middle school surveys were administered to a representative group of Alaska high school and middle school students for the first time in 1995. Surveys were administered in a confidential and anonymous manner, taking care to assure student privacy. A total of 1,634 high school students and 1,265 middle school students completed surveys. The survey revealed that, for the most part, Alaska students are similar to U.S. students. Among high school students, 23.2% of boys and 15.4% of girls seldom or never used seat belts; 36.4% of boys and 36.5% of girls had smoked cigarettes in the previous 30 days; 23.5% of boys and 6.7% of girls had used smokeless tobacco in the previous 30 days; 48.7% of boys and 48.0% of girls reported having had sexual intercourse at least once; 23.7% of boys and 59.5% of girls were trying to lose weight; and 77.9% of boys and 65.6% of girls had exercised vigorously on three of the previous seven days. The middle school survey was somewhat different than the high school survey, so that results are not directly comparable. Nonetheless, the data indicate that high-risk behaviors, such as tobacco use, drug use, and early sexual intercourse, do occur at the middle school level. The survey also showed that Alaska teens have desirable health behaviors as well, such as frequent exercise and eating fruits and vegetables. The 1995 Alaska YRBS was the first time that representative data on Alaska students were collected on a statewide basis. The YRBS provides Alaska with baseline data that can be compared to national data.

Accumulation of calcification in the arterial wall in the course of the atherogenic process is considered to be a manifestation of advanced atherosclerosis. In this study of autopsy specimens from Alaska non-Natives, Alaska Natives, and Greenland Natives, comparisons were made of the prevalence and extent of arterial calcification with that of all raised (advanced) lesions in the thoracic aorta, abdominal aorta, right coronary artery, and left anterior descending coronary artery, to determine the degree to which calcified lesions track the development of advanced lesions. Calcification was determined quantitatively from radiograph images of the fixed specimens; advanced lesion data on these specimens were available from prior studies. Findings show that the prevalence and extent of calcified lesions closely follows the pattern of prevalence and extent of advanced lesions among the groups. We conclude that calcification is a good marker for comparisons of the prevalence and may also provide a good measure of the extent of atherosclerosis in these populations.

The compilation of existing data on contaminants in the marine food chain is essential in addressing concerns regarding the magnitude of potential human exposures and in the evaluation of subsistence food safety. This paper presents a summary of studies on trace metals in tissues of Alaska marine mammals from the 1970s to the present, along with derived mean tissue trace metal concentrations. The derived mean can serve as a norm against which future monitoring results may be compared, and may be used to estimate human exposure to trace metals through the consumption of marine mammals. Additionally, the variation among studies in the reported mean tissue concentrations has been described through a derived standard deviation. Sufficient analytical and methodological details were available to derive means and standard deviations for tissues in bearded seal, bowhead whale, beluga whale, fur seal, harbor seal, Pacific walrus, and ringed seal. A high concordance between trace metal values reported in tissues (i.e., liver, kidney, muscle) was observed despite significant differences in reported sampling and analytical methodologies. Consistent with other reviews of trace metal concentrations in marine species, the standard deviation of tissue metal concentrations was generally < or = 100% of the reported mean. Significant gaps in available information remain, particularly for muscle tissues and for methylmercury, despite the considerable efforts to monitor marine mammal species in Alaska.

Persistent organic compounds and trace metals are found in the arctic food chain, generating concerns about the safety of subsistence food consumption. One approach for evaluating subsistence food safety is a process used extensively in regulating environmental clean-up and pollution standards. This process, regulatory risk assessment, is substantially different from approaches used in public health risk assessment. Limitations to the use of regulatory risk assessment in assessing public health threats from environmental exposures in the diet include a narrow scope, a lack of incorporation of the nutritional and health benefits of subsistence foods, and the overestimation of risks because of the incorporation of worst-case assumptions in the absence of scientific information. Sound public health policy recognizes that attempts to err on the side of safety for one exposure by recommending reduced consumption of a selected food may inadvertently err on the side of harm by reducing a coexisting exposure of potentially great health benefit. The following discussion should serve as a useful background for future multidisciplinary discussions on the safety of subsistence foods in the Arctic.

OBJECTIVE:To test the hypothesis that Alaska Natives have fewer atherosclerotic lesions in the coronary arteries and aorta than nonnative Alaska residents.DESIGN:Systematic standardized collection and evaluation of coronary arteries and aortas collected at autopsy.SETTING:Forensic autopsy service in Alaska.SUBJECTS:One hundred thirty Alaska Natives and 115 Alaska nonnatives who underwent forensic autopsy between February 1989 and December 1993.INTERVENTION:None.MAIN OUTCOME MEASURES:Prevalence and extent of atherosclerotic lesions in the aortas and coronary arteries in both populations studied.RESULTS:Alaska Natives had significantly lower prevalence and extent of raised atherosclerotic lesions in the abdominal aorta and coronary arteries than nonnative Alaska residents.CONCLUSIONS:Differences in coronary heart disease mortality between Alaska Natives and nonnatives are, at least in part, the result of fewer atherosclerotic lesions in Alaska Natives.

Risk assessments relying on the U.S. EPA reference dose (RfD) for methylmercury exposure have led to restrictive fish consumption advisories in many states. These advisories fail to account for the benefits associated with fish consumption. Although the use of an RfD is valuable in efforts to regulate industrial emissions, food consumption advice should occur within a broader context that includes consideration of both risks and benefits.