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Cahnsrt Publicising Company, Inc. 221 Coiumbu* Av*,, Sovtoo, Maw 02116 Owfec -7780/TWX 710-310-0632 pwloarsldtics Editorial Newsletter August, 1974 The old adage "success breeds further expanded to include a per Subsequent experimentation here success" applied to editors reads son who lived downwind of a plant and in Europe indicated that con "Tell me I've done something right that produced PVC from VCM. And centrations of 250 ppm yielded liver and I'll bury you In deathless prose". finally extrapolated by some well cancer in test rats. The problem was We have had so many excellent meaning but technically incapable not suppression of this data, but comments relative to this newsletter newswriters to include people who rather lack of communication to the that I'm on the verge of giving up the had consumed great volumes of li chemical processing community. magazine and going into news quor from PVC containers. (I had a Unfortunately, this shortcoming letters. But. seriously. Joel Frados is great uncle who departed this life as limited further research which, if tt in no danger, because when an a result of cirrosis of the liver, but has been done, would have replaced avocation becomes avocation it also thankfully in 1962 from liquor con the current hysteria with well plann becomes drudgery and I enjoy sumed from glass bottles -- so they ed intelligent action rather than the writing too much to commit to more can't count him). unprovable claims and counter than one newsletter a month. Needless to say. any problem claims now prevailing. which involves death becomes Im decreed a 50 onm emergency limit, l mediately charged with emotion the current flap is over their push for \ alism -- and so it Is here. No single a "no detectable level" limit (a tough The new fire T- life is worth a million dollars and the obvious answer seems to be to stop the production of VCM and Its limit to maintain; in fact, a tough limit to measure effectively). Sure, people are dead, but the Any newsletter in plastics that products (including PVC). Under the deaths have been few and the cause failed to mention the VCM problem would hardly be worth its salt (or postage). This week (July 5) saw the haarlnn on nrmlMlhl.. toJglTTf circumstances this seems a reasonable edict. However, and Its a big however, what has really been proved, isn't that the purpose of the OSHA hearings? a rare disease. The "cause" of the ill ness is not based on scientific probability but rather on "apparent cause" -- a weak reason to wreck an industry. To suppose that a hundred MTMPium chlnrldfl monomer -- a As a statement of pure fact the years from now, medicos will have gas) enter its secon^weekJt seems trite to say that pjastlcshavenever fgcgdamor^fonJj^^2JJS05Jj, Manufacturing Chemists Association(MCA) issued a paper entitled "Vinyl Chloride Chronology", which neither arrived at the conclusion that death is caused by life and practically everything we are and do from the puT7Ri?Ts"a^Salernemonnetrue ract. The OSHA question originally was. what is the level of concentra tion of VCM that can be tolerated by humans without ill effect? Specifical ly, a rare liver cancer had been diagnosed in workers exposed to high concentrations of the mono mer. The question has since been expanded to include people who work with PVC (polyvinyl chlorfde) from which residual VCM may be liberated in processing finished side stepped the fact nor painted It pink. The report stated that In 1961 Dow experiments with rats Indicated that long term exposure at 100 ppm (parts per million) level of VCM produced "slight" liver injuries, so manufactured in manufacturinbge facilities. However, in 1962 as a result of research at Vale, the American Conference of Govern mental Industrial Hygienists (ACGIH) recornmendej^gJoogj^as a safe fimf^ncffini^was^ifl^idopted as moment of our birth. It is unfortunate that the im mediate rebuttal of the SPI has been based on economics rather than an attempt to argue for reason on the basis of meager evidence. VCM may kill and if it does workers most assuredly should be safeguarded. But PVC does not kill and the onus must not spread to PVC any more than the toxicity of sodium and chlorine are extrapolated to com mon table salt. I've been told that sex Is one of the products. This has now been even the "official" permissable limit. killers in heart disease, but I don't BFG26460 Tooo6se2: Prognostications on plastics by Jerry Noth, research editor It Is said that as the Auto Industry goes, so does the nation s economy. Considering that auto sales have been the most obvious victim of the energy crisis, the country's present economic lethargy is not hard to un derstand. Like this year's Detroit output, the 1974 business year suffers by com parison to last. The country is producing sort of a "Compact" economy, if you will. And it's a stripped down version at that Nonetheless, it appears that the worst is over, and while the auto in dustry's recovery will not be dyna mic, it will be steady. Certainly that is good news to the plastics processor who supplies the world's largest industry, it is welcome news, moreover, to anyone concerned with the nation's overall economy. Current indexes According to the latest SPI figures, the index for production / gained in April, but sales of resin for reinforced dropped significantly when compared to Aprii, 1973. Production Total plastics production gained 4.0%, April, 1974 compared to April, 1973. This gain comes on the heels of a smallish, 2.3% increase in March. The index is exactly in line with PW's projection to an Index of 217(1967 100) by years end. This yearly increase of 3% will be fol lowed by a further 6% increase in 1975. PW believes. Reinforced The index of sales for reinforced plastics registered a 12% drop in April and March compared to the same months of a year earlier. However. PW predicts this index will recover and show a 2% gain by year end 1974. This would be a 2%, which we believe will be followed by a 10% gain -- index 198 in 1975. Production Index : All Resins 250 -- -- -- Index - late* t 12-m >nth total 1947 to tat X 10C 225 --^--- -- 200 175 150. DEC JUNE 1971 1972 DEC 1972 Source : Calt ira Re-search Jept., SPI Statistic al Commitiee ________ 1 ______1 _______ _______ 1 JUNE JAN JUNE DEC JUNE DEC) i97a 1974 1974 1974 1975 197S| Month April, 1974 April, 1973 Index 214.7 202.5 | Lb, MHffona 1 2,131 1 2,050 i Consumption Index: Reinforced-Plastic Resins 1971 1972 1972 1973 1973 1974 1974 197S 19751 | Month April, 1974 | April, 1973 1 March, 1974 March, 1973 Index 171.6 163.1 173.6 159.9 Lb, Millions 100 111 95 109 i j BFG26462 emwezez nvr *, AVGVZT 17, 1974 k ed, and further del*? Of' lower diagnowfc *ua, if the bleed { ao*--.sion, parucularty'*' I ,*t { w> nn 43 hours and lo-- the features which /orakova et al." '-ho had endoscopy. i: only 18% of rh^y .:]_oted that 79% bleeding had evidena ' r--:ently, whilst such' . ulcers found afte ' oil n ulcer 3 days or which shows none of j r->t necessarily imply f \ reding. fjfl LANCTT, AUGUST 17, 1974 lesions- Finally, radiology indicates only a possible not the actual source of bleeding, and where rwo lesions are seen endoscopy has the unique value of idually demonstrating the true sice of bleeding. Thus radiology should be carried out only when endoscopy has roved negative. Endoscopy in Relation to Management The value of early endoscopy in management is dial it tells the clinician the site of bleeding and the nature of the underlying lesion. Since acute mucosal lesions often heal rapidly and may be difficult to deal with surgically, while chronic peptic ulcers tend to rebleed and to be amenable to surgery, endoscopic information could allow early decisions on management. However, whether or not this will reduce me::'!iry remains to be evaluated. Other possible benches from early endoscopy, such as reduction in blood-transfusion and reduced hospital stay, muse also be evaluated. it? In that of Cotton toj ; in 20% of cases, . tor this. In a few , 0 pass the endoscope. : t 'icountered in ii whom it may be Atioa while retaining Emergency Endoscopy Services For the best possible results endoscopy should be carried out within 24 hours of the patient's admission, although there is still a good diagnostic yield up to 4S hours after admission. Early endoscopy involves the endoscopist in much time and effort, and, if ade. "3te facilities with properly trained paramedical 397 staff are not easily available, it is prohibitively time consuming. It is inconceivable that a district general hospital with one gastrointestinal consultant trained in endo scopy could provide an adequate service for acutely bleeding patients. Such hospitals planning to develop an endoscopy service should bear the manpower aspects carefully in mind when doing so. Ideally rwo consultants with the help of middle-grade medical staff trained in endoscopy should be employed in each hospital. Requests for rcprists should be addressed to J. A. H. F. umiNCts 1. Memorandum on Future National Need* for Fibre-optic Endoscopy of the Gastrointestinal Tract. British Society for Digestive Endoscopy, 1973. 2. Palmer. E. D. J. Am. mtd. Au. 1969, 207. 1477. 3. Crook. J. N-. Gray, J. W., Nance, F. C, Cohn, I. Ann. Surg. 1972, ITS. 771. 4. Allen, H. M-. Block, M. A.. Schuman, B. .VL Artkt Surf. 1973, IH, 449. 5. $u|twi, C, Werner, M. H., Hayes, D. F., Lucas, C. E., Walt, A. J. Md. 1973, 107, 133. 9. Katoo, R- AL, Smith. F. W. CasrratnitnJagy, (973, SS, 72S. 7. Cotton, P. B., Rotcnbert, AL T., Watdnm. R. p. L-, Axon, A. T. R. Br. mod. J. 1973, ii, 505. 9. McGinn, F. P., WQkca, B. J.J. X. Call. Surf. Edinb. 1974, 19, 112. 9. Forrest. J. A. H., Fialsyson, N. D. C. Br. J. Hasp. Mad. (in the press). 10. Dvorskovs,H.,Jirssek, V., Seeks, J. Urgent Endoscopy of Digestive and Abdominal Diseases; p. 49. Basel, 1972. 11. Ailan,R.K^ Dykes, P. W.,Toyc,D.|C.M. Br. mad.J. 1972, iv, 2SI. e|iexcess blood pre-\' l ;he value of gastric , n^overatal. Palmer**-' J ood endoscopy whilst., j a?y 'vantage of thisi: xf j lesions closely^ il^erosions. Gastric- our series in which ,' aVgesions (16%) was - c| tl/(8 6%x How^l 3.' 'should be able toy : lesions apd trne'i .)-*rage ensures good * h; time required for]| ai- .ge does not then.V mdoscope. * u*r failure to find any d| Ice that they havet, eLJ this is especially J vomited up M dark lo1, a l number of cases, ihese are usually 1 failure is inversely iX The endoscopist. ii : a careful emergency lT"]m by an eatperir rults as endoscopy ceri, our series and shown that approxif 'd 50% of gastric * 'meal examination-' Public Health PROPORTIONAL MORTALITY AMONG VINYL-CHLORIDE WORKERS Richard R. Monson John M. Peters Departments of Epidemiology and Physiology, Harvard Schorl of Public Health, Boston Massachusetts 021 IS, UJui. Maurice N. Johnson B. F. Goodrich Company, Akron, Ohio In a proportional-mortalicy analysis Summary of one hundred and sixry-one deceased workers in two plants using vinyl chloride, a 50% excess of deaths due to all cancer was seen. Specific sites of cancer with the greatest excess included liver and biliary tract, lung, and brain. The excess in cancer was seen mainly in men who died be;w'.-2 age 60. Also, there was a trend in time in the ratio of observed to expected deaths: since 1970 over twice as many cancer deaths as expected have occurred. INTRODUCTION On Feb. 15, 1974, four fatal cases of angiosarcoma of the liver among men who worked in a polyvinyl chloride polymerisation plant were reported.1 We present here a proportional-mortality analysis of all deaths known among workers in that plant. Also inci-.ded are deaths in men who worked in a plant w which vinyl chloride is produced. METHODS Vinyl-chloride monomer is produced at a plant in Calvert City, Kentucky, and is polymerised into polyvinyl chloride at a plant m Louisville. These planu have been in operation since the late 1930s. Whenever an active or pensioned employee at these plants dies, a copy of the death certificate is obtained. An abstract of the certificate is made and the certificate is sent to the insurance company. Using these sources, one hundred and sixty-one deceased White males who were employed at one of the cwo plants were identified. No information was available on workers who left employment before retirement. For all but nineteen a copy of the death certificate was obtained. For the remainder the cause of death as recorded in the company abstract was used. Deaths from 1947 through 1973 were ascertained. Of these deaths, one hundred and thirty-five occurred among Louis ville workers and twenty-six were among Calvert City workers. The distribution of causcs-of-death was tabulated using the code on the death certificate. The expected distribution was calculated on the basis of proportional-mortality ratios for United States White males. The observed deaths from all causes were stratified into 5-year age/timespecific groups, and age/time/cause-specific proportionalmortality ratios were multiplied by these numbers to obtain the stratum-specific expected numbers.1 RESULTS The patterns of mortality among workers in the rwo plants were similar, so all men were grouped together. As seen in table x, a 50% excess of deaths due to cancer was observed 5*7, p<0-02). In addition to the four deaths previously reported,1 a fifth man who died of angiosarcoma of the liver was identified. Also, there was one cancer of each of the following sites: gallbladder, common bileduct, and T00T6SCZ BFG26464 398 / THE LANCET, AUGUST 17, 1974 TAILS l-'CBSUtVID AND SXrtCTXD DIATHS IN YINYL-CHLORIDI WOJUCIM* I.C.D. eo-t Ohm of death 140-209 150-199 199 162, 163 J93 200-209 330-334 400-466 800-998 960-969 All .... All emeu .. Difcsdve Live* end biliary tnei Luna Brain Lymphatic and hematopoietic Other cancer: .. C.M4. vascular Circulatory External Suicide .. All other causes{ .. Observed 161 41 13 8 13 3 9 9 S 66 22 10 24 Expected 161-0 27 9 8-3 07 7-9 1-2 3-4 7-1 9-9 66-6 24 9 9-3 30-9 Ob-/exp. 1-0 1-5 14 11-0 16 4-2 1-3 0-7 0-8 1-0 0-9 1-9 0-8 'Expected numbers based on age/time/cause-sped 6c proportionalmortality ratios for U.S. White males, f International CUssifiuuon of Diseases, seventh revision, t Nasopharynx 1, prostate 1, kidney 1, thyroid I, undetermined 1. | Includes j dnboiii (4 4 expected). liver (type unspecified). There were five brain tumours--three glioblastoma multiforme and two of unspecified type. There was a 60% excess of cancer of the lung, of the following cell types: bronchogenic (one), anaplastic (one), adenocarcinoma (three), un specified (eight). There were two unusual other types of cancer--thyroid and nasopharynx. There was an excess of deaths due to suicide: ten observed and about five expected. The observed and expected numbers of all cancer according to age and year of death are presented in table il Excess death due to cancer was seen primarily in men who died before age 60. There was a trend in the observed/expected ratio with year at death. Before 1965 no excess of deaths due to cancer was observed. However, since then there has been an increase in the proportion of death due to cancer, so that since Jan. 1, 1970, death from cancer has occurred twice as frequently as would be expected on the basis of U.S. vital statistics data. TABLE !!---OMtXYED AND EXPECTED OEATHS DOS TO ALL CANCXX ACCORDING TO AGS AND YEA* OF DEATH Characteristic Age at death (ft.) .. Year o4 death Caeecory <50 90-99 604- <1969 1963-69 1970+ Observed 11 IT 13 12 10 19 Expected Obs./exp. 7-6 01 12-2 11-4 7-3- 9-2' 1-4 2-1 1-1 1-1 1-4 2-1 DISCUSSION These data include the original four vinyl-chloride workers who were known to have died with angio sarcoma of the liver. Four other workers with fatal cancer of the liver and biliary system have been identified. In addition, there is a suggestion that at least two other types of cancer--lung and brain-- appear with excess frequency in vinyl-chloride workers. It also appears that the relative frequency of all cancers is increasing with time. While no pro jection may be made with certainty, additional excess cancer among vinyl-chloride workers would seem likely. An analysis using proportional-mortality ratios does not cake into account the absolute risk of dying in the population being studied. Thus, it is possible that the mortality-rate in the vinyl-cbloride workers is less than that of the United States population. For example, the mortality in White steelworkers was* 86% of that expected1 and in White cotton textile workers 79% of that expected.' However, even if e*ch of the observed/expected ratios in table 11 were multiplied by 0 8 (80%) an excess of cancer, especially of the liver and biliary tract and brain^ would prevail. Further, the increase with time in the ratio for all cancers would still be observed, since each of the observed/expected ratios in table n would be multiplied by 0 8. * Another theoretical objection to a proportional- mortality analysts is that a high ratio of observed to expected deaths may be due either to an excess of one cause of death or a deficit of another cause of death. Based on the data in table i, it seems most likely that the high ratio for cancer reflects an excess of cancer, since the ratios for each of the four major categories other than cancer are all in the range of 0-8-10. It will be several years before a final conclusion can be made with respect io the carcinogenic potential of vinyl chloride. Since any harmful effect in an individual may require many years of exposure, we'; believe that current exposure must be controlled. Requests for reprints should be addressed to R. R. M. ^ REFERENCES r.' 1. Creech, J., Johnson, M. N., Bloc*, B. Morbid. Mortal, mkfy Rif!- 1974,23,49. ^ 2. Menson, R. R. Computers Hamid. Hit. (in the press). 3. Lloyd, J. W., Ciocco, A- J. aatup. Mid. 1949, 11, 299. \ ' 4. Henderson, V., Eorerliae, P. C. Hid. 1973, IS,717. Packaging for Safety 3 A Hospital admissions of children with suspected acd-j' dental poisoning by medicines are not on the increase, and^ death of the child is a very unlikely result of such incidents... All the same, the work-load involved, the unpleasant nature .- ofthe treatment, and the worry to parents justify a hard look .* at any proposal to make medicines safer. A working-group of the Medicines Commission has just reported on the packaging aspects of this question.* The working-group;- opposes the compulsory introduction of redouble child- * proof containers and comes down in favour of a stepwise., introduction of non-redosable containers, where potentially^ dangerous tablets and capsules are packed in individual units r in strip or blister packs. Among the objections to the reclo*^ able containers comes one from the Department's lawyers; b under the draft British Standard such containers would neeo^ to be tested on children who would have to be taught bo*-: to open them to see if they were capable of repeating the__ operation. Ifa child so tutored poisoned himself the ******j might be held liable. But the D.H.S.S. legal division add* $ a further objection: " the position in law is that no pareot or guardian of a child of tender years is entitled * consent to any procedure which is not for the benefit**- the cbild." Medical research workers have long that this was so, but has the Department, now the commuo sioner ofmuch clinical research, stated this publicly before^ Medicines Commission. Report on the Presentation in Relition to Child Safety. ObtiinebU (tom the D.H-S.S-f m Finsbury Square, London EC2A 1PP. BFG26465 23591002