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HomeMy WebLinkAbout2013-05-23 Info Packet�i►� �- •..... CITY COUNCIL INFORMATION PACKET CITY OF IOWA CITY www.icgov.org May 23, 2013 IN Council Tentative Meeting Schedule MISCELLANEOUS IP2 Email from Asst City Manager to George Knorr: Review from Water Superintendent regarding fluoride levels in local water supply. IP3 Civil Service Preferred Hiring list: Management Analyst IN Email from Jenn Bowen: Horace Mann Elementary 1 � Ala CITY OF IOWA CITY Date IP1 City Council Tentative Meeting Schedule Subject to change May 23, 2013 Time Meeting Location Tuesday, June 4, 2013 5:00 PM Work Session Meeting Emma J. Harvat Hall 7:00 PM Formal Meeting Emma J. Harvat Hall Tuesday, June 18, 2013 5:00 PM Work Session Meeting Emma J. Harvat Hall 7:00 PM Formal Meeting Emma J. Harvat Hall a 6. - „,I�1'1� Tuesday, July 23, 2013 5:00 PM Work Session Meeting Emma J. Harvat Hall 7:00 PM Special Formal Meeting Emma J. Harvat Hall Tuesday, August 6, 2013 5:00 PM Work Session Meeting Emma J. Harvat Hall 7:00 PM Formal Meeting Emma J. Harvat Hall Tuesday, August 20, 2013 5:00 PM Work Session Meeting Emma J. Harvat Hall 7:00 PM Formal Meeting Emma J. Harvat Hall � 4'a''A 111 °4` Tuesday, September 3, 2013 5:00 PM Work Session Meeting Emma J. Harvat Hall 7:00 PM Formal Meeting Emma J. Harvat Hall Tuesday, September 17, 2013 5:00 PM Work Session Meeting Emma J. Harvat Hall 7:00 PM Formal Meeting Emma J. Harvat Hall X, I'I ''I'll, 'll „ i Y ;, Tuesday, October 1, 2013 5:00 PM Work Session Meeting Emma J. Harvat Hall 7:00 PM Formal Meeting 1 1 1 Pi i i i Emma J. Harvat Hall - Tuesday, October 15, 2013 5:00 PM 11 1' Work Session Meeting Emma J. Harvat Hall 7:00 PM Formal Meeting Emma J. Harvat Hall Tuesday, November 12, 2013 5:00 PM Work Session Meeting Emma J. Harvat Hall 7:00 PM Special Formal Meeting Emma J. Harvat Hall Tuesday, November 26, 2013 Noon -6PM Strategic Planning TBA ” 11 1na�hl I j 1 I Tuesday, December 3, 2013 5:00 PM Work Session Meeting Emma J. Harvat Hall 7:00 PM Formal Meeting Emma J. Harvat Hall Tuesday, December 17, 2013 5:00 PM Work Session Meeting Emma J. Harvat Hall 7:00 PM Formal Meeting Emma J. Harvat Hall IP2 Marian Karr From: Geoff Fruin Sent: Tuesday, May 21, 2013 8:57 AM To: Julie Voparil; Marian Karr Cc: Ed Moreno; Rick Fosse; Tom Markus Subject: FW: Fluoride in Iowa City's Water Letter Attachments: 20130521081707210.pdf; 20130520152758555.pdf; 20130520152807269.pdf; 20130521081446120.pdf; 20130521081455264.pdf Tom has requested that this email and the attachments be placed in the info packet. Thanks — Geoff From: Geoff Fruin Sent: Tuesday, May 21, 2013 8:55 AM To: 'geoknorr @mchsi.com' Subject: Fluoride in Iowa City's Water Letter Mr. Knorr, Mayor Hayek forwarded your letter to me regarding fluoride levels in our local water supply. I asked our Water Treatment Plant staff to review the study you cited and offer some thoughts and feedback. I have attached their review along with a few accompanying documents for your consideration. Certainly, this is a topic that has been debated across the globe for several decades. The mission of our Water Department is to provide a safe, reliable water supply for all of our residents, businesses and visitors. To that end, we have invested heavily in a state -of- the -art treatment facility that is designed to efficiently comply with all state and federal health guidelines. We take this responsibility very seriously and continually test to ensure compliance while working to identify ways to further enhance our water supply. I very much appreciate you conveying your concerns to us. If you have further questions or concerns about the treatment of our community's drinking water, please feel free to contact me. Sincerely, Geoff Fruin Assistant to the City Manager I City of Iowa City, IA 319.356.5013 Igeoff -fruin @iowa- citv.ore May 21, 2013 Mr. George Knorr 330 Kimball Rd Iowa City, Iowa 52245 r 1 IZON 11C 1 CITY OF IOWA CITY 410 East Washington Strcct Iowa City, Iowa 52240 -1826 (319) 3S6 -5000 (319) 3S6 -5009 FAX www.icgov.org Re: Fluoride and Iowa City Water — Environmental Health Perspective Article This letter is in response to your letter to Mayor Matt Hayek, regarding concerns about the practice of fluoridating drinking water in Iowa City. Your concerns are based on a study' published in the Environmental Health Perspective, a journal that self- identifies as being a source of "peer- reviewed research and news." The article sought to determine a correlation between the occurrence of high fluoride in drinking water and the IQ scores of children. The data set used for the study was children living in areas of China, Mongolia, and Iran where the water supplies have unusually high natural fluoride levels; often in excess of 15 times the recommended levels in the U.S. No new research was performed for this study. Instead, it was a "meta -data study "; meaning, it sought to compile the findings of multiple other primary research works to reach its conclusion. As a result, the credibility of the study is determined by the quality of those other data sources. Those data sources included a number of studies that had been performed in China and published only in Chinese. The co- authors disclose, as a result, some of the data sets used "...have not been available to most expert communities "; meaning, they have not been subjected to a rigorous peer review process. The co- authors ultimately reach the following conclusion. "The results support the possibility or an adverse effect of high fluoride exposure on children's neurodevelopment. Further research should include detailed individual -level information on prenatal exposure, neurobehavioral performance, and covariates for adjustment." The co- authors noted that they identified little difference in IQ scores between children in the high- fluoride group and those in the "low- fluoride" control group. The article notes that the average standardized mean difference in IQ scores "may be within the measurement error of IQ testing." The following excerpts are copied verbatim from the on -line article and offer additional insight into the nature of the study and the appropriate uses for its findings. "The exposed groups had access to drinking water with fluoride concentrations up to 11.5 mg /L; thus, in many cases concentrations were above the levels recommend or allowed in public drinking water in the United States. "... Each of the articles reviewed had deficiencies, in some cases rather serious ones, which limit the conclusions that can be drawn. However, most deficiencies relate to the reporting of where key information was missing. The fact that some aspects of the study were not reported limits the extent to which the available reports allow a firm conclusion. May 21, 2013 Page 2 Some methodological limitations were also noted." It is worth noting that a team of British reseachers2 have also evaluated these studies from China. Their review found "basic errors" and concluded that the lower IQ's were likely traceable to factors other than fluoridate drinking water, such as exposure to lead and arsenic and burning of high - fluoride coal inside homes. As one final piece of anecdotal information, consider the average IQ scores in the U.S. between 1940 and the 1990's. The average IQ scores of American improved 15 points over this period, which is when the practice of fluoridation began and rapidly expanded across the country.3 With respect to community water fluoridation in Iowa City: • According to Iowa Department of Public Health (IDPH) records, fluoride has been added to Iowa City's drinking water since 1953, which is before the water utility was purchased from a private company around 1961. • The average concentration of fluoride in our drinking water is 0.7 parts per million (ppm). The normal level of fluoride in the raw water (alluvial wells) is comparable to the Iowa River at approximately 0.25 ppm. • The Environmental Protection Agency /Iowa Department of Natural Resources (USEPA /IDNR) Safe Drinking Water Act limit for fluoride is 4.0 mg /L. • The fluoride compound used in Iowa City drinking water is hydrofluosilicic acid. For the past three years it has come from Solvay Fluorides out of Houston, Tx. • The average cost to add fluoride to Iowa City's drinking water was about $0.29 per customer per year for the past two years. The fluoride we use is required per the Iowa Department of Natural Resources (IDNR) Chapter 42, Section 42.4(3) "b ", to be certified and in compliance with the National Sanitation Foundation (NSF) /American National Standard Institute (ANSI) 60 for use in an municipal water system for human consumption. It also complies, along with other chemicals used in our treatment process, with the American Water Works Association (AWWA) Standard B703 -00 for use in a municipal water system. Iowa City's drinking water has a fluoride level that is set at 0.7 ppm as per Environmental Protection Agency (EPA) and the Iowa Department of Public Health (IDPH) standards. This level is constantly monitored with other treatment processes twenty four hours per day, seven days per week by city staff persons that are certified by the State of Iowa as Water Treatment Plant Operators. There have been no known incidents of illness or other adverse reactions in Iowa City related to ingestion of municipal water, which is treated as per the EPA/IDPH standards for fluoride. The Iowa City Water Division is committed to providing potable water that is of the highest quality and meets all applicable regulations. We are governed by the USEPA, IDNR and the IDPH. We apply fluoride in a safe, effective, and reliable manner that includes monitoring and control of fluoride levels within limits mandated by State and Federal laws. We will continue to look to the USEPA to be a lead role to regulate drinking water quality. As it is our responsibility to provide safe water for the public health of our community, we will monitor closely when the USEPA will be reviewing the fluoride water quality standards in the future. If you have any other questions or comments regarding this subject or any other about the City's May 21 2013 Page 3 drinking water please feel free to contact me at (319) 356 -5162 or ed- morenoC�iowa- city.org, Sincerely, � /Na<C4-cy Ed Moreno Water Superintendent P.S. I have included a copy of a letter co- written by the Deans of bath the Harvard Medical School and the Harvard School of Dental Medicine, voicing their support for community water fluoridation and calling it a "vital" health practice. Annal.Chol, Guitan Sun, Ying Zhang, Philippe Grandjean; "Developmental Fluoride Neurotoxicity; A systematic Review and Meta - Analysis "; Environ Health Perspectives, October 2012; 120(10); 1362 -1368. Published online July 20, 2012. Available at http: / /www.ncbi.nlm.nih.gov /ocm /articles /PMC3491930/ (December 13, 1012) 2Bazain Inc. "Water Fluoridation." Available at http: //www.bazian.com /case studies /water Fluoridation, (December 13, 2012) 3The Campaign for Dental Health, "Fluoride and IQs." Available at htto: / /www.ilikemy teeth.org/fluoridation /fluoride- igs/. (December 13, 2012) Developmental Fluoride Neurotoxicity: A Systematic Review and Meta - Analysis Page 1 of 8 Enrviron Heaah Perapecl. 2012 OGOber, 120(10). 1362 -136& I'Mclo. P61C3/91930 Publish odins 2012 July 20. Joi a12691eho1104ql2 Review Developmental Fluoride Neurotoxicity: A Systematic Review and Meta - Analysis Anna L. Choi to Guitan Sun .2 Yino Zhana.3 and Philippe Grandieanl•a IWtbor tnrormal*n � Ankle notes � Comraht aM license mrovnallon This anicle has bean cited by other anlldes in MAC. Abstract co to Background: Although fluoride nuay cause neurotoxicity in animal models and acute fluoride poisoning causes neurotoxicity in adults, very little is knonii of its effects on children's neurodevelopment. Objective: We performed a systematic review and meta- analysis of published studies to investigate the effects of increased fluoride exposure and delayed neurobehavioral development. Methods: We searched the MEDLINF., EMBASE, Water Resources Abstracts, and TOXNET databases through 2011 for eligible studies. We also searched the China National Knowledge Infrastructure (CNKI) database, because many studies on fluoride neurotoxicity, have been published in Chinesejournals only. In total, we identified 27 eligible epidemiological studies with high and reference exposures, end points of IQ scores, or related cognitive function measures with means and variances for the two exposure groups. Using random - effects models, we estimated the standardized mean difference between exposed and reference groups across all studies. We conducted sensitivity analyses restricted to studies using the same outcome assessment and having drinking -water fluoride as the only exposure. We performed the Cochran test for heterogeneity between studies, Begg's funnel plot, and Iffier test to assess publication bias, and conducted meta - regressions to explore sources of variation in mean differences among the studies. Results: The standardized weighted mean difference in IQ score between exposed and reference populations was -0.45 (95% confidence interval: -0.56, -0.35) using a random - effects model. Thus, children in high- fluoride areas had significantly lower IQ scores than those who lived in low- fluoride areas. Subgroup and sensitivity analyses also indicated inverse associations, although the substantial heterogeneity did not appear to decrease. Conclusions: The results support the possibility of an adverse effect of high fluoride exposure on children's neurodevelopment. Future research should include detailed individual -level information on prenatal exposure, neurobehavioral performance, and covariates for adjustment. Keywords: fluoride, intelligence, neurotoxicity A recent report from the National Research Council (NBC 2006) concluded that adverse effects of high fluoride concentrations In drinking water maybe of concern and that additional research is warranted. Fluoride may cause neurotoxicity in laboratory, animals, including effects on learning and memory (Chioca et at. 2oo8; Mullenix et al. toos). A recent experimental study where the rat hippocampal neurons were incubated with various concentrations (20 mg /L, 40 mg /L, and Bo mg /L) of sodium fluoride in vitro showed that fluoride neurotoxicity may target hippocmnpal neurons (Zhmig M at al. 2008). Although acute fluoride poisoning may be neurotoxic to adults, most of the epidemiological information available on associations with children's neurodevelopment is from China, where fluoride generally occurs in drinking water as a natural contaminant, and the concentration depends on local geological conditions. In many rural communities in China, populations with high exposure to fluoride in local drinking -water sources may reside in close proximity to populations without high exposure (NBC 2oo6). Opportunities for epidemiological studies depend on the existence of comparable population groups exposed to different levels of fluoride from drinking water. Such circumstances are difficult to find in many industrialized countries, because fluoride concentrations in community water arc usually no higher than t mg/l, even when fluoride is added to water supplies as a public health measure to reduce tooth decay. Multiple epidemiological studies of developmental fluoride neurotoxicity were conducted in China because of the high fluoride concentrations that are substantially above 1 mg/L in well water in many rural communities, although ndcrobiologically safe water has been accessible to many rural households as a result of the recent 5 -year plan (2oot -2oo5) by the Chinese government. It is projected that all rural residents will have access to safe public drinking waterby 2020 (World Bank 2oo6). However, results of the published studies have not been widely disseminated. Four studies published in English (Li XS at al. 1995; Lu et al. 2000; Xiang et ai ooa; Zhao et al. 1006) were http: / /www.ncbi.nlm.nih.gov /pine /articies/PMC3491930/ 5/20/2013 Developmental Fluoride Neurotoxicity: A Systematic Review and Meta - Analysis Page 2 of 8 cited in a recent report from the NRC (zooG), whereas the World FJgaith Organization fzo0zl has considered only two (la XS et al. 1995; Zhao et al mg6) in its most recent monograph on fluoride. Fluoride readily crosses the placenta (Agency for Toxic Substances and Disease Re ig ctD, 2oov). Fluoride exposure to the developing brain, which is much more susceptible to injury caused by toxicants than is the mature brain, may possibly lead to permanent damage (Graudieap and Inndrigan 2oo6). In response to the recommendation of the NRC (2oo6), the U.S. Department of Health and Human Services (DIIIIS) and the U.S. EPA recently announced that DI It IS is proposing to change the recommended level of fluoride in drinking water to 0.7 mg /i. from the currently recommended range of 0.7 -1.2 mg/L, and the U.S. EPA is reviewing the maximum amount of fluoride allowed in drinking water, which currently is set at 4.o mg/l, (US EPA 2010. To summarize the available literature, we performed a systematic review and meta - analysis of published studies on increased fluoride exposure in drinking water associated kith neurodevelopmental delays. We specifically targeted studies carried out in rural China that have not been widely disseminated, thus complementing the studies that have been included in previous reviews and risk assessment reports. Methods Go to. Search strategy. We searched MEDLINE (National Libralg, of Medicine, Bethesda, MD, USA; hlgr: / Amw.ncbi.nhn.niln.gov /pubnned), Embase (Elsevier B.v., Amsterdam, the Netherlands; http //w nw emhase couil, Water Resources Abstracts (Proquest, Ann Arbor, Ml, USA; llStlt: / /awlc esa cam /factsheets/water- resources -set -c pbp), and TOXNET (Toxicology Data Network; National Library of Medicine, Bethesda, 161 1), USA; btgr / /toenet.nla nit eow) databases to identify studies of drinking -water fluoride and neurodevelopmental outcomes in children. In addition, we searched the China National Knowledge Infrastructure (CNKI; Beijing, China; h«p; //wvlr cuki net) database to identity studies published in Chinesejournals only. Key words included combinations of "fluoride" or "drinking water Fluoride," "children," "neurodevelopment" or "neurologic" or "intelligence" or "IQ." We also used references cited in the articles identified. We searched records for 198o -2or. Our literature search identified 39 studies, among which 36 (92.3 %) were studies with high and reference exposure groups, and 3 (7.7 %) studies were based on individual -level measure of exposures. The latter showed that dose - related deficits were found, but the studies were excluded because our meta- analysis focused on studies with the high- and low- exposure groups only. In addition, two studies were published vice, and the duplicates were excluded. Inclusion criteria and data extraction. The criteria for inclusion of studies included studies with high and reference fluoride exposures, end points of IQ scores or other related cognitive function measures, presentation of a mean outcome measure, and associated measure of variance [95% confidence intervals (Cis) or SFs and numbers of participants]. Interpretations of statistical significance are based on an alpha level of o.o5. Information included for each study also Included the first author, location of the study, year of publication, and numbers of participants in high - fluoride and low- Fluoride areas. We noted and recorded the information on age and sex of children, and parental education and income if available. Sta(istiol analysis. We used STATA (version 1t.o; StataCorp, College Station, TX, USA) and available commands • v 2000) for the meta- analyses. Astandardized weighted mean difference (SMD) was computed using both fixed- effects and random- effects models. The fixed- effects model uses the Mantel- Haenszel method assuming homogeneity among the studies, whereas the random - effects model uses the DerSimonian and Laird method, incorporating both a within -study and an additive between- studies component of variance when there is between -study heterogeneity (Egger et al 2001 The estimate of the between -study variation is incorporated into both the SE of the estimate of the common effect and the weight of individual studies, which was calculated as the inverse sum of the within and between study variance. We evaluated heterogeneity among studies using the P statistic, which represents the percentage of total variation across all studies due to between -study heterogeneity (Higgins an(I Thonnuson 20o2). We evaluated the potential for publication bias using Begg and Egger tests and visual Inspection of a Begg funnel plot (Begs and Mazmndar toga; Egger eta], rggvl. We also conducted independent meta- regressions to estimate the contribution of study characteristics (mean age in )ears from the age range and year of publication in each study) to heterogeneity among the studies. The seating standard for the Combined Raven's Test -The Rural edition in China (CRT -RC) test classifies scores of s 69 and 70 -79 as low and marginal intelligence, respectively (Wang D at al. 1989). We also used the random - effects models to estimate risk ratios for the association between fluoride exposure and a Inv /marginal versus normal Raven's test some among children in studies that used the CRT RC test (Wang D et al. 1989). Scores indicating low and marginal intelligence (s 69 and 70 -79, respectively) were combined as a single outcome due to small numbers of children in each outcome subgroup. Results Go to Six of the 34 studies identified were excluded because of missing information on the number of subjects or the mean and variance of the outcome [see Figure i for a study selection flowchart and Supplemental Material, Table St ( t ): /dx (Ioi.ore /10.128()/ehp 1104()12) for additional information on studies that were excluded from the analysis]. Allotherstudy(I'riredi et al. 2oo7) was excluded because SDs reported for the outcome parameter were questionably small http : / /www.ncbi.iilni.nih.gov /pmc /articles /PMC3491930/ 5/20/2013 Developmental Fluoride Neurotoxicity: A Systematic Review and Meta - Analysis Page 3 of 8 (1.13 for the high- Fluoride group, and 1.23 for the low - fluoride group) and the SKID ( -10.8; 95% Cl: -u.9, -9.6) was > to times lower than the second smallest SMD ( -0.95; 95% Cl: -1.16, -0.75) and 15o times lower than the largest SMD (o.07; 95% Cl: - 0.083, 0.22) reported for the other studies, which had relatively consistent SMD estimates. Inclusion of this study in the meta - analysis resulted with a much smaller pooled randonreffects Sh1D estimate and a much larger P ( -o.63; 95% Cl: -0-83,-0-44, P 94.1 %) compared with the estimates that excluded this study (- -0.45; 95% Cl: -o.56, -0.34, P 80 %) (see Supplemental Material, fjbure S0. Characteristics of the 27 studies included are shown in' a -f lea (An et at. loot; Chen et it Inn ; Fan et al. 2007: Goo et al. loot Hone et al 2oo1: U FH et al. 2009; Li XH el al. 2010; U XS 1995; U Y et at. 1994; U Y et al. 2003; Lin et al. tool; Ln et al. 2oo0; Pouresh nti el al. 2ou; Ren et al to8Q; Sere' et al 2oo6; Sun el al tacit Wang G et al. 1996; Wang SH et al. 2001; Wang SX et al. 2007; Wong ZH et al. 2006; Xiang et al. 2oo2; Xu et al toot; yang et al. c q g; Yao et al, wQ6.I ro7 Zhang JW et el. 1998; Zimo el al. toQ6). Two of the studies included in the analysis were conducted in Iran (Pourestoni et all 20 i I; Set ai et al 2onf,J; the other study cohorts were populations from China. Two cohorts were exposed to Fluoride from coal burning (Guo ct al roar; Li XH et al. 2010); otherwise populations were exposed to fluoride through drinking water. 7'he CRT -RC %vas used to measure the children's hntelligence in 16 studies. Other Intelligence measures included the Wechsler Intelligence tests (3 studies; An et al. tuo2; Ren et al. m8o; Wang ZH eta). 1996), Binet IQ test (2 studies; Goo et al, in it: Xu et al. toad), Raven's test (2 studies; Nita ushn ii et al o i t; S(I "aj rt . 20 6 , Japan IQ test (2 studies; Sun et al. lcicil; Zhang J W et al. 1998), Chinese comparative intelligence test (r study; Pane et al. scam , and the mental work capacity index (1 study; Li Yet al. 1994). Because each of the intelligence tests used is designed to measure general intelligence, Ave used data from all eligible studies to estimate the possible effects of fluoride exposure on general intelligence. - Flowdiagra n of the meta- analysis. f = --1 Tablet - Characteristics of epidemiological studies of Fluoride exposure slid children s cognitive -- outcomes. In addition, we conducted a sensitivity analysis restricted to studies that used similar tests to measure the outcome (specifically, the CRT -RC, Wechsler Intelligence test, Binet IQ test, or Raven's test), and an analysis restricted to studies that used the CRT -RC. We also performed an analysis that excluded studies with co- exposures including iodine and arsenic, or with non - drinking -water fluoride exposure from coal burning. Pooled SAID estimates. Among the 27 studies, all but one study showed random- effect SMD estimates that indicated an inverse association, ranging from -0.95 (95% Cl: -1.0, -0.75) t0-0.10 (95% Cl: -0-25,0.04) (Figule 2 . The study with a positive association reported an SMD estimate of 0.07 (95% Cl: -o.8, o.22). Similar results were found with the fixed- effects SMD estimates. The fixed- effects pooled SMD estimate Was -0.40 (95% Cl: -0.44, - 0.35), with a P -value < o.001 for the test for homogeneity. The random- effects SMD estimate was -0.45 (95% CI: -0.56, -0.34) with an P of 8o% slid homogeneity lest p -value < o.00l (t1 ieurc . Because of heterogeneity (excess variability) between study results, we used primarily the random - effects model for subsequent sensitivity analyses, which is generally considered to be the more consetvative method (Leger et al. 2ooil. Among the restricted sets of intelligence tests, the SMD for the model with only CRT -RC tests and drinking -Water exposure (and to a lesser extent the model with only CRT -RC tests) Was lower than that for all studies combined, although the difference did not appear to be significant. Heterogeneity, however, remained at a similar magnitude When the analyses were restricted 1 Nellie 2 - 1 Random - effect standardized Weighted mean difference (SMD) estimates and 95% Cls of child's intelligence score associated %vilh high exposure to fluoride. SMs for individual studies are shown as solid diamonds (#), and the pooled SMD is ... Table 2 Sensitivity analyses of pooled random - effects standardized weighted mean difference (SMD) estimates of child's intelligence score with high exposure of fluoride. http: / /www.nchi.nlm.nih.gov /pine /ailicles /PMC3491930/ 5/20/2013 Developmental Fluoride Neurotoxicity: A Systematic Review and Meta - Analysis Page 4 of 8 Sources ojheterogeneity. We performed meta - regression models to assess study characteristics as potential predictors of effect. Information on the child's sex and parental education were not reported in > 8o% of the studies, and only 7% Of the studies reported household income. These vat tables were therefore not included in the models. Among the two covariates, year of publication (0.02; 95% CI: o.006, o.03), but not mean age of the study children ( -0.02; 95% Cl: - 0.094, 0.04), was a significant predictor in the model with all 27 studies included. f' residual 68.7% represented the proportion of residual between -study variation due to heterogeneity. From lire adjusted R2.39.8% Of between -study variance was explained by the two covariates. The overall test of the covariates was significant (1) = 0.004). When the model was restricted to the 16 studies that used the CRT -RC, the child's age (but not year of publication) was a significant predictor of the SMD. The R° of 65.6% of between -study variance was explained by the two covariates, and only 47.3% of the residual variation was attributable to heterogeneity. The overall test of both covariates in the model remained significant (P = 0.0053). On further restriction of the model to exclude the 7 studies with Arsenic and iodine as co- exposures and fluoride originating from coal burning (thus including only the 9 with fluoride exposure from drinking water), neither age nor year of publication was a significant predictor, and the overall test of covariates was less important Q) = o.o62), in accordance with the similarity of intelligence lest outcomes and the source of exposure in the studies included. Although official reports of lead concentrations in the study villages in China were not Available, some studies reported high percentage (95 -too %) of low lead exposure (less than the standard of o.o1 mg /L) in drinking -water samples in villages from several study provinces (Bi et al. 2oi.lr ; Penig ct al 2008; Still 2010 . Publication bias. A Begg's funnel plot with the SR of SMD tom each study plotted against its corresponding SMD did not show clear evidence of asymmetry, although two studies with a large SE also reported relatively large effect estimates, which maybe consistent with publication bias or heterogeneity (Fictne �i . The plot appears symmetrical for studies with larger SE, but with substantial variation in SMD among the more precise studies, consistent With the heterogeneity observed among the studies included in the Analysis. Begg (p = 0.22) and Egger (p = o.i1) tests did not indicate significant Q) < o.o5) departures from symmetry. P;gure 3 { Beggs funnel plot showing individual studies included in the analysis according to random- effect standardized weighted mean difference (SMD) estimates (s -axis) and the SE (se) of each study- specific SMD (y- axis). The solid vertical line indicates ... Partied risk, ratios. The relative risk (RR) of a low /marginal score on the CRT -RC test (< 8o) among children with high fluoride exposure compared with those with low exposure (16 studies total) was 1.93 (95% Cl: 1.46, 2.55; P 58.5 %). When the model was restricted to 9 studies that used the CRT -RC and included only drinking -water fluoride exposure (Chen et al. yg9i; Fan el al. _m)q; Li XII et el. 2010; Li XS et al. 1995; LI Y et al. 2003; Im et al z000; Wang ZH et al. 2006; Yao ct -e, i9g.6, iq_q.7), the estimate was similar (RR = 1.75; 95% Cl: 1.16, 2.65; P 7o.6 %). Although fluoride exposure showed Inverse associations with test scores, the available exposure information did not allow a formal dose - response Analysis. However, dose - related differences in test scores occurred at a wide range of water- fluoride concentrations. Discussion Go to Findings front our meta- analyses of 27 studies published over 22 years suggest an inverse association between high fluoride exposure and children's intelligence. Children who lived in areas with high fluoride exposure had lower 1Q scores than those who lived in low- exposure or control areas. Our findings are consistent with an earlier review ('Pane et al 2008), although ours snore systematically addressed study selection and exclusion information, and was mire comprehensive in a) including 9 Additional studies, b) performing meta- regression to estimate the contribution of study characteristics As sources of heterogeneity, and c) estimating pooled risk ratios for the association between fluoride exposure and a pow /marginal Raveni s test score. As noted by the NBC committee (NBC 2006), assessments of fluoride safety have relied on incomplete information on potential risks. In regard to developmental neurotoxicity, much information has in fact been published, although mainly as short reports in Chinese that have not been available to most expert committees. We carried out an extensive review that includes epidemiological studies carried out in China. Although most reports were fairly brief and complete information on covariates was not available, the results tended to support the potential for fluoride - mediated developmental neurotoxicity, at relatively high levels of exposure in some studies. We dill not find conclusive evidence of publication bias, although there was substantial heterogeneity among studies. Drinking water may contain other neurotoxicants, such as arsenic, but exclusion of studies including arsenic and iodine as co- exposures in a sensitivity analysis resulted in a lower estimate, although the difference was not significant. The exposed groups had access to drinking water with fluoride concentrations up to 11.5 mg /I. (Wang SX at al. 2007); thus, in many cases concentrations were above the levels recommended (o.7 —t.2 mg/ L; DIII IS) or allowed in public dri nking water (4.o mg/L; U.S. EPA) in the United States (U.S, EPA 201 i . A recent cross - sectional study based on individual -level measure of exposures suggested that low levels of water fluoride (range, 0.24 -2.84 ntg /L) had http : / /www.ncbi.nim.nih.gov /pine /articles /PMC3491930/ 5/20/2013 Developmental Fluoride Neurotoxicity: A Systematic Review and Meta - Analysis Page 5 of 8 significant negative associations frith children's intelligence (Dine el al 2on). This study was not included in our meta - analysis, which focused only on studies with exposed and reference groups, thereby precluding estimation of dose- related effects. The results suggest that fluoride may be a developmental tmurotoxicant that affects brain development at exposures much below those that can cause toxicity in adults (Oran 'eau to82). For meurotaxtcants such as lead mid ntethylmercuty, adverse effects are associated with blood concentrations as low as 10 nmol /L. Serum fluoride concentrations associated with high intakes from drinking water may, exceed r mg /L, or So pool /l— more than I,000 times the levels of some other neurotoxicants that cause neurodevelopmental damage. Supporting the plausibility of our findings, rats exposed to I Fpm (6o Final/ L.) of water fluoride for I year showed morphological alterations in the brain and Increased levels of almnhmm in brain tissue compared with controls (Voter etal. gil). The estimated decrease in average IQ associated with fluoride exposure based on our annlysis may seem small and may be within the measurement error of IQ testing. I lowever, as research on other neurotoxicants has shown, a shift to the left of 1Q distributions in a population will have substantial impacts, especially among those in the high and low ranges of the IQ distribution (Bellinger =7 l. Our review cannot be used to derive an exposure limit, because the actual exposures of the individual children are not known. Misclassification of children in both high- and low- exposure groups may have occurred If the children were drinking water from other sources (e.g., at school or in the field). The published reports clearly represent independent studies and are not the result of duplicate publication of the sane studies (we removed two duplicates). Several studies on •l 2ooc Lin et al. iggt; Wang SH et al. 2001, Nang SX et al. 2007; Xiame et al 200; %hao ct al. toot) report other exposures, such as iodine and arsenic, a neurotoxicant, but our sensitivity analyses showed similar associations between high fluoride exposure and the outcomes even after these studies were excluded. Large tracts of China have superficial fluoride -rich minerals with little, if any, likelihood of contamination by other neurotoxicants that would be associated with fluoride concentrations in drinking water. From the geographic distribution of the studies, it seems unlikely that fluoride - attributed neurotoxicity could be attributable to other water contaminants. Still, each of the articles reviewed had deficiencies, in some cases rather serious ones, that limit the conclusions that can be drawn. However, most deficiencies relate to the reporting of where key information was missing. The fact that some aspects of the study were not reported limits the extent to which Lire available reports allow a firm conclusion. Some methodological limitations were also noted. Most studies were cross - sectional, but this study, design would seem appropriate in a stable population where water supplies and fluoride concentrations have remained unchanged for many years. The current water fluoride level likely also reflects past developmental exposures. In regard to the outcomes, the Inverse association persisted between studies using different intelligence tests, although most studies did not report age adjustment of the cognitive test scores. Fluoride has received much attention in China, where widespread dental fluorosis indicates the prevalence of high exposures. In 2008, the Ministry of Health reported that fluorosis was found in 28 provinces with 92 million residents (China News 2008). Although microbiologically safe, water supplies from small springs or mountain sources created pockets of increased exposures near or within areas of low exposures, thus representing exposure settings close to the ideal, because only the fluoride exposure would differ between nearby neighborhoods. Chinese researchers took advantage of this fact and published their findings, though mainly in Chinese journals and according to the standards of science at the time. This research dates back to the n98os, but has not been widely cited at least in part because of limited access to Chinese journals. In its review of fluoride, the NRC (2006) noted that the safety and the risks of fluoride at concentrations of 2 -4 mg/L were incompletely documented. Our comprehensive review substantially extends the scope of research available for evaluation and analysis. Although the studies were generally of insufficient quality, the consistency of their findings adds support to existing evidence of fluoride- associated cognitive deficits, and suggests that potential developmental neurotoxicity of fluoride should be a high research priority. Although reports from the World Health Organization and national agencies have generally focused on beneficial effects of fluoride (Centers for Disease Control and Prevention icig ; Petersen an([ lennon znOd), the NRC report examined the potential adverse effects of fluoride at 2 -4 mg/l. in drinking water and not the benefits or potential risks that may occur when fluoride is added to public water supplies at lower concentrations (0.7 -1.2 mg /L) (NRC 2006). In conclusion, our results support the possibility of adverse effects of fluoride exposures on children's neurodevelopment. Future research should formally evaluate dose — response relations based on individual -level measures of exposure over time, including more precise prenatal exposure assessment and more extensive standardized measures of neuro6chavioral performance, in addition to improving assessment and control of potential confounders. Supplemental Material co to http:// www. ncbi. nlln. nih .gov /pmc /articles/PMC3491930/ 5/20/2013 Developmental Fluoride Neurotoxicity: A Systematic Review and Meta - Analysis Page 6 of 8 (94 KB) PDF Click here for additional data file eubx, MD Acknowledgments Go 10: We thank V. Malik, Hansard School of Public Health, for the helpful advice on the meta - analysis methods. Footnotes Go to: This study was supported by internal Institutional funds. The authors declare they have no, actual or potential competing financial interests. References Go to. Agency for Toxic Substances and Disease Registry. Toxicological Profile for Fluorides, Hydrogen Fluoride, and Fluorine (Update). 2003 Available: bit [accessed 5 April 20101 An JA, Mci SZ, Liu AP, Fu Y, 'Along CF. Effect of high level of fluoride on children's intelligence. Chin J Control Bndem Dis. 1992;7(2):93 -94. [in Chinese] Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. 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Bio Trace Elem Res. 2008p26:115- 120.1' r\ Trivedi MH, Venma RJ, Chinoy NJ, Patel RS, Sathawara NG. Effect of high fluoride water on intelligence of school children in India. Fluoride. 2007;40(3):178 -183. U.S. EPA. EPA and HHS Announce New Scientific Assessments and Actions on Fluoride: Agencies Working Together to Maintain Benefits of Preventing Tooth Decay while Preventing Excessive Exposure. 2011 Available: http• / /yosemfteepsgov /o a /lZ. ado res•nf /hda•+7QaQ2ce a 8s F7•rco %oa%o z /86Q6a fanca7ab 811 578voosa8 417 ftenDocument [accessed 7 January 20111 Varner JA, Jensen KF, Horvath W, Isaacson RL. Chronic administration of aluminum- fluoride or sodium - fluoride to rats in drinking water: alterations in neuronal and cerebrovascular integrity. Brain Res. 1998;784:284 -298. fPk1bN1Cd Wang D, Di M, Qian M. Tianjin, China: Tianjin Medical University; 1989• Chinese Standardized Raven'rest, Rural Version. Wang G, Yang D, Jia F, Wang 11. 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Ender Dis Bull. 1994;2:83 -84. [in Chinese] Yang Y, Wang X, Goo X, no 11. Effects of high iodine and high fluorine on children's intelligence and the metabolism of iodine and fluorine. Chin J I'athol. 1994;15(5):296 -298. Available: hll0 //1 31w fluoride lert org tin se/ [accessed 20 August 20121 [ > iN 1 Pao LR1, Deng Y, Yang SY, Zhou.11, Wang SL, Cui JW. Comparison of children's health and intelligence between the fluorosis areas with and rlilhout altering water sources. Lit Inf Prey Med. 1997;3(1) :42 -43• [in Chinese] Yao LM, Zhou JL, Wang SL, Cui KS, Lin IT. Analysis of TSH levels and intelligence of children residing in high fluorosis areas. Lit Inf Prev Med. 1996;2(l):26 -27. [in Chinese] Zhang J, Gung Y, Guo J. Beijing: Captial Institute of Pediatrics Health Research Office; 1985• Children Intelligence Scale Handbook. Zhang JW, Yea H, Chen Y. Effect of high level of fluoride and arsenic on children's intelligence. Chin J Public Health. 1998;17(2):57 [in Chinese] Zhang M, Wang A, Xia T, He P. Effects of fluoride on DNA damage, S -phase cell -c)Tle arrest and the expression of NF-KB in primal), cultured rat hippocampal neurons. Toxicol Lett. 2008;179:1 -5. [ r 4 < Man LB, Liang GH, Zhang ON, Wu XR. Effect of a high fluoride watersupply on children's intelligence. Fluoride. 1996;29 (4):190 -192. Articles from Environmental Health Perspectives are provided here courtesy of National Institute of Environmental Health Sconce http : / /www.ncbi.nlm.nih.gov /pinc /articles /PMC3491930/ 5/20/2013 Fluoride and IQs I I Like My Teeth life is better What's Needed? Fluoridation How Fluoride Works Fluoride Questions Fluoride Is Effective Is Toothpaste Enough? Health & Medical Authorities What Surgeons General Say Expert View on Fluoridation Fluoride Myths and Facts Savings from Fluoridation What Opponents Say Fluoride and IQs The Fluoridation Trend Access Education ISSUES Home n Fluoridation» Fluoride and IQs Fluoride and IQs LOCAL CAMPAIGNS Page ] of 2 NEWS & REPORTS BI Jo Gr do In July 2012, anti - fluoride activists circulated an article from a journal called Environmental Health Perspectives (EHP) to support Ire their claim that fluoride lowers IQ scores in children. There are several reasons why the claim being made by opponents lacks credibility. The EHP article reviewed studies on IQ scores for children living in areas of China, Mongolia and Iran where the water supplies have unusually high, natural fluoride levels. In many cases, the high - fluoride areas were significantly higher than the levels used to fluoridate public water systems in the U.S. In fact, the high - fluoride areas in these countries reached levels as high as 11.5 mg1L — more than 10 times higher than the optimal level used in the U.S. This article offers a meta- analysis, and its credibility hinges on whether good - quality studies are reviewed. Yet the article's co- authors admit that "each of the [studies] reviewed had deficiencies, in some cases rather serious, which limit the conclusions that can be drawn." Although the studies compared high- fluoride with low- fluoride areas, the authors acknowledge that "the actual exposures of the individual children are not known." The two Harvard researchers who reviewed these studies have distanced themselves from the way in which anti - fluoride activists have misrepresented their article. After contacting these researchers, the Wichita Eagle newspaper reported, "While the studies the Harvard team reviewed did indicate that very high levels of fluoride could be linked to lower IQs among schoolchildren, the data is not particularly applicable here because it came from foreign sources where fluoride levels are multiple times higher than they are in American tap water." The Harvard researchers wrote in their article that the average standardized rnean difference (0.45) In IQ scores "may be within the measurement error of IQ testing." Despite web pages claiming that the article "confirms" that fluoride reduces IQ scores, the Harvard co- authors did not reach a firm conclusion, writing instead that "our results support the possibility of adverse effects ..." Indeed, their article called for more and better - quality research, including more "precise" data on the children involved and assurances that other factors have been ruled out as reasons for the IQ differences. Given the small difference in IQ scores, it's possible that arsenic levels, school quality, nutrition, parents' educational levels or other factors could have shaped the results. The authors also added that "reports of lead concentrations in the study villages in China were not available " — another factor that could not be ruled out. A British http:// www. ilikemyteeth .org/fluoridation/fltioride -iqs/ 5/20/2013 Fluoride and IQs I t Like My "Teeth Page 2 of 2 research team reviewed similar Chinese studies, found "basic errors" in them, and reported that "water supplies may be contaminated with other chemicals such as arsenic, which may affect IQ." Between the 1940s and the 1990s, the average IQ scores of Americans improved 15 points. This gain (approximately 3 IQ points per decade) came during the same period when fluoridation steadily expanded to serve millions and millions of additional Americans. About Us Our Allies The Campaign for Dental Health was created to ensure every American has access to the I'I cheapest, most effective and most o,A,, ,,,,,,,,, KANSAS basic oral health intervention — fluoridation. We are a network of Shar local groups and scientists working I fluoride > 011 together to protect our nation's SC�E�CE gains in oral health. MOREASOUT MORE ALLIES CAMPAIGN FOR DENTAL HEALTH © 2013 American Academy of Pediatrics Site Map I Privacy I Terms of Use Media Policy http://www.ilikemyteeth.oi-g/fluoridation/fluoi-ide-iqs/ News & Reports Joi 05/16/2013 Article: Science Makes a Case for Fluoridation g p 05/2/2013 Grassroots Advocacy Efforts Protect Shar Community Water Fluoridation likes 04/26/2013 Delta Dental Survey Studies Public Perceptions of Fluoridated Water MORENEWS An of 1 Drm 5/20/2013 5120113 Sh gav ALmuma. Water Fluoridation I Bazian an Economist Intelligence Unit business healthcare S • aCerrf ur • �s�;r�,r yene/ti • Cave Studies • %lcsowrec • CCotdnrt Search Water Fluoridation Client South Cenimt Stmtegic Health Authority (SHA) Background High levels oftooth decay had been an issue for some time in Southampton, particularly amongst children. Despite extensive bveslmenas in oral health progrananes fir over ten years, there had been no reduction in decay rates. For example, in 2004 Somhanpton City PCT reported that 42% of5 -year olds had tooth decay, A& in 2007, 522 children required a gememi anaesthetic to remove teeth, whir a total of 2,903 teeth being removed. Tooth decay in Smtlaupton is liked to social iequali y and deprivrtion The average number of decayed, missing or Jilted teeth for 5 -3-ear olds was 1.74, compared to a national avnage of 1.47. A census showed that in s& schools in socially deprived parts ofSoutuvnpton, the average number of decayed, missing or fffed teeth anong 5 -year olds was ante than 3.0. The problem Sotto Central SHA conducted a public corsndtation process to explore fluoridating the drinking water in Southampton to reduce health inequalities and rates of decay. During the comuhation, members ofthe public were concerned about the findings ofa series ofresearch studies and a book, which they wanted the SHA to impartially assess and consider when making its decision about fluoridation. The SHA needed these submissions from to public analysed independently and in less than three weeks for the consultation process to uwr to schedule. They armed to is, not only because we arc known for producing rapid and methodologically it ansparenl evidence based roviews, but also because we are completely independent of the NHS, and therefore seen by to public to be impartial (and quite rightly, we might add). Our solution Barron analysed the research the public had submiged (20 research articles and one book) to tie Idghest academic standards, using at appropriate research protocols including those used by N ICE, HTA and NIUR. We provided the SHA Board with a surunia y rah a detailed report ion tine for item to keep to comakalion process training to schedule. Tthc dctal also supported them in Waking teir policy decisions. mw.bazim.coriVease studiesMaler Fluoridatim 112 5120/13 Tlne outcome water Fluoridatiat I Bazian The decision as to whether to have a policy of flwuidatng the dri Uig water in Soutanpton was a highly contentions one Ilaaan's in lepehdcut report allowed the decision to be made taking into fill account due scientitic evidence that was brought to Tight by the public during consultation The report has since been used to guide other SHAs who troy be carrying out sunilar consultations on water fluoridating policy. Testruonial "Batiau produced Idgh quality reports within very tight tune constraints and smhuarised their findings in a clear and concise hmmher. wbether to fluoridate or not was a contentions issue, and the level of scrutiny on nfonmtion published by the SHA was highly scrutinised both nationally mid internationally. Baisui s independence firm die SIIA was uhporuhnt and their findings helped infomt the Board paper on the scientific evidence of water fluoridation The ahportant work they carried out will be shared nationally with other SHAs %v ho may be carrying out snllar consultations in the fnhue." PnofessorJohn NevHon, DIrector of Public Health for South Ccntrul SHA • (base Studer • AD]]D e Behid the Headkrtcc C fisnelmut M, e Buoti Cure Pminvav; • CWI l'oh and Pu at • CSAS u (:vstk; P W&0/ o Health DIA11 d u Map of Medicine G MMR vaccis e PAVR C RRT Truncpihnt Services C The Inkhmution Sunnd +rd o Dhra Orman Dniys c water Ptuorklmica O 2013 Bazia 131u; icononfct Intelligence Unit I Sictua I Sic by gcdwij ' wnw.bazim.carJ E sltAMNVater Fl"ldafim 212 wHARVARD MEUIC:AI. SCHOOL March 22, 2013 Dr. Myron Allukian, Jr. Immediate Past President, American Association for Community Dental Programs Associate Clinical Professor, Harvard School of Dental Medicine Via email: myalluk@aol.com Dear Dr. Allukian: As Deans of Harvard Medical School and the Harvard School of Dental Medicine, we continue to support community water fluoridation as an effective and safe public health measure for people of all ages. Numerous reputable studies over the years have consistently demonstrated that community water fluoridation is safe, effective, and practical. Fluoridation has made an enormous impact on improving the oral health of the American people. Our country is fortunate to have over 204 million Americans living in fluoridated communities and having access to the health and economic benefits of this vital public health measure. Sincerely, Jeffrey S. Flier, MD Dean of the Faculty of Medicine Caroline Shields Walker Professor of Medicine Harvard Medical School R. Bruce Donoff, DMD, MD Dean and Walter C. Guralnick Distinguished Professor of Oral and Maxillofacial Surgery Harvard School of Dental Medicine IOWA CITY CIVIL SERVICE COMMISSION May 15, 2013 RE: Civil Service Preferred Hiring list — Management Analyst r 1 IP3 CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240 -1826 (3 19) 356 -5000 (319) 356 -5009 FAX www.Icgov.o% We, the undersigned members of the Civil Service Commission of Iowa City, Iowa, do hereby certify that in accordance with Chapter 400.28 of the Iowa Code, the following named person {s} are being placed on an eligibility list for the position of Heuaimg Pregrern Assista r a period of three years. Wendy Han ATTEST: Mari -K, Karr U,-.) .- S�s�i3 Lyra Dickerson, Chair From: jenn bowen <jennuwine4 @yahoo.com> Sent: Tuesday, May 21, 2013 10:53 AM To: board @iccsd.k12.ia.us Cc: OneVision @lowaCitySchools.org; Council Subject: Horace Mann Elementary Hello, My name is Jenn Bowen and I am the parent of three children, two who currently attend Horace Mann (3rd grade and kindergarten) and one 3 year old. It is my hope that all my children will attend Mann for their entire elementary education. It would be a great loss to the school community, the neighborhood community and the larger Iowa City community for a school like Mann to close. My husband and I chose to live in our neighborhood because of our placement in the Horace Mann school district. To shutter the doors of a beautiful old school in the heart of our strong and thriving northside neighborhood seems counter- intuitive to the stability of our town. The central district, northside and goosetown neighborhoods serve many people, including families like mine: long time residents who intentionally choose their neighborhoods for attributes like walkability, close proximity to shops and restaurants, and a strongly supported local school. Please hear the voices of the Horace Mann community. We love our school, we love our neighborhood. Please vote to invest in these components which make Iowa City such a wonderful place to live. Thank you for listening, Jenn Bowen 102 Parsons Ave Iowa City 319 - 688 -0012