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PETITIONED PUBLIC HEALTH ASSESSMENT

NEWTOWN COMMUNITY
GAINESVILLE, HALL COUNTY, GEORGIA


SUMMARY

The Agency for Toxic Substances and Disease Registry (ATSDR) was petitioned to evaluate health concernsfor residents living in the Newtown Community in Gainesville, Georgia. The petition was filed by theNewtown Florist Club, a fifty-year-old organization in the Newtown community. Area residents expressedconcern over high rates of cancer, lupus and respiratory diseases that community members believe may becaused by emissions from nearby industrial facilities and by the location of the community over a landfill.

ATSDR reviewed all available environmental and health outcome data and concludes that the data do notsuggest a threat to human health. However, some data may not be representative of potential exposureconditions in this community. Available environmental data indicate that environmental media may containchemical contamination, but below levels associated with adverse health effects.

Based on all available data, ATSDR has made the following observations:

  • Air: Current ambient air contamination in the community is not a public health hazard. ATSDR wasunable to determine the public health implications of particulate air emissions because no data wereavailable at the time this document was written. ATSDR was unable to assess health implications ofpast exposure because no historical environmental sampling data exists. However, ATSDR willfurther investigate past emission rates and create models of facility emissions in an attempt toreconstruct an estimate of past contaminant concentration scenarios. Potential human exposure may be approximated from modeling. ATSDR will also determine if the location of the current air monitoring location is sufficient to measure contaminant levels of residential air in Newtown.

  • Water: Current groundwater contamination in this community poses no health hazard, becauseresidents do not drink and are not exposed to groundwater. Chemical contamination of stormwater runoff and lead contamination of tap water are not a threat to the health of residents.

  • Soils: According to available environmental data, residential subsurface soil does not pose a threat tohuman health. Levels of contaminants found in subsurface soils rarely exceeded ATSDR'scomparison values, and it is highly unlikely that residents will be exposed to subsurface soils. Surfacesoils collected from the community playground pose no apparent health threat to children who play in the area. No surface soil outside the playground have been investigated in the community. To better characterize soil contamination and potential exposure, ATSDR recommends additional surface soil collection and analysis in residential yards.

ATSDR will conduct health education activities in Newtown. ATSDR has facilitated and will continue to facilitate the involvement of other agencies, as appropriate, to investigate remaining health and environmental concerns.


INTRODUCTION

On April 10, 1995, a member of the Newtown Florist Club petitioned the Agency for ToxicSubstances and Disease Registry (ATSDR) to investigate the potential public health impact ofcombined industrial emissions on the Newtown Community [1]. ATSDR reviewed and evaluatedavailable data from the Georgia Department of Natural Resources (GaDNR), the Georgia StateUniversity Geology Department (GSU), the Georgia Department of Human Resources (GaDHR),the Newtown Florist Club, the Morehouse School of Medicine, Emory University, and an exposureinvestigation conducted by ATSDR's Exposure Investigation and Consultation Branch (EICB).ATSDR evaluated community concerns and available soil, methane gas, groundwater, tap water, stormwater runoff, air, and biological data to determine the potential and extent of the exposure of residents to environmental contamination. The purpose of this document is to identify potential human exposures and to recommend appropriate public health follow-up activities.


BACKGROUND

Newtown is a residential area located in the southeastern section of Gainesville, Hall County,Georgia. Before 1936, the area currently known as Newtown has been reported to be the site of theGainesville/Hall County landfill. In 1936, a tornado passed through the community and destroyedmany nearby homes. Debris from the tornado were disposed of in the landfill, the fill materials wereburned, and the landfill was covered with soil. No records of the landfill existing before the 1936tornado can be found, and the landfill does not exist in city planning maps dated 1930.Approximately 75 homes were rebuilt on top of the debris landfill and the surrounding area withfederal Reconstruction Finance Corporation loans within a few years following the tornado [2,3].

The Newtown Community is located in a highly industrialized area of Gainesville, Georgia. Withinthree miles of the community, there are 14 facilities required to report to the United StatesEnvironmental Protection Agency (EPA) Toxic Release Inventory, and 56 additional businesses thatare regulated by EPA because they handle, store, or use hazardous materials. The area directly southof Newtown is zoned heavy industrial. To the east and west properties are zoned as a mixture ofgeneral business, light industrial, and residential; the properties include a number of businesses,restaurants, and industries. To the north of the community, properties are zoned as residential. Arailroad track borders the community to the south and provides rail access to the many facilities in the area. The railroad track is within 20 feet of the community playground. There is a hospital and a school within 1/4 mile of the community. For maps of the community, refer to Appendix A.


DEMOGRAPHICS

Previous studies report that the specific area of interest in Newtown is a 10 street block, with 143households and approximately 350 African-American residents [4,5,6,7]. Current populationestimates for Newtown are available for 1998 at the census block group level only [8]. Blockgroups contain between 250 and 550 housing units and are often used to distinguish areaneighborhoods. Newtown is primarily located in census tract 131398 (8), block group 2. AppendixB, Table 1 provides data for this block group as well as comparison data for Hall county.

The block group containing Newtown is predominantly African-American; approximately 76% ofthe 631 residents are African-American. Caucasians account for 22% of the total population andabout 2% are of another race. Median age is about 5 years older than the median age for the county(40.2 and 35 years of age, respectively). Figure 1 and Table 1 in Appendix B illustrate the agedistribution in this community. The median number of school years completed is 11. Medianhousehold income in Newtown is $22,939 compared to the county median household income of$39,849. The area appears to be relatively stable in that the median length of residence is over 18years, in contrast to the county which has a median length of residence of 9.7 years.

There are 350 housing units in block group 2, and the vast majority are occupied (93.4%). Approximately as many houses are occupied by renters as by owners (50.5% and 49.5%,respectively). Almost half the homes in this area were built before 1949 (46.6%) and 80% werebuilt before 1970. The median housing value in the Newtown area is lower than that of the county,with the median home value being 41% of the county value ($40,556 vs. $98,986). For additional demographic information, see Appendix B.


COMMUNITY HEALTH CONCERNS

Specific health concerns expressed by Newtown residents were related to exposure to toxicemissions, discharges, and fallout from surrounding industries. Residents believe a number of healthconditions in the community may be attributable to industrial emissions, including lupus, cancer,kidney failure, respiratory ailments such as chronic bronchitis and asthma, and heart conditions. Thecommunity was built over a landfill in 1936, and residents have concerns about exposure tocontamination from landfill soils and gases [1]. In addition, a junkyard nearby is a source of concernfor many residents who believe stormwater runoff from the site may be contaminating communitysoils with metals, oil, grease, and gasoline. Residents have also expressed concern about leadcontamination of their homes and drinking water. Finally, for a number of years, the communitynoticed a fine dust that settled on houses and cars that could have been attributed to two differentfacilities located within a tenth of a mile of the community. They believe this dust has compromisedtheir respiratory health. No particulate data were available for analysis at the time of this report topermit examination of exposure to ambient dusts in air.

Of particular concern to residents in the area are hexane emissions from a nearby facility. Residentsbelieve an accidental hexane release was the cause of an emergency evacuation of a neighboringcommunity on May 19, 1995. This incident resulted in approximately 25 people visiting the localhospital and two people being kept at the hospital overnight or longer. During the course of thatevening, approximately 100 people were evacuated from their homes. An odor permeated theneighborhood and residents allege that they experienced respiratory discomfort, nausea, and burningitchy eyes from invading fumes. Although residents believe the source to be the nearby soybeanprocessing plant, Cargill, Inc., the United States Environmental Protection Agency (EPA) alsoinvestigated other possible sources of release. EPA staff interviewed facility and hospital staff andinvestigated Cargill, Inc. The plant superintendent indicated that the Cargill plant was beingprepared for "hot work" following all necessary procedural guidelines and that nothing unusualhappened that night. The hot work process requires pumping of all hexane from the extractionsystem to underground storage tanks and purging the system to below the lower explosive limit,with washdown and steaming. The process began at 5 PM and lasted until 3 AM. Gas analysis in thefacility and the adjacent neighborhood did not reveal the presence of an elevated level of gas vapors.The investigation of this incident did not identify the source of the release; however, it was anemergency event that raised concern in the area about exposure to nearby facility emissions to agreater level [9]. ATSDR was also unable to determine the source of the environmental release,given available information.

In addition to concerns over facility emissions, residents expressed concerns about low-lying powerlines and potential exposure to electromagnetic field radiation. Also, residents stated that excessivenoise from the industries and the nearby railroad and that a large rodent population are a nuisance[1]. Noise nuisance issues are best addressed by the local health department. Nuisance noise and rodents are outside ATSDR's purview of work, however limited followup was done on the rodent issue by ATSDR.


DISCUSSION

Methods

The discussion section of this document contains an evaluation of the environmental data availablein the Newtown Community. In preparing this evaluation, ATSDR uses established methodologiesfor determining how people may be exposed to potential contamination related to surroundingindustries and what harmful effects, if any, may result from that exposure. Exposure pathways(ways that humans come in contact with chemical exposure) that ATSDR evaluates includeingestion (eating), inhalation (breathing), and skin contact. ATSDR compares chemicalconcentrations in air, soil, and water to comparison values (CVs) for each of the chemicals.Comparison values are concentrations of chemicals that are considered safe levels of exposure, evenfor sensitive populations such as children and the elderly. Chemicals detected below CVs are notlikely to represent a health concern, and those above CVs require a more detailed evaluation of site-specific exposure conditions. While concentrations at or below a particular CV might be consideredsafe, it does not necessarily follow that any concentration that exceeds a comparison value would beexpected to result in negative health effects in the community. It is important to keep in mind thatthe comparison values are often calculated with safety factors that make them hundreds, or eventhousands, of times below a level that ATSDR would expect to cause illness and disease in humans. If a chemical does not have a comparison value, ATSDR reviews available scientific literature todetermine if the levels are of health concern. For a complete discussion of these criteria (qualityassurance considerations, human exposure pathway analyses, ATSDR's health comparison values, and the methods of selecting contaminants above comparison values), refer to Appendix C.

Extent of Contamination

Electromagnetic Radiation

Power lines, electrical wiring, and appliances all produce electric and magnetic fields (EMFs).EMFs are invisible lines of force that surround any electrical device. Electric and magnetic fieldshave different properties and possibly different ways of causing biological effects. Both electric andmagnetic fields weaken with increasing distance from the source [10]. Most of the concern about theassociation between power lines and cancer stems from studies of people living near power lines andpeople working in electrical occupations. Some of these studies appear to show a weak associationbetween exposure to power line EMF and the incidence of cancer. However, epidemiological studiesdone in recent years show little evidence that power lines are associated with an increase in cancer,and laboratory studies have shown little evidence of a link between power line electromagneticfields and cancer. A connection between power line fields and cancer remains biologically unproven[11].

Residents in Newtown have expressed concern about EMF and its potential relationship tochildhood leukemia. The largest studies ever conducted of childhood leukemias and theirrelationship to power line EMFs reported that the studies revealed no significant evidence for an association between childhood leukemias and power line fields [12,13,14] .

Air

Georgia Environmental Protection Division Air Monitoring

Air emissions in Hall County have decreased dramatically in the past ten years. Improved airpollution controls have been installed in all area facilities since the 1980s. The NewtownCommunity was established in the late 1930s, before most environmentally protective legislationwas passed in the United States. Unfortunately, sampling and air monitoring data do not exist in thisarea prior to the 1990s. Therefore, past emission concentrations and exposure levels are unknown.

In early 1997, the Georgia Division of Natural Resources initiated air monitoring in the Newtowncommunity to monitor air quality. The monitoring station is located at a grade school approximately┬╝ mile north of Newtown's northernmost boundary. A 24-hour sample is taken one or two days amonth. State officials meet with residents from time to time to discuss sampling results.Meteorological data were taken for 9 months prior to installing the monitor and revealed that airdirection was from the industrial areas (south, southwest, west) to the school monitoring stationapproximately 18% of the time [3]. Sampling may therefore not be representative of the trueexposures of residents in the area to industrial air contaminants.

During 1997, there were a total of 22 sampling events at the Fair Street School monitoring station. During this period, several contaminants were detected above comparison values (CVs). These include: benzene, methylene chloride, hexachlorobutadiene, arsenic, and cadmium. Cadmium and methylene chloride were detected twice, and both exceeded comparison values in one sample. Hexachlorobutadiene was detected once above comparison values, but not at all for the rest of the year. Benzene was detected more frequently, approximately a quarter of the time. Arsenic was detected at low levels in almost half of the samples taken. Although many metals and volatile organic compounds (VOCs) were detected in these monitoring efforts, the data reveal that these contaminants were detected far below levels at which adverse health effects have been observed in humans. Furthermore, most were detected infrequently [15]. Refer to Appendix D, Table 1 for further information on contaminants exceeding comparison values. Particulate data were not provided to ATSDR. Because levels rarely exceeded comparison values and were not found with a high level of frequency, ATSDR concludes that ambient air contaminant levels detected by the Fair Street School monitor are not a threat to human health. However, the location of the Fair Street School monitor may not be representative of Newtown ambient air conditions, and an investigation of this sampling location is warranted. No data were available in this document for particulate matter analysis, so no conclusions can be made regarding potential respiratory aggravation from particulates in air.

Air canister analysis-ATSDR Exposure Investigation

In January, 2000 ATSDR conducted an exposure investigation of air and soil. ATSDR staff andresidents collected ten air samples that were tested for VOCs. The purpose of an exposureinvestigation is to provide a timely screening of an environmental media of concern. Exposureinvestigations are not in depth collections of environmental data, and do not provide completecharacterization of sampled media because of the small number of samples collected.

The community was instructed on taking samples with the air canisters. When the samples would betaken was at the discretion of the residents. ATSDR staff trained four residents to take the airsamples and accurately record necessary sample information. ATSDR also took several of thesamples near facilities of concern to the community, including Georgia Chair Company, ConAgraBroiler Company, and Cargill, Incorporated. The air results indicate contaminant levels exceedingCVs for benzene, methylene chloride, toluene, and n-butanone in several samples [16]. However,methylene chloride was found at higher levels in the sample blank than in the residential samples, sothe validity of the methylene chloride level detected is questionable. In this case, a sample blank isan unexposed air canister not carried to the Newtown area; it was handled and analyzed in the lab inthe same manner as air canisters that were actually used to take samples in the community. Sampleblanks ensure that a sample taken is a true representation of the contamination present at a site, andthat levels reported are the result of air contamination, not of instrument contamination or laboratoryerror.

Benzene was the only contaminant detected at levels exceeding CVs within the boundaries of theNewtown residential area. Methylene chloride, toluene, and n-butanone exceeded comparison valuesoutside the residential area, on the perimeter of the previously mentioned facilities. Hexane andhexane constituents, a major concern in the community, were detected in one sample at levels belowATSDR comparison values [16].

In a single sample, benzene exceeded the ATSDR cancer risk evaluation guide (CREG), but thelowest reported level at which cancer has been associated with benzene is 300 ppb [16, 17]. Thisassociation was found in chemical workers who had daily occupational exposure to benzenebetween the period of 1940 to 1970. ATSDR assessed cancer risk of benzene exposure usingambient levels of benzene detected in available environmental data. The risk assessment indicatedthat there is no apparent increase in cancer risk from benzene exposure within or in the areasurrounding the Newtown community. More information about this evaluation is provided inAppendix G. Most likely, the presence of benzene is the result of high vehicle traffic in the area, andis not uncommon in urban and industrialized settings. Generally, background levels of benzene inair range from 2.8 to 20 per billions parts of air (ppb). People living in cities or industrial areas aregenerally exposed to higher levels of benzene in air than those living in rural areas. Smokers are alsoexposed to benzene in cigarettes. The average smoker takes in about 1.8 milligrams of benzene perday. This is about 10 times the daily average intake of nonsmokers [18]. Toluene exceeded thecomparison values in a single sample, but was reported at levels unlikely to result in health effects.The highest detected level of toluene in this investigation was forty times lower than the lowestreported level resulting in adverse health effects [19].

Freon 11 and Freon 113 were detected in low levels in many of the samples. Freon 11 is the mosttoxic of the fluorocarbons, and has been banned from most uses in the United States. It is the mostpersistent fluorocarbon, and may remain in the atmosphere for years. Levels detected in thiscommunity are well below levels at which health effects have been reported. While environmentalexposure limits have not been established, occupational exposures to these contaminants of 1000ppm for 8 hours are not expected to result in health effects [20]. In addition, Freon 113 was detectedin levels higher than in the environmental samples in the sample blank, which indicates uncertaintyin the accuracy of the residential samples. 4-ethyltoluene was detected in two samples at very lowlevels, but does not have a comparison value. Toxicity of 4-ethyltoluene requires a very large oraldose to cause health effects in study animals, but no animal or human inhalation studies could belocated. There are no reports in the scientific literature of human toxicity to environmentalexposures to 4-ethyltoluene. This contaminant was not detected in residential areas or in theNewtown Community, but was detected by air canister samples taken near two industries at lowconcentrations. To review specific levels of concentrations exceeding ATSDR comparison values,see Appendix D, Table 2. In conclusion, data analyzed for the ATSDR exposure investigation donot indicate a health hazard in residential ambient air. However, the isolated elevations of VOCsdetected in air may warrant the relocation of the state air monitor closer to the community sothat these contaminants may be more closely monitored.

Soil

Subsurface soils

A public meeting was held by the Georgia Department of Natural Resources (GaDNR) forNewtown residents in 1993 regarding resident concerns about the contents of the landfill andsinkholes in some residential lots. Following the public meeting, the Georgia Geologic Surveyconducted a subsurface soil and methane gas analysis of the Newtown community. The purpose wasto investigate the causes of sinkholes in some residential yards, determine the type of landfill whichpreviously existed on the site, characterize waste material of the site, and determine if the landfillmaterial, if present, posed any threat or danger to Newtown residents [6].

Later that year, the Georgia DNR drilled 21 borings ranging in depth from 3 to 23 feet in residentialyards along four streets (see Figure 1 in Appendix E for sample locations). The study found thatmajor components of the landfill include glass, china, charcoal, concrete, metal, and bricks. Thelandfill is shallow, with a maximum depth of 6 feet. Most of the landfill materials are located in thearea between Mill and Cloverdale Streets on the north and south, and Elm and Harvey Streets on thewest and east. Eight subsurface soil samples collected from two of the 23 borings were analyzed forVOCs (volatile organic compounds), SVOCs (semi-volatile organic compounds), pesticides, PCBs(polychlorinated biphenyls), and metals [6]. Aluminum, arsenic, and vanadium exceededcomparison values for children who exhibit pica behavior, but not for adults and children who donot exhibit this behavior (see Appendix E, Table 1). Pica behavior is exhibited in individuals whoeat non-food items, such as soil and clay. However, since the most shallow samples were collected atthe subsurface level, any contaminant exposure to children is unlikely.

The Georgia DNR report indicates that the landfill under a portion of the Newtown community wasessentially one where materials were piled and burned. The sinkholes residents reported were due tojumbled construction debris underlying parts of some streets. Only two of the 21 borings wereanalyzed for metals, volatile and semivolatile organics, PCBs, and pesticides. The small sample sizeprevents a complete characterization of surface soils, especially because the two surface soil samplesthat were collected were a composite of 12 inches of soil.

Since the community was built on a landfill, Georgia DNR conducted a methane survey on 44residences, none of which revealed significant levels of methane. No value exceeded 1 percent LEL(the lower explosive limit of methane is 4%) [6].

In 1994 an additional soil analysis was conducted. The University of Georgia drilled 9 borings andanalyzed 27 soil samples for a limited number of metals (see Appendix D, Figure 2 for samplinglocations). Again, only two of these samples were within the top foot of soil, and both werecomposite samples. Aluminum, iron, manganese, molybdenum, and nickel exceeded ATSDRcomparison values for pica children, but not for adults or normal children. In addition, iron exceededEPA's Risk Based Concentration Levels (RBCs) levels in several samples, and lead exceeded RBCsin a single sample. Lead was detected at this level at 9 feet below the soil surface (see Appendix D,Table 2) [7].

Several metals exceed comparison values for children who exhibit pica behavior. In order todetermine whether or not children exhibiting pica behavior are at risk for exposure to any of thesemetals, more information is needed to determine if children in this community exhibit pica behavior,and if so how often and how long they exhibit pica behavior. The likelihood that this behavior iswidespread is low, as this behavior is unusual and occurs in short duration in few toddlers andyoung children. It is highly unlikely that children exhibiting this behavior would be able to accesssubsurface soils. ATSDR concludes that elevated concentrations of some metals were identified insubsurface soil at the location of the Newtown dump site, but the metals detected in subsurfacesoil were not present at levels that threaten human health. However, no surface soil sampleswere analyzed, and the number of samples taken is inadequate to characterize the extent of soilcontamination. Subsurface soils in the community pose no health hazard to residents.

Surface Soils- ATSDR Exposure Investigation

In January, 2000 ATSDR conducted an exposure investigation of air and soil. ATSDR staff andresidents collected five composite soil samples that were tested for metals. The purpose of anexposure investigation is to provide a timely screening of an environmental media of concern.Exposure investigations are not in depth collections of environmental data, and do not providecomplete characterization of sampled media because of the small number of samples collected.

Surface soils were collected at depths of 0-3 inches in the residential playground within thecommunity. Residents had expressed concerns that stormwater runoff from the junkyard adjacent tothe community may be a source of contamination for the playground. The junkyard had been foundout of compliance with Georgia Rules for Solid Waste Management and the Georgia Rules for AirQuality Control twice in 1999. As of November 1999 the manager of the facility had not produceda pollution prevention plan and had no stormwater runoff controls on the property. The runoff watercollects in the playground because the playground is the lowest lying area in the community.

In this investigation, iron, aluminum, selenium, and thallium exceeded comparison values forchildren exhibiting pica behavior [16]. These levels would not be expected to cause adverse healtheffects in adults and children with normal exposure scenarios (see Appendix E, Table 3). However,pica children may be at somewhat greater risk but it is doubtful that pica behavior would be ofsufficient frequency and duration to result in health concerns. The metals detected are not ones thatwould normally be associated with a scrap metal yard, but are instead naturally occurring mineralsfrequently found in soils. Based on the results from the exposure investigation, additional surfacesoil sampling of the playground is not warranted, and playground soils do not represent ahealth threat to Newtown residents.

Water

Groundwater

In July 1993 two groundwater monitoring wells (MWs) were installed by the Georgia Departmentof Natural Resources. Data indicate that the two wells were sampled one time on the residentialproperties. The levels reported did not exceed comparison values, with the exception of iron in oneof the monitoring wells [6]. Iron is a metal commonly found in soil and water. It slightly exceededthe risk-based concentrations (RBCs) established by the US Environmental Protection Agency(EPA) for drinking water, however the water tested in this community is not used for drinkingwater. Newtown has been on a municipal water supply since it was established in the late 1930s.Please refer to Appendix F, Table 1 for the results of this sampling and Appendix F, Figure 1 for amap of groundwater monitoring wells.

Groundwater was also tested by the University of Georgia. Two additional groundwater monitoringwells were drilled to the depths of 10 to 20 feet for the analysis of groundwater samples. All samplestaken fell within acceptable drinking water ranges for metals and major ions as determined by theFederal Primary Drinking Water Standards, with the exception of chlorine (Appendix F, Table 2and Figure 2). Chlorine was found at levels exceeding ATSDR's comparison values in two of thewells. In monitoring well 1 and monitoring well 2, these levels were found to be 8800 ppb (parts perbillion) and 22,800 ppb [7]. These levels exceed ATSDR comparison values for chronic oralRMEGs (non cancer risk) for children (1000 ppb) and adults (4000 ppb). The presence of thechlorine is not naturally occurring, and the source of the chlorine in these samples is not known.However, since groundwater is not used for drinking water in this community, ATSDR concludesthat residents are not likely to be exposed to the water, and that groundwater contamination isnot a threat to human health to this community.

Stormwater Runoff

In October 1993, samples of stormwater runoff water were analyzed for 129 priority pollutants andfor water quality pollutants by the City of Gainesville Public Utilities Department. Four metals werefound to be present above detection limits. These included: lead, chromium, copper, and zinc. Novolatile organic compounds (VOCs), pesticides, or polychlorinated biphenyls (PCBs) were detected. For sampling results and maps see Appendix F, Table 3 and Figure 3.

Levels of these metals were very often below those that are found naturally in the environment, andall fell below ATSDR comparison values [21]. However, there was an unexplained high level offecal coliform bacteria. The source of the bacteria was not identified, but it was concluded thatcontributors could be the Purina plant, a lot where dogs are walked, a faulty sewer service line,leaking septic tanks, and ill-fitting manhole covers. A letter of correspondence between two stateofficials dated as early as 1975 acknowledged elevations of fecal coliform bacteria, stating thatseptic tanks may have been faulty and were discharging into the storm drains. However, there is noevidence that the source of this contamination was identified [22]. City public utility officials havedetermined that background levels of fecal coliform in Hall County commonly exceeds a count of100,000, particularly in summer months. Tributaries of a nearby lake and the heads of smallstreams and creeks are also reported to have elevated fecal coliform counts [23].

Stormwater is not used as a drinking water source by this community. However, children in thecommunity who play or swim in the stormwater runoff may be at higher risk for exposure toorganisms that could cause illness. This is due to contamination of the water from the feces of warmblooded animals, including humans. Fecal coliform bacteria are "indicator" organisms of fecalcontamination which may harbor other organisms. These other organisms can cause a number ofhealth disorders and illnesses including gastro-enteritis, giardiasis, typhoid, dysentery, cholera, andhepatitis [24]. A number of studies have associated outbreaks of coliform-related illnesses withexposure to contaminated water by ingestion and dermal contact [25,26,27].

ATSDR concludes that exposure to chemical contamination in stormwater runoff is not likely toresult in health effects, however, exposure to stormwater contaminated with fecal organisms viadermal absorption, inhalation, or incidental ingestion of contaminated stormwater runoff couldpotentially result in adverse health effects.

Tap Water

On October 19, 1999 the City of Gainesville Public Utilities Department tested seven residentialhomes for lead in tap water. Residents were concerned that their homes may have lead pipes thatmay expose them to unhealthy concentrations of lead. All lead levels found in residential taps werebelow EPA's risk-based concentration levels (see Appendix F, Table 4). Also, municipal water forthe City of Gainesville is regulated under the Safe Drinking Water Act, and is regularly tested forquality assurance [28]. Since no samples exceeded the comparison values, ATSDR concludes thatthe tap water of the homes sampled is not contaminated with lead at levels of health concern.

ATSDR Child Health Initiative

Children are at greater risk than adults for certain kinds of exposure to hazardous substances emittedfrom waste sites and emergency events. They are more likely to be exposed for several reasons:

  • The developing systems of children can sustain damage if toxic exposures occur during certain growth stages.
  • Children play outside more than adults, and therefore have an increased likelihood of coming into contact with chemicals in the environment.
  • Since they are typically shorter than adults, children breathe more dust, soil, and heavy vapors close to the ground.
  • Children are also smaller, resulting in relatively higher doses of chemical exposure per body weight.

Therefore, ATSDR evaluated the types and quantities of chemicals detected in the air, water, andsoil in the community to determine how children might be exposed and whether levels detected inthe community could be associated with any reproductive or developmental effects.

While there are children living in the Newtown community, they generally do not have access tosurrounding sites. Residents have reported problems in the past with children having easy access tothe neighboring facility properties. However, during their visits, ATSDR staff did not notice anycurrent holes in the fences or other points of access for children to the junkyard or any other nearbysites. ATSDR closely reviewed possible exposure situations for children while evaluating this site(for example, air exposure, trespassing, and soil in the community playground). In its evaluation,ATSDR used the Environmental Media Evaluation Guidelines (EMEGs) for children, who areconsidered the most sensitive segment of the population. No special chemical hazards to childrenwere identified on the basis of available data, except slight potential risk in the communityplayground for children exhibiting pica behavior. Because only limited data were available forfacilities in the surrounding community before 1987 (when pollution controls were more elementaryand emissions were greater), no conclusions could be drawn regarding past air exposures.

There were two other hazards to children identified. Children exposed to stormwater runoffcontaminated with fecal materials are at a greater risk for incidental ingestion, inhalation, or dermalcontact with bacterial organisms that may cause gastrointestinal illnesses. In addition, someresidential yards have sinkholes from decaying landfill debris, exposing some of the debris to thesurface of the soil. The debris may pose a physical threat to children who play in or around thesesinkholes, to the extent that children could sustain cuts from glass or other discarded items.

Health Outcome Data

Health outcome data and health statistics are collected by government agencies, hospitals,universities, and other businesses such as insurance companies. It is collected from people on alocal, statewide, or national scale. Some diseases are required to be reported by hospitals togovernment agencies to track their occurrence, such as cancer, heart disease, and birth defects. Thisinformation is included into computer databases that allow researchers to study trends of disease(surveillance), how often diseases are diagnosed (incidence), how many people are living with aparticular disease (prevalence), and how many individuals die of the disease in a given period oftime (mortality). Examining disease this way can help plan health intervention activities, identifydisease trends, and determine the magnitude of disease incidence and prevalence to prioritizeresearch efforts. These databases make it possible to determine if the rate of disease is occurring at anormal rate, or at a rate higher than expected. ATSDR reviewed four studies conducted by thecommunity itself, a state agency, and two universities. Each study used existing health data orcollected new information to examine disease in Newtown. The studies included a report of illnessesby community members, an epidemiologic study of cancer incidence, a study of biological samples,and a lupus study.

Newtown Community Survey- Newtown Florist Club

In the spring of 1990, the Newtown Florist Club members conducted a door-to-door survey thatqueried people about disease incidence and prevalence in their households. The data collection wasself-reported and often the result of family testimony. Results were compiled from 40 householdswhere families were residents for at least 20 years. The report includes the names and addresses ofthose reported with illnesses. Desota Street residents reported a disproportionate number of cancerillnesses, lupus, respiratory ailments, and death [5]. Desota Street is in close proximity to thejunkyard, the Purina plant, and the Leece-Neville company. The results of this survey prompted thecommunity to request the assistance of Georgia Department of Human Resources to conduct a moreintensive health study of the community.

Georgia Department of Human Resources-June/July1990
Newtown Neighborhood Cancer Investigation-A State Epidemiologic Study

A representative from the Newtown Florist Club wrote a letter to the State of Georgia's DirectorsOffice of Epidemiology, Division of Public Health, concerning the high rate of disease observed inthe survey the club conducted and the possible link to exposures to toxic substances. In response, theGeorgia State Department of Human Resources (DHR) agreed to conduct an epidemiologic study inthe Newtown community. Georgia DHR collected information through surveys administered byHall County Health Department employees. The study was directed by a Georgia DHR official anda physician from Morehouse School of Medicine.

The study collected information on cancer incidence through telephone interviews. The telephonenumbers and addresses of community members were obtained through the Gainesville CityDirectory. Each health department employee attempted to contact a resident by telephone for twoconsecutive evenings, after which time if the resident could not be contacted, a visit was made to theresident's house for a face-to-face interview. Of 143 households in the community, 114 (79.7%)were successfully surveyed. Residents were asked to provide information on each member of thehousehold who lived in the household for 6 months or more between 1970-1989. The data from thisinvestigation were compared to the number of expected cancer cases in a comparison population andtested for statistical significance. Observed cases were those which were verified through theNortheast Georgia Tumor Registry, private physician and hospital records, or death certificate [29].

The study concluded that there was a higher incidence of cancers of the buccal cavity and pharynxthan would be expected in a similar population, and that the higher rate of incidence was associatedto the behavior and lifestyle of residents. The study indicated that all four individuals who reportedthis type of cancer had a history of drinking and smoking [29]. However, no data were provided tosubstantiate the association between these cancers and behavior and lifestyle.

The largest limitation of this study is that the comparison population used was Metropolitan Atlanta,a population which may not be representative of the Newtown population, who live in a more ruralarea. An urban population is probably more likely than the Newtown population to have betteraccess to care and a different set of exposure scenarios. Using an urban population for comparison ofcancer rates may mask or exaggerate expected cancer rates, and result in inaccurate analysis ofcancer incidence in this community.

ATSDR obtained additional cancer information from the Northeast Georgia Medical Center cancerregistry for cancers diagnosed from 1980 to 1996 in the Newtown community. This hospital waschosen because it is a public hospital within a quarter mile of the community. The most frequentlyoccurring cancers in this community were prostate cancers, colorectal cancers, breast cancer andcervical cancers. These cancers are among the most commonly reported cancers in the United States,and most are very common in aging populations. The median age in Newtown is about 5 years olderthan in the county (40.2 and 35 years of age, respectively). Incidence and death rates from cancerincrease markedly with advancing age. Because Newtown has a large elderly population, elevationsof certain types of cancer are expected in the community. With the exception of cancers of thebuccal cavity and pharynx, the cancer rates noted are within acceptable ranges given the age and sexdistribution of Newtown's population. No new cancers of the buccal cavity and pharynx have beendiagnosed in the community since 1987.

The lack of cancer patterns makes it difficult to draw conclusions about industrial emissions andtheir relationship to cancer incidence in this community. There were eighteen different types ofcancer observed in Newtown in the study period, and they follow the frequency patterns of theUnited States cancer rates. Cancers caused by contamination of the environment are usuallymarkedly present in highly elevated numbers, with only a single cancer or several related cancerspresent at abnormally high levels. ATSDR cannot associate such a wide distribution of differenttypes of cancers to environmental emissions when environmental exposures experienced by residentsin the past are unknown.

Morehouse School of Medicine-Hair Sample Collection

In April of 1994, a physician instructor at the Morehouse School of Medicine collected biologicalsamples of head hair from sixteen individuals in the Newtown Community. The study was intendedto screen nutrient mineral and toxic mineral levels in the hair of the subjects. ATSDR analyzed theraw data because no report of screening results was written. Levels of the following nutrientminerals were found in the hair of subjects at least fifty percent of the time, and at two standarddeviations above the mean of the EPA comparison population: calcium, magnesium, sodium,potassium, iron, and chromium. Chromium and calcium were the most commonly noted minerals,present approximately sixty-six percent of the time. Chromium was present mostly in young women,and could potentially be related to home or occupational exposure. Chromium levels reported werenot speciated, i.e. differentiated as to the type of chromium, and it is assumed that the reported levelswere for total chromium. Chromium absorption through occupational exposure is possible and hasbeen documented in many studies. For example, absorption of inhaled chromium followingoccupational exposure has been demonstrated by the measurement of chromium in serum, urine, andhair of workers in the leather tanning industry [30,31]. Chromium occurs naturally in theenvironment and has several forms. Chromium III is found in vitamins, dietary supplements, food,water, and air and is an essential nutrient for human survival. Chromium VI and chromium 0 aregenerally produced in industry. Chronic exposure to high levels of any form of chromium can beharmful [32].

Aluminum and nickel were present in approximately half of the subjects at levels two standarddeviations above the mean of the comparison population or more. However, because these metalswere not found to be highly elevated in other environmental media, ATSDR does not believe theelevations to be environmentally related. These minerals are also found in many popular multi-vitamins. One ten year old child was tested and had a significantly high elevation of lead in his hair,but further investigation would be necessary to determine the exposure route and if the exposure isenvironmentally related. The level of followup on this child is unknown.

Emory University-Systemic Lupus Erythematosus in Relation to Environmental Pollution: AnInvestigation in an African-American Community in North Georgia

A study of prevalence and incidence of lupus was conducted in Newtown by a medical resident andfaculty member at the Rollins School of Public Health in 1994 and 1995. Eighty-one householdswere surveyed, lending information on 246 residents. Attempts were made to interview everyhousehold by telephone. Lupus cases were verified with medical records.

The study found a six-fold increase in the prevalence of lupus in this community and a nine-foldincrease in incidence compared to rates in U.S. population studies. The comparison rates used in thisstudy were derived from three population studies and may not be representative of the trueprevalence and incidence of the disease in the United States. The researchers found three cases oflupus in the community and one case from a resident that had recently moved from the community.The study also gathered information on 12 past unconfirmed cases in residents who lived in thecommunity in the 1960s and 1970s. The researchers suggested that the prevalence and incidencecould be under-reported in this particular study, because only 81 of 143 households (56%) weresurveyed [4].

The exact cause of lupus is unknown. However, certain drugs have been shown to be linked tolupus, and it is possible that environmental toxins could induce lupus. The Arthritis Foundationreports that more than 70 drug agents can induce lupus; 90 percent of drug-induced lupus patientsdevelop the disease from one of six agents: procainamide, quinidine, hydralazine, phenytoin, D-penicillamine, or isoniazid. Other possible causes of lupus include family history of lupus, excessiveultra violet light exposure, chemical exposure (such as aromatic amines in drugs, food dyes, andcigarette smoke), infections (such as Epstein-Barr virus, parvovirus), estrogen containing hormones,exposure to hair dyes, and perhaps even certain forms of stress [33].

Lupus is more common in black females than in any other ethnic group, and minority womenconstitute the majority of lupus cases [34,35]. Actual rates are unknown, as prevalence studies aredifficult to conduct and current rates are based on studies with very small sample size andconsiderable variability. This study verified the presence of lupus in three residents and one previousresident. However, the small sample size and lack of sufficient environmental data to substantiateenvironmental relationships with lupus make it difficult to draw associations between disease in theNewtown community and environmental exposure.

Physical Hazards

Access to surrounding facilities is restricted by fences, however, at various times, fences in need ofrepair have allowed children to gain entry to the junkyard. The railroad track that passes directlybehind the playground and is along the southern most border of the community has a footpath nextto it that passes through and around some local facilities. The easy access to the train tracks could bedangerous to area children. Also, some residents report that glass fragments and pieces of brokenchina from the landfill are surfacing because of the shallow depth of the landfill. Some residents have also reported sinkholes where debris has settled from the landfill, creating potentially dangerous uneven ground and exposing landfill materials that were previously not exposed.


CONCLUSIONS

Overall, ATSDR categorizes this site as an Indeterminate Health Hazard to residents living in thecommunity. Although current data do not support evidence of widespread contamination, data areincomplete for some media and require further investigation.

  • Air
    • Ambient Air: Data suggest that ambient air contains many industrial contaminantsbelow levels of health concern. Therefore, there is no apparent current health threatfrom exposure to ambient air in the community as measured at the state monitoringstation. However, this monitoring station may not accurately reflect air qualityconditions in Newtown because of its location relative to the community and themeteorologic and geographic conditions of the area. Health implications of pastexposure are unknown due to the lack of adequate historical emissions and samplingdata.
    • Particulate Matter: Particulate matter data were not available for analysis in this report. Residential concerns about dust and how dust may affect respiratory health in the community could not be addressed without particulate data.
    • Past Air Emissions: Historical emissions data are not available for analysis. Without data, health implications of past exposure cannot be determined.

  • Soil
    • Surface Soil: Data collected for the community playground indicate that there is noapparent health hazard to children. Pica children who ingest large amounts of soilmay be exposed to elevated concentrations of metals, but it is not expected that thesechildren would be exposed to enough contaminated soil to warrant health concern.No additional surface soil (0-3") samples have been collected or analyzed within thiscommunity.
    • Subsurface Soils: Data collected in the soil boring analysis for subsurface soilsindicate no health threat to residents in the community. Although some levels areelevated, very few were above ATSDR comparison values. Residents are notexpected to be exposed to subsurface soils. Only two samples were analyzed forsomething other than metals, and they were both composite samples of the top foot ofsoil. The data are inadequate to permit accurate characterization of contamination inresidential soils, to which residents may be exposed.

  • Water
    • Groundwater: Groundwater data reviewed by ATSDR reported an elevated level ofchlorine and iron. However, since the Newtown Community is on a municipal watersupply, ATSDR has determined that exposure to contaminated groundwater ishighly unlikely. Groundwater is not a threat to health in this community.
    • Stormwater runoff: Contaminant levels of metals did not exceed ATSDRcomparison values in stormwater runoff. Chemical contamination of stormwaterrunoff does not appear to be a threat to human health. However, fecal coliformbacteria was found in unusually high levels. Exposure to contaminated stormwatercan result in gastrointestinal disorders and illnesses. Children can be exposed toillness-causing bacteria while swimming or playing in contaminated stormwaterrunoff. Elevated fecal coliform levels have been found consistently in stormwaterrunoff and in streams and creeks throughout Hall County.
    • Tap water: Lead levels were not found to be elevated in seven residential water taps. Tap water does not appear to be a source of lead exposure in this community.

  • Lead levels were elevated in the only child participant in the Morehouse hair sampling tests conducted. This may indicate another source of lead exposure to community children.

  • Previous health studies in this community were limited and did not investigate all health concerns of residents or lifestyle behaviors that may contribute to disease. Buccal and pharyngeal cancers and lupus have been determined to be elevated in this community in past health investigations.

RECOMMENDATIONS

  • Air: Continue ambient air monitoring for priority pollutants. Reevaluate the location of thepresent air monitoring station to more accurately assess environmental emissions of facilitiessurrounding the Newtown community, and move the monitor to a more appropriate locationif the current site is found to be unrepresentative of community ambient air conditions.Model potential past emission rates to reconstruct an estimate of past contaminantconcentration scenarios and potential human exposure.

  • Soil: Sample soil in the community at depths of 0-3 inches of soil, a depth at which people would be most likely to come into contact with contaminants. Discourage children from putting playground and residential soils in their mouths.

  • Water: Limit the access of children to stormwater runoff, particularly in summer months, to decrease the likelihood of exposure to fecal-contaminated stormwater. If children play in the runoff, they should wash their hands or shower immediately after exposure. The source of the high levels of fecal coliform in the stormwater runoff should be investigated.

  • If residents are concerned about children being exposed to lead, they should have blood tests conducted for children to determine if exposure has occurred.

  • Perform health education in Newtown on community health issues. These issues includelupus, cancer, and respiratory ailments.

PUBLIC HEALTH ACTION PLAN

Completed Activities:

  • ATSDR contacted the City of Gainesville regarding lead in tap water. The city tested the tap water of seven homes chosen by the petitioner.
  • ATSDR contacted the Georgia Department of Natural Resources and asked the department to inspect the Gainesville Scrap Iron and Metal Company. The company was found to be in violation of several mandated environmental requirements for similar facilities.
  • ATSDR contacted the University of Georgia Agricultural Department in response to the concerns of Newtown residents about the rodent problem. A professor and a rodent expert at the University agreed to have a clinic with the community to educate members about how to control the rodent population in their homes.
  • ATSDR contacted the National Center for Environmental Health and the Hall County Health Department to discuss the issue of child blood lead testing. Newtown children on Medicaid under 18 can have free blood lead tests done at the Hall County Health Department; other children can have the tests done for $10 each.
  • ATSDR conducted an exposure investigation for soils in January 2000 and retrieved the last air canister for analysis in May 2000.
  • ATSDR has evaluated all existing environmental data gathered in and around the Newtown Community as a basis for this health assessment.

Future Activities:

  • Public Health Assessment-ATSDR will address any public comments received about thepublic health assessment and prepare a final release to the public.
  • Georgia Department of Natural Resources, Air Quality Branch and ATSDR will investigatethe adequacy of the current air monitor location. If found to be unrepresentative of aircontamination within the community, the feasibility of moving the monitoring station to amore appropriate location within the Newtown Community will be investigated. ATSDRwill model industrial emissions from previous years to estimate past exposures. ATSDR willevaluate air modeling results in a health consultation when air modeling is completed.Included in that report will be a particulate matter analysis from data provided by theGeorgia Air Quality Branch.
  • Residents are currently pursuing grants to conduct surface soil (0-3") sampling inaccordance with an ATSDR recommendation.
  • The local health department will conduct blood lead testing in children under 18 years old ifparents are concerned about their children having exposure to lead. Medicaid recipients can have children tested without charge, and for those without Medicaid, the fee is $10 for each child.
  • ATSDR, Division of Health Education and Promotion, will pursue health educationactivities in the community in the form of physician and community education for lupus,cancer, and respiratory ailments.
  • University of Alabama Birmingham School of Public Health is in the process of analyzing a cross-sectional health study of residents in Newtown. The project is intended to include all Newtown residents and residents in neighboring communities.

AUTHORS/SITE TEAM

Prepared by:

Michelle A. Colledge, M.P.H.
Environmental Health Scientist
Petitions Response Section
Exposure Investigation and Consultation Branch
Division of Health Assessment and Consultation

David A. Fowler, Ph.D.
Environmental Health Scientist/Toxicologist
Petitions Response Section
Exposure Investigation and Consultation Branch
Division of Health Assessment and Consultation

Additional Team Members:

Gregory M. Zarus, MS
Atmospheric Scientist
Exposure Investigation Section
Exposure Investigation and Consultation Branch
Division of Health Assessment and Consultation

Jerome Cater, Ph.D.
Environmental Health Scientist/Immunologist
Health Consultation Section
Exposure Investigation and Consultation Branch
Division of Health Assessment and Consultation

Reviewed by:
Donald Joe, PE
Section Chief
Petitions Response Section
Exposure Investigation and Consultation Branch
Division of Health Assessment and Consultation

Captain John Abraham, PhD
Branch Chief
Exposure Investigation and Consultation Branch
Division of Health Assessment and Consultation


REFERENCES

  1. Petitioner letter. Written by Newtown Florist Club President. April 10, 1995.

  2. Spears, EG. The Newtown Story: One Community's Fight for Environmental Justice. Atlanta: Center for Democratic Renewal and the Newtown Florist Club, 1998.

  3. Cater, J and Gibeaut, D. Report to Petition Screening Committee. ATSDR. Nov 1997.

  4. Kardestuncer, T and Frumpkin, H. Systemic lupus erythematosus in relation to environmental pollution: an investigation in an African-American community in North Georgia. Archives of Environmental Health, March/April 1997: 52(2): 85-90.

  5. Newtown Florist Club. Newtown project: community information data. Gainesville, Georgia: 1990.

  6. Friddell, M. An investigation of environmental conditions at a previous landfill in the Newtown area of Gainesville, Georgia. Georgia Department of Natural Resources, Georgia Geologic Survey; 1993.

  7. Geology 801B. Site characterization report at the former Newtown Dump, Gainesville, Georgia. University of Georgia Geology Department; June 1994.

  8. Claritas, Inc. 1999 Population and Housing Estimates. Arlington, VA, 1999.

  9. Deutsch, John. Correspondence between John Cartwright and William Taylor. U.S. EPA, Region IV. July 6, 1995.

  10. United States Environmental Protection Agency. FAQ Sheet-Electricity and magnetic fields. Region 2, October 1998.

  11. Moulder, JE. Static electric and magnetic fields and human health. Medical College of Wisconsin, March 2000. Version 2.7.0

  12. Petridou, E et. al. Electrical power lines and childhood leukemia: a study from Greece. Int J Cancer 73:345-348, 1997.

  13. McBride, ML et. al. Power-frequency electric and magnetic fields and risk of childhood leukemia in Canada. Amer J Epidem 149:831-842, 1999.

  14. Green, LM et. al. A case-control study of childhood leukemia in southern Ontario, Canada, and exposure to magnetic fields in residences. Int J Cancer 82:161-170, 1999.

  15. Georgia Department of Natural Resources, Air Protection Branch. 1997 Priority pollutants monitoring station at the Fair Street School. January 1997-December 1997.

  16. Agency for Toxic Substances and Disease Registry. Newtown Community Exposure Investigation. Spring 2000.

  17. Ott MG et. al. Mortality among workers occupationally exposed to benzene. Arch Environ Health 1978; 33:3-10.

  18. Agency for Toxic Substances and Disease Registry. Benzene, Toxicological Profile. Department of Health and Human Services. Update, September 1997.

  19. Yin S et al. Symptoms and signs of workers exposed to benzene, toluene, and combination. Ind Health 1987; 25:113-120.

  20. U. S. Department of Health and Human Services, Public Health Service. Guidelines for protecting the safety and health of health care workers. Centers for Disease Control. NIOSH, September 1988.

  21. Surface water runoff in the Newtown community of Gainesville, Georgia-priority pollutants scan and conventional pollutants analysis. City of Gainesville Public Utilities Department, 1995.

  22. Correspondence between William J. Jernigan (Georgia Industrial Wastewater Program) and B.E. Ivey (Georgia Department of Human Resources), November 13, 1975.

  23. Telephone conversation between Michelle Colledge (ATSDR) and David Dockery (City of Gainesville Public Utilities Department); August 22, 2000.

  24. Parrot, K, Ross, B and Woodard, J. Bacteria and other microorganisms in household water. Centers for Disease Control and Prevention, Virginia Cooperative Extension. Publication number 356-487; October, 1996.

  25. Keene, WE et al. A swimming-associate outbreak of hemorrhagic colitis caused by escherichia coli and shigella sonnei. N Eng J Med 1994;331:579-84.

  26. Samonis, G. et al. An outbreak of diarrheal disease attributed to shigella sonnei. Epidemiol Infect 1994; 112:235-45.

  27. Sorvillo, FJ et al. Shigellosis associated with recreational water contact in Los Angeles county. Am J Trop Med Hyg 1988; 38:6613-7.

  28. Dockery, D. Residential lead testing. City of Gainesville, Public Utilities Department, 1999.

  29. McKinley, T and Williams, D. Newtown neighborhood cancer investigation, Gainesville Georgia. Georgia Department of Human Resources, Office of Epidemiology, 1990.

  30. Simpson, JR and Gibson, RS. Hair, serum, and urine chromium concentrations in former employees of the leather tanning industry. Biol Trace Elem Res; 32:155-159, 1992.

  31. Randall JA and Gibson, RS. Hair chromium as an index of chromium exposure to tannery workers. Br J Ind Med; 46:171-175, 1989.

  32. Agency for Toxic Substances and Disease Registry. Chromium, Toxicological Profile. Department of Health and Human Services. August 1998.

  33. Wallace, D. Lupus for the Non-Rheumatologist. Bulletin of Rheumatic Diseases for Evidence Based Management of Rheumatic Diseases. The Arthritis Foundation: 1999: Vol. 48, No. 9.

  34. Petri, M. The effect of race on incidence and clinical course in systemic lupus erythematosus: The Hopkins Lupus Cohort. Continuing Medical Education: Winter 1998.

  35. Krieg, A. Environmental factors and lupus. The Lupus Foundation of America, Lupus News. Vol. 11, No. 3.


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