Document 6BJb2LdzGgdp7Z03MVvYg4yEo

ust}p,C1 a poisoning caused by rice oil contaminated with polychlorinated biphenyls MASANORI KURATSUNE, M.D., TAKESUMl YD5KIMURA, M.D., JUNICHI MATSUZAKA, M.D., and ATSUKO YAMAGUCHf, M.D. SPORADIC outbreaks of a peculiar skin dis ease were reported tn Fukuoka-Kcn (Fuku oka Prefecture). Japan, in early October 1968 It was characterized by such symptoms as follicular accentuation, acneform eruption, pigmentation of the skm and nails, and hypersecretion of the Mei bomian gland Staff members of the department of dermatology of the Faculty of Medicine, Kyushu University, Fukuoka, who examined some of the early patients suspected they had chioracne. A possible causal relationship between the disease and ingestion of a certain brand of nee oil was also suspected in view of the distinct familial ag gregation of the patients and their common use of the oil (/). This relationship was subsequently proved, and the disease was called Yusho, or rice oil disease. To clarify the cause of the epidemic, a study group headed by Prof S. Katsuki of the Kyushu University Faculty of Medicine was organized by the staff of that university, the School of Medicine of Kurumc University, and local health depart ments An epidemiologic study subgroup was set up within the study group on October 19, 1968, which was directed by Kurutsunc and also in cluded the other three authors. This subgroup im mediately designed and carried out a scries of extensive surveys m close cooperation with the department of hygiene of our faculty of medicine and (he departments of public health of the Pre fecture of Fukuoka and of the cities of Kilakyushu, Fukuoka, and Ohmuta. The epidemic spread not only over FukuokaKen but also over 20 other prefectures in the western part of Japan. It produced 1,001 patients --502 males and 499 "females--according to the latest tabulation by the section of food hygiene, Ministry of Welfare, Although our study of the epidemic was confined to Fukuoka-Ken. and the epidemic proved to be caused by accidtmtally con taminated otl, wc~T5gtlcvc tftaPpublicaTion oT our*1 results will help prevent similar food poisonings These incidents can occur anywhere in the world if sufficient care is not exercised. The authors are with the department oi public health. Faculty o/ Medicine, Kyushu University, Fukuoka, Japan Or Kuratsune is a projector ol public health. Or. Yoshimnra and Dr. Mutsuluka are working toward doctoral degrees m pub lic health, and Dr. Yamaguchi is a research stu dent. The study on Yusho war supported by a special research grant from the Japanese Govern ment. Tearsheet requests to Masanori Kuratsune, M D., Facuity of Medicine, Kyushu University, Fukuoka, Japan. Doewnbw 1ST:. Vol. 06, No. 12 IMS MOMS 201115 I i Most of the results of our study have already been published in Japanese (2-5) We refer also, when necessary, to some important observations made by a clinical study subgroup headed by Prof. K. Higuchi of the department of dermatol ogy at our university and also to studies by a chemical study subgroup headed by Prof H Tsukamoto of the Faculty of Pharmaceutical Sciences. Clinical Symptoms The subjective symptoms of the 89 male and the 100 female patients whose cases of Yusho had been diagnosed by the end of October 1968 are luted m table 1. Most of these symptoms related to the skin and eyes. Detailed clinical examina tions of these 189 persons by the clinical study subgroup revealed many of the clinical character istics of Yusho (/,6-9). Dermatological observations. Acneform erup tion--marked enlargement and elevation of the follicular opening; pigmentation of the skin, lips, gingiva, the mucous membrane of the oral cavity, and nails; formation of hyperkeratolic plaque on the soles of the feet and palms of the hands, hyperhidrosis; hypertrichosis: swelling of Mont gomery's gland in the breast, cyst formation of the sebaceous gland in the genital region; dry skin; and, in children, milia near the joints. Table 1. Percent distribution of symptoms of Yusho reported by 189 patients examined be fore October 31,1968 Symptoms Males Females (N - 89) (N - 100) Dark brown pigmentation of nails. ... Distinctive hair follicles..................... Increased sweating *1 palms . .. Acnelike skin eruptions..................... .. Red plaques on limbs......................... Iiching................................................. ... Pigmentation of skin......................... . Swelling of limbs........... .... Stiffened totes in feel and palms of hinth.,. ............. ....................... Kigmenied mucous membrane .... .. Increased eye discharge....................... Hyperemia of conjunctiva.................. . . Tranwcnt visual disturbance ... .. Jaundice.......................................... Swelling of upper eyelids................... ... Feeling of weakness......................... . Numbness in limbs........................ ... Fever. . ..................................... Hearing dilTkullies ......................... Spasm of limbs................................. Vomitire ..................................... . Diarrhea ........................................ ... 30.6 87.6 42 T 56 2 70 8 36.2 7l 9 58.4 32.6 23 6 19.1 73.0 56 0 33 0 82.0 16.0 52.0 72 0 41.0 29.0 47.0 83.0 71 0 55 0 II 0 74.0 32 0 39.0 19 0 19.0 80 39 0 28 0 17 0 Ophthalmic Observations. Hypersecretion of the meibomian gland and abnormal pigmentation of the conpinctiva Neurological observations Numbness. p.nn. hypocsthesia, and lowered sensory conduction by the radial and sural nerves Other observations. Elevated serum triglycer ide Epidemiologic Data Available When the epidemiologic study subgroup began to act, it had several pieces of information Dial appeared to be important but whose implications were uncertain, such as the following* 1. The familial aggregation of patients was not able, and the disease showed no distinct age and sex preference. 2. All the patients seemed to have used one brand of rice oil (abbreviated as K rice oil be cause it was produced by K Company). An emer gency survey undertaken by the health department of the city of Fukuoka had disclosed that some of the patients in a certain area had, as a group, pur chased a can of K rice oil and divided ii among the group members. Those who did not buy ihc oil seemed to be unaffected even though they lived next door to the patients. 3. The patients seemed to be broadly distrib uted throughout Fukuoka-Ken. These data of course were valuable, but we knew that if we relied on them alone, ihcy might mislead us Wc exercised parncular caution, there fore, to avoid such a risk, always seeking possible antitheses when interpreting any result Descriptive Epidemiologic Studies The epidemiologic study subgroup first tried to learn how the 325 patients were distributed by place of residence and time o( onset of ihc disease (2). Those persons who thought they were suf fering from Yusho were asked to report 10 their local health departments. From October 196B until the epidemic practically terminated in i-irui> TY~f969, nplaT of 6.611 persons in FukuokaKcn had reported that they were aflccicd_Anionp them, 325 cases of Yusho were diagnosed by the clinical_study subcroup. An early analysis "of a portion of the 325 persons with confirmed cases, carried out in late October 1968, revealed several peculiar features in the geographic distnbuuon of cases, features which did not basically change dur ing ihc epidemic. Therefore, only the results of J0S4 HIM HA Health ftaports MONS 201116 partment covers an area (hat is primarily agricul tural. Most areas where few Yusho patients were aeen were agricultural. No other common socioe conomic or environmental factor was observed that RVigltt explain the geographic distribution of patients. Oil Used by Patients As stated, K rice oil had been suspected as the possible cause of the epidemic K rice oil is a high-quality salad oil, made from rice bran by the procedure shown m-the chart It was popular in Fukuoka-Ken, even though it was slightly more expensive than other oils on the market. A thor ough investigation was undertaken to determine whether (he patients with Yusho had actually used this brand of oil before they were affected and if so, whether there were any common characteris tics in regard to the container of the oil (bottle or can), dale of production, date of purchase, or route of marketing. To seek information on these points, an investigation was conducted in coopera tion with the local health departments Alt pa tients and their wives were visited and interviewed in their homes. In addition, all the available ship ping records of K Company and all available rec ords of purchases and sales of K rice oif at whole sale oii dealers' offices and at retail stores were carefully examined. These followup surveys soon disclosed an as tonishing fact. All the persons with Yusho had used, toe varying periods. K rice oil which came either front 16.5 kg. cans or 1.65 kg. bottles One hundred seventy of the 325 patients--49 house holds--had used only canned oil, while the re maining 155 patiems--63 households--had used only bottled oil (table 5). We were able to con firm the shipping dates for the oil used by all but four of these 170 patients No matter where the persons lived or what their age was, 166 of .the 170 had apparently used nee oil that was shipped by the K Company on February 5 and 6. 1968. according to the tot numbers on the few remaining cans. Even the four patients for whom we could not confirm shipping dates of the oil had also undoubtedly used a canned rice oil produced by the K company. The chipping or production dates could not be confirmed, however, for the bottled K oil that 155 patients had used exclusively, because they had no old bottles at home. Purchasers of oil in bottles return the empty ones to retail stores when they buy new oil. Nevertheless, all the shipping, pur chase, or selling records at K Company, at ihc oil dealers, and at the retail stores were examined to learn whether any bottled K rice oil h.ul been shipped to, and had reached, the retail stores from which the 155 patients boughi their oil All ship ments of oil to the stores used by the patients were furiher investigated to determine whether any of them had been made on February 5 or 6. 1968, or immediately before or aHcr these dates By this method, we discovered that 143 of ilie 155 patients might have hnnyhi rhe botilcd oil shipped, from the ITCompany tn the period Feb ruary 6-15, 1968. Whether the remaining 12 pa tients might have also purchased oil shipped in this period remains in doubt because of lack of records. Thus, nearly all of the patients had a distinguishing characteristic--they all had a com mon experience of use, or possible use, of rice oiI shipped by one company in a specific period Such a coincidence could hardly be expected uTfiappen by chance. Table 4. Age-specific Incidence rates for Yusho, by sex of patient Age group (years) tncidenct rates per 100.000 M*1c* Females 0-9 ....................... S6 10-19 .............................. 66 20-29 .............................. SO 3 JO-39............................... M9 40-49 .............................. 9J 50-39 ............................ . . 5 4 7 I 60-69 .......................... . .. 3J 24 70 and over................... . .. 17 0 All ages.................... *1 Table 5. Distribution of 325 patients and 112 households that used K rice oil, bs type of oil container and shipping dates of oil Container and Panents Households Number Percent Number Percent Users or canned oil Shipped February 5 and 6................ Shipping dales unknown.. . . Users of bottled oil . Probably used oil shipped February 5-1s , . , Shipping dates unknown............. Total................ no 52 3 166 31 1 4 12 155 47 7 143 44 0 12 3 7 323 too 0 49 43 e 47 42 0 2 IS 63 56 3 56 50 0 7 63 112 < 100 1 1 Does not add to 1000 percenl because of rounding 10M HSMHA Haailh Reports HONS 201117 FLOW SHEET OF RICE OIL PRODUCTION Rica bnn I Diltttid bran N-liauna utid t* artiaet __________ 1__________ Ctuda all Aftar rantaval af aalvant, la traatatf with tedium *U*tissjrh*t* I-----H9H lijrvr Traatad with MaOH 1 Oil NfutnUztd with H.SO. Waahad with hat watar "Dark" all Flltand Calw rtmavad with white percalaln claj Daadariiad by hie lint at avar 200* C. at 3 ta 4 mm. Hi Final products Our survey also demonstrated a high attack rate for oil persons who consumed the oil. Alto gether, 266 persons in 64 households had con sumed canned K rice oil shipped in the period in question, and 170 had confirmed cases of Yusho Thus, the attack rate was as high as 63.9 percent (2). '----------------------------- --- K Oil From Other Shipments An additional survey seemed necessary to de termine whether those persons who regularly used K rice oil but had not used any from shipments made m the penod in question were free of the disease. For this purpose, a group of persons was needed who had reliable records of their health status and of their purchases of K rice oil. A group of 113 persons of 29 households living in one apartment house seemed to be appropriate subjects for this study. According to the records of this group and the oil dealer who supplied them, these 113 persons had purchased canned K rice oil as a unit from one dealer and divided it among themselves fairly regularly from December 1967 to September I96S except for the period from January to April 1968, when this bulk purchasing was noi earned Out. Their disease experience, particularly any skin disease that occurred during 1968, was care fully explored through interviews and. if necessary, through investigation of their medical records at hospitals No eases of Yusho were found among Dacvmtwr 1*71, Vol *6, NO 12 10*7 HONS 201118 members of (his group. Thus, we demonstrated that persons who had used K rice oil regularly for more thjin^a half year but did not use the oil from the specific shipments did not suffer from Yusho U). Retrospective Cise-Control Studies AH these results suggested that Yusho was cau sally connected with use of the K nee oil that was shipped from K Company on February 5 and 6, 1968. or soon thereafter. Nevertheless, some other factors or agents might have been the primary or secondary cause of the epidemic. Therefore two case-control studies were done. In one, the per sonal backgrounds of the patients and matched controls were compared. In the other, the use of oil and fats in the households of the patients and the controls were compared. To discover whether persons with Yusho cases and those without had different personal back grounds, home interviews were conducted with all persons whose cases had been reported by Octo ber 31, 1968, and with healthy controls matched by age, sex, and place of residence. One hundred twenty-one patients and 121 controls (53 males and 68 females) were selected in this manner and asked 60 questions concerning their occupations, Table 6. Percent of 121 patients and 121 controls having various allergies and dietary and per sona) habits, based on case-control study llcms investigated Patients Con trols Allergic lo fish ....................................... Allergic lo aspirin................................ .. Allergic lo drugs oiher than aspirin...., Bathing facilities ai home........................ Bath every day........................................ Pels at home.......................................... Floor space of house smaller than 66 square meten............ *....... ,.......... Handling aenculiural chemical*.............. Taking codliver oil.................................. Taking vitamin pills................................ Taking other rcsioraiive drugs................ Water supply available at home.............. Dining out occti-ooaliy ... . ..... Taking at meals with the (amity............. Green vegetables daily............................. Milk nearly every day............................. Butter nearly every day........................... Eggs nearly every day . ......... Fried food* or icmpura nearly every day. Foods prepared with Oil nearly every day. Fish nearly every day.............................. Mayonnaise nearly every day.................. tnslam "rahmen" or Chinese noodles nearly every day................................... S.O .0 7.J *4 7 73.0 i 18.3 66.9 2.5 10.8 23.2 9. t 8t .3 28. t 88.8 63 t 49 0 22 4 64.7 *22 4 <251.67 10.8 10.8 'Peons. 7, J 4.2 BS 5 70 6 i 36. J 66. t 66 G.3 18 3 7,5 74 7 30.6 89.6 58 9 39 0 24 9 59 t It.6 35 7 29 t 10.8 to 0 Table 7. Distribution of 69 households with pa tients and 207 control households, by use of various fats or oils, based on ease-control study Fat or oil Households with patients Control houichoijs Number Percent Number Percent Butler.. ............. Margarine,........... Sesame oil........... ... 50 7 63 1 21 30 3 105 127 85 50 7 61 4 41.1 Rape-seed oil .. . 10 14.5 77 37 2 Rice-bran oil. . 66 93 7 64 30 9 Lard... ............... 17,4 35 18 4 Other otla.............. 11.1 117 36 J medical background, general health status, habits, customs, diet, pets, and other characteristics of their lives. The patients and the controls differed signifi cantly in respect to only iwo of the personal fac tors tested (table 6). Persons who ate fried foods or tempura nearly every day were more numerous among the patients than among the controls, while more of the controls than the patients had pets. To compare the use of oil and fats, 69 house holds with Yusho patients were matched by place of residence with 207 households without such patients--three control households for each household with cases. As to regular use of fats and oils, a distinct difference was noted between the two groups only for rice-bran oil. About 96 percent of the patients' households and 31 percent of the controls' house holds reportedly used rice-bran oil regularly . (table7). When asked about the use of rice oil from the K Company, all of the households with patients affirmed its use in comparison with only 32 4 per cent of the control households; 61 3 percent of the control households denied using it; the remaining 6,3 percent were uncertain Thus, the case-control studies clearly indicated that none of the factors tested except use of K rice oil could account for the disease (2). Dose-Response Relationship To prove that a causal relationship existed, a distinct dosc-rcsponse relationship needed to be demonstrated. Estimating the quantity of contami nated rice oil consumed by each patient nnd mem bers of his family was not feasible. Nevertheless if we disregarded age and sex, we could estimate roughly the average amount of oil cacti person had consumed by dividing the amount used m a ttWI HSMHA Health Report* HONS 201119 household by the number of persons in it, taking into account the frequency with which these per sons ale.at-home.-but not the possible loss of oil during and after cooking, nor the sarsing tastes and food intake of the family members Dr- Masayasu Goto, a dermatologts'. with no knowledge of the amount of oil used by the 146 consumers of the contaminated oil, examined these persons and then graded the cases of Yusho he diagnosed according to their clinical severity Only later did we link the severity of the cases, as determined by the dermatologist, to the amount of contaminated oil used by the patient Eighty of the 146 users of the contaminated oil were believed to have consumed, individually, less than 720 ml. (table 8) Of these 80 light users, 12 percent were not affected. 49 percent had light cases, and 39 percent had severe cjses; the attack rate was 8B percent. The 45 persons who had used 720-1,440 ml were all affected; 69 percent of this group had severe cases. A still larger pro portion of the severe cases was found among the persons who had used more than 1,440 ml of the contaminated oil; this group had an attack rate of 100 percent. Since the clinical seventy of the disease was not found to differ significantly between the sexes but differed considerably according to age, a standard ization for age seemed necessary to achieve a more accurate interpretation of the observed rela tionship between use of the oil and the clinical severity of the disease With the age composition of the 146 users of the oil as the standard, the factor of age was standardized for each of the three levels of oil intake. The figures, however, hardly changed from those shown m table 8. Thus a very clear dose-response relationship could be demonstrated, even though the estimates of the dose were inaccurate (3). Toxic Agent In view of all these epidemiologic observations, we concluded that K nee oil from specific ship ments had caused IHc Yusho! Now the question arose as to why the oil was toxic. To answer this question, wc of course had to rely on other ap proaches than epidemiology In mid-November 1968, the chemical study subgroup discovered, mainly by gas chromatographic analysis, that the canned K rice oil shipped on February 5. 1968, portions of which had been collected from some of the patients, was contaminated with about ,2,000 ppm of Kuncchlor Kancchior is a cummer- ciat brand of polychlorinated biphenyls containing 48 percent chlorine. Skin fat collected from the patients also contained Kaneehlor (10) In this discovers. Prof K lnagnnu of the de partment of food technology, Fjeultv of Agricul ture, Kyushu University, and his associates played a leading role. A technological inspection of the K Company plant revealed that Kancchior was used as an agent to transfer hc.it to ihe processed oil at a'Teduced pressure so that odorous substances coultTbe removed (see chart") The Kancchior must have leaked from the heating pipe in which it was being conveyed.and contaminated the oil, since small openings were .discovered-in the_ald pipe-- To discover whether only the K rice oil shipped in February 1968 was contaminated with Kanc chior, the chemical study subgroup analyzed 109 samples of the bottled K rice oil which, according to the lot numbers, had been shipped between October 1967 and October 1968. This analysis revealed that only the samples shipped on Febru ary 7, 10, 12, 15, 17, 18, and 19 and on March 11, 18, and 21, 1968, were contaminated wuh Kaneehlor. This contamination was most marked fnr thy nil shipppd pp Frhriiary 7, the COntamina- Con was rapidly reduced to nil after February 10 {10). No analysis could be made of bottled K rice oil shipped February 5 and 6 because of the lack of samples. Similarly, 479 random samples of bottled ncc oil were analyzed for chlorine content by using the X-ray fluorescence method with a count meter from a U.S, instrument manufacturer (the Ap plied Research Laboratory). Again, only those samples shipped fr""\ Frh"'^ a large amount of chlormeTmaximum 462 ppm) 'None of the oils shipped m other months were contaminatctLvriUl jnnu-than a trace amount of Chlorine. Thus, the results of chemical analysis coincided with those achieved by epidemiologic approaches. Other Epidemiologic Results Babies born to patients. In late October 1968 a pregnant patient with Yusho had a stilTbTTTH in which the fetus was unusual; the skin, nails, and gingiva were a peculiar dark brown and stained Similar letuses were delivered by other paiicnts with'Vusho. Since no such birth or stillbirth was known to have been reporicd previously in Japan, the study group investigated these occurrences wilh particular core. The epidemiologic study tacww 1171, Vol IS, No 17 IDS* HONS 201120 subgroup questioned all female patients with Growth of affected children Jo discover Yusho and all unaffected women in the house whether Yusho disturb* children's growth, ihc af hold* of patient* with Yusho about any preg fected school children, 23 boys and 19 girls, were nancies and deliveries in the period from Febru compared in 1967, 1968, and 1969 wuh 719 ary IS, 1961L10 the end of the year. healthy children matched in heighi and body Thirteen women--10 wuh Yusho. two without, weight. The gain in height or in body weighi and one with status uflMx.Tificdir-=had given Wth which each sick child showed before the poison to 11 live born and two stillborn infants during ing, namely from 1967 to 1968, and the gain after the specified period (Eight of the live born in the poisoning, from 1968 to 1969, were compared fants were males and three were females; one of with the distribution of the corresponding gams the stillborn infants was a female and the sex of seen in the corresponding control group the other was unspecified ) Among these infants and fetuses, 10 had the characteristic grityish dark-brown stained skin at birth. ^ve fhe~darlrcolored nails and gingiva, and nine"an~ increased eye discharge. Women with Yusho accounted~for all these deliveries, except for the delivery of one The gains of the affected boys in both height and weight decreased significantly after the poi soning, while the affected girls showed no definite change in this respect. Because of the limited l number of cases available for an alysisTfitrstgin fi ll fcant relationship could be found between"the clin- of the nine babies with eye symptoms. | ^cal severity of the cases and the decrease in gams The high incidence of these unusual phenomena I in height Ifld weight. " among pregnant women with Yusho strongly sug 1 _ gested that the phenomena were caused by inges Discussion tion of the contaminated oil. The fact that nothing unusual was seen in the women's medical histo ries, health conditions, or use of drugs during pregnancy also supported such an interpretation. All these facts, together with the results of h chemical'assays which showed that the^laccnta i and the subcutaneous adipose tissue of the still born Teluses contained components of Kanechlor. piove that babies and fetuses were affectetLbc*--Tause of the women's ingestion of this particular, complex compound (4). The majority of the babies were small for (heir periods of gestation. As they grew older, their stained skin gradually faded. Postnatal growth This unfortunate episode of rice oil poisoning taught us some important lessons In the food industries of many countries, no effective adminis trative control and supervision is apparently exer cised over the use of toxic substances like Ka nechlor. These produets do not contaminate the final products in normal operations, but they do when the operation is accidentally disiurbed or carelessly conducted. In contrast to the case with food additives, too little care has been exercised 10 avoid the hidden risks in the use of such sub stances. A greatly increased effort is needed 10 im prove this situation. curves for the affected babies were found to be similar in shape to the national standards when both sexes combined were compared. When only males were compared, the curves for the affected male infants were plainly lower than the national standard curves A dear comparison between the curves (or girts could not be made because of the limited number of fected by Yusho. female infants who were af / The amount of contaminated rice oil that nine of the 13 mothers consumed during pregnancy was esiimajfd 10 he STl |o j.t> liters. No tliilllYCt dose^effect relationship could be demonstrated be tween oil consumption and the babies' symptoms The polychlorinated biphenyls seem to be par ticularly hazardous in this respect because their use is still increasing in many industries, including food industries. If these substances are absorbed by the body, they will easily accumulate, gradually reaching a level high enough to exert adverse ef fects, since they have an extremely slow rate of metabolization or excretion. Many patients with Yusho rr trill inrlnrfH hy ll^g wwi'after mnre Ilian 7 nJrrtTM,,T.t A 1971 report has indicated that the subcutaneous fat of the patients still contains a large amount of polychlorinated biphenyls although their dermal conditions arc slowly improving (12). because of the limited number of cases available Recently, also, it has been demonstrated ihat for analysis. Nor could evidence be obtained in wide environmental pollution wiih polychlorinated Regard to any possible physical and mental rctar- biphenyls is quietly growing in many countries / dation of f ................. (II). To prevent another epidemic of Yusho. 10*0 HSMHA HMlth Xtocru HONS 201121 which wilt break out on a global scale it the pollu tion worsens, radical efforts arc urgently needed. Our success in identifying the cause of the epidemic'seems to have been due to many factors', (a) common epidemiologic principles were hon estly followed, (b) local health departments and the patients themselves cooperated fully, (c) the causal agent was not multiple, but single, (d) contamination of the oil with Kanechlor was tem porary and marked, (e) the latent period of the epidemic was several months, and the epidemic was relatively short, (/) Yusho had characteristic symptoms, allowing easy differentiation from other diseases, (g) some of tht oil used by the patients, along with the original containers, were still available, and (h) some persons who bought the oil as a group had contracted the disease. All these factors facilitated our study. Epidemiologic study of an illness or of adverse effects which were more chronic, less peculiar, which progressed less noticeably than Yusho, and were caused by multiple agents would present greater difficulties. We need to develop more sensitive and more efficient epidemiologic methods We must, more over, exeri constant efforts to make our epide miologic information more accurate, quantitatively and qualitanvdy, by using the metliodology of olher disciplines when it seems necessary for our purposes. REFERENCES (I) Goto, M., and Hifuehi. K.: The symptomatology of Yusho (chiorobiphenyl poisoning) in dermatol ogy. Fukuoka Acta Medici 60' 409-431 (1969). <2) Kuretsune, M., et al.1. An epidemiologic study on "YushoM or cblorobiphenyl poisoning Fukuoka Act Medic* 60' 313-332 ( 1969) (J) Yoshimurs, T1 Epidemiological analysis of "Yusho" psuenls with special reference lo set, sge, clinical grades and oil consumption Fukuoka Acia Medics 62: t04-IOS (1971). (4) Yamaguchi. A., Yoshimura. T, and Kuratsunc. M.: A survey of pregnant women having con sumed rice oil coniamtniled with chlorobiphenyls, and of their babies. Fukuoka Acta Medic* 62 117-122 (1971). (3) Yoshimura. T.: A case control study on growth of school children wilfa "Yusho" Fukuoka Aci* Medic* 62: 109-116 (1971). (6) Ikui, H., Sugi, K., and Uga, S.: Ocular signs of chronic cblorohlpbenyl poisoning ("Yusho") Fu kuoka Ada Medic* 60'. 02-439 (1969). (7) Okumura, M., and Katsuki, S: Clinical observa tion on Yusho (chiorobiphenyl poisoning). 1-uluoka Ada Medic* 60: 440-441 (1969). (5) Uzawa. H., Iio, Y, Notomi, A. and Katsuki. S Hyperglyccridemia mulling from intake of nee oil contaminated with chlorinated biphenyls. Fukuoka Ada Medic* 60- 449-434 (1969). (9) Kuroiw*. Y,, Murai, Y,, and Santa, T.: Neurologi cal and nerve conduction velocity studies on 23 patients with chiorobiphenyl poisoning. Fukuoka Acta Mediea 60: 462-463 (1969). (10) Tsukamoto, H., et al.: The chemical studies on detection of toxic compounds in the rice bran oils used by patients with Yusho. Fukuoka Ad* Medic* 60: 496-312 (1969). (11) Risebrotigh, It W, et al.; Polychlorinated biphen yls In the global ecosystem. Nature (London) 220 I09S-1102 (1961). (12) Kojrma, T.. Chlorobiphenyls in tbe sputa and usmki. Fukuoka Acta Medic* 62' 23-29 (1971). (IS) Taki, I., Hisanaga, S., and Amsgasc, Y.' Report on Yusho (ehiorobiphenyl poisoning) in pregnant woman and their fetuses. Fukuoka Ada Medic* 60: 471-474 (1969). KUKATSUNE, MASANOR1 (Kyushu University), YOSHIMURA, TAKESU.MI, MATSUZAKA, JUNICIII, anil YAMAGUCHI, ATSUKOi Yusho, a poisoning caused by rice oil contaminated telIft polychlorinated biphenyls. HSlillA Health Report , Vol. 86, December 1971, pp. 1083--1091. A peculiar skin disease, Yusho, was observed in residents of Fukuoka-Ken, Japan, in Octo ber 1969, which later spread over the western part of the country. By use of basic epide miologic rocllvods, the cause of the disease was shown to be a specific brand of rice oil that had become contaminated with a heat transfer agent during processing. This agent, Kaneehlor, is a com plex mixture of polychlorinated biphenyls. Women who consumed the contaminated oil delivered babies or fetuses with peculiar darkbrown stained skin, nails, and gingiva. The poisoning signifi cantly decreased the growth of the boys who were affected, while the girls who were affected showed no such change. Many of the persons who contracted the disease are still tortured by it even 2 or more years Jater, de spite all possible treatment meth ods. In view of the slow recovery from the poisoning and the in creasing pollution of the environ ment with these compounds on a global scale, radical efforts must be made to avoid the hidden risks of canianunatton. Oacmutwr 1*71. Vel. *4. Ht 12 1091 MONS 201122 An Epidemiologic Study of Amputees in the East Harlem Community \ COURTNEY B, WOOO, M.D,, M.P.H., ROBERTA 5. VOLANTE, R.N., MA, and ROBERT BERENSON, M.M.S. MASS screening for one or a number of diseases is the extent that mass screening or any like programs fulfill these classic public health methodologcyri.teria, they perform a valuable The effectiveness of screening pro health service within a commu grams depends on several fac nity; that is, they have the poten tors; notably, their success in tial of leading to reductions in reaching high-risk groups, the ex morbidity, mortality, or disability tent to which the diseases identi The problem often is, however, fied arc subject to therapeutic that existing programs for one attack, and the availability and reason or another are weak, espe accessibility of followup care. To* oicially in reaching the desired population and in the area of Dr. Wood is associate prolessor followup care. The question oi community medicine, Mrs.' arises as to whether there Is any Volante is tommuniiy nursing way of using the valuable ex consultant and instructor in com perience of traditional public munity medicine, and Mr. Beren- health methodology to reach the son is a fourth year medical stu community with an approach that dent, Mount Sinai School of would be more responsive to its Medicine of the City University health needs and more effective of New York. The New York in meeting these needs Community Trust provided funds To that end we proposed and for the study. Tearsheet requests executed a pilot study that was to Courtney B.y Wood, M.D., based on the resol/e of the de Mount Sinai School of Medicine, partment of community medi City University of New York. cine, Mount Sinai School of Medi 19 E. 98th St., New York City cine, *'to identify and solve health 10029. / problems in the community." Wc decided to select a disease that was easily identifiable by the gen eral population and for which there was a relatively simple and highly visible solution. The ap proach was to be one of search and service, with a view to devel oping a network of indigenous epidemiologic intelligence wuhm a given community, namely, East Harlem. Amputation of an extremity was selected as the most recog nizable disease entity for which followup services are accessible, available, and effective. In this study an amputee is defined as a person lacking part or all of one or more extremities. Objective and Method The project had the following objectives: \ 1. To identify ajl amputees in the East Harlem community and to review their medical and socio economic characteristics 2. To assess the current need 10*2 H5MHA Multh ftsports MOWS 201123