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1. ATSDR > Public Health Assessments & Consultations

This section presents the three exposure situations we have determined pose no apparent public health hazards and lists the information we used to make definite conclusions about them. We also describe one situation we have determined does not pose a public health hazard.

ATSDR's public health assessments are exposure, or contact, driven. Chemical contaminants disposed or released into the environment at MTL, and other former Watertown Arsenal properties, have the potential to cause adverse health effects. However, a release does not always result in exposure. People can only be exposed to a chemical if they come in contact with it. Exposure may occur by breathing, eating, or drinking a substance containing the contaminant or by skin (dermal) contact with a substance containing the contaminant.

The type and severity of health effects that occur in an individual from contact with a contaminant depend on the exposure concentration (how much), the frequency and/or duration of exposure (how long), the route or pathway of exposure (breathing, eating, drinking, or skin contact), and the multiplicity of exposure (combination of contaminants). Once exposure occurs, characteristics such as age, sex, nutritional status, genetics, life style, and health status of the exposed individual influence how the individual absorbs, distributes, metabolizes, and excretes the contaminant. Together these factors and characteristics determine the health effects that may occur as a result of exposure to a contaminant.

I. NO APPARENT PUBLIC HEALTH HAZARDS

ATSDR concluded that three exposure situations present no apparent public health hazard (Table 1).

Subsurface Contamination - The general public is not likely to be exposed to residual contamination at the FUDS parcel. The Army has completed their contaminant characterization of soils on the FUDS property and will be remediating small areas of soil. Until remediation is complete, areas with surface soil contamination are temporarily fenced. (9) In unremediated areas where soil contamination poses no current threat, we recommend that procedures be implemented to ensure that future property owners know of potential hazards and avoid inadvertent exposure to residual contamination. We requested and the Army collected additional radiological sampling in sanitary sewers on the FUDS parcel. (10) After review of the recent sanitary sewer sampling (Summer 1996), ATSDR ruled out utility worker exposure to radiological contamination as a potential health hazard.

Fish in the Charles River - In response to ATSDR's request (11,12,13,14), the Massachusetts Department of Environmental Protection (MDEP) sampled fish from the Lower Charles River including the area near the Arsenal and detected high enough levels of polychlorinated biphenyls (PCBs) in carp for the Massachusetts Department of Public Health (MDPH) to issue a fish consumption advisory for the Lower Charles River between Hemlock Gorge Dam and the Museum of Science. (15) If the advisory is followed, this exposure situation poses no apparent public health hazard.

Past Air Releases of Depleted Uranium -Although depleted Uranium (DU) was periodically burned at the Arsenal in the past, the amount of DU released to air was unlikely to be at levels considered harmful to residents of the surrounding community. There were few, if any, community members living close enough to the Arsenal to have been exposed to airborne DU in the past. Very conservative assumptions were used in the radiation dose estimates. We assumed burning occurred 8 hours a day, 365 days per year, for a maximum of 20 years. Based on these assumptions, the lifetime cancer risk was less than the risk of cancer expected from background levels of radiation. The MDPH review of cancer incidence for Watertown (16) showed no observed increase in cancer rates plausibly associated with depleted uranium radiation exposure.

A. Subsurface Contamination (FUDS Parcel, now the Arsenal Marketplace)

The general public is not likely to be exposed to residual contamination at the FUDS parcel. The Army has completed their contaminant characterization of soils on the FUDS property and will be remediating areas where soil levels exceed MDEP standards. Until remediation is complete, areas with surface soil contamination are temporarily fenced. (9) In unremediated areas where soil or debris (e.g., building rubble, unconnected piping) contamination poses no current threat, we recommend that procedures be implemented to ensure that future property owners know of potential hazards and avoid inadvertent exposure to residual contamination. Recent additional radiation surveys (Summer 1996) in the sanitary sewer system along Arsenal Street and Greenough Boulevard in areas where there were connections with former Arsenal buildings 34, 41 and 421 showed that utility workers who enter these confined spaces would not be exposed to radiation at hazardous levels. (19)

Figure 3 depicts the portion of the former Watertown Arsenal (FUDS parcel) which is now the Arsenal Marketplace. Subsurface soil, debris, and groundwater beneath the property are contaminated. We are concerned that future development of the FUDS parcel could unearth residual contamination, possibly leading to worker exposure, particularly radiological contamination associated with remnants of former Arsenal buildings 34, 41 and 421.

Subsurface Contamination: The Army has conducted a preliminary assessment (7), an initial site investigation (5) and a phase II site investigation at the property (12) which provides information about the extent of contamination there. Although groundwater at the site is contaminated with volatile organic compounds and metals, no one is using the water for domestic purposes so exposure is not a concern. Subsurface soils are contaminated with polyaromatic hydrocarbons (PAHs), polychlorinated biphenyls (PCBs), metals and total petroleum hydrocarbons at levels of possible health concern. However, this contamination is well below ground surface, where it does not pose a health threat at this time. Extensive landfilling and regrading activity was done during redevelopment; consequently, little surface soil contamination has been detected. A fence surrounds an area where arsenic levels in surface soil exceed the Massachusetts Department of Environmental Protection (MDEP) guideline of 40 ppm. The Army conducted followup sampling and performed an Imminent Hazard Evaluation for the site. Although the arsenic contamination in the park is not an imminent hazard, the Army, working with MDEP, EPA and local officials, is implementing measures to prevent exposures to the limited area where arsenic levels are elevated. (20,21,22,23) PCBs exceeded MDEP standards in subsurface soils south of the mall area. The area is approximately 50'x50'. The Army is working to better define the area of contamination, but hopes to complete characterization and remediation by the Spring of 1997. (9) No one is currently being exposed.

Radiation: Other investigations included several surface radiation surveys which were conducted after the parcel was redeveloped. The surveys were done to address concerns about residual contamination from past work with thorium and uranium/radium ores in some former Arsenal buildings. The surveys measured radiation levels within background values (7) which confirm that no surface radiation hazards exist. ATSDR was concerned that, although Buildings 34, 41 and 421 were torn down during the redevelopment, foundations and subsurface structures (sewers and storm drains) remained buried on the property. Prior to demolition, radiological surveys confirmed contamination of some of the piping associated with buildings 34 (machine shop) and 41 (foundry). In building 34, radiation levels as high as 40 milliroentgen per hour (mR/hr) in a pipe trench, and 20 mR/hr in a drain were detected. (7) A water and sludge sample from sewer connections in building 41 indicated Uranium and Radium-226 anomalies, which were not described in detail. (7) It is unclear if these contaminated drain lines, and perhaps others, were removed. It is likely they are still contaminated because radiologically-contaminated sanitary sewers and storm drains connected to the foundry and machine shop on the adjacent MTL property required extensive remediation. Further, dye trace studies and sediment sampling done in sewer lines along North Beacon Street and Arsenal Street confirmed that radiologic contamination from the MTL facility had migrated off-post. (4) Therefore, since similar industrial activities were also carried out in former Arsenal buildings 34 and 41, and, to some degree, building 421 on the FUDS parcel, it was likely that discharge points associated with those razed buildings are also contaminated and we requested further sampling in existing sewers. (5,7,24,25) That sampling was conducted in July 1996 and showed that although there was some radiologic activity, it was not at levels that would pose a health hazard for utility workers (19). Figures 4 and 5 show the locations of the additional sampling in the sanitary sewer connections and storm drains on the FUDS parcel.

The supplemental sanitary sewer sampling evaluation included analyses for uranium species, thorium species, and their respective decay products including radium and radon. Access points to the sewer system in areas once connected to these buildings were surveyed on the FUDS parcel, along Arsenal Street and Greenough Boulevard (Figure 4) as well as storm water discharge points along the Charles River (Figure 5).

Figure 3. FUDS Parcel

Figure 4. Sanitary Sewer Sampling Locations - FUDS Parcel
Reference: ABB Environmental Services, Inc. Draft Sampling and Analysis Plan, Former Watertown Arsenal - FUDS Parcel, Watertown, Massachusetts. Phase II Comprehensive Site Assessment. May 1996.

Figure 5. Storm Drain Outfalls - FUDS Parcel

B. Fish Contamination (Charles River)

ATSDR recommended that edible fish species, representing the types that recreational fishermen catch from areas of the Lower Charles River including the area near the Arsenal, be sampled for chemical contamination. (11,12,13,14) The former Arsenal is one of a number of industrial and urban sources that have contributed pollutants to the river. (17,31) Limited surface water and sediment sampling in the section of the river bordering MTL show pesticide, metal and polyaromatic hydrocarbon contamination. We were concerned that some of these chemicals, which are known to biomagnify in the foodchain, could concentrate to levels of health concern in edible fish tissue. (17,32) The Massachusetts Department of Environmental Protection addressed this public health issue by conducting fish sampling in the Lower Charles River including areas near the Arsenal. High enough levels of PCBs were detected in carp for the Massachusetts Department of Public Health (MDPH) to issue a fish consumption advisory for the Lower Charles River between Hemlock Gorge Dam and the Museum of Science. (15)

MTL: Several studies were done to evaluate chemical contamination in sediment and surface water from the Charles River near MTL. Remedial investigation sampling results from 1990 through 1993 show that the river is contaminated with metals, pesticides and PAHs both upstream and downstream of MTL. (17) At EPA's request, the Army is conducting further sediment sampling to aid in determining the need for further study, such as sampling of aquatic biota in the river. (31)

FUDS: The FUDS parcel, which was part of the original Watertown Arsenal, also borders the river. Thus far, none of the environmental investigations there have focused on the river. (33) The current public information program for the FUDS parcel includes providing reports and news releases to the current owners of the property.

Other Pollution Sources: Considering the historic uses of the Charles River, there are clearly other sources polluting the river besides the former Arsenal properties. Because urban and industrial activities within the Charles River watershed have generated both non-point and point sources of pollution (17), ATSDR also brought the issue of suspected fish contamination to the attention of both the Massachusetts Departments of Public Health (MDPH) and Environmental Protection (MDEP). (11,12,14) The state had sampled fish in sections of the Charles River 10-30 river miles either upstream or downstream of the Arsenal site (16). However, no fish sampling had been done to determine if contaminants in surface water and sediment in the Watertown area had entered the food chain. ATSDR was concerned that people were fishing in this section of the river and anglers and their families may have been eating the fish they caught. (34)

State Actions: In November 1995, the MDEP completed fish sampling in the Lower Charles River which included the Arsenal area. As a result of that sampling, in May, 1996, MDPH issued a carp fish consumption advisory for the Lower Charles River between Hemlock Gorge Dam and the Museum of Science. (15) The advisory states that children under 12, pregnant women and nursing mothers should not eat carp. All other people are advised to limit their consumption of carp to two meals per month. The MDPH fish consumption advisory for the Lower Charles River was communicated to the Watertown Board of Health (BOH) as well as the Newton Board of Health for the southerly side of the river. (15)

MDPH already issued a statewide fish consumption advisory for pregnant women because mercury levels detected in fish collected from diverse Massachusetts water bodies provide an inadequate margin of safety for a developing child. (35) The MDPH has also reviewed fish data for other portions of the Charles River and, in August 1995, issued a fish consumption advisory for the section of the Charles River between the Cochran Dam in South Natick and the Hemlock Gorge Dam in Needham / Newton.

C. Past Air Releases of Depleted Uranium

Although depleted Uranium (DU) was burned at the Arsenal in the past, the amount of DU released to air was unlikely to be at levels considered harmful to residents of the surrounding community. There were few, if any, community members living close enough to the Arsenal to have been exposed to airborne DU in the past. Very conservative assumptions were used in the radiation dose estimates. We assumed burning occurred 8 hours a day, 365 days per year, for a maximum of 20 years. Based on these assumptions, the lifetime cancer risk was less than the risk of cancer expected from background levels of radiation. The MDPH review of cancer incidence for Watertown (16) showed no observed increase in cancer rates plausibly associated with depleted uranium radiation exposure.

Controlled incineration of depleted Uranium chips was done because of the pyrophoric properties of the metal. The incineration not only prevented the chips from spontaneously igniting but also reduced the volume of DU waste requiring disposal at Atomic Energy Commission (AEC) licensed facilities and, after 1974-1975, Nuclear Regulatory Commission licensed facilities. (37) The DU was initially burned in a remote part of Watertown (GSA site), away from residential areas. Later, DU was incinerated in building 43 (MTL) where air releases occurred from a stack near the east end of the building. Detailed information about DU burn activities at both the GSA site and building 43 are provided below.

GSA site - Northeast Area

Incineration Practices: Depleted Uranium was incinerated in a fenced area at the Northeast Area, which is now the GSA site, from 1955 to 1967 (Figure 6). (7) During the time period when the burn pit was used it was in a remote area, away from residences. Procedures were implemented to prevent exposure of personnel to airborne radioactivity. These procedures are described in Appendix D-1. (37) A December 23, 1966 letter from the Arsenal (AMRA) to the Atomic Energy Commission (AEC) reported air sampling results for Uranium oxidation procedures. Although numerical data were not provided, the letter indicates that average Uranium concentrations in smoke generated by oxidation were below limits set in the federal regulations in place at that time. (7) The 1966 AEC limit for air releases in unrestricted areas was 5 x 10^-12 Ci/ml for Uranium-238, which is the predominant isotope in DU. This level is applicable for both soluble and insoluble Uranium compounds and assumes constant exposure. The limit in place at that time would result in a whole-body dose of 0.5 rem/year (500 mrem/y) to the general populace and considers the potential presence of children in the group. Based on these data, air releases of DU from the GSA site were not at levels of health concern.

Figure 6. GSA site

Human Exposure: We do not expect that people off site were exposed to significant concentrations of airborne Uranium oxides. The residential areas that now border the western edge of the GSA property, were built after burning ceased. Aerial photographs from 1968 show no housing in the site vicinity. (7) Because DU is extremely dense, particles carried in smoke would quickly settle to the ground in the general proximity of the burn pit. Conceivably, very small particulates could disperse at greater distances from the source. However, deposition of these fine particles would be widely scattered, and consequently, measurable amounts of DU would not occur in localized areas distant from the source. Therefore, significant amounts of fugitive DU particulates in smoke would not be expected to have drifted far off site. Even in the unlikely event that people off site did inhale DU particulates, exposures would have been rare and, based on available air dispersion data, the resulting dose to the lung would have been below health concern.

Radiological surveys to determine the extent of contamination at the GSA property confirm that radiologic contamination is primarily confined to surface soil in discrete, on-site areas. No contamination was found at the boundary of the site outside the new fence or on the southwest side of Greenough Blvd. (38) Residual soil contamination on both the GSA property and adjoining Property 20 does not pose a health threat to people who live in areas adjacent to the site. Access to potentially contaminated areas is restricted by fences surrounding the burn pit, the GSA property boundary and the portion of Property 20 where fill was placed. (38, 39) Additionally, the fence is marked with radiation hazard signs. (38)

Contamination is not widespread. (40) Additional survey work showed that the current DU and Ra-226 levels prohibit releasing the property for unrestricted use under NRC regulations and guidelines (38) as some areas exceeded the NRC standard of 35 pCi/gram. However, the MDEP may have stricter cleanup standards so remediation plans are on hold pending completion of a risk assessment (9). Additionally, some chemical contamination was found (primarily petroleum) and those chemicals will also be included in the risk assessment. No one is currently exposed to soils as the entire area is fenced. Cleanup of this area is expected in 1998. (9)

Building 43 - Foundry on MTL

Incineration Practices: The Arsenal began burning depleted Uranium in building 43, the MTL Foundry, (see Figure 7) as an additional method of incineration after the GSA property was no longer used for that purpose. Although records could not be located that indicate when the incinerator was first used, most DU burns occurred in the 1970s and early 1980s. The Nuclear Regulatory Commission approved the activity on March 28, 1980. In 1981, high efficiency particulate air (HEPA) filters and a scrubber were installed on the incinerator. These engineering controls reduced the amount of DU released to the outside air. By the mid to late 1980s, DU was burned infrequently, and by July 1992, DU was no longer burned at the Arsenal. (41,42)

In the past, a few uncontrolled DU fires also occurred inside the Foundry building. DU chips, that were temporarily stored in barrels, occasionally spontaneously ignited in the presence of air. The fires were contained within the barrel, inside the foundry. To prevent these types of fires from occurring, the DU chips were stored in oil or water. (41, 42, 43)

Human Exposure: To estimate the potential radiation dose resulting from DU released from building 43, we reviewed available air sampling data. The Arsenal had limited stack monitoring data, spanning from 1981 to 1991 (Appendix D-2). After 1980, the amounts of DU released from the stack dropped dramatically. Because the data were not complete, we made several assumptions prior to calculating dose estimates. ATSDR estimated the maximum and minimum amounts of air flow in the crude incinerator, the maximum and minimum amounts of DU in a burn. The 1981 air data were used in the dose estimates because no earlier data could be found. (43). These data represent the greatest documented amounts of material released from the stack. (43)

We also assumed that DU burns occurred 8 hours per day, every day of the year. However, these values likely overestimate the actual duration and rate of burning. Arsenal records from 1972 to 1977 indicate that DU burns usually lasted about 2 hours and occurred 5 times or less a month. (44) Additional data indicated 8 burns in 1980*, 9 burns in 1981 (3.8 hour average burn time), 6 burns in 1982 (4 hour average burn time), 3 burns in 1983 (5.5 hour average burn time), 3 burns in 1984*, 1 burn in 1987*, 1 burn in 1990 (4 hour duration) and 2 burns in 1991 (1 and 4 hour duration). (45⁽¹⁾) The reported volume of air handled by the system ranged from about 400 to 1265 ft³ per minute. (46) From these very conservative assumptions, the total amount of DU and products released from the stack was estimated. The estimated totals for 1981 were between 84 and 267 millicuries (mCi) of Uranium-238 and 217 to 685 mCi of Thorium-234 (a decay product of U-238).

Once the total amounts of radioactive materials released were estimated, ATSDR performed a probability analysis, based on 10,000 trials, to estimate the most probable amount of material released from the stack. These values were then entered into the CAP88-PC radiological assessment software package. (47)

Figure 7. MTL Buildings

CAP88-PC estimates the risk and dose from radionuclides released through the air. Its use is required in 40 CFR 61.93(a) [Code of Federal Regulations], in compliance with the Clean Air Act, when calculating radiation doses to the public.

The results indicate that the maximum effective dose equivalent (EDE) resulting from DU incineration was less than 200 mrem per year (mrem/y), whole body, to an individual living within 200 meters of building 43 in 1981. As the distance one lived from the Arsenal increased, the effective dose decreased. The maximum calculated whole body dose was within the 500 mrem/y federal limit in place in 1981. (48) Even though the current federal limit is 100 mrem/y, (49,50) we do not consider the estimated doses to be a health hazard since very protective margins of safety were used in setting these limits and in the dose calculations. The 100 mrem/y limit assumes a member of the general public is exposed to these levels every day for 70 years; however, 500 mrem/y is still permitted for infrequent exposures. Moreover, the occupational annual limit is 5000 mrem/y and no known adverse health effects have been reported at that level. (49)

Cancer Risk: The CAP88-PC model also develops cancer risk estimates related to the estimated radiological dose summed for all radionuclides entered into the model, in this case, U-238 and Th-234, the major radionuclides present in DU. The estimates are given for several organ systems and the whole body. Uranium-238, for the purposes of radiation dosimetry, is considered to be uniformly distributed throughout the bone. Thorium-234 is considered to be uniformly distributed over the bone surface (51). Therefore, the critical organs affected would be both the bone surface and the red marrow within the bone interior, and the lungs which are the point of entry. However, lung cancer would comprise virtually all the risk from this form of exposure. The data from our CAP88-PC calculations indicates that the exposure to the entire body was less than 200 mrem per year. This equates to a lifetime cancer mortality risk that is 10 times less than the risk expected from 70 years of exposure to natural radiation in the environment. (52)

Population Exposed: Based on the modeling, maximum exposure would have been to people living within 200 meters of building 43. The nearest residential areas, which are about 200 meters from building 43, are on MTL and on the FUDS parcel to the east.

Figure 8 (1980) and Figure 9 (1990) show population estimates within 100, 250 and 500 meters of building 43. These estimates are based on census data, assume even distribution of the population within each census subgroup, and extrapolate the percentage of the census subgroup within each concentric circle. These figures probably underestimate the actual number of people who live closest to building 43. Condominiums and apartments, built on redeveloped former

Figure 8. 1980 Population Estimates

Figure 9. 1990 Population Estimates

Arsenal property, are within 200 meters east of building 43. However, these residential areas were not built until the early 1980s, by which time air releases of depleted uranium from building 43 were significantly reduced. The condominium complex is comprised of an original Arsenal building (building 212) that was renovated and two newer buildings. The Arsenal Apartments, housing for the elderly, includes a five-story apartment building and several renovated former Arsenal buildings (buildings 71, 72 and 73). (7)

The three buildings on the MTL facility that were used for housing are roughly 250 meters or more from building 43. (Figure 7) Building 111 was the Installation Commander's residence, building 117 was a four-bedroom senior officer's quarters, and building 118 comprised five two-bedroom family units. The average length of residence in any of these military housing units was 2 to 3 years. (53)

Health Effects of Particulates: Inhaled particulates penetrate different regions of the respiratory tract based mainly on their size (also referred to as activity mean aerosol diameters [AMAD]). It is the very small DU particulates released to air that are of greatest concern from an exposure standpoint, because they can be inhaled deep into the lung (Table 2).

*Note: The deposition does not add up to 100% because particles larger than 5 are usually expelled before they enter the body and some particles never enter.

The airborne material produced from burning DU is UO₂ and U₃O₈ which are relatively insoluble uranium oxides. These uranium oxides are class Y compounds, which have an estimated lung retention time of greater than 100 days because they are not very soluble in lung fluids. (51) This means that they stay in the lungs for an extended period of time before being distributed throughout the body. The majority of uranium oxide particulates deposited deep in the lung are smaller than 0.3µ. Particles ranging in size from 0.3µ to 5µ also add to the lung burden, but to a lesser extent. And finally, less than 10% of particles with AMAD greater than 5µ penetrate into the deep lung region. (51) Particles deposited in the nose and throat are usually expelled from the upper air ways and ingested. Because these ingested particulates are uranium oxides, which are relatively insoluble, they pass through the digestive system and are excreted fairly rapidly.

The 1981 air data used in the radiation dose estimation model is from the time period after engineering controls reduced the amount of DU released to outside air. However, releases of fine DU particulates (less than 0.3 microns [µ]) to air during burning in 1981 and after, were most likely comparable to earlier years. Although the use of high efficiency particulate air (HEPA) filters on the incinerator decreased air releases of particulates greater than 0.3µ in size, fine particulates continued to be emitted. As discussed earlier, using data representing the greatest amounts of material released from the stack and incorporating assumptions that are very protective of public health, the maximum estimated radiation dose was not at levels which pose a public health hazard.

II. NO PUBLIC HEALTH HAZARD

A. Future Land Use (MTL and GSA site)

Public health issues concerning future land use of MTL and the GSA site (see Figure 1) are of utmost importance and are being actively addressed. Procedures are implemented during sampling and cleanup activities to protect both the general public and remediation workers from possible hazards. Further, before the land can be transferred for reuse, all necessary cleanup actions must be completed.

The Army is conducting site investigations and cleanup at MTL and the GSA site under the guidance of the Commonwealth of Massachusetts Departments of Environmental Protection (MDEP) and Public Health (MDPH), the U.S. Environmental Protection Agency (EPA) and the Nuclear Regulatory Commission (NRC). These regulatory agencies set cleanup levels that are protective of public health considering the land reuse options that are planned. ATSDR supports these activities by providing technical assistance concerning public health issues as requested. We reviewed the "Human Health Radiological Risk Assessment for Massachusetts 21E Sites" for MDEP and concur that the 10 mrem dose limit proposed for cleanup at MTL is protective of public health. (55) We have also reviewed documentation regarding environmental activities at the former Arsenal properties (GSA site and FUDS parcel) and provided comments to the Army and regulatory agencies concerning issues of public health importance. (13,10,39,56)

Residents who live next to MTL and the GSA site expressed concern about possibly being exposed to contaminants because they see on-site workers wearing personal protective equipment (PPE) during sampling and cleanup activities. However, the use of PPE by remediation workers does not necessarily mean that a site is extremely hazardous; rather, PPE is a required precautionary measure to protect workers from possible hazards encountered during field investigations. Other actions are taken during the course of site cleanup that prevent exposures from occurring. These include restricting access in areas where residual contamination is at levels of public health concern. Fencing and/or security measures, which effectively limit site access, are in place at MTL and the GSA site. Finally, Site Health and Safety Plans, which detail proper safety measures to be followed during all site work, are developed. These plans include containment methods to prevent contaminated dusts, vapors, etc from moving away from the site during sampling and cleanup activities.

Agency for Toxic Substances and Disease Registry, 1825 Century Blvd, Atlanta, GA 30345
Contact CDC: 800-232-4636 / TTY: 888-232-6348 

Department of Health and Human Services