Substances In Consumer Products Research Articles

Identification and semi-quantification of protein allergens in complex mixtures using proteomic and AllerCatPro 2.0 bioinformatic analyses: a proof-of-concept investigation

The demand for botanicals and natural substances in consumer products has increased in recent years. These substances usually contain proteins and these, in turn, can pose a risk for immunoglobulin E (IgE)-mediated sensitization and allergy. However, no method has yet been accepted or validated for assessment of potential allergenic hazards in such materials. In the studies here, a dual proteomic-bioinformatic approach is proposed to evaluate holistically allergenic hazards in complex mixtures of plants, insects, or animal proteins. Twelve commercial preparations of source materials (plant products, dust mite extract, and preparations of animal dander) known to contain allergenic proteins were analyzed by label-free proteomic analyses to identify and semi-quantify proteins. These were then evaluated by bioinformatics using AllerCatPro 2.0 (https://allercatpro.bii.a-star.edu.sg/) to predict no, weak, or strong evidence for allergenicity and similarity to source-specific allergens. In total, 4,586 protein sequences were identified in the 12 source materials combined. Of these, 1,665 sequences were predicted with weak or strong evidence for allergenic potential. This first-tier approach provided top-level information about the occurrence and abundance of proteins and potential allergens. With regards to source-specific allergens, 129 allergens were identified. The sum of the relative abundance of these allergens ranged from 0.8% (lamb’s quarters) to 63% (olive pollen). It is proposed here that this dual proteomic-bioinformatic approach has the potential to provide detailed information on the presence and relative abundance of allergens, and can play an important role in identifying potential allergenic hazards in complex protein mixtures for the purposes of safety assessments.

Managing PMT/vPvM substances in consumer products through the concepts of essential-use and functional substitution: a case-study for cosmetics.

Measures are needed to protect water sources from substances that are mobile, persistent and toxic (PMT) or very persistent and very mobile (vPvM). PMT/vPvM substances are used in a diverse range of applications, including consumer products. The combined application of the essential-use and functional substitution concepts has been proposed to phase out substances of concern and support the transition to safer and more sustainable chemicals, a key goal of the European Commission's Chemicals Strategy for Sustainability. Here, we first identified the market share of PMT/vPvM containing cosmetic products. We found that 6.4% of cosmetic products available on the European market contain PMT or vPvM substances. PMT/vPvM substances were most often found in hair care products. Based on their high occurrence, the substances Allura red (CAS 25956-17-6), benzophenone-4 (CAS 4065-45-6) and climbazole (CAS 38083-17-9) were selected as case-studies for assessment of their functionality, availability of safer alternatives and essentiality. Following the functional substitution framework, we found that the technical function of Allura red was not necessary for the performance of some cosmetic products, making the use non-essential. For other applications of Allura red, as well as all applications of benzophenone-4 and climbazole, the technical function of the chemical was considered necessary for the performance. Via the alternative's assessment procedure, which used experimental and in silico data and three different multicriteria decision analysis (MCDA) strategies, safer alternatives were identified for all case-study chemicals. All assessed uses of PMT/vPvM substances were thus deemed non-essential and should consequently be phased out.

Hormonal regulation of mammary gland development and lactation.

Lactation is critical to infant short-term and long-term health and protects mothers from breast cancer, ovarian cancer and type 2 diabetes mellitus. The mammary gland is a dynamic organ, regulated by the coordinated actions of reproductive and metabolic hormones. These hormones promote gland development from puberty onwards and induce the formation of a branched, epithelial, milk-secreting organ by the end of pregnancy. Progesterone withdrawal following placental delivery initiates lactation, which is maintained by increased pituitary secretion of prolactin and oxytocin, and stimulated by infant suckling. After weaning, local cytokine production and decreased prolactin secretion trigger large-scale mammary cell loss, leading to gland involution. Here, we review advances in the molecular endocrinology of mammary gland development and milk synthesis. We discuss the hormonal functions of the mammary gland, including parathyroid hormone-related peptide secretion that stimulates maternal calcium mobilization for milk synthesis. We also consider the hormonal composition of human milk and its associated effects on infant health and development. Finally, we highlight endocrine and metabolic diseases that cause lactation insufficiency, for example, monogenic disorders of prolactin and prolactin receptor mutations, maternal obesity and diabetes mellitus, interventions during labour and delivery, and exposure to endocrine-disrupting chemicals such as polyfluoroalkyl substances in consumer products and other oestrogenic compounds.

Introduction to a Special Issue on Regulatory Applications of Portable Tools and Methods to Monitor Toxic Substances in Consumer Products

No abstract

Trace chemicals in consumer products – Consumers’ acceptance before and after receiving information about toxicological principles

Toxicologists face several challenges when communicating with the public about the potential risks of chemical substances in consumer products. However, based on the consumers' scepticism and detachment from the use of chemical substances in the manufacturing of consumer goods, evidence is needed on how this communication can be improved. Hence, the goal of this study was to experimentally check the effect of an informational video on consumers' acceptance of trace chemicals in consumer products, their willingness to purchase and finally, their perception of the dose-response mechanism. For this, an informational video was developed and evaluated in a pre-post online study with a sample of South Korean consumers (N = 600). The results suggest that providing information on toxicological principles increases people's acceptance of trace chemicals in consumer products and their willingness to purchase a consumer product containing trace chemicals. Within the article, implications for practice and ideas for new research avenues are presented.

Modeling consumer exposure to spray products: an evaluation of the ConsExpo Web and ConsExpo nano models with experimental data.

To ensure safe use of chemical substances in consumer products, the exposure of consumers to these substances needs to be evaluated. For this purpose, generally consumer exposure modeling tools are used. To build confidence in such tools, evaluation of their performance with experimental data is indispensable. This work describes the evaluation of two consumer exposure modeling tools: ConsExpo Web and ConsExpo nano. Both models contain a module to estimate exposure of substances released as an aerosol during the use of spray products. This particular model was tested by comparing measured exposure data with model simulations. Experimental data were obtained from the public literature. These typically provide measured air concentrations under simulated use conditions of spray products. ConsExpo Web and ConsExpo nano were used to simulate experimental settings of the different studies. The resulting simulated air concentrations were compared with the reported ones. Overall, good agreement between modeled and measured data was observed. However, a significant proportion of the studies considered, did not provide sufficient detail in the specification of the experimental conditions to make them suitable for model evaluation. Critical information that was often lacking was on product composition, the mass sprayed during usage, and the generated aerosol size distribution.

Correction to: Consumer protection and risk assessment: sensitising substances in consumer products

Correction to:Allergo J Int 2019 28:167–182https://doi.org/10.1007/s40629-019-0093-3The article “Consumer protection and risk assessment: sensitising substances in consumer products”, written by Hermann-Josef Thierse and Andreas Luch, was originally published Online First without Open Access. …

Korean consumers\u2019 awareness of the risks of chemicals in daily consumer products

BackgroundRecent tragic accidents due to the use of humidifier disinfectants have caused severe distrust and anxiety over chemicals in consumer products in Korea. Therefore, a survey was conducted to determine consumer opinions about the risk of everyday chemical products used in Korea to assess what information should be provided to consumers via risk communication systems.ResultsAn online survey investigated the awareness of 10,000 Korean people regarding potentially harmful substances in consumer chemical products. Concern about the ingredients of chemical products was greatest for pesticides, air fresheners/deodorants, and cleaning agents. There was comparatively little concern about toiletries and personal care products. Respondents were aware of the presence of harmful substances from information on mass media and consumer/environmental organizations, and they also obtained information from ingredient lists and product packaging. Many participants thought that products made from natural materials and products with eco-friendly labeling did not contain harmful substances. Participants replied that they used potentially harmful products as little as possible to reduce the risk. Half of all respondents said that the manufacturers and retailers of products should take responsibility for reducing harmful substances in consumer products. Most respondents were not aware that they could make information disclosure requests for ingredients information.ConclusionThere are numerous concerns about chemicals in consumer products, but many people still do not know exactly what risks they pose. There is a need to communicate information about the risks of chemicals using the media and methods that people can understand.

[Assessment of consumer exposure to chemical agents on the example of the ConsExpo model].

Not only employees in industrial plants but also consumers, by using finished products, are exposed to chemical substances. Therefore, consumer exposure assessment is also important. To assess the risk for the consumer, the exposure magnitude is needed but measuring these values in residential conditions of consumers is usually impossible. ConsExpo has been designed to facilitate the exposure assessment to substances in consumer products. It is available in English as a free web application at www. consexpoweb.nl. The ConsExpo Web tool, developed by the Netherlands National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu), contains a set of models that help in the assessment of exposure to the substances in consumer products. These are mathematical models with increasing complexity, describing exposure by inhalation, dermal and oral routes. Available models are described in this work. ConsExpo is also equipped with a products database with defined exposure scenarios and default values, which could be a starting point for the models. The aim of this work was to review the literature regarding ConsExpo and to present the application to Polish users through the description of the models contained therein and by providing assessments examples. The review was based on databases of scientific journals. ConsExpo is a commonly known tool, and one of its applications is exposure estimation in comparative studies and the development of new models. For lower-tier analyses ConsExpo can be used by less advanced users. The most favorable for Polish users would be the creation of the Polishlanguage version of the ConsExpo application or a detailed Polish-language instruction manual. Med Pr. 2019;70(6):747-62.

Consumer protection and risk assessment: sensitising substances in consumer products

The human immune system is confronted daily with a large, chemically-varied range of potentially sensitising substances. Skin sensitising substances are found, above all, in a plethora of consumer products, e. g. cosmetics, jewellery, earrings, toys, textiles, leather, other everyday commodities and, in some cases, also tattoos. These products may contain sensitisers such as fragrances, preservatives, dyes, or other additives. To provide a greater degree of consumer protection, there is a need for specific legal regulation and risk assessment, which covers each possible human exposure to a sensitising substance or mixture. This review article describes the background and pathway towards the development and implementation of an international legal framework for the classification and labelling of chemicals that contain potentially skin sensitising substances. This includes the implementation of the globally harmonized system of classification and labelling of chemicals (GHS), the classification, labelling and packaging (CLP) regulation, registration, evaluation, authorisation and restriction of chemicals (REACH), and the regulation of cosmetics, among other national laws and regulations. Assessment criteria for classification is derived from a suite of in vitro and in vivo assays, in addition to in silico approaches—validated by the organisation for economic cooperation and development (OECD)—as well as data derived from human studies. New legislation for chemical and product safety is reflected in the classification and labelling of skin sensitising substances under Category 1, Subcategory 1A or 1B, within which the threshold concentrations of several materials are regulated, e. g. p‑phenylenediamine in hair dyes, nickel in piercings, chromium VI in leather and methylisothizolinone in cosmetics. In order to minimise the risk of human contact allergy from consumer products, the scientific committee on consumer safety (SCCS) and the German federal institute for risk assessment (BfR) investigate pathways of exposure and perform risk assessments using new in vitro approaches and new (immuno-) toxicological concepts (i. e. adverse outcome pathways [AOPs], key events as well as an integrated approach to testing and assessment [IATA]). In comparison to cosmetics, substances in textiles and other consumer products are less regulated. Major efforts in research and development are necessary to decode complex substance-specific molecular mechanisms in allergic responses and to define new substance-specific thresholds. Such efforts have been continuously proposed by the BfR with regard to fragrances for over 10 years. Today, skin sensitising substances can be legally regulated and labelled and, depending on the exposure, their content in consumer products can be reduced or eliminated. Furthermore, the risk assessment of potentially sensitising substances makes consumer products safer. Further improvements in research approaches are required in the area of health and consumer protection with regard to allergy.

Proteomic and Bioinformatic Analyses for the Identification of Proteins With Low Allergenic Potential for Hazard Assessment.

Use of botanicals and natural substances in consumer products has increased in recent years. Such extracts can contain protein that may theoretically represent a potential risk of IgE-mediated allergy. No method has yet been generally accepted or validated for assessment of the allergenic potential of proteins. For development of suitable methods datasets of allergenic and nonallergenic (or low allergenic) proteins are required that can serve, respectively, as positive and negative controls. However, data are unavailable on proteins that lack or have low allergenic potential. Here, low allergenic potential proteins are identified based on the assumption that proteins with established human exposure, but with a lack of an association with allergy, possess low allergenic potential. Proteins were extracted from sources considered to have less allergenic potential (corn, potato, spinach, rice, and tomato) as well as higher allergenic potential (wheat) regarding common allergenic foods. Proteins were identified and semi-quantified by label-free proteomic analysis conducted using mass spectrometry. Predicted allergenicity was determined using AllerCatPro (https://allercatpro.bii.a-star.edu.sg/). In summary, 9077 proteins were identified and semi-quantified from 6 protein sources. Within the top 10% of the most abundant proteins identified, 178 characterized proteins were found to have no evidence for allergenicity predicted by AllerCatPro and were considered to have low allergenic potential. This panel of low allergenic potential proteins provides a pragmatic approach to aid the development of alternative methods for robust testing strategies to distinguish between proteins of high and low allergenic potential to assess the risk of proteins from natural or botanical sources.

Determining Exposure Factors of Anti-Fogging, Dye, Disinfectant, Repellent, and Preservative Products in Korea.

Reliable exposure factors are essential to determine health risks posed by chemicals in consumer products. We analyzed five risk-concerned product categories (anti-fogging, dye, disinfectant, repellent, and preservative products) for 13 products (three car anti-fogging products, a lens anti-fogging product, two car dye products, two drain disinfectants, an air conditioner disinfectant, a chlorine-based disinfectant, a fabric repellent, an insect repellent for food, and a wood preservative) considered to be of high risk in order to determine exposure factors via web surveys and estimation of amount of product. Among the 3000 participants (1482 (49%) men) aged ≥19 years, drain disinfectants were used most frequently (38.2%); the rate of usage of the other products ranged between 1.1–24.0%. The usage rates for the consumer products differed by sex, age, income, and education. Some consumer products such as car and lens anti-fogging products, chlorine-based disinfectants, fabric repellents, and drain disinfectants were regularly used more than once a month, while car dye products, air conditioner disinfectants, insect repellents for food, and wood preservatives were not regularly used owing to the specific product purposes and seasonal needs. Our results could be used for managing or controlling chemical substances in consumer products and conducting accurate exposure assessments.

The Role of Healthcare Professionals in Environmental Health and Fertility Decision-Making

There is increasing evidence that raises specific concerns about prenatal exposures to toxic substances which makes it necessary to consider everyday exposures to industrial chemicals and toxic substances in consumer products, including endocrine disrupting chemicals. Pregnant women have measurable levels of numerous toxic substances from exposures in their everyday environments, including those which are associated with adverse developmental and reproductive health outcomes. As a result, environmental contexts have begun to influence the decisions women make related to fertility, as well as the formal guidelines and advice provided by healthcare professionals. This article provides an overview of the potential role for obstetricians and gynecologists in educating their patients about the role of toxic substances in fertility decision-making and pregnancy. It explores the emerging guidelines and recommendations from professional organizations and problematizes the limitations of these approaches.

The Increase in Bismuth Consumption as Reflected in Sewage Sludge

As the use of dangerous substances in consumer products increases, these substances may also be found in society’s end products, among them sewage sludge. Measuring concentrations in sewage sludge can be a way to reflect the consumption of a substance. By using substance flow analysis, the inflow, stock and outflow of the specific substance to, e.g. a city region, may be analysed. Bismuth is a heavy metal that is found in increasing levels in sewage sludge in Swedish wastewater treatment plants (WWTPs) and a similar increase cannot be excluded for WWTPs around the world. This study aims to examine possible sources that could explain the amounts measured in one Swedish WWTP. Household products such as cosmetics (24 %) and plastics (14 %) are found to be major sources of Bi measured in sewage sludge. The remaining unidentified amounts in this study (approximately 50 %) are most likely found in effluent waters from industries or sources outside the household. There is, however, no information on measurements of Bi released by industry available and there is no legislation in place that may encourage industry to conduct such measurements.

Perfluoroalkyl and polyfluoroalkyl substances in consumer products.

Perfluoroalkyl and polyfluoroalkyl substances (PFAS) are used in a wide range of products of all day life. Due to their toxicological potential, an emerging focus is directed towards their exposure to humans. This study investigated the PFAS load of consumer products in a broad perspective. Perfluoroalkyl sulfonic acids (C4, C6–C8, C10-PFSA), carboxylic acids (C4–C14-PFCA) and fluorotelomer alcohols (4:2, 6:2; 8:2 and 10:2 FTOH) were analysed in 115 random samples of consumer products including textiles (outdoor materials), carpets, cleaning and impregnating agents, leather samples, baking and sandwich papers, paper baking forms and ski waxes. PFCA and PFSA were analysed by HPLC-MS/MS, whereas FTOH were detected by GC/CI-MS. Consumer products such as cleaning agents or some baking and sandwich papers show low or negligible PFSA and PFCA contents. On the other hand, high PFAS levels were identified in ski waxes (up to about 2000 μg/kg PFOA), leather samples (up to about 200 μg/kg PFBA and 120 μg/kg PFBS), outdoor textiles (up to 19 μg/m2 PFOA) and some other baking papers (up to 15 μg/m2 PFOA). Moreover, some test samples like carpet and leather samples and outdoor materials exceeded the EU regulatory threshold value for PFOS (1 μg/m2). A diverse mixture of PFASs can be found in consumer products for all fields of daily use in varying concentrations. This study proves the importance of screening and monitoring of consumer products for PFAS loads and the necessity for an action to regulate the use of PFASs, especially PFOA, in consumer products.Electronic supplementary materialThe online version of this article (doi:10.1007/s11356-015-4202-7) contains supplementary material, which is available to authorized users.

Validation of an aggregate exposure model for substances in consumer products: a case study of diethyl phthalate in personal care products.

As personal care products (PCPs) are used in close contact with a person, they are a major source of consumer exposure to chemical substances contained in these products. The estimation of realistic consumer exposure to substances in PCPs is currently hampered by the lack of appropriate data and methods. To estimate aggregate exposure of consumers to substances contained in PCPs, a person-oriented consumer exposure model has been developed (the Probabilistic Aggregate Consumer Exposure Model, PACEM). The model simulates daily exposure in a population based on product use data collected from a survey among the Dutch population. The model is validated by comparing diethyl phthalate (DEP) dose estimates to dose estimates based on biomonitoring data. It was found that the model's estimates compared well with the estimates based on biomonitoring data. This suggests that the person-oriented PACEM model is a practical tool for assessing realistic aggregate exposures to substances in PCPs. In the future, PACEM will be extended with use pattern data on other product groups. This will allow for assessing aggregate exposure to substances in consumer products across different product groups.

Nonoccupational and occupational exposure to isocyanates

This review aims to update the knowledge on the burden of disease due to exposure to isocyanates. Health effects of isocyanates and their major products, polyurethanes, are mainly determined by sensitization to isocyanates. Recent studies on the genetic factors to explain individual susceptibility to sensitization are reviewed. Production of isocyanates has rapidly increased in the past and is predicted to increase at an annual rate of around 5%. Consumer products and the construction area are the main drivers of growth. This leads to increased nonoccupational exposure. The use of sprayed polyurethane foams for insulation in existing homes is one such example of nonoccupational exposure. The percentage of people exposed who show health effects is not known. Occupational exposure increases are mainly caused by the increase in the workforce. The percentage of workers exhibiting health effects remained fairly stable at 5-15% in the last decade. To explain why not all people exposed to isocyanates develop adverse health effects, recent findings on sensitization to isocyanate are reviewed. The skin is the most important route for sensitization. Increased production of isocyanates and rising use of these substances in consumer products is leading to an increased burden of disease, with an increase in nonoccupational exposure as well. Sensitization to isocyanates is the main route for adverse health effects. The skin is the major route for sensitization. Recently, several genetic factors have been identified that play a role in the individual susceptibility for sensitization.

The Individualization of Risk and Responsibility in Breast Cancer Prevention Education Campaigns

Breast cancer is the most commonly diagnosed cancer in women worldwide. The incidence rates are such that one in nine Canadian women will be diagnosed in her lifetime. While social science research has demonstrated the influence of social, political, economic and environmental factors on health outcomes, many still emphasize the role of traditional risk factors for breast cancer, such as family history or diet. However, these factors are unable to account for the increased incidence of the disease in industrialized countries. Thus, there is a call for more attention to environmental links to breast cancer, and as a result, it has become necessary to consider the ‘everyday exposures' that we experience in our daily lives, which often include mammary carcinogens and endocrine disrupting chemicals through exposure to industrial chemicals and toxic substances in consumer products. In this article, the author explores and critiques two breast cancer education campaigns which are promoted by the Canadian federal government and by mainstream breast cancer organizations. Both the responsibilization paradigm and the promotion of precautionary consumption practices engage with issues of risk and responsibility at the level of the individual. This focus on modifiable behaviours and lifestyle factors is highly problematic as it does not adequately account for other determinants of health, particularly those outside one's control, such as environmental contaminants. Only a truly precautionary approach can be effective in protecting women's health.

Determination of hexabromocyclododecane in coatings by gas chromatography-mass spectrometry

A method has been developed for the determination of hexabromocyclododecane (HBCD) in fire proof coatings by gas chromatography-mass spectrometry (GC-MS). The sample was extracted with dichloromethane and purified through an organic membrane before analysis with GC-MS. The characteristic fragments (m/z 157, 239, 319, 401) and the quantitative ion (m/z 239) were selected. With the optimized conditions, the good linear relationship was obtained between the peak area and the mass concentration of HBCD in the range of 5 to 100 mg/L with the correlation coefficient more than 0. 999. The spiked recoveries in the coatings of acrylic and epoxy resins were 92.9% - 116.3% with the RSDs not more than 8%. The LOD (S/N > or = 3) of HBCD was 30 microg/g, and the LOQ (S/N > or = 10) was 100 microg/g, which were much lower than the international maximum residue limit. The method is simple, quick, accurate and precise, which can meet the requirements of the European Commission Regulation (EC) No. 1907/2006 and Norway PoHS instruction (Prohibition on Certain Hazardous Substances in Consumer Products) for the determination of HBCD. It is suitable for the analysis of HBCD in fire proof coatings.

Toward Primary Prevention of Cancer: The Case for a Global Strategy to Limit Avoidable Exposures

Vol. 121, No. 4 News | Science SelectionsOpen AccessToward Primary Prevention of Cancer: The Case for a Global Strategy to Limit Avoidable Exposures Valerie J. Brown Valerie J. Brown Search for more papers by this author Published:1 April 2013https://doi.org/10.1289/ehp.121-a137View Article in:中文版AboutSectionsPDF ToolsDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InReddit At least one-third of all cancer cases worldwide could be prevented, according to recent estimates. Tobacco use, poor diet, physical inactivity, and other behaviors are some of the preventable risk factors involved; other cancers have been attributed to environmental exposures such as outdoor air pollution and occupational hazards such as asbestos, metals, and substances used in consumer products. An international team of public and occupational health experts from the World Health Organization (WHO), universities, and independent agencies now makes a case for a global strategy for preventing these exposures [EHP 120(4):420–426; http://dx.doi.org/1205897].The authors reviewed accounts of effective policies and interventions in PubMed as well as government and nongovernmental organization reports, and supplemented their data with recommendations from a WHO-sponsored conference held in March 2011. Most efforts now concentrate on secondary prevention and treatment, neglecting cost-effective primary prevention approaches, probably because the results are not easily quantifiable. Yet, the authors state, “Primary prevention that controls a common source of exposure to proven and probable carcinogens is far more effective and cost-effective than persuading thousands of persons to each change their individual behaviors.”Persuading people to change their behaviors for health reasons is not always efficient or cost-effective. But primary prevention measures that address communal exposures, such as instituting smoke-free public areas, can protect a large number of people—while potentially encouraging individuals to make healthy lifestyle changes.© Edyta Pawlowska/ShutterstockBut avoiding exposures to many carcinogens can be difficult. The public and workers are often ignorant of both their exposures and ways to prevent them. Further difficulty arises from the long latency period for many cancers, which tends to obscure the connection between exposure to carcinogens and later health effects. The researchers emphasize that widespread “invisible” exposures such as persistent organic pollutants and substances in consumer products should be addressed through policies that work across sectors including housing, food, energy production, and industry. In other words, preventing more cancer cases depends on addressing more sources of a given carcinogen.Yet, a broader perspective indicates there are many ways to reduce environmental risk factors, and some have multiple co-benefits, especially against noncommunicable diseases. For instance, the authors note that legislating smoke-free public places not only prevents secondhand cigarette smoke exposure but also encourages smokers to cut down or quit, potentially reducing cardiovascular disease risk. Likewise, reducing outdoor air pollution, particularly diesel exhaust, also reduces lung disease cases. What’s most needed, the authors say, is recognition that primary prevention is not only important but also feasible. With this recognition, as well as coordination of existing knowledge and tools, they believe primary prevention can become part of the policy framework for all governments.FiguresReferencesRelatedDetails Vol. 121, No. 4 April 2013Metrics About Article Metrics Publication History Originally published1 April 2013Published in print1 April 2013 Financial disclosuresPDF download License information EHP is an open-access journal published with support from the National Institute of Environmental Health Sciences, National Institutes of Health. All content is public domain unless otherwise noted. Note to readers with disabilities EHP strives to ensure that all journal content is accessible to all readers. However, some figures and Supplemental Material published in EHP articles may not conform to 508 standards due to the complexity of the information being presented. If you need assistance accessing journal content, please contact [email protected]. Our staff will work with you to assess and meet your accessibility needs within 3 working days.