Reduction in urinary arsenic levels in response to arsenic mitigation efforts in Araihazar, Bangladesh.BACKGROUND: There is a need to identify and evaluate an effective mitigation MITIGATION. To make less rigorous or penal.
2. Crimes are frequently committed under circumstances which are not justifiable nor excusable, yet they show that the offender has been greatly tempted; as, for example, when a starving man steals bread to satisfy program for arsenic arsenic (är`sənĭk), a semimetallic chemical element; symbol As; at. no. 33; at. wt. 74.9216; m.p. 817°C; (at 28 atmospheres pressure); sublimation point 613°C;; sp. gr. (stable form) 5.73; valence −3, 0, +3, or +5. exposure from drinking water drinking water
supply of water available to animals for drinking supplied via nipples, in troughs, dams, ponds and larger natural water sources; an insufficient supply leads to dehydration; it can be the source of infection, e.g. leptospirosis, salmonellosis, or of poisoning, e.g. in Bangladesh.
OBJECTIVE: We evaluated the effectiveness of a multifaceted mul·ti·fac·et·ed
Having many facets or aspects. See Synonyms at versatile.
Adj. 1. multifaceted - having many aspects; "a many-sided subject"; "a multifaceted undertaking"; "multifarious interests"; "the multifarious mitigation program to reduce As exposure among 11,746 individuals in a prospective cohort study A cohort study is a form of longitudinal study used in medicine and social science. It is one type of study design.
In medicine, it is usually undertaken to obtain evidence to try to refute the existence of a suspected association between cause and disease; failure to refute initiated in 2000 in Araihazar, Bangladesh, by interviewing participants and measuring changes in urinary urinary /uri·nary/ (u´ri-nar?e) pertaining to, containing, or secreting urine.
1. Relating to urine and its production, function, or excretion.
2. As levels.
METHODS: The interventions included a) person-to-person reporting of well test results and health education; b) well labeling and village-level health education; and c) installations of 50 deep, low-As community wells in villages with the highest As exposure.
RESULTS: Two years after these interventions, 58% of the 6,512 participants with unsafe wells (As [greater than or equal to] 50 [micro]g) at baseline had responded by switching to other wells. Well labeling and village-level health education was positively related to switching to safe wells (As < 50 [micro]g/L) among participants with unsafe wells [rate ratio (RR) = 1.84; 95% confidence interval confidence interval,
n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. (CI), 1.60-2.11] and inversely in·verse
1. Reversed in order, nature, or effect.
2. Mathematics Of or relating to an inverse or an inverse function.
3. Archaic Turned upside down; inverted.
1. related to any well switching among those with safe wells (RR = 0.80; 95% CI, 0.66-0.98). The urinary As level in participants who switched to a well identified as safe (< 50 [micro]g As/L) dropped from an average of 375 [micro]g As/g creatinine creatinine /cre·at·i·nine/ (kre-at´i-nin) an anhydride of creatine, the end product of phosphocreatine metabolism; measurements of its rate of urinary excretion are used as diagnostic indicators of kidney function and muscle mass. to 200 [micro]g As/g creatinine, a 46% reduction toward the average urinary As content of 136 [micro]g As/g creatinine for participants that used safe wells throughout. Urinary As reduction was positively related to educational attainment Educational attainment is a term commonly used by statisticans to refer to the highest degree of education an individual has completed.
The US Census Bureau Glossary defines educational attainment as "the highest level of education completed in terms of the , body mass index, never-smoking, absence of skin lesions Skin Lesions Definition
A skin lesion is a superficial growth or patch of the skin that does not resemble the area surrounding it.
Skin lesions can be grouped into two categories: primary and secondary. , and time since switching (p for trend < 0.05).
CONCLUSIONS: Our study shows that testing of wells and informing households of the consequences of As exposure, combined with installation of deep community wells where most needed, can effectively address the continuing public health emergency from arsenic in drinking water in Bangladesh.
KEY WORDS: arsenic, Bangladesh, epidemiology epidemiology, field of medicine concerned with the study of epidemics, outbreaks of disease that affect large numbers of people. Epidemiologists, using sophisticated statistical analyses, field investigations, and complex laboratory techniques, investigate the cause , environmental epidemiology, intervention. Environ en·vi·ron
tr.v. en·vi·roned, en·vi·ron·ing, en·vi·rons
To encircle; surround. See Synonyms at surround.
[Middle English envirounen, from Old French environner Health Perspect 115:917-923 (2007). doi:10.1289/ehp.9833 available via http://dx.doi.org/ [Online 5 February 2007]
Arsenic is abundant in the earth's crust crust
Outermost solid part of the Earth, essentially composed of a range of igneous and metamorphic rock types. In continental regions, the crust is made up chiefly of granitic rock, whereas the composition of the ocean floor corresponds mainly to that of basalt and gabbro. and can be released to groundwater under certain conditions. In many parts of the world where groundwater is an important source of drinking water, As exposure has been linked to increased risks of skin lesions, skin cancer, internal cancers, and cardiovascular diseases Cardiovascular disease
Disease that affects the heart and blood vessels.
Mentioned in: Lipoproteins Test
cardiovascular disease (Chen et al. 1988, 1996; Haque et al. 2003). Widespread As exposure from drinking water in Bangladesh and several neighboring neigh·bor
1. One who lives near or next to another.
2. A person, place, or thing adjacent to or located near another.
3. A fellow human.
4. Used as a form of familiar address.
v. countries, in particular, is presently a public health emergency (Chakraborti et al. 2003). It has been estimated that > 50 million people have been chronically exposed to As by drinking groundwater with As concentrations exceeding the World Health Organization (WHO) standard (10 [micro]g/L) in Bangladesh alone (British Geological Survey The British Geological Survey (BGS) is a partly publicly-funded body which aims to advance geoscientific knowledge of the United Kingdom landmass and its continental shelf by means of systematic surveying, monitoring and research. 1999). Given the potential health consequences of As exposure, there is a need to identify and evaluate an effective mitigation policy that could potentially be implemented at the national scale.
Arsenic mitigation in Bangladesh is a multifaceted public health problem, requiring consideration of geological, engineering, economical, and cultural constraints CONSTRAINTS - A language for solving constraints using value inference.
["CONSTRAINTS: A Language for Expressing Almost-Hierarchical Descriptions", G.J. Sussman et al, Artif Intell 14(1):1-39 (Aug 1980)]. . There still is considerable debate about the technical advantages and pitfalls of various mitigation options in Bangladesh. Remediation options such as piped groundwater, rainwater harvesting Rainwater harvesting is the collection and storage of rain from roofs or from a surface catchment for future use. The water is generally stored in rainwater tanks or directed into mechanisms which recharge groundwater. , pond-sand filters, and the use of dug wells (Anstiss et al. 2001; Berg et al. 2006; Hassan 2005; Hoque et al. 2000, 2004) have been tested, but the record to date shows that they may not be safe, affordable, or sufficiently convenient (Ahmed et al. 2006). These remediation options, all of which require considerable maintenance, also deviate from the currently much more widespread practice of relying on hand-pumped tube wells, shallow or deep. This a concern because, from a public health standpoint, emergency interventions are best accomplished through an existing technology that has already been accepted (Smith et al. 2000), even if an adjustment to existing behavior is required. Several studies have indicated that intervention programs using health education and/or well labeling increase the awareness of As-related health problems (Hadi 2003; Hanchett et al. 2002). However, the effectiveness of such programs in reducing As exposure has rarely been evaluated at a large scale.
In 2000, researchers from Columbia University Columbia University, mainly in New York City; founded 1754 as King's College by grant of King George II; first college in New York City, fifth oldest in the United States; one of the eight Ivy League institutions. (CU) and partner institutions in Bangladesh established a large epidemiologic ep·i·de·mi·ol·o·gy
The branch of medicine that deals with the study of the causes, distribution, and control of disease in populations.
[Medieval Latin epid cohort study of 11,746 men and women to prospectively evaluate long-term health effects of As exposure through in-person biennial biennial, plant requiring two years to complete its life cycle, as distinguished from an annual or a perennial. In the first year a biennial usually produces a rosette of leaves (e.g., the cabbage) and a fleshy root, which acts as a food reserve over the winter. follow-up visits. At the same time, a mitigation program was initiated to promote switching to safe wells in order to reduce the continuing As exposure in the population. The impact of some of the component interventions evaluated on the basis of interviews has been reported previously for subsamples of the cohort cohort /co·hort/ (ko´hort)
1. in epidemiology, a group of individuals sharing a common characteristic and observed over time in the group.
2. (Madajewicz et al. 2006; Opar et al. 2007; Schoenfeld 2006). In this article we document for the first time the effectiveness of the mitigation program in terms of As exposure directly by comparing As concentration in the urine of cohort members at baseline and 2 years later. We also assess various host factors that may further influence urinary arsenic reduction in a subpopulation sub·pop·u·la·tion
A part or subdivision of a population, especially one originating from some other population: microbial subpopulations.
Noun 1. .
The Health Effects of Arsenic Longitudinal Study longitudinal study
a chronological study in epidemiology which attempts to establish a relationship between an antecedent cause and a subsequent effect. See also cohort study. . The principal aim of the Health Effects of Arsenic Longitudinal Study (HEALS) is to investigate health effects of As exposure from drinking water in a well-defined geographic area of 25 [km.sup.2] in Araihazar, Bangladesh. Details of the study methodologies have been presented elsewhere (Ahsan et al. 2006a; Parvez et al. 2006; van Geen et al. 2002). Briefly, before subject recruitment into the cohort, water samples were collected in two stages and geographic coordinates The quantities of latitude and longitude which define the position of a point on the surface of the Earth with respect to the reference spheroid. See also coordinates. were recorded for each well using handheld global positioning system Global Positioning System: see navigation satellite.
Global Positioning System (GPS)
Precise satellite-based navigation and location system originally developed for U.S. military use. (GPS) receivers. During the first stage (Figure 1), 4,999 contiguous Adjacent or touching. Contrast with fragmentation. See contiguous file. wells in the area were sampled in March-June 2000 (van Geen et al. 2002, 2003b). During the second stage, 978 wells were sampled in a contiguous region during November-December 2001 (van Geen et al. 2003b). Demographic information about the users of the 5,966 wells was collected during both stages to provide a sampling framework for HEALS (Parvez et al. 2006).
Eligibility criteria for recruitment in the cohort study during the baseline visits included being married (in order to increase stability of residence), being at least 18 years of age, and having resided in the study area for [greater than or equal to] 5 years. Upon verification of identity and eligibility of subjects, the interviewers explained the details of the study objectives and procedures. Because the average educational attainment was low in the population (50% did not have formal education), verbal consent was obtained from each eligible respondent In Equity practice, the party who answers a bill or other proceeding in equity. The party against whom an appeal or motion, an application for a court order, is instituted and who is required to answer in order to protect his or her interests. who agreed to participate in the study. Participants were given the option of participating with or without donating a blood/urine sample (Ahsan et al. 2006a). A total of 11,746 men and women (a participation rate of 97.5%) were recruited at baseline into the HEALS cohort between October 2000 and May 2002. The HEALS cohort has since been followed at 2-year intervals.
The first 2-year follow-up visit took place between June 2002 and June 2004 (Figure 1). At both baseline and follow-up visits, detailed information on demographics The attributes of people in a particular geographic area. Used for marketing purposes, population, ethnic origins, religion, spoken language, income and age range are examples of demographic data. , lifestyles, and well-water drinking history was collected with in-person interviews. Trained physicians who were blind to participants' As exposure status completed a comprehensive physical examination (Ahsan et al. 2006a). A spot urine sample was collected in 50-mL acid-washed tubes at baseline and the follow-up visits for 95.6% and 94.5% of the cohort participants, respectively. The study protocol and field procedures were approved by the CU Institutional Review Board and by the Ethical Committee of the Bangladesh Medical Research Council.
Arsenic mitigation under HEALS. Several As mitigation programs were implemented by the HEALS investigators, in part concurrently with the baseline recruitment of participants and follow-up (Figure 1).
In-person communication of test results and health education at baseline. After the completion of baseline physical examinations and interviews, all study participants received an individual health education session from trained interviewers concerning As concentrations in their well and potential health impacts related to As exposure. Participants who consumed well water with As concentrations [greater than or equal to] 50 [micro]g/L were specifically advised to switch, if possible, to nearby safer well(s), defined as wells with As concentrations < 50 [micro]g/L. Participants who consumed well water with As concentrations < 50 [micro]g/L were not advised to switch wells.
Well labeling and education campaign at the village level. During January-June 2001, in the area where the first stage of well water sampling took place, metal placards with As concentrations were posted on each well after testing. During the same period, an education campaign was launched at the village level. A team of three educators traveled from village to village. Through the use of skits, songs, and focus-group discussions, they disseminated disseminated /dis·sem·i·nat·ed/ (-sem´i-nat?ed) scattered; distributed over a considerable area.
Spread over a large area of a body, a tissue, or an organ. information on health problems related to As exposure in drinking water, the ineffectiveness of various popular ways of As removal (e.g., boiling water), the importance of switching wells to reduce As exposure, and the meaning of the metal placards posted on the wells. The team also advised that people with unsafe wells should change to a well with a lower level of As if a safe well (based on the Bangladesh standard of As < 50 [micro]g/L) was not available in the vicinity (Madajewicz et al. 2006). There was no village-level education in the smaller area where the second stage of well-water sampling took place, and these wells were not labeled until 2004 when the follow-up survey was completed.
Installations of deep low-As community wells. From 2001 to 2004, but primarily in 2003, a total of 50 deep, low-As community wells were installed across the 25-[km.sup.2] study area, generally in villages where As exposure was particularly high. A description of household response to the first 7 of these community wells has been described elsewhere (van Geen et al. 2003a). The depths of these 50 low-As wells ranged from 36 to 180 m; all community wells met the Bangladesh standard for As of 50 [micro]g/L, and only two did not also meet the WHO guideline guideline Medtalk A series of recommendations by a body of experts in a particular discipline. See Cancer screening guidelines, Cardiac profile guidelines, Gatekeeper guidelines, Harvard guidelines, Transfusion guidelines. for As of 10 [micro]g/L (Opar et al. 2007).
Independently of CU and its local partners, most wells within the study area were painted red or green in 2003 after testing with Hach field kits by NGO NGO
Noun 1. NGO - an organization that is not part of the local or state or federal government
nongovernmental organization (nongovernmental organization nongovernmental organization (NGO)
Organization that is not part of any government. A key distinction is between not-for-profit groups and for-profit corporations; the vast majority of NGOs are not-for-profit. ) workers hired under the Bangladesh Arsenic Mitigation and Water Supply Program (BAMWSP BAMWSP Bangladesh Arsenic Mitigation Water Supply Project ; 2007). Relative to the national standard for arsenic in drinking water of 50 [micro]g/L, these results agreed with our laboratory tests for 88% of a randomly selected subset A group of commands or functions that do not include all the capabilities of the original specification. Software or hardware components designed for the subset will also work with the original. of 799 wells (van Geen et al. 2005). The inconsistencies were primarily underestimates in the 50-100 [micro]g/L range of arsenic concentrations that resulted in unsafe wells being labeled as safe.
Measurements of As exposure. Water samples from all 5,966 tube wells in the study area were collected in 60-mL acid-washed bottles after pumping each well for 5 min (van Geen et al. 2003b). Total As concentrations were first determined by graphite graphite (grăf`īt), an allotropic form of carbon, known also as plumbago and black lead. It is dark gray or black, crystalline (often in the form of slippery scales), greasy, and soft, with a metallic luster. furnace furnace, enclosed space for the burning of fuel. There are many kinds of furnaces, the type depending upon the fuel and the use to which the heat produced within it is put. Most familiar are the furnaces used in the heating of buildings. atomicabsorption spectrometry spectrometry /spec·trom·e·try/ (spek-trom´e-tre) determination of the wavelengths or frequencies of the lines in a spectrum.
n. (GFAA GFAA Graphite Furnace Atomic Absorption
GFAA Game Fishing Association of Australia
GFAA Gainesville Fine Art Association (Florida) ) with a Hitachi Z-8200 system (Hitachi, Tokyo, Japan) at the Lamont-Doherty Earth observatory Lamont-Doherty Earth Observatory (LDEO) is a world-class research institution specializing in the Earth sciences and is part of Columbia University. The current director of Lamont is G. Michael Purdy. of CU (van Geen et al. 2002). Water samples found to have As concentrations at or below the detection limit of GFAA (5 [micro]g/L) were later reanalyzed by inductively-coupled plasma-mass spectrometry, which has a detection limit of 0.1 [micro]g/L (Cheng et al. 2004).
All urine samples collected at baseline and at follow-up visits were analyzed an·a·lyze
tr.v. an·a·lyzed, an·a·lyz·ing, an·a·lyz·es
1. To examine methodically by separating into parts and studying their interrelations.
2. Chemistry To make a chemical analysis of.
3. for total As concentration by GFAA using the Analyst 600 graphite furnace system (PerkinElmer, Wellesley, MA, USA), as previously described (Nixon et al. 1991). Urinary creatinine was analyzed using a method based on the Jaffe reaction Jaffe reaction
a method of creatinine assay based on the orange-red color produced by creatinine reacting with alkaline picrate. for adjustment of urinary total As concentration (Yu et al. 2002). The concentration of total As in urine has often been used as an indicator of recent exposure because urine is the main route of excretion excretion, process of eliminating from an organism waste products of metabolism and other materials that are of no use. It is an essential process in all forms of life. In one-celled organisms wastes are discharged through the surface of the cell. of most arsenic species. Therefore, we consider urinary As concentration to be a good measure of changes in As exposure over time.
Statistical analysis. We evaluated the determinants of switching wells in participants with safe and unsafe wells separately at baseline, because only the participants with unsafe wells were advised to switch. We defined a "safe well" according to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. the Bangladesh standard of < 50 [micro]g/L As in drinking water. Because switching wells is a dichotomized outcome and the analysis involved follow-up time, we used Cox proportional hazard models to compare the likelihood of switching wells among groups with different attributes. We computed rate ratios (RR) for any well switching in participants with safe wells at baseline, and RRs for switching to known safe wells in participants with unsafe wells at baseline. A total of 423 participants had either died (n = 104) or moved (n = 270) since recruitment or were lost at the time of the follow-up survey (n = 49); therefore, their well-switching status was treated as censored cen·sor
1. A person authorized to examine books, films, or other material and to remove or suppress what is considered morally, politically, or otherwise objectionable.
2. . We calculated person-years of observation from the date of baseline visit to the date of well switching (reported at the follow-up) for those who switched wells, to the date of follow-up visit for those who did not switch, to death date and date of move reported by close relatives or neighbors for those who had died and moved, respectively. For the 49 subjects who were lost to follow-up, person-years of observation were considered from baseline to the midpoint mid·point
1. Mathematics The point of a line segment or curvilinear arc that divides it into two parts of the same length.
2. A position midway between two extremes. between baseline and follow-up. Sensitivity analysis was conducted by excluding these subjects, and results did not change appreciably ap·pre·cia·ble
Possible to estimate, measure, or perceive: appreciable changes in temperature. See Synonyms at perceptible. (data not shown). We included a total of 11,280 participants in this analysis (96% of the overall participants); those with unknown values on any of the covariates (n = 466) were excluded from the analysis.
Urinary arsenic is a continuous variable, and therefore multiple linear regression Linear regression
A statistical technique for fitting a straight line to a set of data points. models were conducted to assess changes in urinary As level by baseline well-As level and switching status at follow-up. The underlying assumption of the models was that the relationship between variables is linear. Models were also run with log-transformed urinary As values; the results were similar and therefore are not shown. Participants with data on urinary As at both visits, known well-switching status, age, body mass index (BMI BMI body mass index.
body mass index
Body mass index (BMI)
A measurement that has replaced weight as the preferred determinant of obesity. ), and sex (n = 10,645; 90% of the overall participants) were considered in this analysis. Those who were excluded from the analysis did not differ appreciably from those included in the analysis with respect to demographic and lifestyle factors and arsenic exposure attributes (data not shown). To evaluate host factors that may influence urinary As reductions, we included participants with unsafe wells at baseline who switched to known safe wells (n = 1,517) because well As concentration at baseline and follow-up could be statistically held constant for this group. All analyses were performed using SAS (1) (SAS Institute Inc., Cary, NC, www.sas.com) A software company that specializes in data warehousing and decision support software based on the SAS System. Founded in 1976, SAS is one of the world's largest privately held software companies. See SAS System. , version 8.0 (SAS Institute SAS Institute Inc., headquartered in Cary, North Carolina, USA, has been a major producer of software since it was founded in 1976 by Anthony Barr, James Goodnight, John Sall and Jane Helwig. Inc., Cary, NC, USA).
As previously described (Ahsan et al. 2006b), the study population in general had a low educational level and included more females and middle-aged participants (Table 1). The distribution of sex, age, educational attainment, or land ownership does not differ appreciably by baseline well-As categories. Well labeling and the health education campaign at baseline covered a greater proportion of participants with low As exposure. The proportion of participants with unsafe and safe wells that switched to a new source of drinking water averaged 58% and 17%, respectively (Table 1). Among participants with unsafe wells, most participants that changed their source of water switched to safe wells that were either labeled or installed by CU, or installed by an NGO/DPHE (Department of Public Health Engineering) (27%). The next largest proportion of participants with unsafe wells switched to tube wells that had not been sampled at baseline (23%). Among participants with safe wells at baseline, the majority of participants who changed their source of water switched to a new tube well or another safe well labeled by CU. The majority (83%) of participants with unsafe wells at baseline who later switched wells did so because their wells were unsafe, whereas the majority (64%) of participants with safe wells at baseline who later switched wells stated they did so for convenience.
Among participants with unsafe wells at baseline, those with 5-9 and [greater than or equal to] 10 years of education were more likely to switch to safe wells (wells labeled by CU, installed by CU, or installed by an NGO/DPHE), compared with those with < 5 years of education; the associated RRs were 1.36 [95% confidence interval (CI), 1.17-1.58] and 1.61 (95% CI, 1.36-1.74), respectively (Table 2). Land ownership, on the other hand, was inversely related to switching to safe wells, although not at the statistically significant level of p < 0.05. Well labeling and the village-level health campaign were positively associated with subsequent switching to safe wells (RR = 1.84; 95% CI, 1.60-2.11). Higher baseline As concentration was also positively related to the likelihood of switching to safe wells. An estimate of the distance from each unsafe well to the nearest safe well was calculated on the basis of the available GPS data (van Geen et al. 2002). Participants with unsafe wells located within 50 m of a safe well were approximately 4 times more likely to switch to safe wells compared with participants with an unsafe well located [greater than or equal to] 100 m from a safe well. Among participants with safe wells at baseline, well labeling and the village-level health campaign were inversely related to switching wells (RR = 0.80; 95% CI, 0.66-0.98) (Table 2). In this group, no apparent relationships were observed between switching wells and educational attainment, baseline well As level, or distance to the nearest safe well among participants with safe wells. In both groups, the presence of lesions led to a somewhat higher proportion of switching wells (Table 2).
At baseline, urinary As concentration was on average nearly 3 times higher for participants using unsafe wells (397 [micro]g As/g creatinine) compared with those using safe wells (141 [micro]g As/g creatinine; Table 1). Average concentrations of As in unsafe and safe well water differed by more than an order of magnitude A change in quantity or volume as measured by the decimal point. For example, from tens to hundreds is one order of magnitude. Tens to thousands is two orders of magnitude; tens to millions is three orders of magnitude, etc. (171 and 15 [micro]g/L, respectively). At follow-up, urinary As levels in participants with unsafe wells at baseline dropped by 109 [micro]g As/g creatinine (Table 1). This reduction is attributable to switching wells (Figure 2). The average drop of urinary As in participants who switched to a safe well ranged from 29 to 65%, according to the types of wells participants switched to, with an overall average drop of 46% from 375 to 200 [micro]g As/g creatinine. Most significantly, the urinary As level dropped from 491 to 172 [micro]g As/g creatinine in participants who indicated that they had switched to deep, low-As community wells (Figure 2). The urinary As level in participants who switched to a new well or another unsafe well also decreased. Urinary As levels did not change appreciably in the population that continued to rely on a safe well or in participants with an unsafe well at baseline who had not switched to a different well (Figure 2).
The determinants of changes in urinary As were examined in greater detail for the 1,517 participants with unsafe wells who switched to known safe wells. We controlled for baseline urinary As level, baseline well As level, and well As level at the time of follow-up in the analysis to evaluate the influences of host factors on changes in urinary As in excess of what can be explained by differences in As exposure. The reduction in urinary creatinine-adjusted As was significantly greater in men (p for trend = 0.01) and in participants who had never smoked (p for trend = 0.03), had a higher BMI (p for trend = 0.01), had higher education higher education
Study beyond the level of secondary education. Institutions of higher education include not only colleges and universities but also professional schools in such fields as law, theology, medicine, business, music, and art. (p for trend = 0.01), and had no skin lesions at baseline (p = 0.04) (Table 3). The drop in urinary As increased with time elapsed e·lapse
intr.v. e·lapsed, e·laps·ing, e·laps·es
To slip by; pass: Weeks elapsed before we could start renovating.
n. since switching (p for trend = 0.02) but reached a plateau plateau, elevated, level or nearly level portion of the earth's surface, larger in summit area than a mountain and bounded on at least one side by steep slopes, occurring on land or in oceans. after a duration of [greater than or equal to] 12 months since switching wells. Within participants who switched from an unsafe to a safe well, the reduction in urinary As did not differ significantly by the distance to the nearest safe well, land ownership, or the status of well labeling and village-level health education.
The high proportion of the Bangladesh population that is exposed to arsenic by drinking water from tube wells remains a public health emergency. The present study is the first large prospective analysis to examine the effectiveness of an As intervention program in terms of well-switching behavior and changes in urinary As concentrations.
Among participants with unsafe wells at baseline, 58% switched to other wells at follow-up. The extent of well switching we recorded in the study area for the entire 2002-2004 period is consistent with smaller but more rapid surveys conducted in the same study area in 2002 (Madajewicz et al. 2006) and in 2004 (Opar et al. 2007). In a portion of Araihazar adjacent to the study area, where wells were tested under BAMWSP but the message was not reinforced through additional health education, only 27% of households stopped using 1,870 wells that had been tested to be unsafe (Schoenfeld 2006). In other parts of Bangladesh where blanket testing was conducted by UNICEF UNICEF (y`nĭsĕf'), the United Nations Children's Fund, an affiliated agency of the United Nations. , 38% of the test population switched from 6,359 unsafe wells (Sarker et al. 2005). These comparisons suggest that our team's continued presence in the study area significantly encourages switching of wells. The significant positive association between well labeling/village-level health campaigns and switching to safe wells among participants with unsafe wells (Table 2) confirms the reinforcing effect of these additional efforts.
Participants with unsafe wells who switched to new wells that were not tested by CU, but were possibly tested by BAMWSP, on average did not increase their exposure to As (Figure 2). However, the urinary As levels of these participants indicate that a significant number of these wells probably contain > 50 [micro]g/L As. These data emphasize that well testing should be made available on demand at the village level. The drop in urinary As among participants with unsafe wells who switched to a different unsafe well suggests that they sought wells with a lower As content than their own, albeit still unsafe. This is an argument for not only labeling wells as safe or unsafe but also for indicating each well's actual As level, as was done in our study area. The dose-response relationship The Dose-response relationship describes the change in effect on an organism caused by differing levels of exposure (or doses) to a stressor (usually a chemical). This may apply to individuals (eg: a small amount has no observable effect, a large amount is fatal), or to populations between baseline well As level and switching behavior among participants with unsafe wells at baseline (Table 2) also suggests that participants take into account the actual As concentration that was measured and not only its safe/unsafe status.
Consistent with previous analyses of subpopulation in the study area (Madajewicz et al. 2006; Opar et al. 2007; Schoenfeld 2006), we found that switching wells drops off rapidly when safe wells are located [greater than or equal to] 100 m away. The largest drop in urinary As observed in those villages where participants benefited from the installation of a community well is consistent with the consumption of water with high As (mean 258 [micro]g/L) at baseline and < 10 [micro]g/L at follow-up (van Geen et al. 2006). In view of the particularly beneficial effect of community wells that are periodically monitored (van Geen et al. 2006), the spatial density of such wells in different villages should be calculated to minimize the number of households that live > 100 m from a safe water source. The large existing database of close to 5 million well tests compiled under BAMWSP could be used effectively to produce such estimates and help target those aquifers The following is a partial list of aquifers around the world. A of aquifers is also available.
We observed positive relationships of switching to safe wells and urinary As reduction with educational attainment but not with land ownership (Tables 2 and 3). Persons with higher educational attainment may be more responsive to health education and intervention. On the other hand, persons who own land may be less likely to switch wells because they may tend to use their own well located in the property. Such relationships between well switching and different indicators of socioeconomic status socioeconomic status,
n the position of an individual on a socio-economic scale that measures such factors as education, income, type of occupation, place of residence, and in some populations, ethnicity and religion. need to be considered in the plan and design of intervention programs.
BMI was positively related to urinary As reduction. A high BMI in Bangladesh is an indicator of a better nutrition status, which may influence the excretion of As. Smoking of tobacco products and presence of skin lesions were inversely associated with the reduction of total urinary As, indicating that these factors may be related to a higher body burden of As or a reduced clearance of As from the body. These observations are consistent with our previous findings of a synergistic effect Synergistic effect
A violation of value-additivity in that the value of a combination is greater than the sum of the individual values. of high level of As exposure with tobacco smoking and low BMI on the risk of skin lesions (Ahsan et al. 2006b; Chen et al. 2006).
It is worth noting that there was considerable overlap between the timing of the various interventions and when the baseline data were collected (Figure 1). Wells were labeled and participants were exposed to village-level health education before collection of the majority of baseline urine samples. The installation of most of the deep community wells took place in 2003, after the follow-up survey for a considerable number of participants, and the associated change in behavior and reduction in urinary As level may not have been fully captured. In addition, although the initial half-life of As is short (Buchet et al. 1981; Pomroy et al. 1980), the literature has documented that the human body stores substantial amounts of As (Farmer and Johnson 1990) and may excrete excrete /ex·crete/ (eks-kret´) to throw off or eliminate by a normal discharge, such as waste matter.
To eliminate waste material from the body. it in urine over a period of time, even after the exposure has ceased (Aposhian et al. 1997). Therefore, the urinary As level in persons with high exposure who switched to safe wells may not immediately respond to a drop in well As level. Together, these considerations suggest that the effectiveness of the intervention in reducing urinary As level may therefore be somewhat underestimated in the present study.
Switching to a safe well can reduce urinary As to levels almost as low as that observed in residents consuming water with < 50 [micro]g/L. The large drop in urinary As for participants who switched from an unsafe well to a known safe well, almost to levels in the control population, is very encouraging. On the basis of these observations, we urge a revision of the governmental policy to reinforce the effectiveness of a community-based mitigation program that relies on deeper, low-As aquifers (Ahmed et al. 2006). Significant As contamination in deep aquifers is unlikely unless large amounts of water are withdrawn for irrigation irrigation, in agriculture, artificial watering of the land. Although used chiefly in regions with annual rainfall of less than 20 in. (51 cm), it is also used in wetter areas to grow certain crops, e.g., rice. (Zheng et al. 2005). Additional governmental efforts may therefore have to be considered to manage irrigation (Ahmed et al. 2006).
Our findings not only indicate that response surveys based on interviews are reliable but they also suggest a decrease in an internal biomarker biomarker /bio·mark·er/ (bi´o-mahr?ker)
1. a biological molecule used as a marker for a substance or process of interest.
2. tumor marker.
1. of exposure that may lead to future health benefits. Several studies have suggested that As mitigation eventually reduces As-associated morbidity morbidity /mor·bid·i·ty/ (mor-bid´it-e)
1. a diseased condition or state.
2. the incidence or prevalence of a disease or of all diseases in a population.
n. . Pi et al. (2005) found that a 13-month period of consuming low-As water improved the vascular vascular /vas·cu·lar/ (vas´ku-ler)
1. pertaining to vessels, particularly blood vessels.
2. indicative of a copious blood supply.
adj. response to cold stress in Inner Mongolia Inner Mongolia
Chinese Nei Mongol or Nei-meng-ku
Autonomous region (pop., 2002 est.: 23,790,000), China. Stretching some 1,800 mi (2,900 km) across north-northeastern China, it has an area of 454,600 sq mi (1,177,500 sq km); its capital is Hohhot. , China. Another study in Chile found that provision of water with low As (45 [micro]g/L) for 8 weeks was associated with a decrease in micronucleated cells in exfoliated bladder bladder /blad·der/ (blad´er)
1. a membranous sac, such as one serving as receptacle for a secretion.
2. urinary bladder. cells (Moore et al. 1997). On the other hand, a reduction in ischemic heart disease Ischemic heart disease
Insufficient blood supply to the heart muscle (myocardium).
Mentioned in: Myocarditis
ischemic heart disease mortality and kidney cancer Kidney Cancer Definition
Kidney cancer is a disease in which the cells in certain tissues of the kidney start to grow uncontrollably and form tumors. mortality was observed only decades after tap water (As free) was provided in an arseniasis-endemic area in Taiwan (Chang et al. 2004; Yang yang (yang) [Chinese] in Chinese philosophy, the active, positive, masculine principle that is complementary to yin; see yin, under principle. et al. 2004). We recently described a dose-response relationship between prevalence of As-related skin lesions and As exposure at baseline even at water As levels < 50 [micro]g/L (Ahsan et al. 2006b). The average time of exposure to baseline wells (8 years) was relatively longer than the average duration of switching wells (1.9 years). The extent to which As-related morbidity and mortality Morbidity and Mortality can refer to:
adj capable of going through a series of changes in either direction, forward or backward (e.g., reversible chemical reaction).
n See hydrocolloid, reversible. by the reduction of As exposure awaits further examination with a longer follow-up of the population. The cost-effectiveness or cost-benefit issues also need to be addressed to evaluate the overall impact on the society when such data are available in the future.
Removal of As from groundwater, or human pathogens from surface water, is economically and culturally challenging, particularly on a large scale (Ahmed et al. 2006). Based on the quantitative evidence presented here, it appears that testing and monitoring of wells managed at the village level, combined with judicious ju·di·cious
Having or exhibiting sound judgment; prudent.
[From French judicieux, from Latin i installation of low-As deep community wells in high exposure areas, could rapidly reduce As exposure at the national scale.
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Historically, the ruler or monarch of a Mongol tribe. Early on a distinction was made between the title of khan and that of khakan, or “great khan.” Later the term khan was adopted by the Seljuq and Khwarezm-Shah dynasties as a title for the highest AW, Arewgoda M. 2001. A sustainable community-based arsenic mitigation pilot project in Bangladesh. Int J Environ Health Res 11:267-274.
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see blow dart.
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1. having no organs.
2. not of organic origin.
1. arsenic and its metabolites Metabolites
Substances produced by metabolism or by a metabolic process.
Mentioned in: Interactions after repeated ingestion ingestion /in·ges·tion/ (-chun) the taking of food, drugs, etc., into the body by mouth.
1. The act of taking food and drink into the body by the mouth.
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Haque R, Mazumder DN, Samanta S Samanta is an Indian noble title. In the Hoysala empire, samantas were feudal chiefs paying vassalitic homage to the Maharaja. In the Nepali realm of the Maharaja of Licchavi, samantas held feudal domains but also played a mayor part at court. , Ghosh N, Kalman D, Smith MM, et al. 2003. Arsenic in drinking water and skin lesions: dose-response data from West Bengal West Bengal: see Bengal.
State (pop., 2001: 80,176,197), northeastern India. It is bordered by Nepal and Bangladesh and the states of Orissa, Jharkhand, Bihar, Sikkim, Assam, and Meghalaya and has an area of 34,267 sq mi (88,752 sq km); , India. Epidemiology 14:174-182.
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Harmful effects of arsenic compounds (in pesticides, chemotherapy drugs, paints, etc.), most often from insecticide exposure. Susceptibility varies. Arsenic is believed to combine with certain enzymes, interfering with cellular metabolism. in Bangladesh: spatial mitigation planning with GIS (1) (Geographic Information System) An information system that deals with spatial information. Often called "mapping software," it links attributes and characteristics of an area to its geographic location. and public participation. Health Policy 74:247-260.
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1. in ciliate protozoa, the smaller of two types of nucleus in each cell, which functions in sexual reproduction; cf. macronucleus.
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MMH Monomethyl Hydrazine
MMH Morristown Memorial Hospital (Morristown, New Jersey)
MMH Master of Management in Hospitality
MMH Maintenance Man-Hours
MMH Manchester Memorial Hospital , Matin mat·in also mat·in·al
Of or relating to matins or to the early part of the day.
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New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of :Columbia University.
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n. Abbr. TNF
A protein that is produced in the presence of an endotoxin, especially by monocytes and macrophages, is able to attack and destroy tumor cells, and exacerbates chronic inflammatory diseases. alpha release See alpha version. and tumor necrosis factor receptor A tumor necrosis factor receptor (TNFR) is, as its name would indicate, a receptor which binds tumor necrosis factors (TNF).
Because "TNF" is often used to describe TNF alpha, "TNFR" is often used to describe the receptors that bind to TNF alpha - namely, CD120. 1 signaling in T helper cell T helper cell
see helper lymphocyte. apoptosis apoptosis
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Yu Chen, (1,2) Alexander van Geen, (3) Joseph H. Graziano, (4) Alexander Pfaff, (5) Malgosia Madajewicz, (6) Faruque Parvez, (4) A.Z.M. Iftekhar Hussain, (7) Vesna Slavkovich, (4) Tariqul Islam Mohammad Tariqul Islam is a First class and List A cricketer from Bangladesh. He was born on 2nd February 1972 in Rajshahi and is a right handed batsman and off break bowler. , (8) and Habibul Ahsan (1,9)
(1) Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA; (2) Department of Environmental Medicine and New York University New York University, mainly in New York City; coeducational; chartered 1831, opened 1832 as the Univ. of the City of New York, renamed 1896. It comprises 13 schools and colleges, maintaining 4 main centers (including the Medical Center) in the city, as well as the Cancer Institute, New York University School of Medicine, New York, New York, USA; (3) Lamont-Doherty Earth Observatory of Columbia University, Palisades, New York Palisades, New York is a very small hamlet, part of the Town of Orangetown, located in southeastern Rockland County, New York. It borders the Hudson River to the east, Rockleigh and Alpine New Jersey to the south, Tappan to the west, and Sparkill to the north. , USA; (4) Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, USA; (5) The Earth Institute, Columbia University, New York, New York, USA; (6) Department of Economics, School of International and Public Affairs, Columbia University The School of International and Public Affairs (SIPA) of Columbia University is a public policy school in the United States and one of the most prestigious schools of international affairs and/or public affairs in the world. , New York, New York, USA; (7) National Institute of Preventive and Social Medicine, Dhaka, Bangladesh; (8) Columbia University Arsenic Research Project, Dhaka, Bangladesh; (9) Departments of Health Studies, Medicine, and Human Genetics Human genetics
A discipline concerned with genetically determined resemblances and differences among human beings. Technological advances in the visualization of human chromosomes have shown that abnormalities of chromosome number or structure are surprisingly , University of Chicago Cancer Research Center, Chicago, Illinois, USA
Address correspondence to H. Ahsan, Department of Health Studies, The University of Chicago, 5841 South Maryland Ave., Suite N102, Chicago, IL 60637 USA. Telephone: (773) 834-9956. Fax: (773) 834-0139. E-mail: firstname.lastname@example.org
We thank our staff, field workers, and study participants in Bangladesh, without whom this work would not have been possible.
This research was supported by grants P42ES10349, P30ES09089, and ES000260 from the National Institute of Environmental Health Sciences The National Institute of Environmental Health Sciences (NIEHS) is one of 27 Institutes and Centers of the National Institutes of Health (NIH),which is a component of the Department of Health and Human Services (DHHS). The Director of the NIEHS is Dr. David A. Schwartz. , and grants R01CA107431, R01CA102484, and CA016087 from the National Institutes of Health.
The authors declare they have no competing financial interests.
Received 16 October 2006; accepted 5 February 2007.
Table 1. Baseline and follow-up characteristics by baseline well As levels. <50 [micro]g/L Characteristic (a) (n = 5.234) Baseline characteristics Percent male 42.8 Years of age (%) 17-39 60.6 40-59 37.2 60-75 2.2 Mean [+ or -] SD 37.1 [+ or -] 10.1 Health education/well labeling (%) Yes 85.4 Acres of land owned (%) 0 49.4 [less than or equal to] 1 32.2 > 1 16.0 Amount unknown 2.3 Years of education (%) 0 44.3 < 6 29.3 6-9 15.2 [greater than or equal to] 10 11.2 Mean [+ or -] SD 3.5 [+ or -] 3.9 Mean well As ([micro]g/L) 14.9 Presence of As-related skin 4.4 lesions (%) Creatinine-adjusted urinary As 141.7 [+ or -] 115.7 [[micro]g/g creatinine (mean [+ or -] SD)] Distance to the nearest safe 14.8 [+ or -] 13.7 well [meters (mean [+ or -] SD)] Follow-up characteristics Time since baseline [months 23.5 [+ or -] 5.3 (mean [+ or -] SD)] Creatinine-adjusted urinary As 136.3 [+ or -] 108.1 [[micro]g/g creatinine (mean [+ or -] SD)] Changes in creatinine-adjusted -6.2 [+ or -] 107.4 urinary As [[micro]g/g creatinine (mean [+ or -] SD)] (b) Switching status (%) Did not switch 82.7 Switched to a safe well 5.7 labeled by CU Switched to a community well 0.0 installed by CU Switched to an NGO well 0.4 Switched to an unsafe well 0.9 labeled by CU Switched to new tube wells 10.4 Reasons for switching, within those who switched (%) Well not safe 5.8 Smell/taste not good 5.7 Deleterious relations with 5.7 neighbor/owner Well no longer exists 4.2 Well does not work 14.7 For convenience 63.8 [greater than or equal to] 50 p- Characteristic (a) [micro]/L (n = 6,512) Value Baseline characteristics Percent male 43.0 0.78 Years of age (%) 17-39 60.4 40-59 37.3 60-75 2.3 Mean [+ or -] SD 37.0 [+ or -] 10.1 0.58 Health education/well <0.01 labeling (%) Yes 78.8 Acres of land owned (%) 0 51.8 0.08 [less than or equal to] 1 30.6 > 1 15.6 Amount unknown 2.0 Years of education (%) 0 44.9 0.58 < 6 29.8 6-9 14.7 [greater than or equal to] 10 10.7 Mean [+ or -] SD 3.4 [+ or -] 3.8 0.09 Mean well As ([micro]g/L) 171.1 <0.01 Presence of As-related skin 9.4 <0.01 lesions (%) Creatinine-adjusted urinary As 397.1 [+ or -] 324.0 <0.01 [[micro]g/g creatinine (mean [+ or -] SD)] Distance to the nearest safe 48.5 [+ or -] 38.7 <0.01 well [meters (mean [+ or -] SD)] Follow-up characteristics Time since baseline [months 25.3 [+ or -] 7.0 0.39 (mean [+ or -] SD)] Creatinine-adjusted urinary As 291.9 [+ or -] 265.6 <0.01 [[micro]g/g creatinine (mean [+ or -] SD)] Changes in creatinine-adjusted -108.6 [+ or -] 319.9 <0.01 urinary As [[micro]g/g creatinine (mean [+ or -] SD)] (b) Switching status (%) <0.01 Did not switch 41.9 Switched to a safe well 20.3 labeled by CU Switched to a community well 4.1 installed by CU Switched to an NGO well 2.4 Switched to an unsafe well 8.7 labeled by CU Switched to new tube wells 22.6 Reasons for switching, within those who switched (%) Well not safe 83.4 <0.01 Smell/taste not good 1.5 Deleterious relations with 0.8 neighbor/owner Well no longer exists 1.3 Well does not work 3.2 For convenience 9.7 (a) Data on education level were missing for 5 subjects with safe wells (<50 [micro]g/L As) and for 4 subjects with unsafe wells ([greater than or equal to] 50 [micro]g/L As) at baseline; data were unknown on baseline skin lesion status for 138 and 75 subjects, respectively; data were missing for baseline urinary As for 378 and 148 subjects; data were missing on distance to the nearest safe well for 136 and 101 subjects; data were missing on follow-up urinary As for 340 and 299 subjects; and data were missing on well-switching status for 314 and 271 subjects, respectively. (b) Changes in creatinine-adjusted urinary As = follow-up - baseline. Table 2. Associations of switching wells with sociodemographics and As- related variables. Participants with a safe well at baseline (a) Switched to any well RR for Yes (% switching Baseline characteristic of total) (b) Total (b) (95% CI) Education (years) 0 16.3 2,241 1.00 1-4 18.6 1,485 1.17 (0.98- 1.37) 5-9 15.1 768 0.96 (0.77- 1.19) [greater than or equal to] 10 13.7 554 0.92 (0.71- 1.19) Land owned (acres) 0 17.8 2,505 1.00 [less than or equal to] 1 16.2 1,616 0.92 (0.78- 1.07) > 1 14.0 813 0.83 (0.67- 1.04) Amount unknown 9.7 114 0.53 (0.29- 0.97) Baseline skin lesion status No 16.2 4,828 1.00 Yes 22.7 220 1.56 (1.16- 2.10) Health education and well labeling No 17.1 756 1.00 Yes 16.4 4,292 0.80 (0.66- 0.98) Baseline well As ([micro]g/L) < 10 16.1 2,631 1.00 10-24 17.5 1,006 1.07 (0.90- 1.28) 25-49 16.6 1,411 0.97 (0.82- 1.14) 50-99 100-299 300-499 [greater than or equal to] 500 Distance to nearest safe well (m) [greater than or equal to] 100 0.0 10 1.00 50-99 13.2 211 25-49 18.5 552 1.38 (0.90- 2.09) < 25 16.4 4,275 1.22 (0.83- 1.78) Participants with an unsafe well at baseline (a) Switched to RR for a safe well switching to Yes (% a safe well Baseline characteristic of total) (b) Total (b) (95% CI) Education (years) 0 23.4 2,777 1.00 1-4 25.1 1,867 1.14 (1.01- 1.28) 5-9 28.2 916 1.36 (1.17- 1.58) [greater than or equal to] 10 30.1 672 1.61 (1.36- 1.92) Land owned (acres) 0 25.3 3,216 1.00 [less than or equal to] 1 25.9 1,920 0.93 (0.83- 1.04) > 1 24.8 977 0.83 (0.71- 1.01) Amount unknown 21.9 119 0.75 (0.51- 1.11) Baseline skin lesion status No 25.0 5,656 1.00 Yes 28.5 576 1.15 (0.99- 1.38) Health education and well labeling No 16.8 1,338 1.00 Yes 27.7 4,894 1.84 (1.60- 2.11) Baseline well As ([micro]g/L) < 10 10-24 25-49 50-99 23.0 1,988 1.00 100-299 25.6 3,433 1.38 (1.23- 1.55) 300-499 29.3 724 1.62 (1.37- 1.90) [greater than or equal to] 500 34.5 87 1.85 (1.26- 2.72) Distance to nearest safe well (m) [greater than or equal to] 100 11.3 648 1.00 50-99 20.8 1,691 2.22 (1.72- 2.86) 25-49 30.0 1,886 3.71 (2.90- 4.73) < 25 29.2 2,007 3.95 (3.09- 5.06) (a) RRs were adjusted for all variables in the table and additionally for age and sex. A total of 11,280 subjects were included in the analysis; participants with unknown information for any of the covariates were excluded from the analysis. (b) "Total" indicates the number of participants with the attribute, and "% of total" indicates the percentage of persons with that attribute that switched wells. Table 3. Determinants of urinary As changes (follow-up--baseline) among participants with an unsafe baseline well who switched to a safe well (n = 1,517). Adjusted changes in urinary p-Values creatinine-adjusted As (a) for trend Characteristics No. Mean SD test Sex Female 885 -171.4 13.0 0.01 Male 632 -186.4 12.4 Education (years) 0 621 -159.2 13.6 0.02 1-4 451 -170.1 13.7 5-9 249 -165.0 15.2 [greater than or equal to] 10 196 -200.6 16.6 Land owned (acres) 0 790 -162.0 11.0 0.93 [less than or equal to] 1 470 -160.3 11.8 > 1 234 -155.6 13.9 Amount unknown 23 -216.9 33.0 Age (years) < 30 385 -166.2 15.0 0.45 30-39 511 -175.9 14.1 40-49 403 -165.5 13.8 [greater than or equal to] 50 218 -187.2 15.7 BMI < 17.6 402 -155.5 14.2 0.02 17.6-19.2 401 -172.9 14.6 19.3-21.5 349 -186.3 14.4 [greater then or equal] 21.6 365 -180.1 14.3 Baseline smoking status Never-smokers 999 -189.6 13.0 0.03 Past smokers 93 -171.2 19.3 Current smokers 425 -160.3 14.7 Baseline skin lesion status No 1,357 -186.8 11.8 0.04 Yes 160 -160.6 16.4 Health education and well labeling No 217 -172.7 15.4 0.73 Yes 1,300 -174.7 12.1 Time since switching wells (months) < 6 126 -160.3 17.0 0.03 6-11 117 -156.2 18.4 12-17 364 -180.1 14.2 18-23 507 -185.1 13.9 [greater than or equal to] 24 403 -186.8 15.0 Distance to the nearest safe well (m) < 25 560 -166.1 13.0 0.44 25-49 548 -180.9 12.9 50-99 339 -171.8 14.4 [greater than or equal to] 100 70 -176.0 21.7 (a) Follow-up - baseline; means were adjusted for all variables in the table and baseline urinary creatinine-adjusted As, baseline well As, and well As level in the wells participants switched to.