FIOH-sponsored newsletter misrepresents asbestos hazards in Zimbabwe

The Finnish Institute of Occupational Health (FIOH) has received support from the World Health Organization (WHO) and the International Labor Office (ILO) to publish the African Newsletter on Occupational Health and Safety. The African Newsletter on Occupational Health and Safety should not be a medium for industry propaganda, or the source of misinformation among the workers of Africa. Instead, FIOH should provide the same level of scientific information in Africa that it does in Finland and other developed countries.

Issues of Agricultural Safety and Health

Agricultural work is the most prevalent type of employment in the world. In the United States only a few are engaged in creating food and fiber for many. Agriculture includes farming, ranching, fishing, and forestry, and together they carry significant risk for the development of injury or illness. There are numerous special-population issues related to agriculture. Farmers are old and growing older, many workers are children, and migrant and seasonal help, often foreign born, make up a large percentage of the workforce. It has been only relatively recently that concerns of agricultural safety and health have become a major research focus in the United States.

Treatment of community-acquired methicillin-resistant Staphylococcus aureus in children

PURPOSE OF REVIEW

The concept of methicillin-resistant Staphylococcus aureus (MRSA) associated with broad resistance, nosocomial acquisition, and known risk factors has recently been expanded. A new type of MRSA that is resistant to fewer antibiotics has emerged in pediatric practice since the mid-1990s. These isolates are community acquired and have been reported from diverse geographic regions. Awareness of these organisms is important for appropriate treatment of S. aureus infections in children.

RECENT FINDINGS

Community-acquired MRSA (CA-MRSA) isolates are similar in many respects to community-acquired methicillin-susceptible S. aureus (CA-MSSA). There are usually no differences in risk factors between children with CA-MRSA infections and those with CA-MSSA infections or their household contacts. In one study, however, multivariate analysis showed that age greater than 1 year and health care contact in the preceding month were significant risk factors for CA-MRSA. Skin and soft tissue infections are the most common manifestations, although serious invasive infections and death may occur. Pneumonia has been reported more often in children with CA-MRSA than in those with CA-MSSA. Clindamycin is an effective therapy for CA-MRSA, but there is a risk for development of clindamycin resistance during treatment of a CA-MRSA that is clindamycin susceptible and inducibly erythromycin resistant. Trimethoprim-sulfamethoxazole is likely to be effective, and linezolid is a new option for treatment.

SUMMARY

The appearance of CA-MRSA has important implications for therapy of infections caused by S. aureus in children. Three specific issues are the development of resistance during clindamycin therapy, insufficient data on the use of trimethoprim-sulfamethoxazole in serious CA-MRSA infections, and the appropriate role for newer antibiotics such as linezolid.

Passive dosimetry aboard the Mir Orbital Station: internal measurements

Passive radiation dosimeters were exposed aboard the Mir Orbital Station over a substantial portion of the solar cycle in order to measure the change in dose and dose equivalent rates as a function of time. During solar minimum, simultaneous measurements of the radiation environment throughout the habitable volume of the Mir were made using passive dosimeters in order to investigate the effect of localized shielding on dose and dose equivalent. The passive dosimeters consisted of a combination of thermoluminescent detectors to measure absorbed dose and CR-39 PNTDs to measure the linear energy transfer (LET) spectrum from charged particles of LET infinity H2O > or = 5 keV/micrometers. Results from the two detector types were then combined to yield mean total dose rate, mean dose equivalent rate, and average quality factor. Contrary to expectations, both dose and dose equivalent rates measured during May-October 1991 near solar maximum were higher than similar measurements carried out in 1996-1997 during solar minimum. The elevated dose and dose equivalent rates measured in 1991 were probably due to a combination of intense solar activity, including a large solar particle event on 9 June 1991, and the temporary trapped radiation belt created in the slot region by the solar particle event and ensuing magnetic storm of 24 March 1991. During solar minimum, mean dose and dose equivalent rates were found to vary by factors of 1.55 and 1.37, respectively, between different locations through the interior of Mir. More heavily shielded locations tended to yield lower total dose and dose equivalent rates, but higher average quality factor than did more lightly shielding locations. However, other factors such as changes in the immediate shielding environment surrounding a given detector location, changes in the orientation of the Mir relative to its velocity vector, and changes in the altitude of the station also contributed to the variation. Proton and neutron-induced target fragment secondaries, not primary galactic cosmic rays, were found to dominate the LET spectrum above 100 keV/micrometers. This indicates that in low earth orbit, trapped protons in the South Atlantic Anomaly are responsible for the major fraction of the total dose equivalent.

Passive dosimetry aboard the Mir Orbital Station: external measurements

This paper reports results from the first measurements made on the exterior of a LEO spacecraft of mean dose equivalent rate and average quality factor as functions of shielding depth for shielding less than 1 g/cm2 Al equivalent. Two sets of measurements were made on the outside of the Mir Orbital Station; one near solar maximum in June 1991 and one near solar minimum in 1997. Absorbed dose was measured using stacks of TLDs. LET spectrum from charged particles of LET infinity H2O > o r= 5keV/micrometers was measured using stacks of CR-39 PNTDs. Results from the TLD and PNTD measurements at a given shielding depth were combined to yield mean total dose rate, mean dose equivalent rate, and average quality factor. Measurements made near solar maximum tend to be greater than those made during solar minimum. Both mean dose rate and mean dose equivalent rate decrease by nearly four orders of magnitude within the first g/cm2 shielding illustrating the attenuation of both trapped electrons and low-energy trapped protons. In order to overcome problems with detector saturation after standard chemical processing, measurement of LET spectrum in the least shielded CR-39 PNTD layer (0.005 g/cm2 Al) was carried out using an atomic force microscope.

Clindamycin treatment of methicillin-resistant Staphylococcus aureus infections in children

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) with a narrower antibiotic resistance pattern have emerged. There is a risk for the appearance of resistance during clindamycin therapy of erythromycin-resistant MRSA infections because of the linked resistance mechanisms.

METHODS

We analyzed clindamycin-susceptible MRSA organisms from children (1987 to 2000) along with clinical data. Antibiotic susceptibilities of organisms were tested, pulsed field gel electrophoresis (PFGE) was done and the linked resistance mechanism was detected by the D test.

RESULTS

An average of 11 clindamycin-susceptible MRSA per year were obtained from children since 1993. Of 88 isolates 33 (38%) were erythromycin-resistant. The latter were less often community-acquired (45% vs. 69%), more often from infants <1 month of age (24% vs. 4%) and less likely to be in the community acquisition-associated PFGE Group 1 (62% vs. 87%) than those that were susceptible. The D test was positive in 31 of 33 erythromycin-resistant isolates. A 9-month-old boy with pneumonia/empyema caused by a clindamycin-susceptible, erythromycin-resistant, D test-positive MRSA developed a PFGE-identical clindamycin-resistant isolate and clinical relapse during clindamycin treatment. In contrast a 12-year-old girl with abscesses caused by a similar MRSA developed another abscess after clindamycin therapy, but the organism was unchanged in susceptibility.

CONCLUSIONS

Erythromycin resistance was present in 38% of clindamycin-susceptible MRSA in children, and clindamycin resistance was detected during treatment in one child. Clindamycin remains a treatment option if the clinician is notified of the risk by the microbiology laboratory and the clinical situation is suitable.

The International Commission on Occupational Health (ICOH) and its influence on international organizations

The ICOH has played a key role in the development of some scientific documents and policy recommendations, but it has not always been scientifically objective, particularly in regard to asbestos and other fibers and some chemicals and pesticides. Many ICOH members are employees of corporations or consultants to industry, serving multinational corporate interests to influence public health policy in the guise of a professional scientific organization. ICOH members' conflicts of interest with the public health dominate the organization and damage the standing of the ICOH. Official recognition of the ICOH compromises the credibility of the WHO and the ILO. It is inappropriate for the ICOH to continue to receive WHO and ILO recognition unless the ICOH is recognized as an industry organization.

Dosimetric results from the Mir orbital station

The Mir Orbital Station provided a unique platform on which to carry out a variety of space radiation dosimetry measurements. A number of experiments were conducted using a combination of passive detectors on the interior of the Mir during 1996-97. Thermoluminescent detectors were used to measure absorbed dose. CR-39 plastic nuclear track detectors were used to measure the LET spectra > or =5 keV.microm(-1). Results from TLDs and CR-39 PNTDs were combined to determine total dose and dose equivalent. Mean dose rate was found to decrease while mean dose equivalent rate and average quality factor increased with increasing shielding. Secondary particles from proton-induced target fragmentation interactions, not primary HZE particles, were found to be the largest contributor to the LET spectrum above 100 keV.microm(-1). During the 1997 measurements, mean quality factor was found to vary from 1.7 to 2.1 as a function of location within the Mir.

Differential neutron energy spectra measured on spacecraft in low Earth orbit

Two methods for measuring neutrons in the range from thermal energies to dozens of MeV were used. In the first method, alpha-particles emitted from the 6Li(n,alpha)T reaction are detected with the help of plastic nuclear track detectors, yielding results on thermal and resonance neutrons. Also, fission foils are used to detect fast neutrons. In the second method, fast neutrons are recorded by nuclear photographic emulsions (NPE). The results of measurements on board various satellites are presented. The neutron flux density does not appear to correlate clearly with orbital parameters. Up to 50% of neutrons are due to albedo neutrons from the atmosphere while the fluxes inside the satellites are 15-20% higher than those on the outside. Estimates show that the neutron contribution to the total equivalent radiation dose reaches 20-30%.

Depth distribution of absorbed dose on the external surface of Cosmos 1887 biosatellite

Significant absorbed dose levels exceeding 1.0 Gy day-1 have been measured on the external surface of the Cosmos 1887 biosatellite as functions of depth in stacks of thin thermoluminescent detectors (TLDs) of U.S.S.R. and U.S.A. manufacture. The dose was found to decrease rapidly with increasing absorber thickness, thereby indicating the presence of intensive fluxes of low-energy particles. Comparison between the U.S.S.R. and U.S.A. results and calculations based on the Vette Model environment are in satisfactory agreement. The major contribution to the dose under thin shielding thickness is shown to be from electrons. The fraction of the dose due to protons and heavier charged particles increases with shielding thickness.

Linear energy transfer (LET) spectra of cosmic radiation in low Earth orbit

Integral linear energy transfer (LET) spectra of cosmic radiation (CR) particles were measured on five Cosmos series spacecraft in low Earth orbit (LEO). Particular emphasis is placed on results of the Cosmos 1887 biosatellite which carried a set of joint U.S.S.R.-U.S.A. radiation experiments involving passive detectors that included thermoluminescent detectors (TLDs), plastic nuclear track detectors (PNTDs), fission foils, nuclear photo-emulsions, etc. which were located both inside and outside the spacecraft. Measured LET spectra are compared with those theoretically calculated. Results show that there is some dependence of LET spectra on orbital parameters. The results are used to estimate the CR quality factor (QF) for the Cosmos 1887 mission.

Ethical and practical aspects of human studies

Increasingly, genetic information holds the promise of prevention, earlier detection, and better treatment for cancer and other genetically related diseases. Laboratory markers are giving insight into the role of measurable genetic changes; however, there is often difficulty in translating laboratory data into practical use in human populations. Human populations can be difficult to study, and, correctly, there are strict regulations regarding the use of humans as study subjects for many kinds of research activities. Various study designs have a differential ability to prove cause and effect relationships, and will similarly have a differential ability in validating the usefulness of genetic markers. Just as conducting bench research has a traditional set of problems, working with human populations has its own set of potential difficulties. In reality, workers and others are often exposed to carcinogenic substances, usually without their knowledge, and without their informed consent. As genetic information becomes more readily available, and in finer detail, there is a great risk of misuse by employers, insurance companies and others. Placing blame on someone's genetic make-up may once again put into vogue a "blame-the-victim" mentality instead of continuing efforts to clean up workplaces and the environment, or restricting the use of hazardous products. No genetic information should ever be used to deny employment or modify insurance rates. Individuals should be able to maintain personal control over their genetic information. Positive aspects of the use of genetic information can be used to decrease disease and make environments safer.

Neutron dosimetry in low-earth orbit using passive detectors

This paper summarizes neutron dosimetry measurements made by the USF Physics Research Laboratory aboard US and Russian LEO spacecraft over the past 20 years using two types of passive detector. Thermal/resonance neutron detectors exploiting the 6Li(n,T) alpha reaction were used to measure neutrons of energies <1 MeV. Fission foil neutron detectors were used to measure neutrons of energies above 1 MeV. While originally analysed in terms of dose equivalent using the NCRP-38 definition of quality factor, for the purposes of this paper the measured neutron data have been reanalyzed and are presented in terms of ambient dose equivalent. Dose equivalent rate for neutrons <1 MeV ranged from 0.80 microSv/d on the low altitude, low inclination STS-41B mission to 22.0 microSv/d measured in the Shuttle's cargo bay on the highly inclined STS-51F Spacelab-2 mission. In one particular instance a detector embedded within a large hydrogenous mass on STS-61 (in the ECT experiment) measured 34.6 microSv/d. Dose equivalent rate measurements of neutrons >1 MeV ranged from 4.5 microSv/d on the low altitude STS-3 mission to 172 microSv/d on the ~6 year LDEF mission. Thermal neutrons (<0.3 eV) were observed to make a negligible contribution to neutron dose equivalent in all cases. The major fraction of neutron dose equivalent was found to be from neutrons >1 MeV and, on LDEF, neutrons >1 MeV are responsible for over 98% of the total neutron dose equivalent. Estimates of the neutron contribution to the total dose equivalent are somewhat lower than model estimates, ranging from 5.7% at a location under low shielding on LDEF to 18.4% on the highly inclined (82.3 degrees) Biocosmos-2044 mission.

Approach to the patient with an occupational or environmental illness

This article reviews the importance of the occupational and environmental history, and the approach to a patient with a disease suspected to be of occupational or environmental origin. There is a detailed review of obtaining special aspects of the medical history related to work and environmental exposures as well as illustrative case studies. Sources of additional information are also cited.

TLD efficiency of 7LiF for doses deposited by high-LET particles

The efficiency of 7 LiF TLDs (TLD-700) in registering dose from high-LET (> or = 10 keV/micrometers) charged particles (relative to 137Cs gamma rays) has been measured for a number of accelerated heavy ions at various particle accelerator facilities. These measured efficiency values have been compared with similar results obtained from the open literature and a dose efficiency function has been fitted to the combined data set. While it was found that the dose efficiency is not only a function of LET, but also of the charge of the incident particle, the fitted function can be used to correct the undermeasured value of dose from exposures made in mixed radiation fields where LET information is available. This LET-dependent dose efficiency function is used in our laboratory in determining total absorbed dose and dose equivalent from combined TLD and CR-39 plastic nuclear track detector measurements.

Injuries related to shiftwork

OBJECTIVE

The purpose of this study was to review the relationship of shiftwork to industrial injuries, and possible methods of injury control.

METHOD

The primary method was a systematic review of the published literature. The Cochrane Collaboration protocol was used to conduct the literature search.

SELECTION CRITERIA

Studies were included if they addressed the issue of industrial injuries related to shiftwork.

RESULTS

No controlled interventions were found. All studies were observational, and most were retrospective. The studies were not comparable with one another since they refer to different industrial settings.

CONCLUSIONS

Findings from the literature indicate that shiftwork should be avoided, but that if necessary, certain patterns and rest breaks appear to be associated with fewer injuries. More and better-focused research is needed in this field of study.

Community-acquired and clindamycin-susceptible methicillin-resistant Staphylococcus aureus in children

BACKGROUND

Recognition of children with community-acquired (CA) infections caused by clindamycin-susceptible, methicillin-resistant Staphylococcus aureus (MRSA) prompted a retrospective study in two Chicago hospitals conducted from 1987 through 1997.

METHODS

Laboratory records of MRSA isolates, antibiotic susceptibilities and information from patient medical records were reviewed.

RESULTS

One hundred eleven MRSA isolates from 103 children were studied with 51 isolates CA and 77 susceptible to clindamycin. The CA infections were less frequently associated with prior surgery (P = 0.0039) or a foreign body (P = 0.0001), and clindamycin-susceptible MRSA infections were less frequently associated with a foreign body (P = 0.001) compared with nosocomially acquired or clindamycin-resistant MRSA infections. Clindamycin-susceptible MRSA sources were mostly skin, wound or abscess (69%). Soft tissue diagnoses predominated (70%), but 16% were serious invasive infections. Ninety percent of clindamycin-susceptible MRSA were susceptible to erythromycin and/or trimethoprim-sulfamethoxazole. Antibiotic undertreatment (45%) or overtreatment (17%) of children with the clindamycin-susceptible MRSA occurred, but clindamycin appeared to be effective when used.

CONCLUSION

The impact of these organisms could be substantial if they become more frequent or widespread. S. aureus is a potential pathogen in large numbers of pediatric patients; microbiologic evaluation and both presumptive and definitive treatment of all these children may need to be changed.

Environmental awareness among physicians: what are environmental health and environmental medicine?

Increased awareness of environmental health issues by the biomedical community and the general public places higher demands on all health and medical practitioners to understand the key terms and concepts related to environmental health and medicine. We all exist in 3 different environments (home, workplace, and community), each of which has its own array of hazards and means of exposure. Environmental medicine is a discipline that addresses preventive measures and provides assessment, diagnosis, and treatment of persons who experience adverse health effects of environmental exposures. In addition to basic clinical skills, environmental medicine uses specialized tools including biostatistics and epidemiologic studies, the science of toxicology and risk assessment, the discipline of industrial hygiene, and administrative and public policy skills. Examples of environmental issues that are faced by society today include asbestos exposure in public buildings as well as pesticide and other agricultural chemical residues present in various environmental media.

Ethical aspects of genetic testing

No research study or significant medical treatment can be done involving patients without their informed consent. In workplaces and environmental settings, individuals are often exposed to mutagenic or carcinogenic substances, usually without their knowledge, and not with their informed consent. Such exposures can lead to evermore easily documentable genetic changes. As genetic testing becomes more widespread, there are significant ethical implications regarding employment, insurance coverage, and confidentiality regarding medical information. With an increased ability to detect genetic changes, or 'unfavorable' genetic polymorphisms, this information should not be used to deny employment or increase insurance rates. Rather, such information should be used to increasingly provide appropriately safe workplaces, and place workers in less hazardous settings.

Exporting DBCP and other banned pesticides: consideration of ethical issues

Many developed countries permit the export of pesticides that are banned, restricted, or unregistered within their own borders. This practice, which leads to the exposure of agricultural workers in developing countries to high levels of pesticides that are not permitted in the country of manufacture, raises many ethical issues as well as economic, social, political, and public health issues. Worldwide attempts to control export of such pesticides, through the FAO/UNEP Prior Informed Consent program, moves this issue in the right direction. This article explores the current U.S. and international practices, using the specific example of export of DBCP to banana-producing countries. The actions taken by multinational corporations, manufacturers of the pesticides, and public health officials in both the exporting and importing countries are explored, along with the impacts on workers, local economies, governments, and the environment.

Carcinogenic implications of the lack of tremolite in UICC reference chrysotile

Using light and electron microscopy analysis, as well as electron diffraction, and energy-dispersive x-ray analysis, an aliquot of UICC chrysotile B was analyzed with special attention given to any tremolite contamination. Polarized light microscopy, with its limit of detection of approximately 1 micron when using dispersion staining, revealed chrysotile as the only fibrous asbestos component. Analytical electron microscopy at 333,000x of more than 20,000 consecutive fibers showed only the tubular morphology characteristic of chrysotile. These findings highlight that when this sample was used for exposure disease induced in animal models correlates with chrysotile-induced pathology, and does not support an explanation based on the "amphibole hypothesis." Thus, chrysotile should be considered as having the biologic ability to produce cancers, including mesotheliomas, based on the extensive use of this material as a standard reference material.

Diagnosis and treatment of extracanal invasive resorption

Extracanal invasive resorption is not a well-defined phenomenon. This article describes its clinical, radiographic, and histological characteristics. Treatment of affected teeth based on the location of the resorptive defect is also described.

Tyler asbestos workers: mortality experience in a cohort exposed to amosite

OBJECTIVES

To examine the causes of death among 1130 former workers of a plant in Tyler, Texas dedicated to the manufacture of asbestos pipe insulation materials. This cohort is important and unusual because it used amosite as the only asbestiform mineral in the production process. High level exposure of such a specific type was documented through industrial hygiene surveys in the plant.

METHODS

Deaths were ascertained through various sources including data tapes from the Texas Department of Health and the national death index files. As many death certificates as possible were secured (304/315) and cause of death assigned. After select exclusions, 222 death certificates were used in the analysis. Causes of death were compared with age, race, and sex specific mortalities for the United States population with a commercial software package (OCMAP Version 2.0).

RESULTS

There was an excess of deaths from respiratory cancer including the bronchus, trachea, and lung (standardised mortality ratio (SMR) 277 with 95% confidence interval (95% CI) 193 to 385). Four pleural mesotheliomas and two peritoneal mesotheliomas were identified. The analysis also showed an increasing risk of respiratory malignancy with increased duration of exposure including a significant excess of total deaths from respiratory cancer with less than six months of work at the plant (SMR 268 with 95% CI 172 to 399).

CONCLUSIONS

The importance of the cohort lies with the pure amosite exposure which took place in the plant and the extended period of latency which has followed. The death certificate analysis indicates the pathogenicity of amosite, the predominant commercial amphibole used in the United States. These data confirm a link between amosite asbestos and respiratory malignancy as well as mesothelioma.

Influenza virus infections in infants

BACKGROUND

Universal immunization of children with live attenuated cold recombinant vaccine has been proposed. The renewed recommendation for maternal immunization with influenza vaccine should increase the amount of antibody transmitted to the infant and postpone the need for active immunization. This study examines the risk of influenza during the first year of life to provide information about the time to initiate active immunization.

METHODS

Infants followed from birth to 1 year of age in the Houston Family Study were monitored weekly for influenza virus infection. Serum specimens were tested for evidence of infection at 4-month intervals.

RESULTS

One-third of 209 infants were infected during the first year; most of the infections occurred during the second 6 months of life. Only 26 of 69 infections were detected before 6 months of age compared with 43 afterward. More striking was the concentration of serious illnesses in the latter half of the first year; 8 of 9 otitis media episodes and 9 of 11 lower respiratory tract illnesses occurred in the older infants.

CONCLUSIONS

The combination of increased maternal antibody titers that should result from influenza immunization and the lesser risk of influenza in the first 6 months of life allows initiation of active immunization of children after 6 months of age.

Pharmacokinetics of once-daily dosing of gentamicin in neonates

In a prospective, randomized trial of once-daily versus twice-daily intravenous or intramuscular dosing with gentamicin, 11 neonates received 5.0 mg/kg once daily and 15 received 2.5 mg/kg twice daily for 2 ro 3 days. The once-daily intravenous dosing group and the twice-daily intravenous or intramuscular dosing group, respectively, had mean steady-state gentamicin peak concentrations of 10.7 versus 6.6 micrograms/ml (p < 0.05), 6-hour postdosing concentrations of 4.7 versus 2.8 micrograms/ml (p < 0.05), trough concentrations of 1.7 versus 1.7 micrograms/ml, elimination half-life of 8.8 versus 5.4 hours (p < 0.05), and volume of distribution at steady state of 0.67 versus 0.46 L/kg. No nephrotoxic effects were identified in any group. Once-daily gentamicin therapy with 5.0 mg/kg in neonates achieves peak serum levels that are more suitable for optimal bacterial killing than those which traditional regimens achieve. Similar trough levels suggest that even larger doses and longer dosing intervals may be ideal in term neonates.

The riddle of risk assessment in asbestos carcinogenicity

While there appear to be some legitimate issues of scientific inquiry with regard to asbestos carcinogenicity, there also appear to be continuing areas of controversy which, given the state of scientific evidence, should be considered settled. There have been real costs, both monetarily and in human suffering, with regard to past and current uses of asbestos. With the continuing, often poorly controlled exposure, that workers still have, more disease can be expected. The fitting remembrance of Dr. Selikoff would be to remember the science that he contributed and the interest he took in the lives of workers and others. It then becomes incumbent upon those of us who continue to work in this area to carry on in the spirit of protecting the lives and well-being of workers from this hazardous material, as we would for other known hazards.

Unexpected opportunities: incidental findings detected during impairment evaluations for coal workers' pneumoconiosis

Coal workers' pneumoconiosis impairment evaluations for 374 miners, predominantly from eastern Kentucky, were conducted by our department between January 1, 1989, and June 30, 1992. During a review of the cases, potentially significant findings not directly related to any detected pneumoconiosis were recorded. Sixty-five (17.4%) of the men had blood pressure > or = 150 mm Hg systolic or > or = 90 mm Hg diastolic during one measurement. Of 89 workers who had a previous diagnosis of hypertension and were being treated, 40 (44.9%) had an elevated blood pressure measurement. Twelve cases of incidental, previously undetected chest radiograph findings warranted follow-up; 9 of these were isolated pulmonary nodules. In addition, three patients were immediately referred for evaluation and treatment of conditions newly diagnosed during the examination--one for unstable angina pectoris, one for congestive heart failure, and one for recent cerebrovascular accident. These cases illustrate that physicians doing impairment evaluations, even if they are not the patient's treating physician, have the opportunity and responsibility to intervene and reduce morbidity and mortality.

Intercomparison of radiation measurements on STS-63

A joint NASA Russia study of the radiation environment inside the Space Shuttle was performed on STS-63. This was the second flight under the Shuttle-Mir Science Program (Phase 1). The Shuttle was launched on 2 February 1995, in a 51.65 degrees inclination orbit and landed at Kennedy Space Center on 11 February 1995, for a total flight duration of 8.27 days. The Shuttle carried a complement of both passive and active detectors distributed throughout the Shuttle volume. The crew exposure varied from 1962 to 2790 microGy with an average of 2265.8 microGy or 273.98 microGy/day. Crew exposures varied by a factor of 1.4, which is higher than usual for STS mission. The flight altitude varied from 314 to 395 km and provided a unique opportunity to obtain dose variation with altitude. Measurements of the average east-west dose variation were made using two active solid state detectors. The dose rate in the Spacehab locker, measured using a tissue equivalent proportional counter (TEPC), was 413.3 microGy/day, consistent with measurements made using thermoluminescent detectors (TLDs) in the same locker. The average quality factor was 2.33, and although it was higher than model calculations, it was consistent with values derived from high temperature peaks in TLDs. The dose rate due to galactic cosmic radiation was 110.6 microGy/day and agreed with model calculations. The dose rate from trapped particles was 302.7 microGy/day, nearly a factor of 2 lower than the prediction of the AP8 model. The neutrons in the intermediate energy range of 1-20 MeV contributed 13 microGy/day and 156 microSv/day, respectively. Analysis of data from the charged particle spectrometer has not yet been completed.

Secondary particle contribution to LET spectra on LDEF

Four experiments utilizing passive detectors (P0006, P0004, A0015, M0004) were flown on LDEF to study the radiation environment. These experiments have been summarized in a companion paper (Benton et al., 1996). One of the experimental goals was to measure LET spectra at different locations and shielding depths with plastic nuclear track detectors (PNTD). It was found that the LET spectra extended well above the LET cutoff imposed by the geomagnetic field on GCR particle penetration into LEO. The high LET particles detected were mostly short-range (range < 2000 m), indicating that they were secondaries produced locally within the PNTD. The presence of these high LET particle fluences is important for the determination of dose equivalent because of the high Quality Factors (Q) involved. A relatively small fraction of particle fluence can contribute a large fraction of dose equivalent. Short-range, inelastic secondary particles produced by trapped protons in the South Atlantic Anomaly (SAA) were found to be a major contributor to the LET spectra above 100 keV/micrometer. The LET spectra were found to extend beyond the approximately 137 keV/micrometer relativistic GCR Fe peak to over 1000 keV/micrometer. The high LET tail of the LET spectra was measured in CR-39 and polycarbonate PNTDs using different techniques. GCR made a relatively modest contribution to the LET spectra as compared to the contributions from short-range secondary particles and stopping protons. LET spectra intercomparisons were made between LDEF measurements and exposures to 154 MeV accelerated proton beams. The similarities support the role of nuclear interactions by trapped protons as the major source of secondary particles in the PNTDs. Also techniques were employed to reduce the range cutoff for detection of the short-range secondaries to approximately 1 micrometer, so that essentially all secondary particles were included in the LET spectra. This has allowed a more realistic assessment of secondary contribution to dose equivalent. Comparisons of measured and calculated LET spectra have been made that demonstrate the need for more accurate modeling of secondary particles in radiation transport codes. Comparisons include preliminary calculations in which attempts have been made to include secondary particles.

Absorbed dose measurements on LDEF and comparisons with predictions

The radiation environment on LDEF was monitored by cumulative absorbed dose measurements made with TLDs at different locations and shielding depths. The TLDs were included in four experiments: A0015(a) Biostack, P0004 Seeds in Space and P0006 Linear Energy Transfer Spectrum Measurements at the trailing edge (west side) of the satellite; M0004 Fiber Optics Data Link at the leading edge (east side); and A0015(b) Biostack at the Earth side. The shielding depths varied between 0.48 and 15.4 g/cm2, Al equivalent. Both the directional dependence of trapped protons incident on the satellite and the shielding thickness were reflected in absorbed dose values. The trapped proton anisotropy was measured by TLDs at the east and west sides of LDEF. At the east side doses ranged from 2.10 to 2.58 Gy under shielding of 2.90 to 1.37 g/cm2 (M0004) while on the west side doses ranged from 2.66 to 6.48 Gy under shielding of 15.4 to 0.48 g/cm2 (P0006). The west side doses were more than a factor of two higher, where the vertical shielding thicknesses to space were equal. Other west side doses of 3.04 to 4.49 Gy under shielding of 11.7 to 3.85 g/cm2 (A0015(a)) and 2.91 to 6.64 Gy under shielding of 11.1 to 0.48 g/cm2 (P0004) generally agreed with the P0006 results. The Earth side doses of 2.41 to 3.93 Gy under shielding of 10.0 to 1.66 g cm2 (A0015(b)) were intermediate between the east side and west side doses. Calculations utilizing a model of trapped proton spectra were performed by Watts et al. (1993) and comparisons of dose measurement and calculations may be found in a companion paper (Armstrong et al., 1996).

Neutron fluences and dose equivalents measured with passive detectors on LDEF

Neutron fluences were measured on LDEF in the low energy (< 1 MeV) and high energy (> 1 MeV) ranges. The low energy detectors used the 6Li(n,alpha)T reaction with Gd foil absorbers to separate thermal (< 0.2 eV) and resonance (0.2 eV-1 MeV) neutron response. High energy detectors contained sets of fission foils (181Ta, 209Bi, 232Th, 238U) with different neutron energy thresholds. The measured neutron fluences together with predicted spectral shapes were used to estimate neutron dose equivalents. The detectors were located in the A0015 and P0006 experiments at the west and Earth sides of LDEF under shielding varying from 1 to 19 g/cm2. Dose equivalent rates varied from 0.8 to 3.3 microSv/d for the low energy neutrons and from 160 to 390 microSv/d for the high energy neutrons. This compares with TLD measured absorbed dose rates in the range of 1000-3000 microGy/d near these locations and demonstrates that high energy neutrons contribute a significant fraction of the total dose equivalent in LEO. Comparisons between measurements and calculations were made for high energy neutrons based on fission fragment tracks generated by fission foils at different shielding depths. A simple 1-D slab geometry was used in the calculations. Agreement between measurements and calculations depended on both shielding depth and threshold energy of the fission foils. Differences increased as both shielding and threshold energy increased. The modeled proton/neutron spectra appeared deficient at high energies. A 3-D model of the experiments is needed to help resolve the differences.

Particle directionality and trapped proton fluences on LDEF

Directionality of incident space radiation is a significant factor in spacecraft shielding and astronaut dosimetry in low Earth orbit (LEO). Particle directionality of GCR and trapped protons were measured on LDEF with plastic nuclear track detectors (PNTD) from the P0006 west-side experiment. This experiment consisted of a thick detector stack and is described more fully in a companion article (Benton et al., 1996). The anisotropy of the trapped protons produced maximum intensity for protons arriving from the west. The fluences of the eastward directed trapped protons have been measured by selection of the particles on the basis of range in the PNTDs. The measured fluences are compared with the model calculations of Armstrong and Colborn (1993).

LET spectra measurements on LDEF: variations with shielding and location

LET spectra measurements made with passive plastic nuclear track detectors (PNTDs) were found to depend on detector orientation, shielding and experiment location. LET spectra were measured at several locations on LDEF as part of the P0006 LETSME experiment (Benton and Parnell, 1984), the P0004 Seeds in Space experiment (Parks and Alston, 1984), the A00l5 Free Flyer Biostacks and the M0004 Fiber Optics Data Link experiment (Taylor, 1984). Locations included the east, west and Earth sides of the LDEF satellite. The LET spectra measured with PNTDs deviated significantly from calculations, especially for high LET particles (LET infinity H2O > or = 100 keV/micrometer). At high LETs, short-range inelastic secondary particles produced by trapped proton interactions with the nuclei of the detector were found to be the principal contributor to LET spectra. At lower LETs, the spectra appeared to be due to short-range, inelastic and stopping primary protons, with primary GCR particles making a smaller contribution. The dependence of LET spectra on detector orientation and shielding was studied using the four orthogonal stacks in the P0006 experiment. Both measurements of total track density and LET spectra showed a greater number of particles arriving from the direction of space than from Earth. Measurements of LET spectra in CR-39 PNTD on the east (leading) and west (trailing) sides of LDEF showed a higher rate of production at the west side. This was caused by a larger flux of trapped protons on the west side as predicted by the east/west trapped proton anisotropy in the South Atlantic Anomaly (SAA). Track density measured in CR-39 PNTDs increased as a function of shielding depth in the detector stack. A similar measurement made in a thick stack of CR-39 interspersed with layers of Al and exposed to 154 MeV protons at a ground-based accelerator showed a similar result, indicating that a significant fraction of the particle events counted were from secondaries and that the total cross-section for production of proton-induced secondaries increased as the energy of primary protons attenuated. Little change was seen in either total differential or integral LET spectra as a function of shielding depth, indicating that the increase in cross section with decreasing proton energy affected mostly the shorter range secondary components. Similarity in the slopes of LET spectra from ground-based proton exposures and the A00l5 LET spectra showed that modeling of a monoenergetic proton beam transported through a 1-D geometry was a useful first step in modeling the production of secondary particles by trapped protons in the SAA.

Influenza vaccination of children during acute asthma exacerbation and concurrent prednisone therapy

OBJECTIVES

The influenza vaccination rate is very low among children with moderate to severe asthma. This may be partly because of poor patient motivation and failure to visit clinics for vaccination. Another important factor may be health care providers' deferral of vaccination because of concern about the efficacy and safety of influenza vaccination during asthma exacerbations and concurrent prednisone therapy. We therefore examined the safety and immunogenicity of influenza vaccination during acute asthma exacerbation with concomitant prednisone therapy.

SETTING

A pediatric allergy and pulmonology clinic and a pediatric emergency department.

DESIGN

Children (n = 109) with a known diagnosis of asthma 6 months to 18 years of age were recruited. All participating patients, 59 without asthma symptoms (no prednisone, control group) and 50 with acute asthma exacerbation requiring prednisone burst therapy (prednisone group) received trivalent subvirion influenza vaccine. Fifteen children in the control group and 12 in the prednisone group received a booster dose according to American Academy of Pediatrics guidelines. Serum antibody titers to influenza A/Beijing/32/92 (H3N2), influenza A/Texas/36/91 (H1N1), and influenza B/Panama/45/90 were measured before and 2 weeks after vaccination. Adverse effects noted within 48 hours after vaccine dose were ascertained during the follow-up visit.

RESULTS

The antibody response was analyzed by comparing mean postvaccine titers, the percentage of patients achieving protective antibody levels (> or = 5log2), and the percentage of patients achieving rises in titers of 2log2 or greater. Antibody responses to influenza A/Beijing/32/92 (H3N2) and influenza A/Texas/36/91 (H1N1) in the prednisone-treated and control groups were not different. A significantly better response to the influenza B/Panama/45/90 antigen was seen in the prednisone group for all three parameters. Children who received a booster dose and the subgroup of children with low prevaccination titers (< or = 3log2) showed similar patterns. Adverse effects, including asthma exacerbation, local swelling at the injection site, fever, rash, and headache, were not different in the two groups.

CONCLUSIONS

Influenza vaccination can be given safely and effectively to asthmatic children regardless of asthma symptoms or concurrent prednisone therapy when necessary. Vaccination of all moderate to severe asthmatic patients visiting clinics or emergency departments would improve the overall vaccination rate significantly.

Scientific and ethical aspects of human monitoring

Screening and monitoring activities have their place in the prevention of workplace and environmental disease and injury. Testing, while still relatively nonspecific at this time, can be appropriately used in such prevention activities. Unfortunately, such information can be misused or even put to malevolent purpose, and this complicates the moral and ethical aspects of such testing. With advances in molecular biology, one can anticipate more refined and individualized testing in the future.

Prevention into the 21st century

Prevention in the United States has suffered because of the use of a traditional "medical" model rather than a "health" model. Financing, medical education, and research support have favored a focus on disease rather than prevention, although the greatest gains in man's physical well-being have come from preventive rather than curative activities. Although prevention has not been a major focus within medicine to date, despite its significant contributions, it appears that major changes will take place in the twenty-first century that will markedly change this situation. Mount Sinai, because of its meaningful role in studying the health of groups and in health service delivery, and its founding as a medical school with a focus on populations, has made, and will make, contributions to preventive activities in the future.

Kaolinosis in a cotton mill worker

A 62-year-old white male employed for 43 years in the polishing room of a cotton textile mill was admitted to a tertiary care center with progressive dyspnea and productive cough that had not responded to therapy for tuberculosis. In spite of aggressive antibiotic therapy and respiratory support, the patient died as a consequence of respiratory failure. Small rounded and irregular opacities had been noted on the chest radiograph. Review of job-site spirometry demonstrated a worsening restrictive pattern over a 4-year period prior to his death. Additional occupational history revealed long-term exposure to kaolin in the polishing room, and pathologic examination of lung tissue confirmed extensive fibrosis and substantial quantities of kaolin. Kaolinosis is a disease typically found among individuals involved in mining or processing this material rather than in user industries. This case illustrates the importance of obtaining a complete occupational history in reaching a diagnosis. The clinicopathologic aspects of kaolinosis are also reviewed.

Causation, impairment, disability: an analysis of coal workers' pneumoconiosis evaluations

The relation of exposure, impairment, and awarded disability in coal dust disease cases is often unclear. Surveillance data from large mining populations has demonstrated a decline in pulmonary function associated with coal dust exposure, even in miners with normal roentgenographs, though the frequency with which this results in impairment is not well defined. This study examines a more specific group, 374 disability claimants, for whom evaluation data is less extensive. In this group, several pulmonary function variables declined in association with years mining, even after controlling for roentgenograph status and smoking. This was particularly seen among underground miners, although the declines were small and of marginal statistical significance. Awards were evaluated for 203 resolved cases. Among 59 with completely normal roentgenographs and pulmonary function tests (PFTs), 38 (64%) received some disability award. These findings support development of a more rational impairment/disability system for those with potential coal dust disease.

In-flight radiation measurements on STS-60

A joint investigation between the United States and Russia to study the radiation environment inside the Space Shuttle flight STS-60 was carried out as part of the Shuttle-Mir Science Program (Phase 1). This is the first direct comparison of a number of different dosimetric measurement techniques between the two countries. STS-60 was launched on 3 February 1994 in a nearly circular 57 degrees x 353 km orbit with five U.S. astronauts and one Russian cosmonaut for 8.3 days. A variety of instruments provided crew radiation exposure, absorbed doses at fixed locations, neutron fluence and dose equivalent, linear energy transfer (LET) spectra of trapped and galactic cosmic radiation, and energy spectra and angular distribution of trapped protons. In general, there is good agreement between the U.S. and Russian measurements. The AP8 Min trapped proton model predicts an average of 1.8 times the measured absorbed dose. The average quality factor determined from measured lineal energy, y, spectra using a tissue equivalent proportional counter (TEPC), is in good agreement with that derived from the high temperature peak in the 6LiF thermoluminescent detectors (TLDs). The radiation exposure in the mid-deck locker from neutrons below 1 MeV was 2.53 +/- 1.33 microSv/day. The absorbed dose rates measured using a tissue equivalent proportional counter, were 171.1 +/- 0.4 and 127.4 +/- 0.4 microGy/day for trapped particles and galactic cosmic rays, respectively. The combined dose rate of 298.5 +/- 0.82 microGy/day is about a factor of 1.4 higher than that measured using TLDs. The westward longitude drift of the South Atlantic Anomaly (SAA) is estimated to be 0.22 +/- 0.02 degrees/y. We evaluated the effects of spacecraft attitudes on TEPC dose rates due to the highly anisotropic low-earth orbit proton environment. Changes in spacecraft attitude resulted in dose-rate variations by factors of up to 2 at the location of the TEPC.

Medical and public health approaches to asbestos disease

Asbestos is known to cause a wide range of nonmalignant and malignant disease among occupationally and environmentally exposed individuals. Lung cancer and mesothelioma are of special importance. X-rays are evaluated utilizing the ILO classification, and the clinical signs and symptoms of many chronic lung diseases may occur. The fibrous nature of asbestos appears to be important, and fiber size plays a role in carcinogenic outcome. Because of the significant legal and public health implications of exposure, it appears that purposeful obfuscation of asbestos science has taken place. There are also worldwide efforts to shift patterns of use and manufacturing, leading to a wider dissemination of death and disease, especially when coupled with spreading tobacco usage.

The use of asbestos in Japan and China and malignancy related findings

Asbestos use in industrialized countries is generally being curtailed, with the exception of Japan which, even if it is not a major producer, is now the world's largest user, and this use is still increasing. On the contrary, China is one of the major producers at world levels. The author refers data from the literature dealing with epidemiological, and also experimental, studies performed in these two countries, which confirm that asbestos produces mesotheliomas in man and laboratory animals. The author underlines the possibility of demonstrating, through epidemiological studies, differences with respect to western countries, possibly related to different life styles and genetic and racial influences, and proposes some categories at risk, for either environmental or occupational reasons, which are particularly interesting for this type of study.