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Brenda Eskenazi,¹ Jonathan Chevrier,¹ Lisa Goldman Rosas,¹ Henry A. Anderson,² Maria S. Bornman,³ Henk Bouwman,⁴ Aimin Chen,⁵ Barbara A. Cohn,⁶ Christiaan de Jager,⁷ Diane S. Henshel,⁸ Felicia Leipzig,⁹ John S. Leipzig,^9,10 Edward C. Lorenz,^9,11 Suzanne M. Snedeker,¹² and Darwin Stapleton¹³

¹School of Public Health, University of California, Berkeley, California, USA; ²Wisconsin Division of Public Health, Madison, Wisconsin, USA; ³Department of Urology, University of Pretoria, Pretoria, South Africa; ⁴School of Environmental Sciences and Development, North-West University, Potchefstroom Campus, Potchefstroom, South Africa; ⁵School of Medicine, Creighton University, Omaha, Nebraska, USA; ⁶Public Health Institute, Oakland, California, USA; ⁷School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa; ⁸School of Public and Environmental Affairs, Indiana University, Bloomington, Indiana, USA; ⁹Pine River Superfund Citizen Task Force, St. Louis, Michigan, USA; ¹⁰Center for Responsible Leadership, and ¹¹Public Affairs Institute, Alma College, Alma, Michigan, USA; ¹²Sprecher Institute for Comparative Cancer Research, Cornell University, Ithaca, New York, USA; ¹³Emeritus, Rockefeller University, New York, New York, USA

Abstract
Objectives: Dichlorodiphenyltrichloroethane (DDT) was used worldwide until the 1970s, when concerns about its toxic effects, its environmental persistence, and its concentration in the food supply led to use restrictions and prohibitions. In 2001, more than 100 countries signed the Stockholm Convention on Persistent Organic Pollutants (POPs) , committing to eliminate the use of 12 POPs of greatest concern. However, DDT use was allowed for disease vector control. In 2006, the World Health Organization and the U.S. Agency for International Development endorsed indoor DDT spraying to control malaria. To better inform current policy, we reviewed epidemiologic studies published from 2003 to 2008 that investigated the human health consequences of DDT and/or DDE (dichlorodiphenyldichloroethylene) exposure.

Data sources and extraction: We conducted a PubMed search in October 2008 and retrieved 494 studies.

Data synthesis: Use restrictions have been successful in lowering human exposure to DDT, but blood concentrations of DDT and DDE are high in countries where DDT is currently being used or was more recently restricted. The recent literature shows a growing body of evidence that exposure to DDT and its breakdown product DDE may be associated with adverse health outcomes such as breast cancer, diabetes, decreased semen quality, spontaneous abortion, and impaired neurodevelopment in children.

Conclusions: Although we provide evidence to suggest that DDT and DDE may pose a risk to human health, we also highlight the lack of knowledge about human exposure and health effects in communities where DDT is currently being sprayed for malaria control. We recommend research to address this gap and to develop safe and effective alternatives to DDT.

Key words: DDE, DDT, dichlorodiphenyldichloroethylene, dichlorodiphenyltrichloroethane, health effects, organochlorine pesticides, persistent organic pollutants. Environ Health Perspect 117:1359–1367 (2009) . doi:10.1289/ehp.11748 available via http://dx.doi.org/ [Online 4 May 2009]

Address correspondence to B. Eskenazi, School of Public Health, University of California, Berkeley, 2150 Shattuck Ave., Suite 600, Berkeley, CA 94720 USA. Telephone: (510) 642-3496. Fax: (510) 642-9083. E-mail: eskenazi@berkeley.edu

We thank S.R. Wyrobek and R.H. Weldon for their contributions.

This publication was supported in part by grant RD83171001 from the U.S. Environmental Protection Agency (EPA) and grants P01 ES009605 and R01 ES015572 from the National Institute of Environmental Health Sciences (NIEHS) .

The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the NIEHS, National Institutes of Health, or U.S. EPA.

F.L., J.S.L., and E.C.L. are members of the Pine River Superfund Citizen Task Force. E.C.L. also represents Alma College ; individuals at this institution may have been exposed to DDT contamination of the Pine River. The remaining authors declare they have no competing financial interests.

Received 30 May 2008 ; accepted 4 May 2009.