Occupational and

Environmental MedicineAdopted as the Journal of the Faculty of

Occupational Medicine of the Royal College ofPhysicians ofLondon

Editor: Anne Cockcroft (United Kingdom)Technical Editor: Judith HaynesEditorial Assistant: Rachel HarveyEditorial Board:T C Aw (United Kingdom) R McNamee (United Kingdom) M Singal (United States)F J H Van Dijk (Holland) J Myers (South Africa) D C Snashall (United Kingdom)J S Evans (United States) B Nemery (Belgium) 0 Svane (Denmark)R M Harrison (United Kingdom) T Okubo (Japan) G Theriault (Canada)J Jeyaratnam (Singapore) P Paoletti (Italy) K M Venables (United Kingdom'F Kauffmann (France) L Rosenstock (United States) Editor, British Medical Journal

R L Maynard (United Kingdom) M Sim (Australia)

NOTIC F TO CONTRIBUTORS Occupational and EnvironmentalMedicine is intended for the publication of original contribu-tions relevant to occupational and environmental medicine,including toxicological studies of chemicals of industrial, agri-cultural, and environmental importance, and epidemiologicalstudies. As well as full papers, short papers dealing with briefor preliminary observations relevant to occupational and envi-ronmental medicine will also be considered. Case reportsshould cover substantial new ground to merit publication.Other articles, including review or position papers, will be con-sidered but should not be submitted without first approachingthe Editor to discuss their suitability for the Journal Letters tothe Editor are always welcome.INSTRUCTIONS TO AUTHORS Three copies of all submissionsshould be sent to: The Editor, Occupational and EnvironmentalMedicine, BMJ Publishing Group, BMA House, TavistockSquare, London WC1H 9JR, UK. All authors should sign thecovering letter as evidence of consent to publication. Papersreporting results of studies on human subjects must be accom-panied by a statement that the subjects gave written, informedconsent and by evidence of approval from the appropriateethics committee. These papers should conform to theprinciples outlined in the Declaration of Helsinki (BMJ1964;ii: 177).

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names and addresses of three people who they considerwould be suitable independent reviewers. They will notnecessarily be approached to review the paper.

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standard journal article: authors (list all authors when seven orfewer, when eight or more, list only six and add et al), title,abbreviated title of journal as given in Index Medicus (if notin Index Medicus give in full), year of publication, volumenumber, and first and last page numbers.

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Reprints Reprints will be charged for. The number ofreprints required should be stated on the form provided withthe proofs.Copyright C 1995 Occupational and Environmental Medicine.This publication is copyright under the Berne Convention andthe International Copyright Convention. All rights reserved.Apart from any relaxations permitted under national copyrightlaws, no part of this publication may be reproduced, stored ina retrieval system, or transmitted in any form or by any meanswithout the prior permission of the copyright owners.Permission is not, however, required to copy abstracts ofpapers or of articles on condition that a full reference to thesource is shown. Multiple copying of the contents of the publi-cation without permission is always illegal.NO I ICE TO ADVERT ISERS Applications for advertisementspace and for rates should be addressed to the AdvertisementManager, Occupational and Environmental Medicine, BMJPublishing Group, BMA House, Tavistock Square, LondonWC1H 9JR.NOTICE TO SUBSCRIBERS Occupational and EnvironmentalMedicine is published monthly. The annual subscription rate(for 1995) is £139 (US $240). Orders should be sent to theSubscription Manager, Occupational and EnvironmentalMedicine, BMJ Publishing Group, BMA House, TavistockSquare, London WC1H 9JR. Orders may also be placed withany leading subscription agent or bookseller. (For the conve-nience of readers in the USA subscription orders with or with-out payment may also be sent to British Medical Journal, P0Box 408, Franklin, MA 02038, USA. All inquiries, however,must be addressed to the publisher in London). All inquiriesregarding air mail rates and single copies already publishedshould be addressed to the publisher in London.

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ISSN 1351-0711.

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Does occupational exposure to dust prevent colorectal cancer?

8 Armstrong BK, McNulty JC, Levitt U, Williams KA,Hobbs MST. Mortality in gold and coal miners inWestern Australia with special reference to lung cancer.BrJ Ind Med 1979;36:199-205.

9 Wyndham CH, Bezuidenhout BN, Greenacre MJ,Sluis-Cremer GK. Mortality of middle aged SouthAfrican gold miners. BrJ7Ind Med 1986;43:677-84.

10 Nair RC, Abbatt JD, Howe GR, Newcombe HB, FrostSE. Mortality experience among workers in the Uraniumindustry. In: Stocker H, ed. Occupational radiation safety inmining. Proceedings of the International Conference.Toronto: Canadian Nuclear Association, 1985.

11 Waxweiller RJ, Roscoe RJ, Archer VE. Mortality follow-upthrough 1977 of the white underground uraniumminers cohort examined by the United States PublicHealth Service. In: Gomez M, ed. Radiation hazardsin mining: control, measurement, and medical aspects.New York: Society of Mining Engineers, 1981:823-30.

12 Samet JM, Pathak DR, Morgan MV, Key CR, ValdiviaAA, Lubin JH. Lung cancer mortality and exposure toradon progeny in a cohort of New Mexico undergrounduranium miners. Health Phys 1991;61:745-52.

13 Sevc J, Tomasek L, Kunz E, Placek V, Chmelevsky D,Barclay D. A survey of the Czechoslovak follow-up ofcancer mortality in uranium miners. Health Phys 1993;64:355-69.

14 Chen R, Wei L, Huang H. Mortality from lungcancer among copper miners. Br J Ind Med 1993;50:505-9.

15 Kinlen LI, Willows AN. Decline in the lung cancer hazard:a prospective study of the mortality of iron ore miners inCumbria. BrJ Ind Med 1988;45:219-24.

16 Lawler AB, Mandel JS, Schumann LM, Lubin JH. A retro-spective cohort mortality study of iron ore (hematite)miners in Minnesota. JT Occup Med 1985;27:507-17.

17 Chen SY, Hayes RB, Liang SR, Li QG, Stewart PA, BlairA. Mortality experience of haematite mine workers inChina. BrJ Ind Med 1990;47:175-81.

18 Pham QT, Caillier I, Chau N. Teculescu D, Patris A,Trombert B. La mortalite des mineurs de fer du Bassin deLorraine. Arch Mal Prof 1993;54:391-6.

19 Fox AJ, Goldblatt P, Kinlen U. A study of the mortality ofCornish tin miners. BrJ7Ind Med 1981;38:378-80.

20 Chen J, McLaughlin JK, Zhang J, Stone BJ, Luo J, ChenR. Mortality among dust-exposed Chinese mine andpottery workers. J Occup Med 1992;34:311-6.

21 Hodgson JT, Jones RD. Mortality of a cohort of tin miners1941-86. BrJ Ind Med 1990;47:665-76.

22 Battista G, Belli S, Carboncini F, Comba P, Levante G,Sartorelli P. Mortality among pyrite miners with low-level exposure to radon daughters. ScandJ7 Work EnvironHealth 1988;14:280-5.

23 Carta P, Cocco P. Picchiri G. Lung cancer mortality andairways obstruction among metal miners exposed to silicaand low levels of radon daughters. Am J Ind Med1994;25:489-506.

24 Morrison HI, Semenciw RM, Mao Y, Wigle DT. Cancermortality among a group of fluorspar miners exposed toradon progeny. Am J Epidemiol 1988;128: 1266-75.

25 Koskela RS, Klockars M, Jarvinen E, Kolari P, Rossi A.Cancer mortality of granite workers 1940-1985. In:Simonato L, Fletcher AC, Saracci R, eds. Occupationalexposure to silica and cancer risk. Lyon: IARC, 1990.(IARC Sci Publ No 97.)

26 Mehnert WH, Stanaczek W, Mohner M, Konetzke G,Muller W, Ahlendorf W. A mortality study of slatequarry workers in the German Democratic Republic. In:Simonato L, Fletcher AC, Saracci R, eds. Occupationalexposure to silica and cancer risk. Lyon: IARC, 1990.(IARC Sci Publ No 97.)

27 Steenland K, Beaumont J. A proportionate mortality studyof granite cutters. AmJ Ind Med 1986;9:189-201.

28 Davis LK, Wegman D, Monson RR, Froines J. Mortalityexperience of Vermont granite cutters. Am 7 Ind Med1983;4:705-23.

29 Potter JD, Slattery ML, Bostick RM, Gapstur SM. Coloncancer: a review of the epidemiology. Epidemiol Rev1993;15:499-545.

30 Spiegelman D, Wegman DH. Occupation-related risks forcolorectal cancer. J Natl Cancer Inst 1985;75:813-21.

31 Brownson RC, Zahm SH, Chang JC. Occupational risk ofcolon cancer: an analysis by anatomic subsite. Am JEpidemiol 1989;130:675-87.

Vancouver styleAll manuscripts submitted to Occup EnvironMed should conform to the uniformrequirements for manuscripts submitted tobiomedical journals (known as theVancouver style.)

Occup Environ Med, together with manyother international biomedical journals, hasagreed to accept articles prepared in accor-dance with the Vancouver style. The style(described in full in the BMJ, 24 February1979, p 532) is intended to standardiserequirements for authors.

References should be numbered consec-utively in the order in which they are firstmentioned in the text by Arabic numeralsabove the line on each occasion the refer-ence is cited (Manson' confirmed otherreports2 5. . .). In future references topapers submitted to Occup Environ Med

should include: the names of all authors ifthere are seven or less or, if there are more,the first six followed by et al; the title ofjournal articles or book chapters; the titlesof journals abbreviated according to thestyle of Index Medicus; and the first and finalpage numbers of the article or chapter.Titles not in Index Medicus should be givenin full.

Examples of common forms of refer-ences are:

1 International Steering Committee of Medical Editors,Uniform requirements for manuscripts submitted tobiomedical journals. BrMedJ 1979;1:532-5.

2 Soter NA, Wasserman SI, Austen KF. Cold urticaria:release into the circulation of histamine and eosino-phil chemotactic factor of anaphylaxis during coldchallenge. N EnglJ Med 1976;294:687-90.

3 Weinstein L, Swartz MN. Pathogenic properties ofinvading micro-organisms. In: Sodeman WA Jr,Sodeman WA, eds. Pathologic physiology, mechanismsof disease. Philadelphia: W B Saunders, 1974:457-72.

149

Mortality from lung cancer and other diseases related to smoking amongfishermen in north east Italy

Possibly, old age at cessation, few years ofabstinence, and heavy past consumption oftobacco do not elicit a decrease in mortalityfrom lung cancer.An excess of liver cancer was also found in

our cohort. It is known that high alcohol con-sumption increases the risk of liver cancer,and fishermen tend to be heavy drinkers.'7Gathering information on the smoking habitsof decedents is difficult, but it may be an evenmore delicate matter obtaining informationon alcohol consumption. We thereforedecided to avoid asking for information fromnext of kin about their deceased relatives'alcohol consumption.

ConclusionsLung and liver cancer are the most frequenthealth hazards among Veneto deep sea fisher-men. Smoking, not occupation, is the mainrisk factor in the mortality from lung cancer.Another study, however, suggested that ciga-rette smoking increased with workshift hoursat sea. A high percentage of decedents wereex-smokers, and probably the low mortalityfrom diseases related to smoking other thanlung cancer may be due to the early effect ofstopping smoking.

The study was supported by a grant from the "Centro diCancerogenesi Ambientale".

1 Schilling RSF. Hazards of deep-sea fishing. BrJ Ind Med1971;28:27-35.

2 Hagmar L, Linden K, Nilsson A, Norrving B, Akesson B,Schutz A, Moller T. Cancer incidence and mortalityamong Swedish Baltic Sea fishermen. Scand J7 WorkEnviron Health 1992;18:217-24.

3 Neutel CI. Mortality in fishermen: an unusual age distribu-tion. BrJ7 Ind Med 1990;47:528-32.

4 Mastrangelo G, Rizzi P, Casson FF. Mortality per causanel Comune di Chioggia confrontata con quella dellaProvincia di Venezia. Atti del Convegno "Pescatori eSalute ". Chioggia: Veneta Editrice, 1989.

5 BMDP Statistical Software Manual. Berkeley: University ofCalifornia Press, 1992.

6 Casson FF, Mastrangelo G, Saia B. Lo stato di salute deipescatori d'alto mare di Chioggia. Atti del Convegno"Pescatori e Salute". Chioggia: 1989.

7 Istituto Nazionale di Statistica. Indagmie statistics sullecondizioni di salute della popolazione e sul ricorso aiservizi sanitary (novembre 1986-aprile 1987). ISTA TNote e Relazioni 1991;2:182.

8 Hasselback P, Neutel CI. Risk for commercial fishingdeaths in Canadian Atlantic provinces. Br J Ind Med1990;47:498-501.

9 Norris AE, Cryer PC. Work related injury in New Zealandcommercial fishermen. BrJ7 Ind Med 1990;47:726-32.

10 Greenberg M. Cancer mortality in merchant seamen. AnnNYAcad Sci 1991;643:321-32.

11 Rapiti E, Turi E, Forastiere F, Borgia P, Comba P,Perucci CA, Axelson 0. A mortality cohort study of sea-men in Italy. Am J Ind Med 1992;21:863-72.

12 Hammond EC, Selikoff IJ, Seidman H. Asbestos expo-sure, cigarette smoking and death rates. Ann NY AcadSci 1979;330:473-90.

13 Steenland K, Beaumont J, Halperin W. Methods of con-trol for smoking in occupational cohort mortality stud-ies. Scandj7 Work Environ Health 19841O:143-9.

14 Kawachi I, Colditz GA, Stampfer MJ, Willet WC, MansonJE, Rosner B. et al. Smoking cessation in relation to totalmortality rates in women. A prospective cohort study.Ann Intern Med 1993;119:992-1000.

15 Halpern MT, Gillespie BW, Warner KE. Patterns ofabsolute risk of lung cancer mortality in former smokers._J Nat Cancer Inst 1993;85:457-64.

16 Alcohol drinking. IARC Monogr Eval Carcinog Risks Huni1988;44:207-15.

17 Brix K, Hunter D, Colley P. Incidence of treated alco-holism in north-east Scotland, and Shetland fishermen,1966-70. BrJInd Med 1982;39:11-7.

Instructions to authorsThree copies of all submissions should besent to: The Editor, Occupational andEnvironmental Medicine, BMJ PublishingGroup, BMA House, Tavistock Square,London WC1H 9JR, UK. All authorsshould sign the covering letter as evidenceof consent to publication. Papers reportingresults of studies on human subjects must beaccompanied by a statement that thesubjects gave written, informed consentand by evidence of approval from theappropriate ethics committee. These papersshould conform to the principles outlinedin the Declaration of Helsinki (BMJ 1964;ii: 177).

If requested, authors shall produce thedata on which the manuscript is based, forexamination by the Editor.Authors are asked to submit with

their manuscript the names andaddresses of three people who theyconsider would be suitable independentreviewers. They will not necessarily beapproached to review the paper.Papers should include a structured

abstract of not more than 300 words,under headings of Objectives, Methods,Results, and Conclusions. Pleaseinclude up to three keywords or keyterms to assist with indexing.

153

Sex ratios of births, mortality, and air pollution

cancer and particularly for all causes ofmortality than the unexposed areas, even

when the definition of exposure was basedon estimates rather than on data from a

sampling network for air pollution. This find-ing indicated the need for investigations to

exclude the possible effects of otherconfounding variables and to determine thenatures and sources of the toxic air pollutantsin those environments. It also suggested thatpublic health authorities could monitor themortality in their populations exposed to

industrial pollution even in the absence ofdetailed information from pollution monitor-ing networks. If the cause-effect relation sug-

ested in this paper is confirmed by suchstudies, the findings would also indicate thatthe legislation on air quality control should bestrengthened to minimise exposures to theseenvironmental hazards.

We thank Mrs Wendy Mitchell for help with data processingand Professor C du V Florey for his very helpful suggestionsfor improving this paper. This work was supported by an

MRC grant: MRC A 601/108.

1 McDowall ME. Occupational reproductive epidemiology: theuse of routinely collected statistics in England and Wales1980-82. Studies on medical and population subjects.London: HMSO, 1982:50.

2 Goldsmith JR, Potashnik G, Israeli R. Reproductive out-comes in families of DBCP-exposed men. Arch EnvironHealth 1984;39:85-9.

3 James WH. The human sex ratio. Part 2: a hypothesis anda programme of research. Hum Biol 1987;59:873-900.

4 James WH. The human sex ratio. Part 1: a review of theliterature. Hum Biol 1987;59:721-52.

5 Rehan NE. Sex ratio of live-born Hausa infants. BrObstet Gynaecol 1982;89:136-4.

6 Jakobovits AA. Sex ratio of spontaneously aborted fetusesand delivered neonates in second trimester. EurJ ObstetGynaecol Reprod Biol 1991;40:211-3.

7 Hytten FE. Commentary: boys and girls. Br ObstetGynaecol 1982;89:97-9.

8 Erickson JD. The secondary sex ratio in the United States1969-71: association with race, parental ages, birthorder, paternal education, and legitimacy. Ann HumGenet 1976;40:205-12.

9 Chandra HS. Is human X chromosome inactivation a sex-

determining device? Proc Nad Acad Sci USA 1985;82:6947-9.

10 Lyster WR, Bishop MWH. An association between rainfalland sex ratio in man. Jf Reprod Fertil 1965;10:35-47.

11 Lyster WR. Sex ratio of human births in a contaminatedarea. MedjAust 1977;1:829-30.

12 Lloyd 0, Lloyd MM, Holland Y, Lyster WR. An unusualsex ratio of births in an industrial town with mortalityproblems. BrJ Obstet Gynaecol 1984;91:910-07.

13 Lloyd OL, Smith G, Lloyd MM, Gailey F. Raised mortal-ity from lung cancer and high sex ratios of births associ-ated with industrial pollution. Br Ind Med 1985;42:475-80.

14 Williams FLR, Lawson AB, Lloyd OL. Low sex ratiosof births in areas at risk from air pollution fromincinerators, as shown by geographical analysis and 3-dimensional mapping. IntJ7 Epidemiol 1992;21:311 -9.

15 Williams FLR. The epidemiological surveillance of mortal-ity and other health indices in traditional communitiesin Scotland. Dundee: University of Dundee, 1989. (PhDthesis.)

16 Lloyd OL, Lloyd MM, Williams FLR, Lawson AB.Twinning in human populations and in cattle exposedto air pollution from incinerators. Br Ind Med1988;45:56-60.

17 Smith GH, Lloyd OL. Soil pollution from a chemicalwaste dump. Chemistry in Britain 1986;22:139-41.

18 Lloyd OL, Lloyd MM, Williams FLR, McKenzie A, HayA. Ragwort poisoning, fat cow syndrome, or industrialchemical toxicity? The value of an epidemiologicalanalysis. Sci Total Environ 199 1;106:83-96.

19 Whorton D, Milby TH, Krauss RM, Strubbs HA.Testicular function in DBCP exposed pesticide workers.Occup Med 1979;21:161-6.

20 Potashnik G, Goldsmith J, Insler V. Dibromochloro-propanes-induced reduction of the sex ratio in man.

Andrologia 1984;16:213-8.21 Baker RG, Nelder JA. The GLIM system. In: Release 3 ed.

Oxford: Numerical Algorithms Group, 1978.22 Lloyd OLL, Ireland E, Tyrrel H, Williams FLR.

Respiratory cancer in a Scottish industrial community: a

retrospective case-control study. Soc Occup Med 1986;36:2-8.

23 Elliott P, Hills M, Beresford J, Kleinschmidt I, Jolley D,Pattenden S, et al. Incidence of cancers of the larynx andlung near incinerators of waste solvents and oils in GreatBritain. Lancet 1992;339:854-8.

Correspondence and editorialsOccupational and Environmental Medicine wel- minimum. Letters are accepted on thecomes correspondence relating to any of the understanding that they may be subject tomaterial appearing in the journal. Results editorial revision and shortening.from preliminary or small scale studies may The journal also publishes editorials whichalso be published in the correspondence are normally specially commissioned. Thecolumn if this seems appropriate. Letters Editor welcomes suggestions regardingshould be not more than 500 words in length suitable topics; those wishing to submit an

and contain a minimum of references. Tables editorial, however, should do so only afterand figures should be kept to an absolute discussion with the Editor.

169

Nishijo, Nakagawa, Morikawa, Tabata, Senma, Miura, et al

in the men. As the excessive mortality due torespiratory disease found in our study was

mainly due to pneumonia and bronchitis andthe route of Cd exposure differed from that offactory workers, it is considered that thesedeaths may not have been due to a directinfluence of Cd but rather to a worsening ofthe general state of health.

In our study we found a high SMR forrenal diseases, in particular nephritis andnephrosis, and in the study of Shigematsu et alSMR for uraemia was significantlyincreased." 12 In the Kakehashi River basintargeted in our study, the SMR for diabetesmellitus was also high in the women. Most ofthe deaths from diabetes occurred early in theobservation period when renal dysfunctioninduced by Cd was not recognised. Renal dys-function due to Cd is often accompanied byraised urinary glucose. Diabetes may havebeen mistakenly diagnosed in some of thesesubjects. Lauwerys et al reported frequentdeaths from renal disease among inhabitantswith a long history of exposure in regions pol-luted by Cd in Belgium, and Elinder et a"'8and Kjellstrom et al"9 in a study of mortalitiesin factory workers exposed to Cd found signi-ficantly high values for deaths due to nephritisand nephrosis. These findings suggest thatsubjects with renal tubular disorder inducedby Cd may have advanced renal dysfunctionand be at high risk of premature death.

In studies on causes of death in factoryworkers the impact or lack of impact of Cd on

mortality from malignant neoplasms, particu-larly prostate and lung cancers, has becomean issue.'8 20-22 In our study the number ofdeaths was small and it was not possible todetermine cancer mortalities according to site.A longer follow up period is necessary to eval-uate this.

1 Tsuchiya K, Sakurai H. Shigematu I, et al.Epidemiological studies. In: Tsuchiya K, ed. Cadmiumstudies in Japan. A review. Tokyo: Kodansha, 1978:133-267.

2 Nakagawa H, Kawano S, Okumura T, Fujita T, Nishi M.Mortality study of inhabitants in a cadmium-pollutedarea. Bull Environ Contam Toxicol 1987;38:553-60.

3 Nakagawa H, Nishijo M, Morikawa Y, Tabata M, SenmaM, Kitagawa Y, et al. Urinary P,-microglobulin concen-tration and mortality in a cadmium-polluted area. ArchEnviron Health 1993;48:428-435.

4 Cox DR. Regression models and life tables. Journal of theRoyal Statistical Society (B) 1972;34:187-220.

5 Armitage A. Standardization. In: Armitage A, ed.Statistical method in medical research. Oxford: BlackwellScientific Publication, 1985:384-91.

6 Fukutomi K, Hashimoto S. Some remarks on the stan-dardized mortality ratio. Japanese Journal ofPublic Health1989;36: 155-60. (In Japanese.)

7 Nogawa K, Ishizaki A, Kawano S. Statistical observations ofthe dose-response relationships of cadmium based on

epidemiological studies in the Kakehashi River basin.Environ Res 1978;15:185-98.

8 Kido T, Honda R, Tsuritani I, Yamaya Y, Ishizaki M,Yamada Y, et al. An epidemiological study on renal dys-function of inhabitants in Cd-exposed areas inKakehashi River basin in Ishikawa Prefecture. JapaneseJournal ofHygiene 1987;42:964-72. (In Japanese.)

9 Ishizaki M, Kido T, Honda H. Tsuritani I, Yamada Y,Nakagawa H, et al. Dose-response relation between uri-nary cadmium and /,h-microglobulin in a Japanese envi-ronmentally cadmium exposed population. Toxicology1989;58:121-31.

10 Iwata K, Saito H, Moriyama M, Nakano A. Follow up

study of renal tubular dysfunction and mortality in resi-dents of an area polluted with cadmium. Br Ind Med1992;49:736-7.

11 Shigematsu I, Takeuchi J, Minowa M, Nagai M, Usui T,Fukushima M, et al. A retrospective mortality study on

cadmium exposed pollution in Japan. Kankyo HokenReport 1980;46: 1-71. (In Japanese.)

12 Shigematsu I, Minowa M, Nagai M, Omura T, TakeuchiK. A retrospective mortality study on cadmium-exposedpollution in Japan: an investigation of mortality rates by a

pollution level in Toyama Prefecture. Kankyo HokenReport 1982;48(suppl): 118-36. (In Japanese.)

13 Nakagawa H, Tabata M, Morikawa Y, Senma M,Kitagawa Y, Kawano S. High mortality and shortenedlife-span in patients with itai-itai disease and subjectswith suspected disease. Arch Environ Health1990;45:283-7.

14 Nogawa K, Kawano S. A survey of the blood pressure ofwoman suspected of itai-itai disease. Journal of the Juzen

Medical Society 1969;77:357-63. (In Japanese.)15 Armstrong BG, Kazantzis G. Prostatic cancer and chronic

respiratory and renal disease in British cadmium work-ers: a case-control study. BrJrInd Med 1985;42:540-5.

16 Armstrong BG, Kazantzis G. The mortality of cadmiumworkers. Lancet 1983;25:1425-7.

17 Lauwerys R, De Wals. Environmental pollution by cad-mium and mortality from renal diseases. Lancer 1981;i:383.

18 Elinder CG, Kjellstrom T, Hogsted C, Andersson K,Spang G. Cancer mortality of cadmium workers. Br JfInd Med 1985;42:651-5.

19 Kjellstrom T, Friberg L, Rahnster B. Mortality and cancer

morbidity among cadmium-exposed workers. EnvironHealth Perspect 1979;28: 199-204.

20 Thun MJ, Schnorr TM, Smith AB, Halperin WE, LemenRA. Mortality among a cohort of US cadmium produc-tion workers.J Nad Cancer Inst 1985;74:325-33.

21 Ades AE, Kazantzis G. Lung cancer in a non-ferroussmelter: the role of cadmium. Br Ind Med1988;45:435-44.

22 Sorahan T. Mortality from lung cancer among a cohort ofnickel cadmium battery workers: 1946-84. BrJ7 Ind Med1987;44:803-9.

Rejected manuscriptsFrom February 1994, authors whose sub- be returned to them. The Journal willmitted articles are rejected will be advised destroy remaining copies of the article butof the decision and one copy of the article, correspondence and reviewers' commentstogether with any reviewers' comments, will will be kept.

184

Occupational and Environmental Medicine 1995;52:214-216

The effect of occupational exposure tomercury vapour on the fertility offemale dental assistants

Editor-Rowland et al found lower fertilityamong women who did not work withamalgam compared with women exposed tolow levels of mercury.' Other exposures tomercury incurred by dental assistants whodo not work with amalgam was offered as apossible explanation.

In 1994 as health and safety representa-tive for a surgical ward at a metropolitanhospital, I found that 60% of trays at thebase of sphygmomanometers, wall mount-ed, at the head of each patient's bed, con-tained leaked mercury.2 Nurses unprotectedhands are often in this cuff tray. Theinspecting authorities, with a Jeromeanalyser, found mercury vapour concentra-tions of 85 ,yg/m' in the breathing zone of apatient at one bed. This is of course thework zone of the nurse. The rate of replace-ment of thermometers for the complex was750/month, which becomes 72 kg mercury/10 y at 0-8 g/thermometer. Cases of acrodyniacaused by one broken thermometer in thedomestic environment are documented.'No mercury hygiene protocol was in place.With the same poor hygiene factors that

Rowland et al used to assess risk of expo-sure to vapour-for example, hand contactwith mercury-general nurses seem to be atrisk. With factors such as lack of knowledgeof general nurses about mercury toxicityand the appropriate hygiene protocol,4 areported rate of leakage from hospitalsphygmomanometers of 48%,5 the absenceof hazard warning labels on sphygmo-manometers (mercury is a classified haz-ardous substance), the hazard tosphygmomanometer repairers having beenunreported until 1986,6 the understandablefocus of medical professionals on accuracyrather than safety in blood pressuremeasurement,7 and reported poorer repro-ductive outcomes for general nurses,8 9 itbecomes difficult not to conclude that gen-eral nurses are chronically exposed to mer-cury.

If the unexposed group in the paper ofRowland et al were taking blood pressuresand temperatures, exposure to mercury issuggested. Dentists have shown interest inthe suggestion that general nurses areexposed to mercury from sphygmanometersand thermometers because a percentage ofclients who choose non-amalgam restora-tions will be general nurses."I

PHILLIP J COLQUITTPO Box 175, Fortitude Valley,

Queensland 4006, Australia

1 Rowland AS, Baird DD, Weinberg CR, ShoreDL, Shy CM, Wilcox AJ. The effect ofoccupational exposure to mercury vapouron the fertility of female dental assistants.Occup Environ Med 1994;51:28-34.

2 Colquitt PJ. Unpublished report, to Division ofWorkplace Health and Safety, North BrisbaneRegion. 1994.

3 Muhlendahl KE. Intoxication from mercuryspilled on carpets. Lancet 1990;336:1578.

4 National Health and Medical ResearchCouncil. Approved occupational health guide-inorganic mercury. Canberra: Common-wealth Department of Health, 1982.

5 Burke MJ, Towers H, O'Malley K, FitzgeraldDJ, O'Brien ET. Sphygmomanometers in

hospital and family practice: problems andrecommendations. BMJ 1982;285:469-71.

6 Wide C. Mercury hazards arising from therepair of sphygmomanometers. BMJ 1986;293:1409-10.

7 Bailey R, Bauer J. A review of common errorsin the indirect measurement of blood pres-sure. Arch Intern Med 1993;153:2741-8.

8 Matte TD, Mulinare J, Erickson JD. Case-control study of congenital defects andparental employment in health care. AmInd Med 1993;24:11 -23.

9 Roeleveld N, Zeilhuis G, Gabreels F. Mentalretardation and parental occupation: a studyon the applicability of job exposure matri-ces. BrJ Ind Med 1993;50:945-54.

10 Akers H. Response to letter "mercury expo-sure in general nurses". Australian DentalAssociation Newsletter-QLD, 1994;386:20.

Potential public health problems ofasbestos in Jamaica

Editor,-Bad industrial hygiene practices,improper waste disposal methods of poten-tially harmful materials, and public igno-rance of these subjects can breed seriouspublic health problems, especially in devel-oping countries. Alarmed by the deplorablycallous attitude of construction workerstowards safe asbestos disposal procedures,'we sought to determine how pervasive theserisky procedures are in Jamaican industriesand if there are morbidities or mortalitiescaused by asbestos.

Pipes manufactured at a former (1969-85) asbestos cement factory (now a foodstore) should, from the documented formu-lation2 and verbal accounts of formeremployees, have been of standard composi-tion (about 3-34-3% crocidolite, 7-5-10%chrysotile, and 85-7-89-2% cement). Analyses(powder x ray diffraction) of four samples,however, taken from the factory site and anassociated surface dump nearby, a resi-dent's yard, and the town roadside, showedthe presence of crocidolite (a carcinogen3 4),not chrysotile. Most importantly, thesematerials were improperly disposed of.Some of them are freely chipping and erod-ing due to poor quality and have been usedby residents as flower pots, foundations todwellings, garbage dumps, and driveways(some of which were obtained as original wetmix) in the residents' yards, or appear alongdusty roads, and roadsides accessible toplaying children.

Six samples of ceiling tiles from a modemoffice building in Kingston contained eitheramosite or wollastonite fibres. Disposal wasimplemented by a major real estate com-

pany in the presence of one of us (IAK); theexercise generated much dust but the work-ers resisted instructions to wear dust masksremarking that "this is how we always doit". The methods used by the disposal con-tractor and the landfill site are unknown(Jamaica has no authorised landfill site forasbestos). These deplorable disposalmethods for asbestos materials are alsopractised at a power plant and a brake shoeand clutch refurbishing facility. The work-ers in these factories were found to be laxabout hygiene but there are institutionalworker safety and health monitoring mea-sures for factories. Samples of insulationmaterials (34 in house and one for thisstudy) from several boilers at the power

plant contained principally amosite andanthophyllite with tremolite, crocidolite,and actinolite impurities. The brake andclutch lining mix and raw material samples(two) contained chrysotile.

Hospital records showed two cases ofasbestosis with a history of occupationalexposure to asbestos (thermal insulation).Of the 9200 postmortem reports (1971-94)at the University Hospital of the WestIndies three cited mesothelioma as thecause of death but the histories of thedeceased were not clear. There are fiveadditional deaths suspected to be related toasbestos. The incidence of mesothelioma(about 0-03%) is small compared with0-2-0-7% for some European com-

munities,6 but this could be due to diagnos-tic difficulties,7 few necropsies, orinsufficient time because of mesotheliomalatency.3

Clearly this study, the first for theCaribbean, shows a potentially serious pub-lic health problem related to asbestos; adetailed investigation that includes manmade mineral fibres is in progress.We thank the UWI Centre for the

Environment and Development for finan-cial support and Drs M Lowe and BHanchard for the medical data.

HOWARD 0 REIDISHENKUMBA A KAHWA

Chemistry Department,University of the West Indies,Mona, Kingston 7, Jamaica

1 Kominsky JR, Freyberg R, Amick RS, PowersTJ. Assessment of asbestos removal carried outusing EPA purple book guidance. Cincinnati:USA Environmental Protection Agency,1991. (EPA/600/S2-91/003.)

2 P-E Consulting Group. Business appraisal forthe Caribbean asbestos products. Kingston,Jamaica: P-E Consulting Group, 1974.

3 Wagner JC, Sleggs CA, Marchand P. Diffusepleural mesothelioma and asbestos exposurein the north western Cape Province. Br _J

Ind Med 1960;17:260-71.4 Wagner JC. The discovery of the association

between blue asbestos and mesotheliomasand the aftermath. Br J7 Ind Med 1991;48:399-403.

5 Warren, Anderson, and Partners, Ffolkes,Harrison and Partners. Reports on conditionsof the Marlie Plant owned by the CaribbeanAsbestos Products. Kingston, Jamaica:Warren, Anderson, and Partners, FfolkesHarrisson, and Partners, 1974.

6 Meyers JMM, Planteydt HT, Slangen JIM,Swaen GMH, van Vliet C, Sturmans F.Trends and geographical patterns of pleuralmesotheliomas in the Netherlands 1970-87.BrJInd Med 1990;47:775-81.

7 Zeilhuis RI. Public health risks of exposure toasbestos. London: Pergamon Press, 1977.

NOTICES

IHF 60th ANNUAL SCIENTIFICMEETING, Occupational Health andSafety- Past - Present - Future.11-12 April 1995. Pittsburgh, PA, USA.

Among the topics planned for discussionare: occupational health and safety, ergo-nomics, toxicology, tuberculosis, EMF,industrial ventilation, occupational medi-cine and nursing, OSHA regulationsupdate, licensing and certification, and riskassessment.

For further information contact IHF, 34Penn Circle West, Pittsburgh, PA 15206 USA.Phone 412/363-6600. Fax 412/363-6605.

CORRESPONDENCE

214

Notices

Industrial Audiometry Courses. 5-7April and 17-19 May 1995. Manchester.

These two identical three-day coursesoffer training in audiometry for industrialmedical staff, safety officers, and othersconcerned with hearing conservation inindustry. The courses, which comply withthe syllabus recommended by the BritishSociety of Audiology have approval of theSociety. The courses will be held at theWendover Hotel, Eccles, Manchester.

For further information contact: Dr WTempest, Kismet, Croyde Road, St Annes,Lancs FY8 lEX. Telephone (01253)712550.

The Forest Occupational Health andSafety Group. Current Issues in Healthand Safety at Work: One DayConference, 11 April 1995. The SwallowHotel, Waltham Abbey, Essex.

An introduction to the papers being pre-sented:* Industrial injury-a medical review:-Accidents: definition and causation.-Relative risks of employment hazards.-Disease associated with work.-Types of injury and consequences for

employment.-Investigation and evaluation of injury.-Symptoms-genuine or not?-Principles of rehabilitation.* Integrated risk assessmentCurrent legislation calls for assessment tobe carried out by the employer. Suchassessments are designated within manyindividual regulations. It is the intention ofthis paper to introduce integrated assess-ment techniques, whereby physical (e.g.manual handling), chemical (e.g. COSHH)and biological hazards are brought togetherin one assessment.* Work related upper limb disorder (RSI)-what are the facts?Are we all as confused as the judges?

Knowledge gained in dealing with R.S.I.from industry and commerce through theeyes of an Occupational Health Practi-tioner. Examination of the medical, andergonomic aspects of R.S.I. looking atspecific disorders and their causes.

Here is your opportunity to consider theevidence and join the discussion.* The legal costs offailing to assess riskA legal view on the employer's duty todevise, record and implement assessments.The penalty for failing to assess will be illus-trated with relevant case law.* Revision ofRIDDORThe revised incident reporting requirementsfor injuries, diseases and dangerous occur-rences are explained by speakers from theHealth and Safety Executive. This newlyrevised legislation will come into force inApril 1995.* Sick building syndromeSick Building Syndrome (SBS) will bedefined, distingishing it from other building-related health issues; explains the impor-tance of SBS criteria; summarises what isknown about possible causes. Initial guid-ance will be given on how to avoid SBS.The conference is designed to give dele-

gates a thorough understanding of the cur-rent issues in occupational health andsafety. In this constantly developing area it

is vitally important for employers and occu-pational health and safety practitioners toupdate themselves on the latest changes inprocedures, legislation and their practicalapplication in the workplace.

For further information contact: Mr PHewitt, 3 Morgan Crescent, Theydon Bois,Epping, Essex CM16 7DU. Tel: 0992813357.

15th Annual New England Epidemi-ology Summer Programme of one andtwo week courses. 5-30 June 1995.Medford, MA, USA.

The New England Epidemiology Institute'ssummer programme at Tufts University'sMedford campus includes methodological,statistical, and substantive courses. Thisprogramme is intended for those seeking anintroduction to modem epidemiologicalconcepts as well as those desiring a reviewof recent developments in epidemiologicalthinking.One and two week courses cover the

following: theory and practice of epidemiol-ogy (introductory and advanced levels),introductory biostatistics, regression andcategorical data methods, survival analysis,epidemiology in developing countries, phar-macoepidemiology, cancer epidemiology,perinatal epidemiology, health care useresearch, occupational and environmentalepidemiology and exposure assessment,causal inference, and ethics. Invited facultyinclude excellent teachers and prominentresearchers from leading universities.Registrants may receive graduate-degreecredit or continuing education credits fromTufts University, Continuing MedicalEducation (AMA category 1) through TuftsUniversity Medical School, or certificationmaintenance from the American IndustrialHygiene Association. Nursing CEUs mayalso be available.

For further information contact: TheNew England Epidemiology Institute,Department PA-OEM, One NewtonExecutive Park, Newton Lower Falls, MA02162-1450, USA. Telephone: (617)244-1200. Fax: (617) 244-9669.

Second Arnold 0 Beckman/IFCCEuropean Conference on Biomarkersin Environmental Toxicology. 1-3 June,1995. Cannes, France.

The second Arnold 0 Beckman/IFCCEuropean Conference on Biomarkers inEnvironmental Toxicology will considerbiomarkers of effect and biomarkers ofsusceptibility. The conference is organisedby the International Federation of ClinicalChemistry in co-operation with theEuropean Commission, InternationalCommission on Occupational Health,International Programme on ChemicalSafety, International Society of Environ-mental Epidemiology, International Unionof Pure and Applied Chemistry, Inter-national Union of Toxicology, and theWorld Health Organization.

In addition to the invited presentationsopportunities are available to presentposters with the same general theme. Anobjective of the conference is to begin todevelop recommendations concerning the

monitoring of exposure to toxic substances.For further information contact: Gerald

Bishop Associates, Hillview House, 34 NewStreet, Charfield, Wotton-under-Edge,Gloucestershire, GL12 8ES, UnitedKingdom; or in North America from:Individualized Events attn: Ramona Larson,2620 N Harbor Boulevard, Fullerton, CA,92635, USA.

5th Conference of OccupationalMedicine, Epidemiology, and Ergo-nomics in small and medium business-es. 21-23 June 1995. Amiens, France.

The conference is organised by l'Associa-tion pour les Services MWdicaux Inter-entreprises du department de la Somme.The theme is actions that occur in the workplace with specific emphasis on an evalua-tive approach within small and mediumbusinesses.

For further information contact:ASMIS-Medecine du travail, Comit6Scientifique, 77 rue Debaussaux-BP 0132,80001 AMIENS CEDEX 1, France.Telephone: 22 54 58 11. Fax: 22 54 58 01.

Advanced Course in Occupationaland Environmental Epidemiology:Principles of Exposure Assessment.3-14 July 1995. Wageningen, TheNetherlands.

The course will take place at theWageningen International ConferenceCenter IAC, Lawickse Allee 11, 6701 ANWageningen, The Netherlands.The validity of studies in environmental

and occupational epidemiology depends toa large extent on the accuracy and precisionof the assessment of exposure to potentiallyharmful factors in the general or occupa-tional environment. Thus, it is importantthat investigators involved in the design,conduct and interpretation of studies in thisfield, have a thorough understanding ofhowlack of accuracy and/or precision affect astudy.The general objectives of this course are

to increase participants' knowledge of prin-ciples and methods of exposure assessment,and demonstrate how those methods can beapplied to occupational and environmentalepidemiology, in order to improve the qual-ity of epidemiologic studies, and conse-quently the scientific basis for controlmeasures.The progamme will be a combination of

lectures, seminars, group discussions andindividual advice. The lectures includemethodological topics subsequently illus-trated by applications in current research.The first week will be in plenary to discussgeneral aspects of exposure assessment inenvironmental and occupational epidemiol-ogy. The second week will offer separatemodules for occupational and environ-mental epidemiology applications respec-tively.The course focuses on epidemiologists

with an interest in exposure assessment,hygienists with a background in epidemio-logy, exposure assessors, toxicologists,physicians, biostatisticians, health officialsand others with previous training in basicepidemiology.

215

Book reviews

The course will be conducted in English.For further information, please contact

the course coordinator: Ms Susan Peelen,MSc, Department of Epidemiology andPublic Health, University of Wageningen,PO Box 238, 6700 AE Wageningen, TheNetherlands. Tel +31 8370 84124; Fax:+31 8370 82782; E-mail: Susan.Peelen@medew.hegl.wau.nl

BOOK REVIEWSBook review editor: R L Maynard

If you wish to order, or require furtherinformation regarding the titles reviewedhere, please write or telephone the BMJBookshop, PO Box 295, London WX1H9TE. Tel: 071 383 6244. Fax: 071 3836662. Books are supplied post free in theUK and for British Forces Posted Overseasaddresses. Overseas customers should add15% for postage and packing. Payment canbe made by cheque in sterling drawn on aUK bank, or by credit card (MasterCard,VISA, or American Express) stating cardnumber, expiratory date, and your fullname.(The price and availability are occasionallysubject to revision by the Publishers.)

The Laboratory Environment. Edited byRUPERT PURCHASE. (Pp 258; price £49-50.)1994. Cambridge: The Royal Society ofChemistry. ISBN 0-85186-605-0.

The Laboratory Environment is based on theproceedings of a symposium that wasorganised by the Royal Society ofChemistry Environment and ToxicologySubject Groups in association with theHealth and Safety Group of the Society ofChemical Industry. The one day sympo-sium on The Laboratory Environment:Working with Dangerous Substances washeld in March 1993. The contents consid-ered the principal areas of surveillance,handling, disposal and control of exposurein 13 chapters contributed by a range ofspecialists in occupational medicine, archi-tecture, radiological protection, toxicology,microbiology, and chemistry.The book sets out to describe the "design

and management of the laboratory environ-ment for the 1990s" and is aimed primarilyat managers, safety officers, and staff whoare concerned with the administration ofwork in laboratories, dispensaries, and simi-lar workplaces and with the implementationof health and safety policies. The subjectmatter will, indeed, be of considerableinterest to these groups but, also, chapterssuch as methods for the disposal of carcino-gens and carcinogenic waste and runawayreactions will also be of value to scientistswho work within their laboratories.

Inevitably, the wide subject range cov-ered in a single volume of 258 pages means

that most of the chapters give an overviewof their subject rather than a detailed treat-ment and as such may not present muchnew information to those experienced in thehealth and safety aspects of laboratory man-agement. However this compilation doesprovide an excellent starting point for thosewho may just be getting to grips with theproblems of laboratory safety, in that it sup-plies the discussion of a number of relevantand important topics in a single volume.Also, the individual articles are well sup-ported by reference lists that will facilitatefurther detailed study. The requirements forgood health and safety management are setout in a chapter on an insurer's approach tohealth, safety, and environmental issues inthe laboratory and valuable information onhealth surveillance, carcinogens, hazardouspharmaceuticals, and the handling of radio-active materials and infectious waste is alsopresented.

Those contemplating a move to newpremises or the modification of existingfacilities will find that they are well servedby two chapters that together comprisealmost one third of the book. Interactionbetween client and architect in the processof laboratory design is discussed from thearchitects point of view and a comprehen-sive description of the planning and com-pletion of a major commercial researchlaboratory building provides a practicalexample of the "design and build" process.

At a cost of nearly £50, a value formoney judgement will depend on howclosely the contents list matches the individ-ual requirements of the prospective pur-chaser. Those interested in detailedinformation on a limited number of thesubjects covered might find better value inindividual specialist texts.

D WIDDOWSON

Environmental and Occupational Risksof Health Care. By DAVID R MORGAN. (Pp211; price £;15-95 (BMA members) £;16-95(non-members).) 1994. London: BMA.ISBN 0-7279-0887-1.

There are few publications that devotethemselves entirely to the hazards of thehealth care industry, but now this BMAreport ambitiously aims to set out "the evi-dence relating to the environmental andoccupational risks arising from medicalpractice". Aimed at a general and profes-sional readership, it often seems to fallbetween stools in attempting to find thecorrect balance of complexity and generalinterest. After an introductory canterthrough the historical hazards of medicalpractice, the second chapter summarisesbasic concepts and uncertainties in environ-mental toxicology and seems to be pitchedtowards a lay readership. The authors of thechapter on chemical hazards have sensiblybaulked at detailing the thousands of com-pounds in use in hospitals but have chosenfour examples; formaldehyde, glutaralde-hyde, ethylene oxide, and methyl methacry-late. One can sense their frustration as theauthors struggle to summarise the evidenceon workplace exposure for these fourcommonly used substances in health servicesettings, and plead for more published workon exposures and resultant effects. Sections

follow on anaesthetic gases, microbialhazards, radiation, and genetic modifica-tion. An excellent analysis of the problem ofclinical waste disposal highlights the scantattention paid to a proper waste manage-ment policy throughout the NHS and con-cisely describes future options and barriersto change. The respective roles of specialistsin occupational and public health are dis-cussed and it is good to see space devotedto health and safety issues for general prac-titioners and the contribution of buildingdesign to the working environment.

In any report of such ambitious scope bymany authors there are bound to be repeti-tions and gaps in its coverage and this bookis no exception. The accent on risks arisingprimarily from chemical and other obviouslyenvironmental hazards suggests that theeditorial board wished to cover the uniquehazards of health care rather than the com-mon ones. More attention is paid to thespeculative but interesting hazards associatedwith activities such as genetic modificationthan the real disorders seen daily by occu-

pational physicians. A glaring omission isthe almost complete absence of any refer-ence to musculoskeletal disorders, the mainoccupational morbidity in health care.Barely more than a paragraph covers irritantand allergic contact dermatitis, despite asubstantial scientific literature on its preva-lence in health care workers, and allergy tolaboratory animals is not mentioned at all.The book is also vulnerable to criticism inits treatment of the pharmaceutical indus-try, which is mentioned only in passingthroughout. Inclusion of such a highly spe-cialised manufacturing environment shouldmerit at least a chapter to its :lf. 'here areerrors of fact, such as the suggestion thatdefinitive exposure standards for anaestheticagents have been set by the HSC-theyhave not (although one can forgive the con-fusion on this point), and contentious state-ments, such as the assertion that "darkroomdisease" results from sensitisation. Somechapters are guilty of confusion in their lay-out and there is some irritating duplicationof material, particularly with regard tohealth and safety legislation.

These criticisms can be forgiven whenthe report is taken as a whole, and the BMAare to be congratulated for bringing theseissues to the attention of a wider readershipin a relatively accessible style. A refreshinghonesty is seen in admitting that in manyareas, there is still insufficient research to beable to quantify the suspected risks. A chal-lenge is thereby set to those working inNHS occupational medicine to improveepidemiological databases and exposurerecords. It is rewarding to see the authors setout a vision of the future that emphasisesthe collaboration required between man-agers, a consultant led occupational healthservice, and departments of public health. Ifa detailed and comprehensive review isbeing sought, this report comes up wellshort of expectations, although the refer-ences are useful. Its arguments for betterand more structured occupational and envi-ronmental risk management in the NHSwill, however, act as valuable ammunitionfor occupational physicians and others. As aresult, it will interest every occupationalhealth department in the NHS and at rela-tively modest cost should achieve a wide-spread circulation.

ALEXANDER G ELDER

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