1. CEDEP Regional Epi Meeting Montgomery Bell State Park April 30, 2014 Joe George, Sutapa Mukhopadhyay, David Borowski, Craig Shepherd – CEDEP - EEP ENVIRONMENTAL

3. Eve of Christmas Eve Dinner Extended family gathering 4 adults 2 children Chili, hot dogs, French fries, coleslaw An adult becomes violently ill Tingling in face Nausea Vomiting Diarrhea

4. …3 Hours Later… Seeks medical treatment at Veterans Affairs hospital Patient admitted December 2013 Ventilator Hospitalized 3 weeks Discharged in January 2014 Patient and family did not return to their home

5. Patient’s Medical/Social History Adult male – mid 40s Military Veteran Restricted diet Does not work Does not leave the house a great deal Something else…

7. A Household Mystery Veterans Affairs medical doctor requests assistance from TDH ENVIRONMENTAL Dr. May brought the case to EEP Metals testing revealed barium in blood Patient believed something in his home was causing his illness Home was new construction when purchased in October 2010 Symptoms began in January 2011 Illness continued while in home - hospitalized ~16 other times

8. Blood Barium Patient’s measured blood barium level ~14,000 ng/mL = 14,000 µg/L = 1,400 µg/dL ENVIRONMENTAL Published “normal ranges” in literature: 30 – 200 µg/L 30 – 290 µg/L 80 – 400 µg/L Level is 35 to 70 times higher than high end of “normal range”

9. What is Barium (Ba 2+ ) ? ENVIRONMENTAL A silvery-white metal Exists in nature in ores containing a mixture of elements Combines with other chemicals to form barium compounds Commercial Uses: drilling mud paint bricks ceramics pesticides medical tests (opaque medium)

10. Acute Barium Toxicity Symptoms: gastrointestinal disturbances (vomiting, abdominal cramps, diarrhea) muscle weakness (face numbness) paralysis changes in heart rhythm hypokalemic periodic paralysis Not likely to be carcinogenic to humans Do not know if children are more or less sensitive than adults

11. Patient must have recently ingested something to have elevated blood barium rat poison brazil nuts fireworks supplement seaweed fish major dietary sources such as milk, potatoes, and flour soil or water Suspected Sources ENVIRONMENTAL

12. EEP’s Investigation Conducted phone conferences with patient’s VA doctor Conducted phone conferences with TN Poison Center 85-question conference call survey with patient ENVIRONMENTAL

13. Survey included questions about: family house occupational history medical history military deployment history food habits social history/behaviors water source neighborhood hobbies travel history EEP’s Investigation ENVIRONMENTAL

14. Recommended patient be retested – VA will not test unless symptoms return EEP’s Investigation ENVIRONMENTAL Recommended other family members have blood tested – done Conferred with TDEC, ATSDR, TN Poison Center, and EPA Requested EPA Emergency Response assistance to investigate items in home Scheduled home visit

15. Home – Looking for a Clue Friday, February 28, 2014 EEP, EPA, and TDEC met patient’s wife at home – provided access EPA used portable X-ray Fluorescence unit XRF scanner measures many metals Patient stopped by State Lab analyzed soil, water, and dust

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18. Findings Nothing found in the home with XRF suggesting a source for patient’s elevated blood barium ENVIRONMENTAL Drinking water tested well below EPA’s MCL or RSL Soil tested well below EPA’s RSL Vacuum cleaner dust tested well below EPA’s RSL for soil

19. Follow Up Informed patient’s doctor at VA ENVIRONMENTAL Informed patient and family by phone and letter with analytical results of water, soil, and vacuum dust Informed TN Poison Center Will provide patient with EPA Site Investigation Report when available

20. Other Stuff Patient still believes the house is ENVIRONMENTAL We won’t know if patient’s illness and symptoms are related to barium unless patient gets sick and is tested again Reported case of intentional barium poisoning in TN Surveillance for heavy metals “suspect”

21. Uncertainties Blood tested only once for barium ENVIRONMENTAL Patient’s other medical conditions Chance for units of results to be misreported Chance for blood sample contamination No blood barium confirmation test No other family members ill

22. ENVIRONMENTAL