WHAT WAS ACCOMPLISHED UNDER THESE GOALS?
During the third year of the U01 and U2R grants, outstanding progress has been made in meeting the research and research training goals. In summary:
• Eight (8) doctoral-level trainees, including individuals from Ghana, Côte d’Ivoire, Senegal, and Benin, have completed, or will have completed by June 30, 2018, four month stints of intensive, customized research training in North America: six at the University of Michigan and two at McGill University. In addition, one senior mentor from Ghana spent the first month of the four month program at the University of Michigan. [The content of this training is described in greater detail in section B.4 of this progress report.]
• Data collection for Rounds 2 (rainy season July and August 2017) and 3 (Harmattan winds ‘season’ January and February 2018) were successfully completed, with some challenges due to higher than expected loss to follow-up rates. These challenges were successfully addressed, bringing the total number of participants in the study from Agbogbloshie to 154 workers, and the comparison group residing in Madina-Zongo to 74 individuals.
• Data from Rounds 1, 2, 3 have been entered, cleaned, and undergone analyses. These data include survey instruments, spirometry, cardiovascular endpoints, analysis of blood and urine samples for metals and organic compounds, and both fixed site and personal breathing zone measures of size-specific particulate.
• New partnerships have been forged and additional postdocs, doctoral students, and master’s students have been recruited to and supported on the parallel U2R and U01 grants.
Field Data Collection:
The diagram (Figure 1) above illustrates the breakdown of tasks (workflow) during field data collection. As shown in Station 1, a participant enters the study after informed consent and participant registration, which culminates in the creation of a personal biodata file. Upon completion of registration, the subject is handed copies of the complete surveys (including a check-list of tasks to be accomplished at each of the remaining six (6) stations) and proceeds to Station 2. At Station 2, anthropomorphic/physical measurements are taken and then the subject proceeds to the next stage, until all stations are visited. After Station 6 (the last station), the subject returns to Station 1, with the check-list for an audit of the completed tasks. Once the auditor is satisfied that the subject has been seen at all the work stations and has completed all the tasks required at each station, the auditor schedules the subject for backpack and personal air monitoring data.
We faced some unexpected challenges with initially higher than expected loss to follow-up rates in the later rounds of the study, reflecting the nature of the informal sector work environment. Notably, most of the Agbogbloshie workers, as well as a substantial fraction of the Madina-Zongo comparison group, are internal migrants who were involved with subsistence farming in the northern part of Ghana and then came to Accra to work on e-waste recovery and other activities. A number of these individuals, during Round 2 or Round 3, had returned temporarily to northern Ghana to help manage crops. With the assistance of a number of the respected leaders among the Agbogbloshie workers, we were able to locate many of these workers in the north of Ghana and obtain their consent to return to Accra to participate in the next round of the study. As described further below, we also made use of durbars (community meetings) to help improve enrollment and attainment of study participants. Thus, we were able to enroll new subjects to replace most of those who remained lost to follow-up (see Table 1 below).
Table 1: Summary of subject participation in each round of data collection.
*New subjects enrolled in Round 2 and 3 to replace those lost to follow-up.
Revisions to the study design:
• The originally planned study design was to have most workers from Agbogbloshie represent a true inception cohort, i.e., to enroll most study participants over a 12 month period as they first arrived at the site to do electronic waste recovery work, with the second and third rounds of data collection, for these individuals, to occur at 12 months and 24 months after entry into the study (requiring a total of three years of data collection). However, prior to initiating the study, through more detailed discussions with the leaders of the Agbogbloshie workers, it became evident that there was no tracking system available to identify new workers as they first arrived on the site, making it impossible, in practice, to enroll such an inception cohort. We amended the study design, while still collecting three rounds of data from each individual in the study, to a strategy of enrolling all study participants and collecting data at an accelerated rate to enable additional time for data cleaning, management, and analysis during the five-year grant period, while also being able to investigate and adjust for seasonal differences in exposures. Specifically, we enrolled study participants over a three week period during the dry season in Accra (Year 2), brought back participants for a second round of data collection during the rainy season, and for a third round of data collection during the Harmattan (winds blowing from desert areas north of Ghana increasing background PM levels) season (Year 3).
• During the first round of data collection we obtained only baseline spirometry from each participant. To increase the sensitivity to detect potential acute respiratory effects of exposures during the day, for Rounds 2 and 3, we obtained both a pre-shift and a post- shift spirometry. Pre- and post-shift spirometry collection occurred on the same day that the participant was wearing a customized backpack that provided personal breathing zone filter-based measures of PM2.5, real-time once per minute measures of size specific PM using an Aerocet device, and a mounted camera taking a photograph what the individual was looking at, also once per minute.
• During Round 2 data collection, we had an unexpectedly high percent of subjects lost to follow-up (subjects who could not be located or who declined participation in this round). However, we were successful in recruiting new subjects to replace many of those lost to follow-up. The initial subject loss to follow-up rate in Round 3 data collection also has been higher than projected. Lastly, because of the higher than expected loss to follow-up in rounds described in the paragraph above, and to help ensure that we would have adequate numbers of subjects who would participated in at least two, or, preferably, three rounds, so that we can adequately evaluate seasonal impacts, we plan to initiate a 4th round of data collection in July and August 2018. This 4th round will help ensure that we have adequate numbers of subjects with three rounds of data collection. In addition, this introduction of a 4th round of data collection will also enable us to include additional types of data collection of primary interest to colleagues from the National Cancer Institute with whom we are collaborating -- much of the new data to be collected will also be useful in our evaluation of nonmalignant respiratory health outcomes (See section further below on New Opportunities).
In preparation for the third round of sampling to coincide with the Harmattan winds, we organized two major community engagement durbars (public meetings which e-waste workers, community members, and government agencies along with study staff discuss, learn, and comment on the study) at both Agbogbloshie and Madina-Zongo communities in December 2017. During these durbars, workers were screened for malaria and given a blood glucose test. A medical doctor (Dr. Afua Amoabeng) was present to review and discuss results with workers (ECGs, blood glucose, etc.) and provide standard medical treatment, if requested (i.e. basic prophylaxes and anti-malaria medication). Dr. Amoabeng also followed up to link to medical facilities and practitioners for those workers who appeared to need ongoing medical care for an identified problem.
Data and Laboratory Analyses Samples were shipped to McGill University, in Montreal, Canada, for metal analysis. The remainder of the samples were shipped to the University of Michigan, in Ann Arbor, Michigan, primarily for organic analyses. It should be noted that, at both institutions, trainees from West Africa have directly participated in conduct and interpretation of laboratory analyses under the supervision of Prof. Stuart Batterman at University of Michigan and Prof. Nil Basu at McGill University.
University of Michigan
Particulate matter data (PM2.5, some TSP = total suspended particulate) for Rounds 1 to 3 have been processed, and concentrations are available for personal samples and for area samples (fixed site samples). Personal samples are shift samples, based on typically 3-4 hours of the workday; area samples integrate over 24 hours. PM2.5 results are summarized in Table 2 (below), and show elevated PM2.5 levels for workers (averaging 122 ug/m3 based on 252 valid shift samples) relative to the control community (averaging 46 ug/m3 based on 90 valid samples). The personal samples tend to be considerably elevated over ambient measurements, which are taken at an upwind site (averaging 32 ug/m3), a downwind site (averaging 53 ug/m3, and at a mosque at the e-waste facility (averaging 87 ug/m3). Elevated background levels are suggested in Round 3, and is likely to be the Harmattan dust cloud, and possibly additional burning taking place near the upwind site.
Additional PM data was collected and processed as measured using real-time optically-based measurements for PM1, PM2.5, PM4, PM10 and TSP at both fixed and personal samples. These data have been processed for Round 1 and parts of Round 2. They show high correlation with the filter-based PM2.5 data, and also with 1-min stop motion photos collected each minute on the workers. Together, these data are being used to identify pollutant exposures during specific tasks. Approximately 12,000 photos from Round 1 have been reviewed and processed. Similar numbers of photos and real-time PM data are available for Rounds 2 and 3, but have not been processed.
The air pollution data also includes measurements of formaldehyde and volatile organic compounds (100 compounds) at fixed sites. These samples have been processed and were unremarkable; elevated levels were not observed.
Biological samples from Rounds 1 to 3 have been obtained, and plasma for Round 1 has been processed for three groups of organic compounds. This includes valid samples from 85 workers and 54 individuals in the reference community. These have been analyzed by GC/MS for three broad groups of contaminants: halogenated compounds including pesticides (e.g., pentachlorobenzene, alpha-HCH, hexachlorobenzene, B-HCH, Aldrin, dachtal, octachlorostyrene, B-heptachlorepoxide, oxychlordane, trans-G-chlordane, cis-A-chlordane, trans-G-nonachlor, dieldrin, p,p'-DDE, endrin, cis-nonachlor, p, p'-DDD, p,p'-DDT, TBBPa); brominated compounds (TBBPa and 20 PBDE congeners), and PCBs (16 congeners). In addition, lipids content was determined. For most compounds, several individuals had unusually high levels, however, overall levels in the two groups (workers and reference population) appear fairly similar; statistical analysis is ongoing.
Summary of research on personal inhalation exposure and time-lapse photography:
In rounds two and three of the study, three items were collected from subjects during the personal air sampling: a) photos (1/minute), using a Go-Pro camera mounted to the front straps of the backpack, of current activities, b) a personal breathing zone PM2.5 collection filter, and c) real-time optical size specific PM using Aerocet. We used the time-lapse photography from the personal GoPro cameras to generate time-activity patterns (TAPs) and combine them with the continuous PM readings in order to describe differences in PM2.5 and PM10 (µg/m3) across work activities (e.g. burning, dismantling, collecting, or sorting), non-work activities (e.g. resting, eating, praying) and transportation (walking, bicycling, driving) on- and off- the e-waste work site. The TAPs generated from the photos are the product of an iterative process that included interviewing e-waste workers to validate activity assignments. The PhD student, Zoey Laskaris, leading this research and two trained undergraduate students at the University of Michigan categorized 443 activities from 12,620 photos among 57 study e-waste worker participants. To summarize our preliminary unadjusted results, we found that among the work-related activities, burning e-waste is associated with the highest median PM2.5 and PM10 concentrations (99.8 and 301.4 µg/m3 respectively) followed by collecting, sorting, and loading (59.7 and 171.8 µg/m3). However, many of the non-work activities, such as eating and drinking (median PM2.5: 61.5 µg/m3) and resting (median PM2.5: 50.8 µg/m3) on the e-waste site are equally as high. These findings emphasize the need to not only reduce exposure generated from work activities but also to isolate workplace exposures from life activities and the broader community.
Spriometry results are currently under review.
Blood and urine samples from Round 1-3 were sent to McGill University and all have been digested for metals analyses.
We have measured a panel of metals in blood and urine from Round 1. We have relatively good quality data for urinary copper, zinc, cadmium, and arsenic. We have relatively good quality blood data for calcium, magnesium, copper, zinc, silver, cadmium, lead, iron, and selenium.
Samples from Rounds 2 and 3 will be processed in the coming months. There is a technical issue with the ICPMS, which is being resolved.
Sample Round 1 data has been cleaned and is currently being finalized by Sylvia Takyi (PhD student from the University of Ghana.
Training and Capacity Building (more details in Section B.4):
In August 2017, two additional full-time doctoral students were recruited at the University of Ghana. This brings the number of full-time PhD students, at the University of Ghana, receiving support from the grant to six (6).
May 2018, eight (8) promising M.Sc dissertation research topics, closely related to e-waste work at Agbogbloshie, were selected for a dissertation research support award to fund their field work/data collection (see Table 2).
Two scholars, Sylvia Takyi (University of Ghana) and Karel Houessionon (University of Abomey at Calavi, Cotonou) arrived at McGill University in mid-January 2018. They are part of first cohort of scholars travelling to North America for their intensive 4-month training program.
At the beginning of March 2018, a second group of six (6) scholars (Augustine Acquah, Lawrencia Kwarteng and Dr. Afua Amoabeng, from the University of Ghana; Comfort Kugblenu, from the Ghana Health Service; Fatou Sylla, from Cheikh Anta Diop University in Senegal; and Ahua Rene Kouao, from the Universite Felix Houphouet-Boigny in Cote d’Ivoire) arrived at the University of Michigan to embark upon their 4-month intensive training program.
In keeping with the initial training program agreements, Dr. John Arko-Mensah, senior mentor from the University of Ghana, arrived in Michigan for 1 month (March 2018) to work with his North American counterparts, Drs. Tom Robins and Stuart Batterman, as well as the scholars. Dr. Arko-Mensah met with scholars on a regular basis, attended classes and workshops with them, and provided valuable feedback during discussions, to aid in refining their project designs and project proposals.
After a pre-inception meeting with collaborators at Kwame Nkrumah University of Science & Technology (KNUST), a committee was formed on March 3, 2016 (Year 2) to develop a research training and teaching curriculum in Occupational and Environmental Health Sciences (OEHS) under the chairmanship of Dr. Samuel Newton, the local PI for the GeoHealth program. Other members of the committee were Dr. Jonathan Hogarh, from the College of Science, Dr. Easmon Otupiri, Dean of the School of Public Health, and Dr. Peter Agyei Barfour, also of the School of Public Health. The curriculum for the Master of Science/Master of Public Health in Occupational and Environmental Health was completed and presented to the Resource and Planning Committee of KNUST in January 2018 (Year 3). This new program has now received approval. The new program in Occupational and Environmental Health Sciences (OEHS) has been advertised in the Daily Graphic and on the KNUST website for the 2018/2019 academic year. A first batch of 15 applicants were interviewed for admission into the program in early May 2018. A second interview was scheduled in mid-May 2018 for another set of applicants and a maximum of 25 applicants are expected to be admitted.
At University of Abomey at Calavi (UAC), Cotonou, and other participating Francophone institutions, across the five (5) countries (Benin, Cameroon, Nigeria, Cote d'Ivoire, and Senegal), there are total of 7 doctoral students and postdoctoral fellows that have received different combinations of tuition fees, stipend/subsistence, and research cost support, while making sure that each of the five (5) countries receive at least one slot for four months of intensive research training in North America. Of the seven (7) doctoral students/postdoctoral fellows, three (3) of them - one each from Benin (Gédéon Karel Houessionon), Cote d’Ivoire (Ahua Rene Kouao), and Senegal (Fatou Sylla), are among the first cohort of trainees sent to North America.
At the University of Ibadan (UI) in Nigeria one (1) M.Sc students and one (1) PhD student have received tuition/research support under this grant. At the Dschang University in Cameroon, one (1) M.Sc student and one (1) PhD student has received tuition/research support.
[Lastly, of interest, supported by an entirely separate funding stream (GIZ in Germany) from those of NIH and IDRC, a sod cutting ceremony was held at the Agbogbloshie site in Accra in May 2018, to signify the commencement of construction of a health post and training workshop. This facility will provide opportunities for e-waste workers to receive first aid treatment for minor injuries, as well as provide training opportunities for the acquisition of new skills that will enable them expand their opportunities for various types of work.]
Strategy and Capacity building meetings:
At the annual GEOHealth grantees networking meeting, in Bethesda, MD in October 2017, four (4) of our senior hub members (Drs. Julius Fobil, Thomas Robins, Nil Basu and Stuart Batterman) attended and made presentations on the West Africa-Michigan GEOHealth activities. Following this meeting, U01 PI (Julius Fobil) attended the annual meeting of the International Federation of Clinical Chemists (IFCC) held in Durban, South Africa to network and to identify new opportunities for collaborations for analyzing stored biological samples.
At a joint international conference of the Public Health Foundation of India (PHFI) and the Pacific Basin Consortium (PBC), held in New Delhi, India (November 2017), the U01 PI (Julius Fobil) participated and presented on the West Africa GEOHealth hub activities. The immediate outcome of participation in this conference was interaction and engagement between GEOHealth hubs. This provided an opportunity for two members of the GEOHealth West Africa hub (one doctoral and an M.Sc student) to participate in a short course on air pollution modelling, organized by the Indian GEOHealth hub in January 2018.
On April 24, 2018, three (3) members (Julius Fobil, Stuart Batterman and Thomas Robins) of the GEOHealth team, and 6 doctoral students/scholars, attended a 3-day international expert meeting held in Ann Arbor, Michigan on the theme: “Changing the global cycle of e-waste”. The first full-day public event provided an excellent opportunity to our scholars, where experts in sustainability, population health, policy, and design processes led discussions on the complex issues surrounding global production and transportation of electronic waste and its impact in vulnerable communities around the world. This international, interdisciplinary symposium included representatives from UM’s School of Public Health, the Ford School of Public Policy, College of Engineering, and the School of Natural Resources and Environment. Internationally, there were representatives from Kasetsart University and Mae Fah University in Thailand, Kalasin Provincial Public Health Office and the Thai National Ministry of Public Health, University of Chile, Plataforma RELAC (Regional Platform for Electronic Residues in Latin America and the Caribbean), from ACCIONA: Sustainable Infrastructure and Renewable Energy and the University of Ghana. Ms. Comfort Kugblenu, Ms. Lawrencia Kwarteng, Dr. Afua Amoabeng, and Mr. Augustine Acquah, along with Dr. Stuart Batterman, Dr. Julius Fobil, Dr. Thomas Robins and Ms. Zoey Laskaris, subsequently attended the 2-day (April 25-26th) working meeting to address specific aspects of e-waste. One important outcome of this meeting was serious discussion and early planning for a study to assess the impact of interventions designed to reduce exposures both to informal sector electronic waste workers and to surrounding communities, with a primary focus on the Agbogbloshie site in Accra, together with possible inclusion of sites in Thailand and Chile.
In early February 2018, a concurrent U2R + U01 joint meeting took place to discuss initial data analyses and an update of the status and progress of U01 field research activities. This was held in Ann Arbor, Michigan between the two PIs (Drs. Thomas Robins and Julius Fobil) and two other project personnel (Dr. Stuart Batterman and Zoey Laskaris – a doctoral student). Following the meeting in Ann Arbor, the core project team, Drs. Thomas Robins, Niladri Basu and Julius Fobil, travelled to the National Cancer Institute (NCI) in Rockville, Maryland and the World Bank Headquarters in Washington, D.C. where we participated in meetings in connection with forging new collaborations with the West African Hub. The principal interest of a partnership with the NCI focuses on pooling resources to conduct methylation and metabolomics on the stored/reserve samples from each round of sampling. The World Bank offers expertise and resources to create new opportunities for both partners by collaborating with our team on their new GEF project (https://www.thegef.org/project/ehpmp-environmental-health-and-pollution-...).
Following an agreement to partner with NCI, to conduct metabolomics and methylation analyses on the samples collected, an amendment to the U01 protocol was made to reflect these new analyses. The amended protocol was submitted to the Protocol & Ethical Review Committee (PERC) at the University of Ghana, College of Health Sciences, in mid-March 2018.
In line with the amendments to the U01 protocol to incorporate metabolomics and methylation analyses, one of the UG doctoral students (Dr. Afua Amoabeng) and U01 PI (Julius Fobil) visited the National Cancer Institute (NCI) and received training on the application of the U01 amended protocol sections, at the end of April 2018. During this training instruction was given on how to collect buccal scrapings, buccal rinses, and nasal scrapings. The training focused on preparations prior to sample collection, collection, and post processing (before storage) and then, transportation and storage procedures.
Sample collection is expected to commence in July 2018. This will also provide us the opportunity to collect a 4th Round of data from our participants. NCI’s interest in data from e-waste workers coincides with the interest of our group. As we have previously mentioned there was some loss to follow-up of participants during Round 2 and 3 and partnering with NCI for a 4th round of data collection will help us reach our goal of 3 rounds of data collected for most participants.