Document b48LRBrp0GyR4y7Kgr2xNLMg
July 15, 1974
Anthony J. DIKarino, M. D. 735 Delaware Paulaboro, New Jersey 08066
Dear Dr- DUterino:
We appreciated the opportunity of meeting with you the other, day in
.
Pauleboro. Enclosed you will, find those things which X agreed to'send
to you(i.e*, the CDC Report on liver angiosarcoma, NIOSH recommendations
for medical surveillance of persons working with VCM and the PPG medical
history and physical examination record). Please contact me if you have
any further questions concerning the periodic medical examination program
of the employees at the Paulaboro Terminal.
Sincerely yours.
Lee B. Grant, M. D. Medical Director
LOG:pc
Enclosures
cc: G. Barton F, De'.ioody
I
SL 093012
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US, DEPARTMENT OF HEALTH, EDUCATION; AND WELFARE * PUBLIC HEALTH SERVICE
DATE OF RELEASE: FEBRUARY 15. T374 - ATLANTA. GEORGIA 30333
EPIDEMIOLOGIC NOTES AND ItFPOR TS ANGIOSARCOMA OF Till. LIVER AMONG POLYVINYL CHLORIDE WORKERS - Kentucky
Between September Oft? ami December 1073, 4 cjscs nf angiosarcoma of llie liver were diagnosed among men em ployed in the polyvinyl chloride polymerization section ol a ILL, Goodrich plant near Louisville, Kentucky, this section of the plant began operations in PUX. It employs about 270 persons and produces polyvinyl chloride as well as a variety id copolymers by polymerization ol vinyl tldoiide monomer, AH 4 men bad worked eonimuously in the section lor at least 14 years prior to onset ol illness (Table I);.dl 4 hud worked directly in various phases ul the polymerization process.
Case I presented in August |Df>7 with an cpiguslnc mass and thrombocytopenia. An exploialury laparotomy was per-
CONTENTS
Epidemiologic Noun and Reports
Angiosarcoma of the Liver Among
Polyvinyl Chloride Workers -- Kentucky ............................49
Wild Mushroom Poisoning - Pennsylvania ..............................50
Current Trends
Influenza - Umted'States .............................................
55
formed in September 1967; liver biopsy revealed angiosar coma. (`use 2 presented in January ID7() with gastrointesti nal (Gl) bleeding. Rciuncnl bleeding in May J 970 led loan exploratory laparotomy at which time a diagnosis ol angio sarcoma was made on liver biopsy. Case 3 presented in Janu ary I Oo4 with Gl bleeding which recurred inMuy !Vf>^ with
TAliLL I CASES OF SCI C D IED NOTIFIABLE DIM.ASKS. UNHI D STATES (Cumulative totals iiuludc revised and delayed reports through previous weeks)
Mh Wl.FK ENDING
CUMUI.ATIVE, FIRST 6 WEEKS
DISEASE
February 9, * February 10.
I 9r9-1 973
MEDIAN
)
Aseptic meningitis
1974 34
1971 29
1974
1973
1969-1973
35 213 238 218
brucellosis................
....
i3
i
9 II tl
Clmkenpox.....................................................
3,609
5 305
-
IS.KII
27,061
Diphtheria...........
.. ,
12 2
7 12 17
Encephalitis'
Primary. Arthropod home mu! unspecified
Post-Infectious . .
................
Hepatitis, Viral
19 12
21 4
IK 5
S6 95 120 27 20 26
lyin' II........................
Tvpc A
,,.
Type unspecified
............. ...
135 120 871 j 1.027 153
12 | 1.067
934 4,9 T4
812
J
805 5,775
805 j 6,407
Malaria .
...................
.....................
6
6 39
IS 17 241
Measles (rttheola) ...
....
Meningococcal infei lions, toial ........................
Civilian ........................... Military...................................
........................ .................
Mumps ................
Pertussis
..
Rubella (German measles) T<u.unis .
luhcrculoNis. new .irhu*
Tularemia typhoid fever .
..
1) pints, ink borne (Itky. Ml. spoiled fever) Venereal Doe ises
521 34 34
1,762 12
25* -*
5 2V 3 6
704 34 U
2,145 _
441 1
S 62 2 4 I
704 50 49 s
2,502
821 t
2 4
2.414 156 156
9 14S IH2
I 098 6
3,041) 10 1.5 12
3,461 174 166 8
10 400 __ _
2 269 6
3 027 10 22 6
.
3.663 JM 307 15
12,594 __ .
2,964 6
,,,,
10 26
1
Lnnurrlie i Svplnbs pnmarv and mm utut.irs Rabies m animals
I6.HI0
462 j 4i
14 ;5') Sir, 69
97,831
85,951
67*
2.661 Z67
| _______ 2J,91k7 J
347
JTAIH L II NO'IIM A III. I DIM AM S Ol I OW FREQUENCY
Anlhr.i\, hutiiliNrn U.ish 2
Cnngviiil.il rubella svudrmnc M.i Lvprnw ' Hawaii )
I rptuspirusis, Hawaii I. Ll.i I
1*1 ![`l|l*
Tex I
( WUl
1 2 7 4 6
Potiomselitis. total
...
P.ir.tl v tie
Psittacosis, Tex I
,
Kalurs in m m
,,,
fm hinosjs, NYC I.Okla, 1
f'vpfius. murine, t'ahl l,V;i 1
,,,,
......................... ....................................
....................................
f nm
T tt
-
SL 093013
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"- * 50
Morliiility and Mortality Wro.ltly li('|io,-t
I I IIUHAHY IS. 1)74
ANGIOSARCOMA* - Continued
m^jis Of portal hypertension A put l.u aval stumi \wi< periormed, :md liver biopsv yielded ;i dugnusi* ol cirrhosis. Repeal biopsies >n October 107f| jml September 1972 Conhr/ned tins (Ii.ihiidms Autopsy in M tn.li I V7 ^ reve.ded angio sarcoma. Case d picscnlod m July 1971 with hcpatosplcnomeg.ily, weight loss, and i.iimdiu', I wo liver biopsies were interpreted js showing sl sere cirrhosis Autopsy m Ueeember 1973 revealed ;ni|'tos,in *mj
In each case, pathologic inaUnal revealed the presence of extensive cmhosis ol a non-alcoholic type in addition to angiosarcoma In 2 cases, the diagnosis of angiosarcoma was made only at autopsy, cirrhosis having been dijgnoscd 7
years before in Case 3 and 5 months hctoie in Case 4 None of the patients gave histones ol prolonged alcohol use or ex posure to hepatolnxius outside then work pljte. In particu lar, none had ever hud exposuie to thorium dioxide ou-+o arsenic, 2 materials known specifically to induce -hepatic angiosarcoma in man (7.21 (Reported hy John Creet h. M l) . Hunt Physician, H p\ (joodlich Chemual Company. Lmnsn/le. Kcntiu ky; Maurice N. Johnson. Ml) . Duccfor of Environmental Health, H K Goodm h Chemical Company. Akron Ohio. Bradford Hhnk, M !)., Medical Consultant. Kcntuck i ()t i npaiitnud SaJ'ete and Health Administration, Kcntuck e State Deportment of Labor, National Institute jor Otutpahonal Safety and Health, and the Cancer and Ha th Dejects Division, Hureau oj hpidcmtofo' XV. CDC ) IxJitoruI Note
Angiosarcoma of the liver is an exceedingly rare tumor. It is estimated that only about 25 such cases occur cadi year in the United Stales, hour cases, therefore, among a small number of porkers at a single plant is a most unusual event, and one which raises the possibility of sonic work-related tarcinofien, conceivably vinyl chloride itself. Although no data are yet available concerning the occurrence ol angiosar coma among wotkeis al other vinyl chloride plants in the United States, it seems distinctly possible that the problem may be industry-wide. Epidemiologic studies have started to
Tabic t Case* of Anjpos.iremn;} ol (ho I.jm r iimnng Poly vinyl (Morale Workcis
H F Goodrich PI ml Louisville Keanuky
Ago .il
C,ise illness
ousel
Illness onset
1 4 l A"g IWi7
> 36 J.in l'J/0
3 41 J.in l%4
4 SK July 1*173
Date ol
i
Diagnosis
Sept 1 %7
May l70 Mjr 1771 IX-1- 1>>73
__ ------is .me
J.1H 7. iw.x S<_-1.<. 77. 1')/1 Mar 1. 1 *J7 1 Dei. 1 I')71
V, ,n ,
wilt) PVl
l>t h.i, illiit/ss
i;
14
14 2/
determine the extent nf the piobUm in the United Stales, with respect both (o angiosarcoma of the liver and to its pos sible relationship to post-toxic cnrlmsfx
Published dj(a concerning the potential hep.ito-lo\eiy and oncogenicity of vm>| chloride me limited. Studies in Germany have suggested a link between hcp.ilic damage and occupational exposure to vinyl chloride (J), while Italian .workers have suggested that vinvl chloride may cause a wide
variety of tumors m pnimuls (41. The chemical concenhations used in these latter expenmenls. however, far exceed levels likely to be encountered in industrial environments. l-.Uorts to confirm such observations and to measure effects at lower dose levels are now in progress.
References
1. <h Silva llwla J, Ahbatt Ji>, (ayultu da Muita L. Run/ ML.'Malig nancy and other laic effects following adminblralton of thorotrasi. Lancet 2:201-205, 1965
2, Rcgalson W, Kim U. Ospina J, Holland JFr lieniangiitendothciial
\aiconu of liver from chrome arsenic intoxication by FnwIcPs solution, ('anter 21.514-522. 196#
3 Marsiellcr 11 J. Lelhaeh WK, Muller U. el al (luoiusch (nxisi lie tehcisehaden bei Aibcilern in dcr PVC-Produklmn. Dl.sch Med Witchur
v:hr9:7U U2314. 197? 4, Viola PL, Uigntti A, C.ipuio A: Oncogenic response of rat skin,
lungs, and bone to vinyl thlnude Cancer Research 31 516-522, 1971
WILD MUSHROOM POISONING - Pennsylvania
On October 9, 1973, 37 nuns ale their evening meal at a
convent m Berks County Pennsylvania. Between V% and 4%
hour* later (median - appiovmutcly 2 hours), 17 turns devel
oped an illness characterized hy proluse sweating
wjt-
cry diarrhea (76%), chills i5S). and abdominal pain (427*)
(I able 2) Six of the mm* were hospitalized; none died.
Food-specific attack r^ses for foods ingested in the 24
hours hcloie illness strong!', implicated mushrooms as the in
toxicating food ('I able 3), Svol specimens rmm 4 of the ill
nuns and bat lenoIocK uilc of the remaining mushrooms
yielded no enteric pulhng.-s Remnants of tlie mushrooms
were idcntilied as Clitoi i; y> and Lepiofa sp. Some species
ol the foimer genus are known to contain inuscaimc, which
pioduccs paraxympalhonur'ctic effects
The mushrooms had '-.en picked on the grounds of the
convent on the afternoon , the outbreak I or several years,
the nuns had eaten these _shroom\ jt meals, and no appar
ent illness had occurred. O" October 9, however, the nun who
'I able 2 Symptoms in 17 til Nm\ Berks County Convent October 9, 1973
Symptom
Diarrhea Sweating Chills Ahilomimil p.iin Nausea Vomiting Excessive sahvulion I'cvensh reeling Uiy moulli Blurred vision Ihuihidii1 We,ikne.s.s l-'aint tccling
Percent with Symptom
70 7(> 5K 12
7,1 " 23
IX
12 12 r. r, 6 (Continued on pace 3 D
SL 093014
NATIONAL INS 1 IT U 1 L LOR I OCCUPATIONAL SAP'LT Y AND 11 LA LI II
;
i1 Attached arc the vinyl chloride medical surveillance recommendations which were ti'ansmitted to 1)0!, "ii 'la i cli - I .
j MAR 2 5 1974
MFG. dfot
US. DEPARTMENT Of HEALTH. F.DUCATIOM. AND V/ELPARE
SL 093015
h. Medj cn ] Survei 11 mice
Thu followin'1, rccommcndn U on:, arc directed pr ima r i. ] y at medical .sc reciting
to detect liver disease and/or hepatic tumor. They should he con.wdcred
in the context of routine health screening for any general employee health
problems, including non-hcpatic health corn! ilions potent iaJly related to
vinyl chloride monomer exposure. Routine health screen inj; should include
at time of initial employment the recording of past medical history and
the performance both of a general physical examination and certain basic
laboratory procedures (c.g., complete blood pounT, urinalysis, chest x-ray);
provisions should also be made for.routine- periodic health followup
examinations.
-
liinployees covered by the following specific rceommendal i ons sliall encompass all persons engaged in vinyl chloride monomer production and polymer izat ion, including personnel peripherally involved such as in clerical and management assignments. 'Ihc recommendations shall be applied both as a pre-employment requirement and as part of periodic health followup, Screening priority should be given to current employees with prolonged and close potential exposure to vinyl chloride monomer, whether in present or past work settings.
(i) At time of initial employment, or upon institution of screening, a physical examination shall be performed with specific attention to detecting enlargement of liver or spleen by abdominal palpation.
' (ii) At time of initial employment, or upon institution of- screening and annually thereafter, a medical history dice],-list shall be completed by tiie employee. This list shall include questions concerning:
(a) alcohol intake; (b) past history of hepatitis; (c) past exposure to potential hepatotoxic agents, including drugs and chemicals; (d) past history of blood transfusions; and (e) past history of hospitalizations.
Completed medical check-lists shall be reviewed by a physician and should be acted upon as medical 1)' indicated for each individual employee.
(iii) At time of initial employment, or upon institution of screening, a scrum specimen shall be obtained for screening with respect to the following five bio-chemical determinations of liver function:
(a) (h) (c) (cl) T (e)
tot a 1 hi 1i nibin; alkaline phosphatase; serum glutamic oxalacetic trausaminase (SCO!);-. serum glutamic pyruvic transaminase (SORT); and gamma glutamyl 1 r.mspept id.ase (CCIT).
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SL 093016
1
Additional tf-L'-. that m.iy optionally ho considered foi 11 c in screen in;; include lactic deli) d i ogen.i sc fi,|j||), sennit protein dote imnaL ions , serum protein o 1 cot i nphorcM s , and platelet count. I.aiiura Lot ^ ana 1) ses^ alia 1 1 bo performed in laboratories accrtdiled by the College ol Amcricinj Pathologists or licensed in accoidance with the provisions of the Clinical Laboratories Improvement Act of l`J07.
(jvj If results of laboratory screen ini; arc npimul, screen in;;
shall be repeated on an annual basis. If the person being screened has
been employed direct])' in vinyl chloride monomer production or polymer
ization for 10 years or .longer,..serening shall be repeated every six (0)
months.
"
' .......
(v) If one or more liver function tests are nbnoima1, scrum testing shall be repented as soon as possible, preferably within two (21 to four (-1) wecl.s. If no abnormalities arc present upon rcscrooning, testing should be repeated in three (.5) months.
(vi) If abnormalities persist on reserecning, the employee shall be removed from contact with vinyl chloride monomer operations and nil individualized medical workup shall be instituted. Suggested as initial steps in medical workup arc a complete physical examination and various special procedures suclt as hepatitis B antigen determination and liver
scanning.
If liver function abnormalities are determined to bo unrelated to live)' disease (e.g., elevated alkaline phosphnt nes in a young., physically active man or elevated bilirubin in filbert's syndrome) or to be transient (e.g., due to recent hepatitis or recent alcohol intake), the employee may be permitted to return to vinyl chloride-related employment, subject to individual medical evaluation.
(vii) In. uiew._o.C.lliC-urGlini.iJiar>' results of animal toxicology studies, it is_recommended that., no,, woman ..who is..pregnant or" who expects to become pregnnpt. should be employed, directly in vinyl chloride monomer
operations.
}
fcfi iShj-l
ii ..-i M- 1
SL 093017