Document mq30DVvY1XLBEZ5QO5OwqzGaJ

f. fetters to the Editor - :. "*v . I ? I. j ji 1 i i: i*; i.i siLetters to the Editor will be reviewed ESnd'ane. published as space permits. By ^Submitting-a Letter-to. the Editor, the author, gives permission for its pttblicanorvim-jhe Journal. Letters should not plicate..material -being, published or itbmitted elsewhere: Those referring to a ecehtJournal article should be received jjW.tfWn 3 months of the article's appear ance.; The Editors reserve the right to edit %md..:abridge and to publish responses. \Submit three copies. Both, text and referreiiiemust be typed double-spaced. Text Mmited to 406 words andfewer than JO fteferencesJ.. WSf- .Reprinis can be ordered through the ^author whose address is listed at the end tthe. letter.: . RYv>i-, B'dereslimating' LCsorame.Use during ^jnancy;:; ^Paradoxically, the article by McCalla ST^aL1,.showing a decrease in the percentagejjof.women with cocaine in their urine fajjjhe time, of delivery from 1988 through 989 to 1991 through 1992 sheds light on fiejneed to. expand drug, treatment for pregnant and other women..... ^Although the epidemic of cocaine fiseriamong pregnant women may have Jeajced^several .years ago,. further de^-jases seem to have plateaued. New York ^birth certificates show a slowing in ainej use during pregnancy: 2.11% in |8;i peaking. at 2.32% (1989), then peaeasing from 1.76% (1990) to 1.63% ^gl) to 1.31% (1992) to 1.21% (1993). Jowever, the Substance Abuse and Mentl^Health Services Administration's Drug Jpuse]. Warning Network found a 21.2% Bcrease-in cocaine-associated emergency pom-]visits from 1988. through 1989 to ^i-through 1992 among New York City dpril 1997. Vol. 87, No. 4 women aged 15 through 44 years (per sonal communication from Janet Greenb- Harlem Hospital, 506 Lenox Ave, New York, NY 10037. latt, February 17,1994). Why the discrepancy? One possible reason is that women who use cocaine during pregnancy have become harder to identify at delivery. During the past References 1. McCalla S. Feldman J, Webbeh H, Ahmodi R, Minkoff HL. Changes in perinatal cocaine use in an inner city liospiial, 1988 to 1992. Am J Public Health. 1995:85:1695- decade the New York City Health and Hospitals Corporation has gradually tight ened its policy regarding maternal and newborn drug testing; it now prohibits maternal urinary drug surveillance during 1697. 2. New York City Department of Health, Bureau of Maternity Services and Family Planning. PACE (Parent and Child Enrich ment) Final Report and Evaluation. October 31,1994. pregnancy and delivery without informed consent. The New York City Department ^Asbestos-Related of Health collaborated from 1990 through 1994 in developing, administering, and evaluating PACE (Parent and Child En richment), a drug treatment program for Cancer and the Amphibole Hypothesis cocaine-using pregnant and postpartum women. Unfortunately, most women en tered the program in order to be drug free at the time of delivery so that they could 1. The First Documentation of the Association retain custody of the infant, and many An annotation1 and a paper2 pub women left the program prematurely after lished in a recent issue of your journal they were awarded custody.2 While absti must have confused readers on the subject nence from cocaine use during the third of the association between exposure to trimester of pregnancy is beneficial for asbestos dust and diffuse mesoiheliomas mother and child, women who leave of the pleura and peritoneum. It is treatment prematurely must be considered important that this situation be clarified, as at high risk for relapse. misrepresentation can affect ihe use and We must not become complacent. control of these materials in many coun Cocaine use among pregnant women will tries. As the original discoverer of the not go away. Overestimating a decrease development of mesoiheliomas in people may lead policymakers to decrease vital exposed to asbestos dust,31 would appre funding for drug treatment for pregnant ciate an opportunity to try to clarify the and other women using cocaine. situation. Kenneth D. Rosenberg, MD, MPH In 1957. in the Cape area of South David M. Bateman, MD Africa, we established that mesotheliomas Don C. Des Jarlais, PhD of the pleura were occurring in people living in the vicinity cf mills processing Kenneth D. Rosenberg is with the Oregon Health Division, Portland. David M. Bateman is with the Department of Pediatrics. Harlem Hospital Center, New York, NY. Don C. Des Jarlais is with the Chemical Dependency Unit, Berh Israel Hospital. New York. NY. Requests for reprints should be sent to David A. Bateman. MD. Newborn Service. blue (crocidolite) asbestos and in people milling and mining the material.The main paper was published in I960, and in 1963 we confirmed that the tumors were occurring in the crocidolite mining area, but not in the amosite or chrysotile areas of southern Africa. Southern Africa was t American Journal of Publl <o a s EXHIBIT X)(o HWBUI0010769 ' * * rv Letters to the Editor S the ideal area for these investigations, as mesothelioma and asbestos exposure. We asbestos. Such exposure' should be re the three main types of asbestos were agree with Dr Wagner's main point, which garded as a serious potential public health produced in the same amounts by a is that the incidence of mesothelioma is hazard. . . .;<. similar labor force. In an international greater in epidemiologic studies of work Leslie T. Stayner, PhD. . study, we set out to see whether the role of ers exposed to crocidolite than either DavidA. Dankovic,'PhD.. crocidolite could be confirmed in other chrysotiie or amosite, and recognized this RichardA. Lemen, PhD. countries. Over the years, our initial fact in our paper. Interpretation of these hypothesis has held. The vast majority of mesotheliomas are associated with expo epidemiologic findings is hampered by the lack of control for potential differ Leslie T. Stayner and David A. Dankovic-are: ' with the National Institute for Occupational. .., Safety and Health. Cincinnati, Ohio. Richard A." sure to crocidolite asbestos. A small ences in exposure levels and fiber dimen Lemen is the assistant surgeon general [retired], number of cases have been recorded sions. Atlanta, Ga. V f: following exposure to other forms of amphibole asbestos: amosile, tremolite, and anthophylite. No mesotheliomas have Nonetheless, ample evidence sug gests that exposure'to chrysotiie is a risk factor for mesothelioma. As we reviewed Requests for reprints should be sent to. , Leslie T. Stayner, PhD, National Institute fot'i Occupational Safety and Health, Robert A. Taft. -." Laboratories, 4676 Columbia Pkwy--Mailstop' A been shown to have occurred in chrysotile- in our paper, numerous cases of mesothe C15, Cincinnati, OH 45226-1998. . exposed workers, unless the exposure has been intense and for more than 20 years. lioma have been reported in several References -V-.-v ; In addition, there must be tremolite studies of workers exposed to chrysotiie. 1. Stayner LT. Dankovic DA, Lemen. ;RA. . .. contamination of the chrysotiie. In fact. Dr Wagner recognized in his early Occupational exposure to chrysotiie. ashes-.*' \ Two other facts are of great impor tance: 1. The majority of these tumors occurred following prolonged exposure to papers2'3 that there were cases ofmesothe lioma in South Africa and Britain whose only known exposure was to chrysotiie asbestos. Toxicologic studies, some of which were conducted by Dr Wagner,4 tos and cancer risk:..a. review ,of,:.the amphibole hypothesis. An I Public fiealth'K'X. 1996;86:179-186. ''"'V'"' '-' 2. WagnerJCSleggsCA'.MardiandP.Diffistyriifc mesothelioma and asbestos .expDsure:injbeI',;*T: northwestern Cape Province. BrJ. IndMetC-rcigi large quantities of fiber. This situation also demonstrate an increase in mesothe 1960;17:260-271.. .: rarely exists today. 2. There is a "natural" incidence of these diffuse mesotheliomas. At least 10% of these diffuse mesotheb'omas occur without exposure to asbestos dust, and sporadic cases of these tumors were liomas among animals exposed to chryso tiie. Dr Wagner suggests mesotheliomas occur in chiysotile-exposed workers only when there is tremolite contamination. 3. Wagner JC Asbestos dust exposure'.'and,]:;:^ malignancy. 14th International Congress bn Occupational Safety and Health, Madrid.'^.^ 1964:1066-1067.'. -X\ '.Lnr'iv.iiS'-'vla 4. Wagner JC, Betty G,.Skidmore JW,,Tun-.:'...ii brel! V. The effects of the inhalaliorrof};:: asbestos in rats. Br J Cancer. I974;29:252~:i3 reported before the widespread use of asbestos. J. Christopher Wagner, MD, While this statement is technically cor rect, it is virtually uninformative. Contami nation by small percentages (<1%) of 269. . ' 5. Wagner ' JC.. Historical background -'and'.'yjl perspectives of mesothelioma. In: Jaurand r-xj M-C, Bignon J, eds.-77re Mesothelial.CelljQ FRCPath, FFOM tremolite has been present in all of the and Mesothelioma. New York. NY: Marcel reported epidemiologic studies of chryso- Dckker, 1994:1-15. Vol 78 in Lung Biol6gy$ Correspondence should be sent to J. Chris topher Wagner, MD. FRCPath, FFOM, "Foxs- tile-exposed workers. Unfortunately, stud ies of workers exposed to pure chrysotiie in Health and Disease. : - .... - ;*.':* - r : tones." 59 Coombe Valley Rd. Preston. Wey mouth, Dorset, DT3 6NL England. have yet to be reported. In addition, this issue may be viewed as academic since 3. The Amphibole Hyp.oth.esis:M Neither Gone norForgbtitep^^ References 1. Cullen MR. Annotation: The amphibole hypothesis ofasbestos-related cancer--gone but not forgotten. Am J Public Health. 1996;86:158-159. 2. Slayner LT, Dankov ic DA, Lemen RA. Occupational exposure to chrysotiie asbes tos and cancer riskr a review of the amphibole hypothesis. Am J Public Health 86:179-186. 3. Wagner IC Historical background and perspectives of mesothelioma. In: Jaurand M-C, Bignon J, eds. The Mesothelial Cell and Mesothelioma. New York, NY: Marcel Dekker; 1994:1-15. Vol 78 in Lung Biology in Health and Disease. __ workers are exposed to a mixture of fiber types and to commercial chrysotiie con taining tremolite. A key' point of our paper is that irrespective of mesothelioma, exposure to chrysotiie asbestos should be viewed as a significant carcinogenic hazard. There is no serious disagreement in the scientific community that chrysotiie asbestos expo sure .is causally associated, with lung cancer and appears to be as potent a lung carcinogen as crocidolite or other forms of asbestos.' The excess of lung cancer is generally far. larger-than the excess of Stayner et al.` and Cullen2'failed tolf present the amphibole' hypothesis5lin 'as developmental context that lent'credence^ to their assertions that' the hypothesis-Vej lacked scientific merit Both indicated thafj^ chrysotiie may be less potent than son amphibole asbestos minerals' :in- causing^ mesothelioma.-'For crocidolite, the'i'eviFS dence is well beyond maybe.'1 Inr'-l964 Wagner3- reported bn !:a'''series - of.flSQ mesotheliomas in the Republic of'Soutn| Africa, (where-the three-major'commer-* ciai asbestos fiber ''types-~--cr6dd6ii amosite) and chrysotile-^were mm5s:i- mesothelioma in most epidemiologic stud milled). One hundred'cases-ibcctih^p^ 2. Stayner and Colleagues Respond ies of asbestos-exposed workers, a fact recognized in a recent review by Dr Wagner.5 Dr Wagner suggested that our paper " individuals exposed to-the crocidoliu mined and milled in the Cape Proving 10 cases occurred in industrial wbrkfe'.fgjp exposed to crocidolite); I-mesothelioma! We thank Dr Wagner for his com ments regarding our paper.1 We do not believe our article misrepresented the evidence for an association between and the accompanying editorial may have "confused- readers." We hope that this letter will help to clarify any remaining confusion about exposure to chrysotiie followed chrysotiie exposure - in': SwazK| land; and -none' followed u'expostir^M amosite in ' the Transvaal:'-No'-exposufe data are available for the remaining'c*2^1 688 American Journal of Public Health J -iiSS April 1997, VoL 87, No,-' HWBUI0010770