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FILE NAME Brakes BRK DATE 1963 June DOC BRK021 DOCUMENT DESCRIPTION Journal Article - Differential Mortality from Lung Cancer by Occupation - Journal of Occupational Medicine Differential Mortality from Lung Cancer by Occupation PHILIP E. ENTERLINE Ph.D. and MARGARET F. McKIEVER B.A. Washington D. C. 4 A NEED for estimating the effect of occupation is there the 200 on mortality has been recognized for nearly years but very few studies of large popula- possibility of a response difference in occupation but there is also a conceptual differ- ence tion groups have been undertaken.,, The most extensive compilations to date have been the For the year 1950 a study was made to measure oc- mortality reports made by the Regis- trar General of England and Wales after each differences between the reporting of occupations on the schedules of the population census and on decennial census since 1881 1941 excluded death certificates of the records The results while system. the most recent of which is for the year 1951.2 biases exist in supporting the belief that International interest has encouraged the British mortality data by occupation indi- cate that the to continue the series with an expansion of the net errors are in most instances not analysis For the United States data on mortali- very great identifies Possibly more important this study ty by occupation were published for the years major occupational groupings where overstatement 1890 1900 1930 and 1950.3-7 These data have is or understatement of death rates not been extensively analyzed as result in part likely to occur and is of value in the results of the interpreting of questions as to possible bias arising from the manner in which they were compiled by the National VmitoarltaSltiattyisttiacbsulDaitviiosnisopnrfeoprartehde 1950 The major objection to death rates year tion as by occupa- This is an analysis of they tional are usually compiled is that occupa- the trachea bronanalysischus amnodrtality from cancer of information appearing on the death certifi- for the lung by occupation description cate and used in establishing the numerator of year 1950. A detailed of the - the death rate is defined differently and is col- method by which data were compiled appears lected under a different set of circumstances from elsewhere Cancer of the trachea bronchus and occupational information collected lung has been chosen for study study because of its im- schedules and on census i | the death appearing in the denominator of rate The occupation item the portance as a cause of death in the working popu- lation and because causative factors have been certificate is on death demonstrated in certain ordinarily director from obtained by the funeral ments and are occupational environ- a relative or some other person who can provide the strongly suspected in others To simplify the presentation which necessary facts while in the ulation census information is obtained popfrom the of the trachea bronchus and follows cancer ferred to lung will be re- person himself or from some other member of only as lunglung cancer his household Moreover the In the data presented certain precautions have on the death certificate calls forocucsuupaaltion item been taken to minimize bias Only deaths among tion while the occupa- occupation item on census sched- males at ages 20-64 who have work among experience ules asks for current occupation Thus not only are shown Occupational attachment and labor- Dr. Enterline is Chief Biometrics and Branch and Miss McKiever is a Public HeaSloctihalReSsteuadricehs APunballiycst both with the Division of Occupational Health U. S. Health Service Submitted for publication Jan. 7 1963 anIdnt1e6r3naWtoirolndalHeStaalttihstical Classification I.S.C. Codes 162 Organization Geneva 1948 Data presented here will be shown in tion and Cause of Death Mortality by Occupa- Among Men 20-64 Years of Age United States 1950 Vital Statistics Special Reports Vol 53 No. 3:93 in preparation 283 EA A caWahlr oe at 2 Tenie RAE ey A TORR reiN ee r rR oo ae 6 Werbea 284 CANCER MORTALITY Journal of Occupational Medicine force participation among males is more stable than among females thus lessening the likelihood of reporting differences between the census and death certificates Confining data to persons in the age group 20-64 with a work history tends to eliminate problems associated with reporting occupational status of retired persons or persons not otherwise in the labor force To assist in drawing conclusions mortality is presented both in terms of standardized mortali- ty ratios SMRs and proportionate mortality ratios PMRs The SMRs were derived from ratios of the number of lung cancer deaths observed to the number which would have been ex- pected had the specific scheduloef lung can- cer mortality rates in the total population of males ages 20-64 with work experience pre- vailed SMRs are frequently used measures of the force of mortality and can be interpreted in the same fashion as a standardized death rate They have an advantage over standardized death rates in that expected mortality is always 100 and excess mortality can therefore easily be noted The PMRs shown are based on ratios of the number of deaths observed to the number which would have been expected had the agespecific schedule of proportionate mortality rates in the total population of males 20 6w4ith work experience prevailed A proportionate mortality rate is the ratio between deaths due to a particular cause and deaths due to all causes Since proportionate mortality for a particular occupation depends only upon information on death certificates and not upon combining death certificate information with the results of a cen- sus as do SMRs PMRs are not affected by dif- ferences in reporting occupation and industry between census schedules and death certificates If for a particular occupation both the SMR and the PMR are high there is some assurance therefore that this is not due to differences in defini- tions and collection procedures between death certificates and the census PMRs tend to avoid a fallacy of a number of studies noted by Berkson tendency to attach significance to a high death rate for a particular disease based on some preconception and to ignore high death rates for other causes of death Results Table 1 shows numbers of deaths SMRs and PMRs for lung cancer by the intermediate occupational classification used by the U. S. Bureau of the Census Ratios have not been calculated where there were less than 20 deaths There is a good agreement between SMRs and PMRs sug- gesting that many of the high ratios are probably not artifacts but may actually represent a rela- tively high death rate for persons in certain oc- cupations . SMRs and PMRs for major occupational groups are shown in Table 2 with data from the study of occupation reporting in the census and on death certificates The latter provide esti- mates of the extent to which SMRS may be overor understated because of differences in the man- ner in which data are collected for these two documents It must be noted that the ratios shown in the last column apply to deaths for all causes and it is not known whether for particu- lar causes such as respiratory cancer they strictly apply In the study from which the ratios were taken it was concluded however that in general there were probably no important cor- relations between broad causes of death and the comparability of reports on occupation Thus there is some assurance that these estimates of bias apply to the SMRs shown here Table 3 shows two major occupational group- ings and 11 subgroupings excluding certain residual categories which had both significantly high SMRs and PMRs p < .05 The measure of statistical significance is that used by the Registrar General of England and Wales in studies of occupational mortality. It is an approximation and probably slightly understates the signifi- cance of some of the ratios This may be more true for PMRs than for SMRs The assumptions under which ratios were designated as statistically significant include the following deaths in various occupations are independent of one another a test of statistical significance was performed for each ratio and each test performed was independent of other tests performed Data from the study of occupation reporting in the census and on death certificates shown in Table 2 indicate that there is an overstatement of craftsmen foremen and kindred workers on death certificates Table 3 shows that SMRs and PMRs were significantly high for this major oc- of cupational grouping and for nine its subgroup- ings No doubt there is an upward bias in SMRS reported for this major occupational group as well as for most of its subgroupings If the over- statement of SMRs is estimated at 10 on the For technical reasons data could not be shown for every occupation on the intermediate list des oe ube aces. Mi-bine re Le Pitas i, tsadie ae aySE Sane ty RELahha S| 9 RETR.Y ea vg MEE SP Oh MayePL g yes)HBAt ge a * ON tgBs,eh>lRAO GF a SUty Seman, TABLE 1. POPULATIONS NUMBERS OF DEATHS FROM LUNG CANCER I.S.C. 162 163 STANDARDIZED RATIOS AND PROPORTIONATE MORTALITY RATIOS BY OCCUPATION IN MEN 20-64 YEARS OLD MORTALITY WITH WORK EXPERIENCE UNITED STATES 1950 Occupation Estimated population No. of deaths from lung cancer Standardized mortality ratio Professional technical and kindred workers Accountants and auditors Architects Artists and art teachers Authors editors and reporters Chemists Clergymen College presidents professors and instructors 2,950,400 324,997 23,036 48,472 70,062 67,870 151,075 498 78 8 7 19 6 27 83 115 ~~ 63 n.e.c. ) Dentists Designers and draftsmen Engineers aeronautical 95,456 3 68,492 19 143,655 19 17,651 - Engineers civil - 122,474 28 Engineers electrical Engineers mechanical Other technical engineers Lawyers and judges Musicians and music teachers Natural scientists n.e.c. Pharmacists 108,376 14 111,860 10 168,433 26 163,131 36 79,384 25 34,802 2 78,132 35 Physicians and surgeons Social scientists 167,280 24 24,144 5 Social welfare and recreation workers 32,265 2 Surveyors . 24,319 2 Teachers n.e.c. 288,663 16 Technicians medical and dental 33,660 9 Other professionals technical and kindred 502,711 78 _ _ 93 ~ 87 80 . 192 . 152 59 ~ _ 21 Farmers and farm managers , 3,834,661 660 21 Managers officials and proprietors except farm State and local administrators ; Other specified managers and officials Managers officials and proprietors n.e.c. Manufacturing Wholesale and retail trade Miscellaneous industries a . . Clerical and kindred workers ., Bookkeepers Mail carriers Other clerical and kindred workers Sales workers Insurance agents and brokers Real estate agents brokers Other specified sales workers Salesmen and clerks n.e.c. 4,331,784 103,057 478,765 611,787 1,918,158 1,220,017 2,524,175 160,153 164,736 2,199,286 2,406,102 272,770 106,936 74,954 , 1,207 19 . 180 162 508 338 477 17 8 - / / ... ... , . 22 22 120 222 222 222 2125 2125 2125 2125 103 103 135 142 Mar.ufacturing Wholesale trade Retail trade ; Other industries 299,050 392,935 1,160,477 74 47 220 123 61 106 . | Craftsmen foremen and kindred workers 98,980 7,840,330 20 2,478 100 130 Bakers 106,920 43 Blacksmiths forgemen and hammermen 172 Boilermakers 53,796 38 190 x ; ~ Cabinetmakers and patternmakers _ Carpenters ne, 40,045 22 105,224 23 947,908 316 183 79 112 Significantly high mortality ratios have been set boldface p < .05 n.e.c. means not elsewhere classified continued Proportionate mortality ratio 89 111 54 92 - 118 86 114 117 62 90 59 103 - 135 - 105 93 109 108 133 109 101 97 104 104 128 98 98 97 128 126 152 129 92 127 ; (los i: fh: 3 nfs 4 j} 4 7 2. 4 pods, ay a : 4 4 poaes sf ; i: i. # ; | i.e ; iag: ie a fi. Pas Poin? a He Pork j hi i yg i i i : f 7 | ig - poe a Mie fae ; i? a ee ae fin: oon 7 : in - , Table 1 continued Occupation Estimated population No. of deaths from lung cancer Standardized mortality ratio Proportionate mortality ratio Compositors and typesetters Cranemen hoistmen and construction machinery operators Electricians Foremen manufacturing n.e.c. Durable goods a Nondurable goods Foremen nonmanufacturing n.e.c. Linemen and servicemen telegraph telephone and power Locomotive engineers Locomotive firemen Machinists and job setters Masons tile setters and stonecutters Mechanics and repairmen airplane Mechanics and repairmen automobile Mechanics and repairmen radio and television Other mechanics and repairmen Millwrights Molders metal Painters construction paperhangers and glaziers Plasterers and cement finishers . Plumbers and pipefitters Printing craftsmen except compositors Shoemakers and repairers except factory Stationary engineers Structural metal workers Tailors and furriers Tinsmiths coppersmiths and sheetmetal workers Toolmakers and die makers Other craftsmen and kindred workers 163,530 221,844 328,869 284,868 190,297 - 325,474 213,673- 71,821 57,226 553,458 178,464 74,559 681,485 76,284 949,997 60,706 62,905 442,656 96,491 295,379 86,487 51,489 215,566 55,103 72,733 130,143 157,213 487,717 Operatives and kindred workers Apprentices Attendants auto services and parking Brakemen and switchmen railroad Bus drivers Filers grinders polishers metal Furnacemen smeltermen and heaters Laundry and dry cleaning operatives Meat cutters except slaughter and packing house Mine operatives and laborers n.e.c. Motormen street subway and elevated railway Painters except construction and maintenance Power station operators Spinners and weavers textile Stationary firemen Taxicab drivers and chauffeurs Truck drivers and deliverymen Welders and flame cutters Other specified operatives and kindred workers Operatives and kindred workers n.e.c. Sawmills planing and misc wood products Furniture and fixtures Stone clay and glass products Primary metal industries 8,416,334 97,737 203,514 145,982 156,361 148,829 67,576 141,881 170,219 613,355 27,336 107,122 21,515 82,645 123,438 217,178 1,616,558 275,265 196,292 165,573 95,966 138,056 253,889 53 50 800 69 62 106 32 48 7 190 65 6 119 6 236 24 34 212 38 127 | 25 33 108 15 64 46 26 146 1,656 - 16 41 23 19 19 37 44 214 6 16 5 16 34 77 219 34 48 23 7 28 77 143 120 119 131 139 111 93 129 107 130 168 139 123 126 - 138 148 123 117 106 127 128 107 150 227 167 158 174 139 = _ 194 159 206 127 - 136 160 170 . 129 " 141 146 139 138 137 - 136 184 159 68 79 129 133 107 7 128 Baliqpeova _ - 114 79 105 115 148 122 174 - 83 188 106 92 114 72 108 145 - ... 94 | | | | 113 128 108 103 145 79 | 122 143 continued TABLE 1 continued Occupation Estimated population Fabricated metal industries Machinery except electrical Electrical machinery equipment and supplies Motor vehicles and equipment Transportation equipment except motor vehicle Other durable goods Food and kindred products Yarn thread and fabric mills Knitting and other textile products Apparel and other fabricated textile products Paper and allied products Chemical and allied products _. Leather and leather products Other nondurable goods Transportation communication and public utilities Wholesale and retail trade Other industries 199,993 291,592 161,030 304,726 90,413 145,273 312,259 226,783 89,491 161,857 149,916 ~ 148,853 143,980 200,900 173,108 169,135 213,415 Private household workers 66,181 No. of deaths from lung cancer 34 49 22 40 19 35 43 36 14 48 17 18 37 37 79 27 36 10 Standardized mortality ratio - 92 84 2010 2010 ~ 277 125 277 277 _ 104 Proportionate mortality ratio 121 153 138 121 _ 175 98 73 150 103 95 176 80 | 112 123 125 142 103 Service workers except private household Barbers beauticians and manicurists Charwomen janitors and porters Cooks except private householdElevator operators Firemen fire protection Guards and watchmen Policemen sheriffs and marshals ir Waiters bartenders and counter workers Other service except private household Farm laborers and foremen Laborers except farm and mine Fishermen and oystermen Longshoremen and stevedores Lumbermen raftsmen and wood choppers Other specified laborers Laborers n.e.c. 2,240,266 185,469 543,086 209,031 56,959 113,156 216,889 215,169 347,941 352,566 = 1,481,657 3,456,905 ' 68,756 71,853 177,406 208,634 . 836 95 181 91 45 40 112 -74 100 98 155 967 23 31 28 57 123 151 89 165 214 190 111 151 132 114 54 127 144 172 82 100 105 123 92 92 155 121 108 104 111 98 55 82 121 103 58 108 ears Transportation F45urniture and fixtures Stone clay and glass products 170,187 44 138 73 76,620 9 Primary metal industries - Fabricated metal 224,155 82 167 105 53,337 13 Machinery including electrical 79,253 28 - , Transportation equipment 72,404 156 100 Other durable goods 30 200 73 Food and kindred 16,413 10 - Rew products 138,963 30 Textile mills products and apparel 58,298 111 61 te Chemicals and allied products Other nondurable 23 65,141 16 192 128 goods 115,456 41 - Construction 195 INNO Railroads and Railway Express service 740,661 147 98 INNO 283,070 96 135 a except railroad 109,447 59 INNO , -, Telecommunication and utilities and sanitary 295 INNO + By a services % * Wholesale and retail trade 127,474 28 . 90 NNX 3 = .. Other industries 265,236 20 122 NNX s ee, 323,938 20 104 NNX 288 CANCER MORTALITY Journal of Occupational Medicine TABLE 2. STANDARDIZED MORTALITY RATIOS PROPORTIONATE MORTALITY RATIOS AND ESTIMATES OF BLAS FOR MAJOR OCCUPATIONAL GROUPS LUNG CANCER I.S.C. 162 163 MALES 20-64 YEARS OF AGE WITH WORK EXPERIENCE UNITED STATES 1950 Major occupational group Farmers and farm managers Farm laborers Professional technical and kindred workers Managers officials and proprietors except farm Clerical and kindred workers Sales workers Operatives and kindred workers Service except private household Laborers except farm Craftsmen foremen and kindred workers Standardized mortality ratios 54 54 83 94 95 103 . 107 123 127 130 Proportionate mortality ratios 59 55 89 103 108 101 128 105 82 128 Estimates of bias ratios of death certificate total to census total 102 106 104 82 99 90 96 101 109 Arrayed by increasing magnitude of SMR " This may be considered an estimate of the extent to which the standardized mortality ratios are overstated ratios over 100 or understated ratios less than 100 For a more complete explanation of these ratios see Reference 8 basis of data shown in Table 2 and if SMRs are under industrial policies with the Metropolitan reduced accordingly the major grouping con- Life Insurance Company during 1937-39 for tinues to have a significantly high SMR how- ever two of its subgroupings carpenters which there were probably higher than average death rates for cancer of the lung For most oc- and automobile mechanics and repairmen cupations only a few deaths were observed so would have to be dropped from Table 3. That is that the results generally lack significance in the when SMRs for these occupational subgroups are usual statistical sense There were five occupa- reduced by 10 they are no longer statistically tions where more than 10 deaths were observed significant blacksmiths 11 deaths brick and stone masons For other occupational groupings shown in 18 deaths ) painters and varnishers 62 deaths Table 3 data from the study of occupation re- plumbers steamfitters and gasfitters 29 porting in the census and on death certificates do deaths and tailors and clothing workers 37 _ not indicate that SMRs are overstated In fact deaths Of these all except brick and stone for operatives and kindred workers and its sub- _ masons are represented in Table 3. This is of groupings there may be a considerable under- statement of SMRs due to an understatement of particular interest in view of methodological differences between the study reported by Lew and these occupations on the death certificates the data presented in this report Because of a probable lack of uniformity in the over error recorded for major occupational groupings no formal attempt will be made here Breslow obtained long occupational histories on 518 cancer patients and a like number of matched controls in 11 California hos- to correct occupational subgroup SMRs shown in Table 1. It is not certain for example that the error in the major occupational grouping craftsmen foremen and kindred workers applies specifically to carpenters and automobile me- pitals and concluded that exposure to - metallic particles or fumes asbestos or paint seems to play a role A similar study by Wynder and Graham involving interviews with 200 hospital patients and 200 controls indicates an excess of chanics and repairmen These occupations will lung cancer among painters and metal workers.12 therefore be treated as having significantly high a Using certificate data for England and SMRs in the material which follows although Wales Kennaway and Kennaway examined 63 evidence in favor of this is weakened by data occupations employing about 30 of the male from the study of occupation reporting on death certificates and in the census population 20 years of age and over Applying the test of statistical significance used here to Comparisons with Other Data those occupations in which 20 or more lung cer deaths were observed for the years 1933 38 In 1952 Lew publisheda list of 18 occupations representing white male wage earners insured reveals nine occupations with significantly high ratios of registered to calculated deaths These > Vol No. 6 June 1963 ENTERLINE & MCKIEVER 289 TABLE 3. OCCUPATIONAL GROUPS WITH SIGNIFICANTLY HIGH P < .05 STANDARDIZED MORTALITY RATIOS AND PROPORTIONATE MORTALITY RATIOS FOR LUNG CANCER I.S.C. 162 163 MALES 20-64 YEARS OF AGE WITH WORK EXPERIENCE UNITED STATES 1950 high death rate for automobile mechanics and re- pairmen is of interest and may be a true reflection of respiratory carcinogens Discussion Occupational group Standardized mortality ratios Major group Craftsmen foremen and kindred workers 130 Operatives and kindred - workers 107 Subgroup Blacksmiths forgemen and hammermen Carpenters Mechanics and repair- men automobile Moulders metal Painters construction paperhangers and glazers Plumbers and pipefitters Stationary engineers Tailors and furriers Tinsmiths coppersmiths and sheetmetal workers Operatives n.e.c. in primary metals industry Elevator operators 190 112 128 227 167 174 159 206 184 145 214 Proportionate mortality ratios 128 128 152127 127 170 129 146 137 136 159 143 155 \ are gas stokers and oven chargers council laborers road sweepers and dustmen motor driv- ers goods and passengers cabinetmakers stone- masons cutters and dressers drivers of horse- drawn vehicles painters licensed victualers and printers - Excess mortality for lung cancer for the entire - United States generally conforms to a pattern which might have been predicted on the basis of other studies It should be emphasized that the data presented here were not available until recently and are not reflected in previous reports They represent a considerably greater coverage and a larger number of deaths than have hereto- - fore been available Probably of as much interest from an environmental standpoint as occupations having a high mortality are those where mortality from lung cancer is low While not emphasized in this analysis these may provide some leads in establishing etiological agents The very low mortality among agricultural workers for example may be of considerable significance in evaluating the effects of air pollution on the incidence of lung cancer while the average mortality for persons in professional and technical tions may be a gross reflection of the impoorctcaunpcae- of the occupational environment Excluding the 11 residual occupational groupings occupational subgroups identified here with an excess mortality from lung cancer in- volve a population of over 3 million male work- ers Within this group it may be possible in the future to identify further subgroupings with an exceptionally high mortality and by a study of the working environment of these workers identify and remove the causal agent or agents a Heuper has reviewed evidence on industrial carcinogens and has prepared list of occupa- tions in which he believes an excess of lung cancer exists There is good agreement between occupations in identified here and those appearing Heuper's list Four of the subgroups shown in Table 3 do not appear however These are auto- mtaoibliorlseanmdecfhuarnriiecrss aanndd elreevpaatiorrmen carpenters of these automobile mechanics oapnedrarteoprasirTmweon and elevator operators were not in fact noted in any of the studies reviewed above For elevator operators it seems probable that selective factors are important in the excess mortality from lung cancer particularly in view of a high turnover in this occupation In view of recent evidence link- ing automobile exhausts with lung cancer the Summary Data are presented on mortality from cancer of the trachea bronchus and lung for men 20-64 years of age with work experience by occupation for the United States for the year 1950. Precau- tions are taken to avoid bias in mortality data which arises occupational- because of ences in the way occupational informationdiisfcfoelr-- lected for census schedules and for death certifi- cates Two major occupational groups and 11 subgroups are identified with significantly high death rates There is good agreement between occupations identified in this study and those identified in previous studies Division of Occupational Health U. S. Public Health Service Washington 25 D. C. Soy $ meet 4 zdale i at i Lh, ye wa ag blaet roe creEa ayes mer cy Be penis ronBaEn t 5 re bt Le i tui Someyopymnthy eqn pleantets meme 7 Aa FANT on ae ak ens ters: pean tenho atmo ety me beertin fu 14 tnd - etinmao HL ce te heer OR SE 4 Me caneTUE A TES a , ee | Journal ** 290 CANCER MORTALITY Occupational Medicine Medicine References 1950. Vital Statistics Special Reports 53 No. 2 . pp 49-92 1962 1. DARIC J. Mortality occupation and economic status Vital Statistics Special Reports 175 1951 8. KAPLAN D. L. PARKHURST E. and WHELPTON P. K. The comparability of reports on occupation 2. Registrar General Great Britain Decennial Sup- from vital records and the 1950 census Vital Sta- plement England and Wales 1951 Part II Occu- tistics Special Reports 53 No. 1 pp 1-48 1961 pational Mortality Her Majesty's Stationery Lon- BERKSON J. Mortality and marital status Am J. don 1958 Pub Health 1318 1962 U. S. Bureau of the Census 11th Decennial Census 10 LEW E. A. Use of life insurance company records 1890 Vol IV Report on Vital and Social Statistics in the United States Part I. U. S. Government for cancer studies A.M.A. Arch Indust Hyg & Occup Med 198 1952 Printing Office Washington D. C. 1896 11. BRESLOW L. Industrial aspects of bronchiogenic neoplasmsE.DisbroCnchhioegesnict GRAHAM 1955 EtiologicEtiologic WYNDER carcinoma refer- bronchiogenic 4. U. Bureau of the Census 12th Census of the United States 1900 Vol III Vital Statistics Part I. 12. 12. Etiologic fac- carcinoma Washington S. Printing Office ence to industrial exposures A.M.A. Arch Indust ; U. C. Government . .D Ocupation Hyg Occup Med 221 1951 == KENNAWAY N. 5. WHITNEY S. Death Rates by Occupation Based 13. M. and KENNAWAY further =~ on Data of the U. S. Bureau of Census 1930. Na- tional Tuberculosis Association New York 1934 study of the incidence of cancer of the lung and larynx Brit J. Cancer 260 1947 6. MORIYAMA I. M. and GURALNICK L. Occupational 14. HEUPER W. C. A Quest into the Environmental and , Round Table at the 1955 Annual Conference Milbank Memorial Fund New York Milbank Memorial Fund 1956 GURALNICK L. Mortality by occupation and indus- try among men 20 to 64 years of age United States graph Washington January Educa- No. graph , U. S. Department Department of Health Educa- and Welfare D. 15. Motor Vehicles Air Pollution and Health A Re- port of the Surgeon General to the U. S. Congress House Document No. 489 U. S. Government Print- ing Office Washington D. C. June 1962 arial International Conference on Tetanus opens An international conference on the Prevention and Treatment of Tetanus will be held Nov. 8-10 1963 in Bombay India The language of the conference will be - English od s3 a Attention will be given to the incidence of tetanus in various parts of the world and to its epidemiology etiology pathogenesis and clinical features The dosage as of A.T.S. the use of tetanus toxoid and the use of antibiotics will be discussed in 4 . relation to both prevention and treatment of tetanus The use of artificial respira- ws tors and tracheotomy and the use of relaxant and anticonvulsant drugs in ere the treatment of tetanus will be evaluated In the prevention of tetanus consideration will be given to separate administration of tetanus toxoid and other preventive vaccines according to a fixed schedule and combined administration of toxoid and other vaccines in a single formulation ; Further information may be obtained from Dr. J. C. Patel Organizing Secretary International Conference on Tetanus K.E.M. Hospital Parel Bombay 12 India