estimates of exposure dose and duration. In addition, published literature is likely to be biased toward reporting worst­ case scenarios, as opposed to the more typical exposures that do not cause symptoms or attract attention. Despite their limitations, the data and lit­ erature reviewed here are the best available sources of information on children’s exposure to elemental mercury during release events in the United States. Discussion and Conclusions For this review, we set out to address three objectives. Our first objective was to identify the common sources of elemental mercury exposure among children. We found that children are most frequently exposed to mercury when mer­ cury is mishandled or when people improperly clean up spilled mercury. Children are exposed when mercury is scavenged, collected, and pooled from sources such as industrial prop­ erty, school chemistry laboratories, and electri­ cal or medical equipment (Azziz­ Baumgartner et al. 2007; Baughman 2006; CDC 2005a, 2005b; Gordon 2004; Tominack et al. 2002). Providing locations to appropriately dispose of mercury and information on how to properly dispose of mercury can potentially reduce the likelihood that children will come in contact with stored mercury. Broken thermometers are the most com­ mon exposure source, based on calls to AAPCC poison control centers. However, these calls are decreasing. This reduction may reflect the decreasing availability of mercury thermome­ ters. In 2008, the Interstate Mercury Education and Reduction Clearinghouse of the Northeast Waste Management Officials’ Association reported an 11% decrease in mercury sales from 2001 to 2004 (Interstate Mercury Education and Reduction Clearinghouse 2008). The second objective was to describe the location, demographics, and proportion of children affected by elemental mercury expo­ sure in the United States. We divided mercury exposures into three categories based on loca­ tion: in the home, at school, and at other loca­ tions, such as improperly remediated industrial property and medical facilities. At all locations, the primary exposure pathway of concern for elemental mercury is inhalation. The demographics and proportion of U.S. children affected by these exposures are not directly quantifiable using the various data sources we reviewed. Most data sources that collect information on the release of hazard­ ous substances do not systematically collect information on the persons affected. The typical exposure scenario involves relatively small amounts of mercury without reports of human illness. Neither urine nor blood mer­ cury levels correlate well with the presence or severity of symptoms (Cherry et al. 2002; Gattineni et al. 2007; Tominack et al. 2002). Elevated mercury vapor levels have been docu­ mented, but demonstrable health effects are rarely reported after small mercury spills, such as broken fever thermometers. Regardless, all spills should be cleaned up properly. Recommendations The third and final objective for this review was to clarify what is needed to reduce ele­ mental mercury exposure and to appropri­ ately respond to mercury spills and releases. The primary prevention guidelines below sup­ port the Healthy People 2010 goal to reduce human exposure to heavy metals such as mer­ cury, as measured by blood and urine mercury concentrations (U.S. Department of Health and Human Services 2000). Health education. Some states have devel­ oped culturally appropriate educational materi­ als on the risks of elemental mercury exposure and ways to prevent exposure. The federal gov­ ernment should encourage and support other states in developing similar materials. Persons that would benefit from these materials include parents, teachers, school administrators, chil­ dren, medical and dental health care workers, religious practitioners, folk healers, and people who sell, develop, own, or manage real estate. For parents, teachers, and school admin­ istrators, the educational messages should include health hazards of elemental mercury, sources of mercury exposure in homes and schools, risks associated with misuse and dam­ age to mercuryc­ontaining devices , proper dis­ posal of the mercury present in homes and schools, mercury substitutes and mercuryf­ree devices, proper containment and cleanup pro­ cedures for small mercury spills, and sources of additional information on mercury exposure and related health effects. For children, the educational messages should include sources of mercury exposure in homes and schools, how to identify mercury, health risks of playing with mercury, and what to do if mercury is found. For health care practitioners, the educa­ tional messages should include importance of stopping exposure for everyone at risk; signs, symptoms, and health effects of acute and chronic mercury exposure; how to ask patients about mercury exposure; and resources avail­ able for information and medical consultation. Public health professionals also should communicate with religious practitioners and botanica owners who use or sell mercury. The educational messages provided for parents, teachers, and children are also important for practitioners who use mercury ceremonially. Although no single predictable path to success exists, culturally sensitive communication is important to ensure that people who engage in these practices understand the acute and chronic health risks associated with mercury exposure. Environmental Health Perspectives • volume 117 | number 6 | June 2009 Children’s exposure to elemental mercury Finally, persons involved in the man­ agement, redevelopment, sales, or leasing of industrial or residential property should be aware of mercury­related hazards, who m to contact if mercury is found, and the applicable state and local liability laws. Federal, state, and local policy initiatives. Some states have developed policy initiatives to reduce the potential for mercury exposure. For example, after the event at the New Jersey child care, the State of New Jersey passed a law requiring that an environmental evalua­ tion be conducted before a child care or school is opened (ATSDR 2007b). The federal gov­ ernment should encourage and support other states in developing similar initiatives to reduce mercury exposures in their communities. Moreover, each initiative should include the ability to assess its effectiveness. The primary prevention capacities recom­ mended in the CDC’s Preventing Lead Exposure in Young Children: A Housing-Based Approach to Primary Prevention of Lead Poisoning (2004) comprise a framework for making housing lead­ safe by preventing future exposures and protect­ ing previously exposed children from further exposure. Although mercury exposures are less pervasive than are environmental lead expo­ sures, some similarities exist between the two types of exposures, and these can assist in devel­ oping mercuryb­ased prevention initiatives. State and local mercury initiatives can assist in preventing mercury exposure by promoting alternatives, such as mercury­ free devices and mercury substitutes; providing for safe and secure disposal of recovered mercury and mercury­containing products, including CFLs; providing information on the pur­ chase of mercury cleanup kits; ensuring that land and buildings chosen for redevelopment undergo sufficient environmental review of previous activities; and determining whether property remediation is sufficiently protective for future occupants. Surveillance. Although small spills are often not reported, better surveillance of such low­risk exposures is not likely to protect children. The various data sources reviewed suggest that most releases do not lead to demonstrable harm if the exposure period is short and the mercury is properly cleaned up. Small spills of mercury (i.e., the quantities of mercury in fever thermometers or less) are easily handled by adults who are familiar with mercury cleanup procedures. Errors made in handling elemental mercury are best addressed through education and policy initiatives that preempt or minimize exposure potential. Larger releases of mercury (i.e., more than the amount in a fever thermometer) cause greater concern. As the amount of mercury released increases, so does the risk of harmful exposure and subsequent health effects. More comprehensive information and longitudinal 877