Page 3 - Fourth Report on Human Biomonitoring of Environmental Chemicals in Canada

8 Summary and results for acrylamide

8.1 Acrylamide

Acrylamide (CASRN 79-06-1) is a chemical used primarily in the production of polymers such as polyacrylamides (ATSDR, 2012a). Polyacrylamides are used to clarify drinking water and treat effluent from water treatment plants and industrial processes (ATSDR, 2012a). They are also used as binding, thickening, or flocculating agents in grout, cement, pesticide formulations, cosmetics, food manufacturing, and soil erosion prevention (Environment Canada and Health Canada, 2009a). Polymers of acrylamide are also used in ore processing, food packaging, and plastic products (Environment Canada and Health Canada, 2009a). In Canada, polyacrylamide is used as a coagulant and flocculant for the clarification of drinking water, in potting soils, and as a non-medicinal ingredient in natural health products and pharmaceuticals (Environment Canada and Health Canada, 2009b). Acrylamide can also form naturally in certain foods during processing or cooking at high temperatures (Health Canada, 2009a). It is formed mainly in carbohydrate-rich plant-based foods such as potatoes and grains with the highest concentrations detected in potato chips and french fries (Health Canada, 2009a).

Entry into the environment may occur during production and industrial use (ATSDR, 2012a). Residual monomers may be released to drinking water during polyacrylamide treatment processes and are the main source of drinking water contamination by acrylamide (ATSDR, 2012a). Acrylamide is a component of cigarette smoke and may be released to indoor air as a result of smoking (NTP, 2005a; Urban et al., 2006).

Acrylamide exposure in the general population occurs primarily through food and to a lesser degree through air, drinking water, and soil (Environment Canada and Health Canada, 2009a). Inhalation of tobacco smoke, including second-hand smoke, is also a major source of inhalation exposure for the general population (ATSDR, 2012a). Animal studies indicate that acrylamide is readily absorbed via oral and pulmonary routes, and to a lesser degree following dermal exposure (ATSDR, 2012a). Once absorbed, acrylamide is widely distributed throughout the body accumulating in red blood cells (ATSDR, 2012a). Acrylamide is metabolized via glutathione conjugation to form a mercapturic acid acrylamide derivative or by oxidation to form the epoxide derivative, glycidamide, which can be further metabolized via conjugation with glutathione. Both acrylamide and glycidamide react with haemoglobin in red blood cells forming adducts (ATSDR, 2012a). Absorbed acrylamide and its metabolites are rapidly eliminated in urine, primarily as mercapturic acid conjugates of acrylamide and glycidamide (ATSDR, 2012a). Acrylamide and glycidamide haemoglobin adducts are considered markers of exposure over the previous 120 days, the average life span of red blood cells (ATSDR, 2012a).

Exposure to acrylamide is known to cause a number of health effects in humans, including neurotoxicity. Inhalation exposure to acrylamide in occupational settings has been associated with peripheral neuropathy characterized by muscle weakness and numbness in hands and feet (Environment Canada and Health Canada, 2009b). Studies with laboratory animals have observed adverse reproductive and developmental effects and shown that acrylamide is genotoxic and carcinogenic (Environment Canada and Health Canada, 2009b; FAO/WHO, 2006). Reviews of existing epidemiological studies have found that there is inadequate evidence in humans to establish an association between acrylamide exposure and carcinogenicity (Health Canada, 2008a; IARC, 1994). However, on the basis of evidence in experimental animals, the International Agency for Research on Cancer (IARC) and the U.S. Environmental Protection Agency (U.S. EPA) have classified acrylamide as probably carcinogenic to humans (EPA, 2010; IARC, 1994). Further, on the basis of available evidence from animal studies, the Joint FAO/WHO Expert Committee on Food Additives determined that the estimated intake of acrylamide from certain foods may be a human health concern (FAO/WHO, 2006; FAO/WHO, 2011a).

Health Canada and Environment Canada (now referred to as Environment and Climate Change Canada) concluded, on the basis of carcinogenic potential, that acrylamide in Canada may constitute a danger to human life or health (Environment Canada and Health Canada, 2009b). Acrylamide is listed on Schedule 1, List of Toxic Substances, under the Canadian Environmental Protection Act, 1999 (CEPA 1999). The Act allows the federal government to control the importation, manufacture, distribution, and use of acrylamide in Canada (Canada, 1999; Canada, 2011a). Health Canada's risk management strategy for acrylamide in food is focused on reducing foodborne exposure to acrylamide (Health Canada, 2009b). To reduce exposure to acrylamide from food sources, Health Canada suggests following the recommendations provided in Canada's Food Guide, thereby limiting consumption of carbohydrate-rich foods that are high in fat (such as potato chips and french fries), sugar, or salt (Health Canada, 2009a). However, occasional consumption of these products is not likely to be a health concern. Other suggestions for reducing exposure to acrylamide from certain foods include paying careful attention to oil and baking temperatures, following the manufacturer's cooking instructions, storing potatoes at a temperature above 8°C, washing or soaking cut potatoes in water prior to frying, and toasting bread or baked goods to the lightest colour acceptable (Health Canada, 2009a). Health Canada regularly reviews data on the concentrations of acrylamide in foods sold on the Canadian market; these results may be shared with industry, particularly if elevated levels of acrylamide are identified in certain products. Health Canada continues to encourage the food industry to further pursue reduction efforts for acrylamide in processed foods (Health Canada, 2012b). In order to obtain additional information demonstrating successful acrylamide reduction strategies on the part of food manufacturers, Health Canada initiated a one-year call for data in September 2013 seeking submissions of published and unpublished technical information on the occurrence of acrylamide in foods available for sale in Canada (Health Canada, 2013b). Health Canada has also amended the Food and Drug Regulations to permit the use of asparaginase in certain food products to reduce the formation of acrylamide during cooking (Canada, 2012a; Health Canada, 2013c). Acrylamide is included as a prohibited ingredient on the List of Prohibited and Restricted Cosmetic Ingredients (more commonly referred to as the Cosmetic Ingredient Hotlist or simply the Hotlist). The Hotlist is an administrative tool that Health Canada uses to communicate to manufacturers and others that certain substances, when present in a cosmetic, may contravene the general prohibition found in section 16 of the Food and Drugs Act or a provision of the Cosmetic Regulations (Health Canada, 2015b).

Because acrylamide-containing polymers are used in drinking water treatment, most Canadian jurisdictions have requirements to meet health-based standards for additives that limit the amount of acrylamide present in the treated drinking water (NSF International, 2016a; NSF International, 2016b). Health Canada has also set a maximum level for acrylamide in polyacrylamide-containing formulations used in natural health products in Canada (Environment Canada and Health Canada, 2009a; Health Canada, 2016b).

In a study carried out on Montreal Island to assess the levels of acrylamide in 195 non-smoking teenagers aged 10-17 years, the geometric mean concentrations of haemoglobin adducts of acrylamide and glycidamide were 45.4 pmol/g haemoglobin and 45.6 pmol/g haemoglobin, respectively (Brisson et al., 2014).

Acrylamide and its metabolite glycidamide were analyzed as adducts in whole blood of CHMS participants aged 3-79 years in cycle 3 (2012-2013) and cycle 4 (2014-2015). Data are presented in blood as pmol/g haemoglobin (Hb). Finding a measurable amount of acrylamide or glycidamide haemoglobin adducts in blood is an indicator of exposure to acrylamide and does not necessarily mean that an adverse health effect will occur.

Table 8.1.1 - Acrylamide haemoglobin adducts - Geometric means and selected percentiles of whole blood concentrations (pmol/g Hb) for the Canadian population aged 3-79 years by age group, Canadian Health Measures Survey cycle 3 (2012-2013) and cycle 4 (2014-2015).
Cycle n %<LODFootnote a GM (95% CI) 10th (95% CI) 50th (95% CI) 90th (95% CI) 95th (95% CI)

a If >40% of samples were below the LOD, the percentile distribution is reported but means were not calculated.

E Use data with caution.

Total, 3-79 years
3 (2012-2013) 2492 0 73 (65-82) 35 (30-40) 64 (57-70) 190 (160-230) 240 (190-290)
4 (2014-2015) 2529 0.04 67 (62-73) 38 (35-41) 60 (55-66) 150 (130-180) 200 (180-230)
Males, 3-79 years
3 (2012-2013) 1225 0 79 (69-90) 36 (31-40) 68 (61-75) 200 (150-260) 270Footnote E (160-380)
4 (2014-2015) 1267 0.08 70 (62-79) 37 (33-42) 64 (57-71) 170Footnote E (110-230) 220 (180-250)
Females, 3-79 years
3 (2012-2013) 1267 0 68 (59-78) 35 (29-41) 60 (51-69) 180 (130-230) 210 (180-250)
4 (2014-2015) 1262 0 65 (58-72) 38 (36-41) 58 (53-62) 140 (100-180) 180 (140-220)
3-5 years
3 (2012-2013) 471 0 59 (55-64) 39 (35-43) 59 (55-63) 87 (73-100) 100 (82-120)
4 (2014-2015) 484 0 60 (56-65) 37 (32-43) 61 (55-66) 96 (84-110) 100 (83-120)
6-11 years
3 (2012-2013) 505 0 61 (57-65) 37 (34-41) 62 (58-67) 100 (88-110) 110 (98-120)
4 (2014-2015) 507 0 62 (59-66) 42 (39-45) 62 (58-66) 90 (83-96) 100 (94-110)
12-19 years
3 (2012-2013) 507 0 63 (59-67) 37 (31-42) 57 (53-61) 110 (87-130) 170Footnote E (96-240)
4 (2014-2015) 505 0 63 (55-72) 37 (33-42) 60 (51-70) 100 (83-120) 120 (91-160)
20-39 years
3 (2012-2013) 348 0 80 (65-97) 34 (24-43) 74 (59-89) 190 (130-260) 260 (190-340)
4 (2014-2015) 363 0 70 (60-80) 37 (33-41) 61 (53-70) 170 (120-220) 210 (170-250)
40-59 years
3 (2012-2013) 311 0 83 (67-100) 35 (24-47) 66 (49-82) 230 (180-290) 330 (210-450)
4 (2014-2015) 312 0.32 71 (62-80) 38 (34-42) 60 (50-70) 180 (130-230) 250 (170-330)
60-79 years
3 (2012-2013) 350 0 63 (59-68) 34 (29-40) 62 (59-65) 130 (100-150) 160 (130-190)
4 (2014-2015) 358 0 63 (56-71) 34 (26-43) 59 (53-65) 150 (110-190) 190 (170-210)
Table 8.1.2 - Glycidamide haemoglobin adducts - Geometric means and selected percentiles of whole blood concentrations (pmol/g Hb) for the Canadian population aged 3-79 years by age group, Canadian Health Measures Survey cycle 3 (2012-2013) and 4 (2014-2015).
Cycle n %<LODFootnote a GM (95% CI) 10th (95% CI) 50th (95% CI) 90th (95% CI) 95th (95% CI)

a If >40% of samples were below the LOD, the percentile distribution is reported but means were not calculated.

E Use data with caution.

Total, 3-79 years
3 (2012-2013) 2492 0.76 68 (62-75) 36 (34-38) 65 (59-70) 150 (120-180) 190 (150-220)
4 (2014-2015) 2529 1.86 60 (54-67) 34 (30-37) 57 (52-62) 120 (100-140) 170 (150-200)
Males, 3-79 years
3 (2012-2013) 1225 1.14 69 (62-77) 37 (35-38) 66 (58-74) 170 (120-210) 210 (160-260)
4 (2014-2015) 1267 2.37 61 (53-70) 33 (27-39) 58 (50-66) 130 (100-160) 170 (130-200)
Females, 3-79 years
3 (2012-2013) 1267 0.39 67 (60-74) 36 (32-40) 64 (57-71) 130 (100-160) 160 (120-200)
4 (2014-2015) 1262 1.35 59 (53-67) 34 (31-37) 56 (51-62) 110 (81-140) 170 (110-240)
3-5 years
3 (2012-2013) 471 0 80 (75-85) 51 (43-59) 78 (74-81) 120 (110-130) 140 (120-150)
4 (2014-2015) 484 0.21 76 (69-84) 49 (44-53) 73 (65-82) 120 (100-130) 140 (110-180)
6-11 years
3 (2012-2013) 505 0 73 (70-77) 47 (45-48) 74 (68-81) 110 (97-120) 130 (110-150)
4 (2014-2015) 507 0.39 70 (65-74) 44 (41-48) 66 (60-73) 100 (95-110) 120 (110-130)
12-19 years
3 (2012-2013) 507 1.18 62 (59-65) 35 (32-37) 60 (57-62) 110 (95-130) 160 (120-200)
4 (2014-2015) 505 2.38 58 (51-67) 34 (27-41) 55 (49-62) 99 (83-120) 120Footnote E (58-180)
20-39 years
3 (2012-2013) 348 0.86 72 (60-86) 38 (30-46) 74 (62-86) 160 (130-190) 210 (160-260)
4 (2014-2015) 363 2.20 62 (52-74) 34 (29-39) 57 (49-66) 170 (110-230) 190 (170-220)
40-59 years
3 (2012-2013) 311 1.29 71 (58-86) 36 (31-42) 62 (50-74) 180 (140-220) 230 (170-290)
4 (2014-2015) 312 1.92 63 (55-71) 35 (30-39) 58 (50-65) 130 (97-160) 160Footnote E (57-260)
60-79 years
3 (2012-2013) 350 1.71 60 (53-67) 34 (29-39) 60 (50-70) 100 (90-110) 120 (110-130)
4 (2014-2015) 358 5.03 50 (44-57) 25 (<LOD-33) 50 (44-56) 98 (87-110) 120 (93-150)

9 Summaries and results for environmental phenols

9.1 Bisphenol A

Bisphenol A (BPA; CASRN 80-05-7) is a synthetic chemical used as a monomer in the production of some polycarbonate plastics and as a precursor for monomers of certain epoxy-phenolic resins (EFSA, 2007). Polycarbonate is used in the manufacture of food and beverage containers such as repeat-use water bottles and storage containers; it was also used in infant bottles in Canada prior to 2010. Epoxy resins are used as an interior protective lining for food and beverage cans. Additional end-use products containing polycarbonate plastics and resins include medical devices, some dental fillings and sealants, sporting and safety equipment, electronics, and automotive parts (EFSA, 2007; NTP, 2007). BPA is also used in the paper industry to produce thermal paper used for various products including receipts, prescription labels, airline tickets, and lottery tickets (Geens et al., 2011).

BPA does not occur naturally in the environment (Environment Canada and Health Canada, 2008a). Entry into the environment may occur from industrial sources or from product leaching, disposal, and use (CDC, 2009).

The primary route of exposure to BPA for the general public is through dietary intake as a result of various sources, including migration from food packaging and repeat-use polycarbonate containers (Health Canada, 2008b). Health Canada has recently updated its dietary exposure estimates for BPA following the completion of a number of specific food surveys, including canned foods and beverages, liquid infant formula, and Total Diet samples (Health Canada, 2012c). Exposure can also occur from contact with environmental media, including ambient and indoor air, drinking water, soil, and dust, and from the use of consumer products (Environment Canada and Health Canada, 2008a). BPA exposure from dental fillings and sealants is short term and considered unlikely to contribute substantially to chronic exposure (WHO, 2011a). However, further clinical research would help to answer questions about the potential harms caused by the exposure to BPA from dental composite materials (CADTH, 2015).

In humans, BPA is readily absorbed and undergoes extensive metabolism in the gut wall and the liver (WHO, 2011a). Recent studies have also suggested that it may be absorbed and metabolized by the skin following dermal exposure to free BPA in products such as those made from thermal printing papers (Mielke et al., 2011; Zalko et al., 2011). Glucuronidation has been recognized as a major metabolic pathway for BPA, resulting in the BPA-glucuronide conjugate metabolite (EFSA, 2008; FDA, 2008). Conjugation of BPA to BPA-sulphate has been shown to be a minor metabolic pathway (Dekant and Völkel, 2008). The BPA-glucuronide metabolite is rapidly excreted in urine with a half-life of less than 2 hours (WHO, 2011a). Urinary levels of total BPA, including both conjugated and free unconjugated forms, are commonly used as biomarkers to assess recent exposures (Ye et al., 2005).

Characterization of the potential risk to human health from exposure to BPA includes key effects on the liver, kidney and on reproduction, including fertility and developmental effects (EFSA CEF Panel, 2015; Environment Canada and Health Canada, 2008a; EU, 2010). The potential role of BPA and other environmental estrogens in the prevalence of obesity and related metabolic diseases, as well as certain types of cancer, is under intensive debate and investigation among scientific communities (Ben-Jonathan et al., 2009; Carwile and Michels, 2011; Newbold et al., 2009; Song et al., 2014; Soto et al., 2008).

The Government of Canada has conducted a scientific screening assessment of the impact of human and environmental exposure to BPA and determined that it is toxic to human health and the environment as per the criteria set out under the Canadian Environmental Protection Act, 1999 (CEPA 1999) (Canada, 1999; Environment Canada and Health Canada, 2008a). Because of the uncertainty raised by the results of some laboratory animal studies relating to the potential effects of low levels of BPA, a precautionary approach was applied when characterizing risk. Considering the highest potential exposure and subpopulations with potential vulnerability due to potential differences in the toxicokinetics and metabolism of BPA identified in the assessment, the risk management strategy for health focused on decreasing exposure to newborns and infants (Environment Canada and Health Canada, 2008b).

Health Canada has concluded that current dietary exposure to BPA through food packaging uses is not expected to pose a health risk to the general population, including newborns and young children (Health Canada, 2012c). However, the general principle of as low as reasonably achievable (ALARA) was applied to continue efforts on limiting BPA exposure from food packaging applications to infants and newborns, specifically from pre-packaged infant formula products as a sole source food. As part of this ALARA approach, Health Canada committed to supporting industry to reduce levels of BPA in infant-formula can linings (Health Canada, 2010b). In addition, Health Canada has assessed a number of proposed industry alternatives to BPA and deemed them acceptable for packaging of liquid infant-formula. Infant-formula manufacturers have abandoned or phased out the use of BPA-containing packaging materials for liquid infant formula, and the can-coating industry has developed various BPA-free alternatives for can coatings currently available on the market (Health Canada, 2014b). Health Canada will continue to review pre-market submissions for infant-formula packaging to ensure the lowest levels of BPA achievable (Health Canada, 2010b). As of March 2010, under the Canada Consumer Product Safety Act, Health Canada has prohibited the manufacturing, advertisement, sale, or import of polycarbonate baby bottles that contain BPA (Canada, 2010a). BPA is also included as a prohibited ingredient on the List of Prohibited and Restricted Cosmetic Ingredients (more commonly referred to as the Cosmetic Ingredient Hotlist or simply the Hotlist). The Hotlist is an administrative tool that Health Canada uses to communicate to manufacturers and others that certain substances, when present in a cosmetic, may contravene the general prohibition found in section 16 of the Food and Drugs Act or a provision of the Cosmetic Regulations (Health Canada, 2015b). Risk management actions also have been developed under CEPA 1999 with the objective of minimizing releases of BPA in industrial effluents (Canada, 2012b).

The Maternal-Infant Research on Environmental Chemicals (MIREC) Study is a national-level prospective biomonitoring study carried out in pregnant women aged 18 years and older from 10 sites across Canada (Arbuckle et al., 2013). In the MIREC Study of 1,936 participants in their first trimester of pregnancy, the geometric mean and 95th percentile for total BPA in urine were 0.80 µg/L and 5.40 µg/L, respectively (Arbuckle et al., 2014). The Plastics and Personal-care Products use in Pregnancy (P4) Study is a targeted biomonitoring study carried out in 80 pregnant women aged 18 years and older from the Ottawa area. The geometric mean and 95th percentile for total BPA in urine were 1.1 µg/L and 6.4 µg/L, respectively, based on analyses of multiple samples per woman (Arbuckle et al., 2015). The First Nations Biomonitoring Initiative (FNBI) is a nationally representative biomonitoring study of adult First Nations peoples living on reserves south of the 60° parallel (AFN, 2013). It comprises 13 randomly selected First Nation communities in Canada with 503 First Nations participants aged 20 years and older. The geometric mean and 95th percentile for total BPA in urine were 1.55 µg/L and 11.27 µg/L, respectively.

Urinary total BPA (including both free and conjugated forms) was analyzed in the urine of Canadian Health Measures Survey participants aged 6-79 years in cycle 1 (2007-2009), and 3-79 years in cycle 2 (2009-2011), cycle 3 (2012-2013), and cycle 4 (2014-2015). Data from these cycles are presented as both µg/L and µg/g creatinine. Finding a measurable amount of BPA in urine is an indicator of exposure to BPA and does not necessarily mean that an adverse health effect will occur.

Table 9.1.1 - Bisphenol A (BPA) - Geometric means and selected percentiles of urine concentrations (μg/L) for the Canadian population aged 3-79 years by age group, Canadian Health Measures Survey cycle 1 (2007-2009), cycle 2 (2009-2011), cycle 3 (2012-2013) and cycle 4 (2014-2015).
Cycle n %<LODFootnote a GM (95% CI) 10th (95% CI) 50th (95% CI) 90th (95% CI) 95th (95% CI)

a If >40% of samples were below the LOD, the percentile distribution is reported but means were not calculated.

b Data not available as participants under the age of 6 years were not included in cycle 1 (2007-2009).

E Use data with caution.

F Data is too unreliable to be published.

Total, 3-79 years
1 (2007-2009)Footnote b - - - - - - -
2 (2009-2011) 2560 5.04 1.2 (1.1-1.3) 0.27 (0.22-0.31) 1.2 (1.1-1.3) 4.5 (4.0-5.0) 6.7 (4.8-8.6)
3 (2012-2013) 5670 7.80 1.1 (1.0-1.2) 0.29 (0.27-0.32) 1.1 (0.95-1.2) 4.2 (3.6-4.8) 6.6 (5.8-7.5)
4 (2014-2015) 2560 7.30 1.0 (0.95-1.1) 0.26 (<LOD-0.33) 1.0 (0.94-1.1) 4.0 (3.2-4.8) 6.0 (5.0-7.1)
Males, 3-79 years
1 (2007-2009)Footnote b - - - - - - -
2 (2009-2011) 1281 4.84 1.3 (1.1-1.5) 0.27 (<LOD-0.36) 1.3 (1.1-1.5) 4.6 (4.1-5.2) 7.9Footnote E (4.3-11)
3 (2012-2013) 2826 6.97 1.2 (1.1-1.4) 0.35 (0.25-0.46) 1.2 (0.99-1.4) 4.4 (3.7-5.0) 6.4 (5.2-7.7)
4 (2014-2015) 1273 5.89 1.2 (1.0-1.3) 0.35 (0.28-0.43) 1.2 (0.97-1.3) 4.3 (3.0-5.6) 6.2 (4.3-8.0)
Females, 3-79 years
1 (2007-2009)Footnote b - - - - - - -
2 (2009-2011) 1279 5.24 1.2 (1.0-1.3) 0.26 (0.21-0.32) 1.1 (0.98-1.3) 4.1 (3.0-5.1) 6.6 (4.9-8.4)
3 (2012-2013) 2844 8.61 1.0 (0.88-1.2) 0.29 (<LOD-0.39) 1.0 (0.91-1.1) 4.1 (3.3-4.9) 6.9 (5.4-8.4)
4 (2014-2015) 1287 8.70 0.92 (0.79-1.1) <LOD 0.98 (0.82-1.1) 3.4 (2.8-4.0) 5.4 (3.6-7.3)
3-5 years
1 (2007-2009)Footnote b - - - - - - -
2 (2009-2011) 524 4.20 1.4 (1.1-1.8) 0.30Footnote E (<LOD-0.46) 1.3 (1.1-1.5) 5.4Footnote E (1.9-9.0) 9.9Footnote E (5.5-14)
3 (2012-2013) 521 5.76 1.2 (0.87-1.6) 0.29Footnote E (<LOD-0.47) 1.2 (0.95-1.5) 4.0 (2.6-5.4) 6.0 (4.3-7.7)
4 (2014-2015) 511 7.83 1.2 (1.0-1.4) 0.28Footnote E (<LOD-0.44) 1.2 (1.0-1.3) 4.0 (3.5-4.5) 6.4Footnote E (2.9-9.9)
6-11 years
1 (2007-2009) 1031 6.79 1.3 (1.2-1.4) 0.28 (<LOD-0.37) 1.3 (1.1-1.6) 4.5 (3.8-5.1) 7.1 (5.5-8.7)
2 (2009-2011) 516 5.81 1.4 (1.1-1.7) 0.25Footnote E (<LOD-0.41) 1.3 (0.94-1.7) 4.6Footnote E (2.6-6.6) Footnote F
3 (2012-2013) 1004 5.58 1.2 (1.1-1.4) 0.39 (0.30-0.49) 1.2 (1.0-1.3) 3.8 (2.8-4.8) 5.3Footnote E (3.0-7.6)
4 (2014-2015) 511 6.46 1.1 (0.90-1.4) 0.29 (<LOD-0.40) 1.1 (0.83-1.4) 3.5 (2.6-4.4) 5.0 (4.0-6.0)
12-19 years
1 (2007-2009) 980 6.22 1.5 (1.3-1.8) 0.29 (0.22-0.36) 1.6 (1.3-1.9) 5.9 (4.8-7.0) 8.3 (6.2-10)
2 (2009-2011) 512 4.69 1.3 (1.1-1.6) 0.35 (0.23-0.47) 1.3 (0.99-1.6) 4.4 (2.9-5.9) 7.6Footnote E (4.3-11)
3 (2012-2013) 992 6.15 1.3 (1.1-1.6) 0.30Footnote E (<LOD-0.46) 1.4 (1.3-1.6) 4.8 (3.4-6.2) 8.0Footnote E (4.1-12)
4 (2014-2015) 505 4.95 1.1 (1.1-1.2) 0.26 (<LOD-0.35) 1.2 (1.0-1.3) 3.8 (3.1-4.6) 5.5 (4.5-6.5)
20-39 years
1 (2007-2009) 1165 8.84 1.3 (1.2-1.5) Footnote F 1.4 (1.2-1.6) 4.8 (4.1-5.4) 7.3 (5.2-9.5)
2 (2009-2011) 357 2.80 1.3 (1.1-1.5) 0.32 (0.21-0.42) 1.3 (0.92-1.6) 4.6 (3.7-5.5) Footnote F
3 (2012-2013) 1040 7.88 1.1 (0.92-1.4) 0.29 (<LOD-0.39) 1.1 (0.81-1.3) 5.5 (3.9-7.0) 6.7 (5.1-8.3)
4 (2014-2015) 362 7.73 1.1 (0.93-1.4) <LODFootnote E (<LOD-0.35) 1.2 (0.97-1.4) 5.6Footnote E (3.3-7.8) 7.4 (5.1-9.7)
40-59 years
1 (2007-2009) 1219 12.06 1.0 (0.96-1.1) <LOD 1.2 (1.1-1.4) 4.4 (3.5-5.3) 6.6 (4.8-8.4)
2 (2009-2011) 360 6.11 1.2 (0.97-1.5) 0.25Footnote E (<LOD-0.37) 1.2 (0.98-1.4) 4.3Footnote E (2.7-6.0) 6.7Footnote E (2.6-11)
3 (2012-2013) 1075 9.86 1.1 (1.0-1.3) 0.30 (<LOD-0.36) 1.1 (0.94-1.2) 4.2 (3.1-5.3) 7.5Footnote E (4.3-11)
4 (2014-2015) 311 7.72 0.86 (0.74-1.0) 0.28 (<LOD-0.38) 0.94 (0.77-1.1) 2.4 (1.9-2.9) 4.2Footnote E (2.4-5.9)
60-79 years
1 (2007-2009) 1081 11.66 0.90 (0.81-0.99) <LOD 0.99 (0.87-1.1) 3.7 (3.3-4.2) 5.2 (3.8-6.6)
2 (2009-2011) 291 7.22 1.0 (0.84-1.3) 0.21Footnote E (<LOD-0.31) 0.99 (0.76-1.2) 4.4Footnote E (2.5-6.2) 6.3 (4.4-8.1)
3 (2012-2013) 1038 10.31 0.88 (0.77-1.0) <LOD 0.88 (0.76-1.0) 3.3 (2.8-3.7) 5.5 (4.2-6.7)
4 (2014-2015) 360 10.28 1.1 (0.96-1.2) <LOD 1.0 (0.84-1.2) 4.2 (3.1-5.3) 5.5Footnote E (2.3-8.7)
Table 9.1.2 - Bisphenol A (BPA) (creatinine adjusted) - Geometric means and selected percentiles of urine concentrations (μg/g creatinine) for the Canadian population aged 3-79 years by age group, Canadian Health Measures Survey cycle 1 (2007-2009), cycle 2 (2009-2011), cycle 3 (2012-2013) and cycle 4 (2014-2015).
Cycle n %<LODFootnote a GM (95% CI) 10th (95% CI) 50th (95% CI) 90th (95% CI) 95th (95% CI)

a If >40% of samples were below the LOD, the percentile distribution is reported but means were not calculated.

b Data not available as participants under the age of 6 years were not included in cycle 1 (2007-2009).

E Use data with caution.

F Data is too unreliable to be published.

Total, 3-79 years
1 (2007-2009)Footnote b - - - - - - -
2 (2009-2011) 2550 5.04 1.2 (1.1-1.3) 0.39 (0.35-0.44) 1.0 (0.92-1.1) 4.1 (3.6-4.6) 6.9 (5.1-8.7)
3 (2012-2013) 5667 7.80 1.1 (1.0-1.2) 0.40 (0.36-0.45) 0.99 (0.94-1.0) 3.6 (3.0-4.2) 5.9 (4.4-7.5)
4 (2014-2015) 2559 7.30 0.93 (0.87-0.99) 0.32 (<LOD-0.36) 0.87 (0.80-0.94) 3.1 (2.6-3.5) 4.5 (3.9-5.2)
Males, 3-79 years
1 (2007-2009)Footnote b - - - - - - -
2 (2009-2011) 1277 4.84 1.1 (0.96-1.2) 0.36 (<LOD-0.48) 0.99 (0.93-1.1) 3.7 (2.7-4.8) 6.2Footnote E (3.5-8.8)
3 (2012-2013) 2826 6.97 1.1 (0.96-1.2) 0.38 (0.32-0.45) 0.98 (0.90-1.1) 3.1 (2.8-3.4) 5.1 (3.9-6.4)
4 (2014-2015) 1272 5.89 0.92 (0.83-1.0) 0.30 (0.24-0.36) 0.87 (0.76-0.98) 2.8 (2.2-3.5) 4.1 (3.2-4.9)
Females, 3-79 years
1 (2007-2009)Footnote b - - - - - - -
2 (2009-2011) 1273 5.24 1.3 (1.2-1.5) 0.48 (0.40-0.57) 1.1 (0.95-1.3) 4.5 (3.5-5.5) 6.9 (4.5-9.4)
3 (2012-2013) 2841 8.61 1.2 (1.1-1.4) 0.42 (<LOD-0.46) 1.0 (0.91-1.1) 4.0 (3.1-5.0) 7.1Footnote E (4.4-9.9)
4 (2014-2015) 1287 8.70 0.94 (0.85-1.0) <LOD 0.88 (0.78-0.97) 3.4 (2.5-4.3) 5.0 (4.2-5.8)
3-5 years
1 (2007-2009)Footnote b - - - - - - -
2 (2009-2011) 523 4.20 2.4 (1.9-3.1) 0.88Footnote E (<LOD-1.2) 2.0 (1.8-2.3) 10Footnote E (4.6-15) 13 (8.6-17)
3 (2012-2013) 520 5.76 2.3 (1.8-2.9) 0.86Footnote E (<LOD-1.2) 2.1 (1.4-2.7) 5.9 (4.1-7.8) 8.4 (6.7-10)
4 (2014-2015) 511 7.83 2.0 (1.7-2.4) 0.64Footnote E (<LOD-0.90) 1.8 (1.5-2.2) 6.7 (4.7-8.7) 13Footnote E (4.4-21)
6-11 years
1 (2007-2009) 1028 6.79 2.0 (1.8-2.2) 0.68 (<LOD-0.82) 2.0 (1.8-2.1) 5.8 (4.8-6.9) 9.8 (7.4-12)
2 (2009-2011) 514 5.81 1.5 (1.2-1.9) 0.44Footnote E (<LOD-0.68) 1.4 (1.1-1.7) Footnote F 10Footnote E (3.0-18)
3 (2012-2013) 1004 5.58 1.5 (1.3-1.7) 0.58 (0.46-0.69) 1.4 (1.1-1.6) 3.9 (2.6-5.2) 5.3Footnote E (2.0-8.6)
4 (2014-2015) 510 6.46 1.2 (1.0-1.5) 0.41 (<LOD-0.54) 1.1 (0.94-1.3) 3.2 (2.6-3.8) Footnote F
12-19 years
1 (2007-2009) 978 6.22 1.3 (1.2-1.4) 0.40 (0.30-0.50) 1.2 (0.99-1.4) 4.2 (3.3-5.0) 6.4Footnote E (4.0-8.8)
2 (2009-2011) 510 4.69 1.0 (0.83-1.2) 0.30Footnote E (0.17-0.43) 0.94 (0.79-1.1) 3.4Footnote E (1.5-5.2) 5.0 (3.8-6.3)
3 (2012-2013) 991 6.15 1.0 (0.85-1.2) 0.35 (<LOD-0.44) 0.95 (0.82-1.1) 3.0 (2.3-3.8) 5.4Footnote E (2.6-8.2)
4 (2014-2015) 505 4.95 0.83 (0.74-0.93) 0.30 (<LOD-0.35) 0.74 (0.61-0.87) 2.7 (2.1-3.3) 3.9 (2.6-5.1)
20-39 years
1 (2007-2009) 1161 8.84 1.5 (1.4-1.6) 0.44 (<LOD-0.55) 1.4 (1.2-1.6) 4.4 (3.4-5.4) 6.8 (5.9-7.7)
2 (2009-2011) 355 2.80 1.1 (0.89-1.3) 0.39 (0.27-0.50) 0.99 (0.85-1.1) 2.8 (1.8-3.7) Footnote F
3 (2012-2013) 1040 7.88 1.0 (0.90-1.2) 0.36 (<LOD-0.43) 0.93 (0.80-1.1) 3.3 (2.6-3.9) 5.4Footnote E (2.7-8.1)
4 (2014-2015) 362 7.73 0.91 (0.80-1.0) <LOD 0.87 (0.75-0.99) 3.5Footnote E (1.7-5.3) 4.6Footnote E (2.0-7.1)
40-59 years
1 (2007-2009) 1214 12.06 1.3 (1.2-1.5) <LOD 1.2 (1.0-1.4) 4.7 (3.8-5.7) 7.5 (6.1-8.8)
2 (2009-2011) 358 6.11 1.2 (0.99-1.4) 0.39 (<LOD-0.50) 1.1 (0.86-1.3) 4.2Footnote E (2.3-6.2) 6.9Footnote E (3.4-10)
3 (2012-2013) 1074 9.86 1.2 (1.1-1.3) 0.47 (<LOD-0.52) 0.99 (0.90-1.1) 3.8 (2.9-4.6) 6.1Footnote E (3.7-8.5)
4 (2014-2015) 311 7.72 0.78 (0.70-0.86) 0.33 (<LOD-0.40) 0.71 (0.64-0.78) 1.9Footnote E (0.95-2.9) 3.8Footnote E (2.2-5.4)
60-79 years
1 (2007-2009) 1081 11.66 1.2 (1.1-1.4) <LOD 1.1 (0.94-1.3) 4.3 (3.0-5.6) 7.6 (5.4-9.8)
2 (2009-2011) 290 7.22 1.2 (0.99-1.4) 0.29Footnote E (<LOD-0.45) 1.0 (0.89-1.1) 4.7 (3.3-6.0) 6.8Footnote E (2.9-11)
3 (2012-2013) 1038 10.31 1.0 (0.97-1.1) <LOD 0.99 (0.94-1.0) 3.0 (2.7-3.4) 4.7Footnote E (2.7-6.7)
4 (2014-2015) 360 10.28 1.0 (0.92-1.2) <LOD 0.99 (0.89-1.1) 3.5 (2.5-4.4) 4.8Footnote E (2.1-7.4)

9.2 Triclosan

Triclosan (CASRN 3380-34-5) is a synthetic chemical with wide application since 1972 as an antimicrobial agent and as a preservative (Jones et al., 2000). It is used as a medicinal ingredient in non-prescription drug products and as a non-medicinal ingredient in cosmetics, natural health products, and drug products. Cosmetic products containing triclosan have been imported or manufactured for sale in Canada, including skin moisturizers (body, face, and hands), face and eye makeup, deodorant sticks/sprays, fragrances, tanning products, skin cleansers, shaving preparations, and shampoos (Environment and Climate Change Canada and Health Canada, 2016a). In addition, a number of products containing triclosan as an active medicinal ingredient are regulated as non-prescription drug products in Canada, including anti-bacterial hand sanitizers and soaps (Health Canada, 2016c). Triclosan has also been used to control the spread of bacteria in household items such as cleaners, textiles, carpets, cutting boards and other food contact materials, and in medical devices (Jones et al., 2000). As of December 31, 2014, triclosan is no longer registered as a pesticide for material preservative uses under the Pest Control Products Act (Canada, 2006; Environment and Climate Change Canada and Health Canada, 2016a). Triclosan does not occur naturally in the environment (Environment and Climate Change Canada and Health Canada, 2016a). The use of triclosan-containing products results in its release to waste-water systems and subsequently surface water (Environment and Climate Change Canada and Health Canada, 2016a). The potential routes of exposure for the general public are oral and dermal contact with products such as toothpastes and cosmetics that contain triclosan, ingestion of triclosan-contaminated drinking water, breast milk, or ingestion of household dust (Environment and Climate Change Canada and Health Canada, 2016a).

Following oral exposures, triclosan is rapidly absorbed and distributed in humans, with plasma levels increasing rapidly within 1 to 4 hours (Environment and Climate Change Canada and Health Canada, 2016a). Absorption following dermal exposure to triclosan-containing products ranges from 11% to 17% in humans (Maibach, 1969; Queckenberg et al., 2010; Stierlin, 1972). Only limited absorption (approximately 5% to 10%) occurs under normal conditions of toothpaste use (SCCP, 2009). Following all routes of administration, absorbed triclosan is nearly totally converted to glucuronic and sulfuric acid conjugates (Fang et al., 2010). Triclosan is rapidly eliminated after metabolism with an observed half-life in humans ranging from 13 to 29 hours following oral administration (SCCP, 2009). About 24% to 83% of absorbed triclosan is excreted in urine, mostly as the glucuronide conjugate (Fang et al., 2010; Sandborgh-Englund et al., 2006). Excretion of triclosan in feces is as the free unchanged compound and represents a smaller portion of the administered dose (10% to 30%) (Environment and Climate Change Canada and Health Canada, 2016a). Currently, there is no evidence of bioaccumulation potential in humans (SCCP, 2009). The concentration of total triclosan in urine (conjugated and free) can be used as a biomarker of exposure to triclosan (Calafat et al., 2007).

Triclosan is not acutely toxic to mammals, but it can interact with a cellular receptor and several enzymes (Calafat et al., 2007). The potential effects of these interactions remain unknown. In rodents, there have been observations of adverse effects of triclosan on thyroid hormone homeostasis resulting from liver toxicity; however, the overall weight of evidence does not currently support effects of triclosan on thyroid function as a critical effect for risk characterization in humans (Environment and Climate Change Canada and Health Canada, 2016a). To date, triclosan has not been assessed for carcinogenic potential by the International Agency for Research on Cancer; the United States Environmental Protection Agency has classified triclosan as not likely to be carcinogenic to humans (EPA, 2008a).

Health Canada and Environment and Climate Change Canada have jointly reviewed triclosan in an assessment and have concluded that it is not entering the environment in a quantity or concentration or under conditions that constitute or may constitute a danger in Canada to human life or health (Environment and Climate Change Canada and Health Canada, 2016a). However, at current environmental levels, triclosan is concluded to be an ecological concern and it was found to meet the definition of toxic under the Canadian Environmental Protection Act, 1999 (CEPA 1999) (Canada, 1999; Environment and Climate Change Canada and Health Canada 2016a).

Currently, Health Canada regulates triclosan under the Food and Drugs Act for its inclusion in personal care products such as cosmetics, natural health products, and non-prescription drugs. Triclosan is included as a restricted ingredient on the List of Prohibited and Restricted Cosmetic Ingredients (more commonly referred to as the Cosmetic Ingredient Hotlist or simply the Hotlist). The Hotlist is an administrative tool that Health Canada uses to communicate to manufacturers and others that certain substances, when present in a cosmetic, may contravene the general prohibition found in section 16 of the Food and Drugs Act or a provision of the Cosmetic Regulations (Health Canada, 2015b). The Hotlist indicates concentration limits of triclosan in mouthwash and other cosmetic products (Health Canada, 2015b). In addition, the Hotlist indicates that oral cosmetics containing triclosan shall include a label statement indicating that the product is not to be used by children under 12 years of age (Health Canada, 2015b). The Hotlist also indicates that mouthwashes include a label statement to the effect of "avoid swallowing" (Health Canada, 2015b). Consistent with the Hotlist, Health Canada has also set concentration limits for non-medicinal use of triclosan as an antimicrobial preservative in natural health products and for use as an active medicinal ingredient in non-prescription drug products in Canada (Health Canada, 2016c; Health Canada, 2016b). As of December 31, 2014, triclosan is no longer registered in Canada as a pest control product because of voluntary withdrawal from the market (Canada, 2006; Environment and Climate Change Canada and Health Canada, 2016a). A risk management approach, including a requirement for the preparation and implementation of Pollution Prevention Plans, has also been proposed under CEPA 1999 with the objective of reducing releases of triclosan to the aquatic environment as a result of the use by consumers of triclosan-containing products (Environment and Climate Change Canada and Health Canada, 2016b).

The Maternal-Infant Research on Environmental Chemicals (MIREC) Study is a national-level prospective biomonitoring study carried out in pregnant women aged 18 years and older from 10 sites across Canada (Arbuckle et al., 2013). In the MIREC Study of 1,861 participants in their first trimester of pregnancy, the geometric mean and 95th percentile for triclosan in urine were 12.64 µg/L and 697.58 µg/L, respectively (Arbuckle, Marro et al., 2015). The Plastics and Personal-care Products use in Pregnancy (P4) Study is a targeted biomonitoring study carried out in 80 pregnant women aged 18 years and older from the Ottawa area. The geometric mean and 95th percentile for triclosan in urine were 21.6 µg/L and 833.4 µg/L, respectively, based on analysis of multiple urine samples per woman (Arbuckle, Weiss et al., 2015).

Total triclosan (including both free and conjugated forms) was analyzed in the urine of Canadian Health Measures Survey cycle 2 (2009-2011), cycle 3 (2012-2013), and cycle 4 (2014-2015) participants aged 3-79 years, and is presented as both µg/L and µg/g creatinine. Finding a measurable amount of triclosan in urine is an indicator of exposure to triclosan and does not necessarily mean that an adverse health effect will occur.

Table 9.2.1 - Triclosan - Geometric means and selected percentiles of urine concentrations (μg/L) for the Canadian population aged 3-79 years by age group, Canadian Health Measures Survey cycle 2 (2009-2011), cycle 3 (2012-2013) and cycle 4 (2014-2015).
Cycle n %<LODFootnote a GM (95% CI) 10th (95% CI) 50th (95% CI) 90th (95% CI) 95th (95% CI)

a If >40% of samples were below the LOD, the percentile distribution is reported but means were not calculated.

E Use data with caution.

F Data is too unreliable to be published.

Total, 3-79 years
2 (2009-2011) 2550 28.20 16 (13-20) <LOD 9.5Footnote E (5.8-13) 400 (280-520) 710 (540-880)
3 (2012-2013) 5645 34.47 17 (15-19) <LOD 9.9 (8.4-11) 350 (270-430) 720 (460-980)
4 (2014-2015) 2558 44.57 - <LOD 5.9 (<LOD-7.6) 310Footnote E (160-460) 660Footnote E (370-940)
Males, 3-79 years
2 (2009-2011) 1274 26.77 18 (13-26) <LOD 12Footnote E (5.3-18) 510 (330-690) 790Footnote E (350-1200)
3 (2012-2013) 2815 34.03 17 (14-21) <LOD 10 (7.4-13) 330Footnote E (180-480) 760Footnote E (380-1100)
4 (2014-2015) 1273 44.85 - <LOD 6.1Footnote E (<LOD-8.5) 270Footnote E (120-430) 640Footnote E (320-970)
Females, 3-79 years
2 (2009-2011) 1276 29.62 14 (11-18) <LOD 7.5Footnote E (3.1-12) 310Footnote E (140-470) 680Footnote E (410-960)
3 (2012-2013) 2830 34.91 17 (13-22) <LOD 9.6 (7.8-12) 390Footnote E (220-550) 700Footnote E (280-1100)
4 (2014-2015) 1285 44.28 - <LOD 5.7 (<LOD-7.4) 360Footnote E (120-590) 880Footnote E (320-1400)
3-5 years
2 (2009-2011) 523 29.45 8.9 (7.3-11) <LOD 7.3 (4.9-9.6) 50 (40-61) 120Footnote E (68-160)
3 (2012-2013) 518 36.29 9.5 (7.4-12) <LOD 7.7Footnote E (<LOD-11) 78Footnote E (43-110) 110Footnote E (47-170)
4 (2014-2015) 511 49.12 - <LOD 4.8 (<LOD-6.5) 33Footnote E (13-53) Footnote F
6-11 years
2 (2009-2011) 515 33.98 8.5 (6.7-11) <LOD 3.8Footnote E (<LOD-5.9) 130Footnote E (54-210) 250Footnote E (82-410)
3 (2012-2013) 1001 36.26 11 (8.4-16) <LOD 7.2Footnote E (<LOD-10) Footnote F 340Footnote E (190-500)
4 (2014-2015) 510 49.22 - <LOD 5.2 (<LOD-6.6) Footnote F 170Footnote E (93-250)
12-19 years
2 (2009-2011) 510 19.02 20 (14-27) <LOD 13Footnote E (7.7-18) 350Footnote E (230-480) 640Footnote E (400-870)
3 (2012-2013) 984 28.35 19 (14-26) <LOD 10 (7.2-13) 510Footnote E (220-800) 840 (580-1100)
4 (2014-2015) 504 38.89 13 (8.7-18) <LOD 6.4Footnote E (<LOD-9.8) Footnote F Footnote F
20-39 years
2 (2009-2011) 353 19.26 21Footnote E (13-32) <LOD 17Footnote E (9.1-25) 470Footnote E (180-760) 910Footnote E (430-1400)
3 (2012-2013) 1035 27.44 24 (18-30) <LOD 15 (11-19) 420Footnote E (250-580) Footnote F
4 (2014-2015) 361 34.63 12Footnote E (7.2-20) <LOD 5.4Footnote E (<LOD-8.0) 420Footnote E (190-650) 880Footnote E (480-1300)
40-59 years
2 (2009-2011) 359 28.97 19Footnote E (12-29) <LOD 12Footnote E (4.3-20) 470Footnote E (200-740) 740Footnote E (290-1200)
3 (2012-2013) 1072 37.22 16 (12-22) <LOD 8.9 (6.6-11) 380Footnote E (140-620) 910Footnote E (250-1600)
4 (2014-2015) 312 41.03 - <LOD Footnote F Footnote F Footnote F
60-79 years
2 (2009-2011) 290 41.72 - <LOD 4.8Footnote E (<LOD-6.8) 360Footnote E (160-560) 590 (430-750)
3 (2012-2013) 1035 41.84 - <LOD 6.9 (6.0-7.7) 260Footnote E (140-380) 580Footnote E (270-890)
4 (2014-2015) 360 52.50 - <LOD <LOD Footnote F Footnote F
Table 9.2.2 - Triclosan (creatinine adjusted) - Geometric means and selected percentiles of urine concentrations (μg/g creatinine) for the Canadian population aged 3-79 years by age group, Canadian Health Measures Survey cycle 2 (2009-2011), cycle 3 (2012-2013) and cycle 4 (2014-2015).
Cycle n %<LODFootnote a GM (95% CI) 10th (95% CI) 50th (95% CI) 90th (95% CI) 95th (95% CI)

a If >40% of samples were below the LOD, the percentile distribution is reported but means were not calculated.

E Use data with caution.

F Data is too unreliable to be published.

Total, 3-79 years
2 (2009-2011) 2540 28.20 15 (11-19) <LOD 9.0 (7.5-10) 370 (260-480) 610 (400-830)
3 (2012-2013) 5642 34.47 17 (15-20) <LOD 9.9 (9.2-11) 350 (310-390) 640 (510-770)
4 (2014-2015) 2557 44.57 - <LOD 6.1 (<LOD-8.1) 250 (160-340) 540Footnote E (310-770)
Males, 3-79 years
2 (2009-2011) 1270 26.77 15 (10-21) <LOD 8.7 (6.4-11) 390 (280-490) 700Footnote E (360-1000)
3 (2012-2013) 2815 34.03 15 (12-18) <LOD 8.7 (7.1-10) 310Footnote E (190-440) 470 (340-610)
4 (2014-2015) 1272 44.85 - <LOD 5.2 (<LOD-7.0) 190Footnote E (80-290) 410Footnote E (220-610)
Females, 3-79 years
2 (2009-2011) 1270 29.62 14 (11-19) <LOD 9.9 (8.4-11) 320Footnote E (150-480) 570Footnote E (340-800)
3 (2012-2013) 2827 34.91 21 (16-27) <LOD 11 (8.0-13) 390 (260-520) 810 (560-1100)
4 (2014-2015) 1285 44.28 - <LOD 7.2 (<LOD-9.2) 320Footnote E (120-510) 810Footnote E (380-1300)
3-5 years
2 (2009-2011) 522 29.45 14 (12-17) <LOD 10Footnote E (3.9-16) 84 (58-110) 180 (140-230)
3 (2012-2013) 517 36.29 18 (15-23) <LOD 13 (<LOD-17) 110Footnote E (47-180) 260 (170-350)
4 (2014-2015) 511 49.12 - <LOD 9.2 (<LOD-11) 70Footnote E (38-100) 120Footnote E (46-200)
6-11 years
2 (2009-2011) 513 33.98 8.5 (6.2-12) <LOD 4.4Footnote E (<LOD-6.9) 150Footnote E (57-250) 270Footnote E (82-470)
3 (2012-2013) 1001 36.26 14 (11-17) <LOD 8.8 (<LOD-11) Footnote F 340Footnote E (160-530)
4 (2014-2015) 509 49.22 - <LOD 5.4 (<LOD-7.4) Footnote F 190Footnote E (60-330)
12-19 years
2 (2009-2011) 508 19.02 14 (10-19) <LOD 8.9Footnote E (5.3-13) 280Footnote E (150-420) 490Footnote E (280-710)
3 (2012-2013) 983 28.35 14 (11-19) <LOD 8.7 (7.0-11) 350Footnote E (160-540) 530 (380-680)
4 (2014-2015) 504 38.89 9.1 (6.7-12) <LOD 5.1Footnote E (<LOD-7.2) Footnote F 440 (290-590)
20-39 years
2 (2009-2011) 351 19.26 17Footnote E (11-27) <LOD 11Footnote E (6.2-15) 410Footnote E (220-600) 680Footnote E (290-1100)
3 (2012-2013) 1035 27.44 22 (16-29) <LOD 11 (7.6-15) 350 (270-430) 560Footnote E (320-810)
4 (2014-2015) 361 34.63 9.7Footnote E (5.4-17) <LOD 5.8Footnote E (<LOD-8.8) 270Footnote E (71-460) 740Footnote E (350-1100)
40-59 years
2 (2009-2011) 357 28.97 17Footnote E (11-28) <LOD 9.7Footnote E (2.7-17) 410Footnote E (230-590) 820Footnote E (440-1200)
3 (2012-2013) 1071 37.22 17 (13-22) <LOD 9.4 (7.1-12) 400Footnote E (240-560) 900Footnote E (410-1400)
4 (2014-2015) 312 41.03 - <LOD 8.2Footnote E (<LOD-13) Footnote F Footnote F
60-79 years
2 (2009-2011) 289 41.72 - <LOD 6.6 (<LOD-9.0) 370Footnote E (200-550) 600Footnote E (280-910)
3 (2012-2013) 1035 41.84 - <LOD 9.5 (8.2-11) 340Footnote E (200-480) 720Footnote E (430-1000)
4 (2014-2015) 360 52.50 - <LOD <LOD Footnote F Footnote F
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