The majority of US sewage sludges are disposed by application to land for use as a soil amendment. Class B sludges, containing a complex mix of chemical and biological contaminants, comprise the majority. Residents near land application sites report illness. Symptoms of more than 328 people involved in 39 incidents in 15 states are described. Investigation and tracking of the incidents by agencies is poor. Only one of 10 EPA regions provided substantial information on the incidents in their region. Investigations, when conducted, focused on compliance with regulations. No substantial health-related investigations were conducted by federal, state or local officials. A system for tracking and investigation is needed. Analysis of the limited data suggests that surface-applied Class B sludges present the greatest risk and should be eliminated. However, even under less risky application scenarios, the potential for off-site movement of chemicals, pathogens and biological agents suggest that their use should be eliminated.