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Health Effects of Arsenic Longitudinal Study (HEALS): Description of a multidisciplinary epidemiologic investigation


Health Effects of Arsenic Longitudinal Study (HEALS), a multidisciplinary and large prospective cohort study in Araihazar, Bangladesh, was established to evaluate the effects of full-dose range arsenic (As) exposure on various health outcomes, including premalignant and malignant skin tumors, total mortality, pregnancy outcomes, and children's cognitive development. In this paper, we provide descriptions of the study methods including study design, study population, data collection, response rates, and exposure and outcome assessments. We also present characteristics of the study participants including the distribution of exposure and the prevalence of skin lesion at baseline recruitment. A total of 11,746 married men and women between 18 and 75 years of age participated in the study at baseline (a response rate of 98%) and completed a full questionnaire interview that included a food frequency questionnaire, with a response rate of 98%. Among the 98% of the participants who completed the clinical evaluation, over 90% provided blood samples and spot urine samples. Higher educational status, male gender, and presence of premalignant skin lesions were associated with an increased likelihood of providing blood and urine samples. Older participants were less likely to donate a blood sample. About one-third of the participants consumed water from a well with As concentration in each of three groups: >100 μg/l, 25–100 μg/l, and <25 μg/l. Average urinary As concentrations were 140 and 136 μg/l for males and females, respectively. HEALS has several unique features, including a prospective study design, comprehensive assessments of both past and future changes in As exposure at the individual level, a large repository of biological samples, and a full dose range of As exposures in the study population. HEALS is a valuable resource for examining novel research questions on the health effects of As exposure.

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The Health Effects of Arsenic Longitudinal Study


The United Nations Children's Emergency Fund


geographic positional system


Lamont–Doherty Earth Observatory


graphite furnace atomic absorption


inductively coupled plasma-mass spectrometry


cumulative arsenic index


food frequency questionnaire


body mass index


non-governmental organization


  • Ahsan H., Perrin M., Rahman A., Parvez F., Stute M., Zheng Y., Milton A.H., Brandt-Rauf P., van Geen A., and Graziano J. Associations between drinking water and urinary arsenic levels and skin lesions in Bangladesh. J Occup Environ Med 2000: 42 (12): 1195–1201.

    Article  CAS  Google Scholar 

  • Alain G., Tousignant J., and Rozenfarb E. Chronic arsenic toxicity. Int J Dermatol 1993: 32 (12): 899–901.

    Article  CAS  Google Scholar 

  • Anawar H.M., Akai J., Mostofa K.M., Safiullah S., and Tareq S.M. Arsenic poisoning in groundwater: health risk and geochemical sources in Bangladesh. Environ Int 2002: 27 (7): 597–604.

    Article  CAS  Google Scholar 

  • Bangladesh Bureau of Statistics., 2004.

  • Brown K.G., Boyle K.E., Chen C.W., and Gibb H.J. A dose–response analysis of skin cancer from inorganic arsenic in drinking water. Risk Anal 1989: 9 (4): 519–528.

    Article  CAS  Google Scholar 

  • Buchet J.P., and Lison D. Mortality by cancer in groups of the Belgian population with a moderately increased intake of arsenic. Int Arch Occup Environ Health 1998: 71 (2): 125–130.

    Article  CAS  Google Scholar 

  • Chakraborty A.K., and Saha K.C. Arsenical dermatosis from tubewell water in West Bengal. Indian J Med Res. 1987: 85: 326–334.

    CAS  PubMed  Google Scholar 

  • Chen C.J., Chiou H.Y., Chiang M.H., Lin L.J., and Tai T.Y. Dose–response relationship between ischemic heart disease mortality and long-term arsenic exposure. Arterioscler Thromb Vasc Biol 1996: 16 (4): 504–510.

    Article  CAS  Google Scholar 

  • Chen C.J., Chuang Y.C., Lin T.M., and Wu H.Y. Malignant neoplasms among residents of a blackfoot disease-endemic area in Taiwan: high-arsenic artesian well water and cancers. Cancer Res 1985: 45 (11 Part 2): 5895–5899.

    CAS  PubMed  Google Scholar 

  • Chen C.J., Hsueh Y.M., Lai M.S., Shyu M.P., Chen S.Y., Wu M.M., Kuo T.L., and Tai T.Y. Increased prevalence of hypertension and long-term arsenic exposure. Hypertension 1995: 25 (1): 53–60.

    Article  Google Scholar 

  • Chen C.J., Kuo T.L., and Wu M.M. Arsenic and cancers. Lancet 1988: 1 (8582): 414–415.

    Article  CAS  Google Scholar 

  • Chen C.J., and Wang C.J. Ecological correlation between arsenic level in well water and age-adjusted mortality from malignant neoplasms. Cancer Res 1990: 50 (17): 5470–5474.

    CAS  PubMed  Google Scholar 

  • Chen Y., and Ahsan H. Cancer burden from arsenic in drinking water in Bangladesh. Am J Public Health 2004a: 94 (5): 741–744.

    Article  Google Scholar 

  • Chen Y., Ahsan H., Parvez F., and Howe G. Validity of a Food Frequency Questionnaire for a Large Prospective Cohort Study in Bangladesh. Br J Nutr 2004b: 92 (5): 851–859.

    Article  CAS  Google Scholar 

  • Cheng Z., Zheng Y., Mortlock R., and van Geen A. Rapid multi-element analysis of groundwater by high-resolution inductively coupled plasma mass spectrometry. Anal Bioanal Chem 2004: 379 (3): 512–518.

    Article  CAS  Google Scholar 

  • Chiou H.Y., Chiou S.T., Hsu Y.H., Chou Y.L., Tseng C.H., Wei M.L., and Chen C.J. Incidence of transitional cell carcinoma and arsenic in drinking water: a follow-up study of 8102 residents in an arseniasis-endemic area in northeastern Taiwan. Am J Epidemiol 2001: 153 (5): 411–418.

    Article  CAS  Google Scholar 

  • Chiou H.Y., Huang W.I., Su C.L., Chang S.F., Hsu Y.H., and Chen C.J. Dose–response relationship between prevalence of cerebrovascular disease and ingested inorganic arsenic. Stroke 1997: 28 (9): 1717–1723.

    Article  CAS  Google Scholar 

  • Demling R.H., and Way L.W. Burn and other thermal injuries. Current surgical diagnosis and treatment, 10th edn. Appleton and Lange, East Norwalk, CT 1994.

  • EPA. Arsenic occurrence in public drinking water supplies (EPA-815-R-00-023/December 2000)., 2000.

  • EPA. Fact sheet about the Janurary 2001 arsenic rule (EPA 815-F-00-015)., 2001.

  • Guha Mazumder D.N., Chakraborty A.K., Ghose A., Gupta J.D., Chakraborty D.P., Dey S.B., and Chattopadhyay N. Chronic arsenic toxicity from drinking tubewell water in rural West Bengal. Bull World Health Organ 1988: 66 (4): 499–506.

    CAS  PubMed  Google Scholar 

  • Hafeman D.M., Ahsan H., Louis E.D., Siddique A.B., Slavkovich V., Cheng Z., van Geen A., and Graziano J.H. Association between arsenic exposure and a measure of subclinical sensory neuropathy in Bangladesh. J Occup Environ Med 2005a: 47 (8): 778–784.

    Article  CAS  Google Scholar 

  • Hafeman D., Ahsan H., Islam T., and Louis E. Betel nuts (Areca catechu): A study of their tremor-producing effects in Araihazar, Bangladesh. Movement Disorders 2005b, in press.

  • Hertz-Picciotto I., and Smith A.H. Observations on the dose–response curve for arsenic exposure and lung cancer. Scand J Work Environ Health 1993: 19 (4): 217–226.

    Article  CAS  Google Scholar 

  • Hopenhayn-Rich C., Biggs M.L., and Smith A.H. Lung and kidney cancer mortality associated with arsenic in drinking water in Cordoba, Argentina. Int J Epidemiol 1998: 27 (4): 561–569.

    Article  CAS  Google Scholar 

  • Hosegood V., and Campbell O.M. Body mass index, height, weight, arm circumference, and mortality in rural Bangladeshi women: a 19-y longitudinal study. Am J Clin Nutr 2003: 77 (2): 341–347.

    Article  CAS  Google Scholar 

  • Hsueh Y.M., Cheng G.S., Wu M.M., Yu H.S., Kuo T.L., and Chen C.J. Multiple risk factors associated with arsenic-induced skin cancer: effects of chronic liver disease and malnutritional status. Br J Cancer 1995: 71 (1): 109–114.

    Article  CAS  Google Scholar 

  • Lai M.S., Hsueh Y.M., Chen C.J., Shyu M.P., Chen S.Y., Kuo T.L., Wu M.M., and Tai T.Y. Ingested inorganic arsenic and prevalence of diabetes mellitus. Am J Epidemiol 1994: 139 (5): 484–492.

    Article  CAS  Google Scholar 

  • Mitra S.R., Mazumder D.N., Basu A., Block G., Haque R., Samanta S., Ghosh N., Smith M.M., von Ehrenstein O.S., and Smith A.H. Nutritional factors and susceptibility to arsenic-caused skin lesions in West Bengal, India. Environ Health Perspect 2004: 112 (10): 1104–1109.

    Article  CAS  Google Scholar 

  • National Research Council (U.S.). Subcommittee on Arsenic in Drinking Water. Arsenic in Drinking Water. National Academy Press, Washington, DC, 1999.

  • Nixon D.E., Mussmann G.V., Eckdahl S.J., and Moyer T.P. Total arsenic in urine: palladium-persulfate vs nickel as a matrix modifier for graphite furnace atomic absorption spectrophotometry. Clin Chem 1991: 37 (9): 1575–1579.

    CAS  PubMed  Google Scholar 

  • Smith A.H., Arroyo A.P., Mazumder D.N., Kosnett M.J., Hernandez A.L., Beeris M., Smith M.M., and Moore L.E. Arsenic-induced skin lesions among Atacameno people in Northern Chile despite good nutrition and centuries of exposure. Environ Health Perspect 2000: 108 (7): 617–620.

    CAS  PubMed  PubMed Central  Google Scholar 

  • The British Geological Survey. Groundwater studies for arsenic contamination in Bangladesh—Phase 1 findings. 1999.

  • Tsai S.Y., Chou H.Y., The H.W., Chen C.M., and Chen C.J. The effects of chronic arsenic exposure from drinking water on the neurobehavioral development in adolescence. Neurotoxicology 2003: 24 (4–5): 747–753.

    Article  CAS  Google Scholar 

  • Tseng C.H. Abnormal current perception thresholds measured by neurometer among residents in blackfoot disease-hyperendemic villages in Taiwan. Toxicol Lett 2003: 146 (1): 27–36.

    Article  CAS  Google Scholar 

  • Tseng C.H., Tai T.Y., Chong C.K., Tseng C.P., Lai M.S., Lin B.J., Chiou H.Y., Hsueh Y.M., Hsu K.H., and Chen C.J. Long-term arsenic exposure and incidence of non-insulin-dependent diabetes mellitus: a cohort study in arseniasis-hyperendemic villages in Taiwan. Environ Health Perspect 2000: 108 (9): 847–851.

    Article  CAS  Google Scholar 

  • van Geen A., Ahmed K.M., Seddique A.A., and Shamsudduha M. Community wells to mitigate the arsenic crisis in Bangladesh. Bull World Health Organ 2003b: 81 (9): 632–638.

    PubMed  PubMed Central  Google Scholar 

  • van Geen A., Ahsan H., Horneman A., Dhar R.K., Zheng Y., Hussain A.Z.M.I., Ahmed K.M., Gelman A., Stute M., Simpson H.J., Wallace S., Small C., Parvez M.F., Slavkovich V., Lolacono N.J., Becker M., Cheng Z., Momotai H., Shahnewaz M., Seddique A.A., and Graziano J. Promotion of well-switching to mitigate the current arsenic crisis in Bangladesh. Bull World Health Organiz 2002: 80: 732–737.

    Google Scholar 

  • van Geen A., Zheng Y., Versteeg R., Stute M., Horneman A., Dhar R.K., Steckler M., Gelman A., Small C., Ahsan H., Graziano J., Hussain I., and Ahmed K.M. Spatial variability of arsenic in 6000 tube wells in a 25 km2 area of Bangladesh. Water Resour Res 2003a: 39 (5): 1140.

    Article  Google Scholar 

  • Verret W.J., Chen Y., Parvez F., Alauddin M., Islam T., Graziano J.H., and Ahsan H. A randomized double-blind placebo-controlled trial to evaluate the efficacy of vitamin E and selenium supplementation on arsenic-induced skin lesions in Bangladesh. J Occup Environ Med 2005, in press.

  • Wasserman G.A., Xinhua L., Parvez F., Ahsan H., Factor-Litvak P., van Geen A., Slavkovich V., Lolacono N.J., Cheng Z., Hussain I., Momotai H., and Graziano J. Water arsenic exposure and children's intellectual function in Araihazar, Bangladesh. Environ Health Perspect 2004: 112: 1329–1333.

    Article  CAS  Google Scholar 

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This research was supported by US National Institute of Environmental Health Sciences Grants # P42 ES10349 and # P30 ES09089.

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Correspondence to Habibul Ahsan.

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Ahsan, H., Chen, Y., Parvez, F. et al. Health Effects of Arsenic Longitudinal Study (HEALS): Description of a multidisciplinary epidemiologic investigation. J Expo Sci Environ Epidemiol 16, 191–205 (2006).

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