3NL-W192
MEDICAL STATUS OF MARSHALLESE ACCIDENTALLY EXPOSED
I TO 1954 BRAVO FALLOUT RADIATION: J JANUARY 1985 THROUGH DECEMBER 1987 ‘
William H. Adams, M.D., Peter M. Heotis, and William A. Scott
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( .,i MEDICALDEPARTMENT
BROOK J-IAVEN NATIONAL LABORATORY ASSOCIATED UNIVERSITIES, INC.
uNDER CONTRACT NO DE-AC02-76CHOO016WITH THE .
UNITED STATES DEPARTMENT OF ENERGY
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MEDICAL STATUS OF MARSHALLESE ACCIDENTALLY EXPOSED TO 1954 BRAVO FALLOUT RADIATION: JANUARY 1985 THROUGHDECEMBER 1987
William H. Adams, M.D., Peter M. Heotis, and William A. Scott
MEDICALDEPARTMENT
BROOK HAVEN NATIONAL LABORATORY UPTON, LONG IS AL ND, NEW YORK 11973
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This report is dedicated to the captain and crew of the M.V.Liktanur. For ten years the Liktanurs 11and III have ser~red as home and workplace for much of each medical mission to the Marshall Islands. Throughout this time it has been the good fortune of the medicaI program to have the excellent support of the ship’s crew. More impotzantly, that good fortune was extended to the population served by the medical team: the emergency rigging of oxygen tanks to treat hypoxic patients, lighting of a small airstrip at night to facilitate an emergency air evacuation. radio liaison. transportof patients between the atolls and to and from shore. and the emergency repair of medicai equipment are just some of the non nautical activities that benefited the medical missions. Now. a new support vessel for work in the~arshall Islands has come under contract to the Department of Energy. Therefore, on the departure of the Liktanur, we would like to acknowledge our debt to Capt. Keith Coberly Monroe Wlghtman. engineen Jim Whitney and Jan Kocian, first mates Cisco Peru, cook Les Nunes, boatswain; Tony Ned and Mathan Almen, seamen: and other crew members who, for shomer periods, also contributed to the effectiveness of the missions. We thank them for a job well done.
IN MEMORIAM Two former members of the Brookhaven medical team who participated in several surveys died during the past year. Colonel Austin Lowrey, Jr., died at the age of eighty-six. He was a well-known ophthalmologist with a long career in the army. He was a most kind and generous person and contributed a great deal to the evaluation of possible radiation effects on eyes. Dr. Leo Meyer, who died at age eighty-two, was a well-known hematologist and was Director of the Sickle Cell Anemia Program of the Veterans’ Administration. He made outstanding contributions to the program in evaluating hematological radiation effects. Leo will be remembered for his joviality, for always having a joke ready [o cheer us. Both of these men were well liked by medical teams and the Marshallese people. and we shall truly miss them.
Robert A. Conard. .M.D. January ’23, 1989
Ill 500HPN CONTENTS Page Introduction ...... ””””-”” 1 Exposure Groups ...... 1 The .Marshall Islands Medical Program ...... 1 Policies ...... ”. “.””” 1 Procedures ...... - ...... 3 Medical Findings ...... 5 Overall Sufival ...... - ...... OO.O.0 5 Causes ofRecent Modality ...... 5 ,Rongelap ...... 5 Utirik ...... 5 Comparison population ...... 6 Laboratory Findings ...... 7 Neopiasms ...... 7 Thyroid nodules ...... 7 Nonthyroidal tumors ...... 11 Autoimmune Thyroldlnjury...... 13 Noncancerous Thyroid Morbidity in Exposed MarshaUese ...... 14 Review ofCancers in the Comparison Population ...... 17 References ...... 21 .+ppendices ...... 23
v 50011100 INTRODUCTION .%lin gnae groups are combined and referred to as the Rongelap group, for those persons This report updates. through 1987, the medi- exposed on Ailingnae atoll were \’isiting from cal findings on a population of .Marshallese nearby Rongelap at the time of the fallout. .Uso accidentally exposed to radioactive fallout in exammea was the Comparison group that dates 1954. The Marshall Islands Medicai Program of from 1957 when 86 unexposed people from the Medical Department, Brookhaven National Rongelap were selected so that the Comparison Laboraco~, issues these summaries for distri- group approximated. in age and sex distribu- bution to institutions and individuals world- tion.the exposed Rongelap group (Conard et al., wide who are concerned about the adverse med- 1958). Sixty persons remain in this group, ical consequences of radiation exposure in against which the overall survival of the exposed general or, in particular. the plight of the population is compared (Figure 1). However, a radiation-exposed Marshallese. larger unexposed group is also followed. Cur- The exposed Marshallese population origi- rently numbering 135, the age and sex distribu- nally comprised 64 persons on Rongelap Atoll tions of its members were statistically similar to who received an estimated 190 rads of whole- those of the Rongelap and Utirik groups in 1982 body external gamma radiation. 18 on Ailingnae (Adams et al,, 1983). Included among the 135 Atoll who received 110 rads. and 159 on Utirik are most of the remaining 60 individuals selected Atoll who received 11 rads. In addition. there in 1957. It is this expanded unexposed popula- were 3 fetuses on Rongelap, 1 on Ailingnae. and tion that is used for statistical comparisons of 8 on Utirik. each of which received equivalent year-to-year medical events: this provides the whole-body doses. Because of radioiodines in baseline prevalence from which any unex- the fallout, the thyroid gland received an addi- pected consequences of the radiation exposure . tional exposure that was much greater than the can be identified. whole-body dose, although its magnitude wss. in part, a function of age at the time of exposure (Lessard et al.. 1985). .. —=------The content of this repon is restricted to the .-.. .— ...-----.- more recent medical findings, some aspects of “’---w._y_ ..— which bear on late effects of radiation exposure. ----- Those feat u res of the Marshall Islands Medical .-. ,< :o- Program by which medical diagnosis and treat- — +NGELL?Y40AILINGNAE[WISEDS6I ment are prowded are discussed. For detailed . . ‘RIKEWISED 67) .---. ‘: NGELLF“?JPARISDNGi?OUP $6I information on the nature of the 1954 fallout and the acute effects suffered by the population. the reader is referred to several earlier publica- tions [Bond, et al., 1955; Cronkite et al.. 1955: Cronkite et al.. 1956: Conard et al., 1957).Other Fig. 1: Percent survivors of the different exposure reports provide reviews of delayed effects of the groups since 1964. The number of persons m each exposure (Conard et al., 1980 Conard, 1984: group are given in the parentheses. Robbins and Adams, 1989).
EXPOSURE GROUPS THE MARSHALL ISLANDS MEDICAL PROGRAM The medical program examines and treats about 800 persons annually. However, the popu- Policies: lations on which this report is based include The Marshall Islands Medical Program pro- only the exposed persons and a selected group vides medical care twice yearly to the exposed of unexposed individuals. In December i 987. population by visiting the islands where most the number of exposed persons was: Rongelap - now reside, namely Rongelap (and, temporarily, 50, Ailingnae - 12, and Utirik - 112. For most Mejato ), Utirik. Ebeye, and Majuro. In addition, purposes in (his report the Rongelap and the medical team provides health care to a con-
1 5oou loi ------
siderable number of unexposed persons. AHthe teers. primarily faculty from medical schools, inhabitants of Rongelap. Me.jato. and Utirik are often \vith past exp,.rience with the program. eligible for medical attention at the time of the Logistical support is provided by the Depart- team \isits to those islands. Team physicians ment of Energy, capably facilitated by Holmes need not be aware of the status of radiation and Xarver. Inc.. Honolulu. HI. The Marshall exposure of the individual patient because Islands government. as requested. temporarily health care delivery is the same for everyone. assigns nurses. transistors. and other health The only difference allotted to the exposed pop- care workers to each mission. ulation ISa U.S. Department of Energy-sponsored Although there are two medical missions each referral system to the Marshallese health care year. in the interim the exposed population has system or to tertiary care facilities m the United access to the MarshaUese health care system. To States for diseases that can reasonably be con- expedite exchange of medical information, sidered to be radiation-related or for diagnosis copies of all examination and laboratory data of such diseases. Unexposed persons are from the Marshall Islands Medical Program are directed into the referral channels of the Health forwarded to the Marshall Islands Health Ser- Senlces of the Republic of the Marshall Islands vice hospitals on Ebeye and Majuro and to the whereby referrais are assigned on the basis of special programs set up for persons from the priorities set by a medical committee in Majuro. radiation-affected atolls, currently the 177 .Any exposed person who has, or who mu?ht Health Care Plan \vith administrative offices at have. a malignant neoplasm. IS referred to the Majuro hospital. In addition. copies of the secondary or tertiary medical facdities for a examinations and laboratory data are given to definitive evaluation and for therapy if a lesion E the examinees. found. The usual hospitals to which patients are A computer program with data base was referred are in Honolulu and Cleveiand. the lat- developed for portable (lap-cop) computers. ter because of the presence there of a preemi- Computerization of the clinical data permits nent thyroid surgeon who has long been rapid access while in the field to all findings involved with the exposed and Comparison obtained during the preceding five years of groups of Marshallese. examinations and to selected data collected The medical program also dispenses prima~ over more than thirty years. Itis hoped that in medical care and preventive medical services, the near future the development of compatible such as immunizations, during \mits to the programs by the Marshallese 177 Health Care exposed population. In bringing modern facili- Plan wdl permit sharing of up-to-date problem ties for diagnosis and treatment of disease to the lists and other medical record items that are exposed Marshallese, the physicians of the med- important to effective continuity of care. icai program come into contact wxh children The Marshall Islands Medical Program. as a and other family members of the exposed. as sateilite clinic of the Clinical Research Center, well as other inhabitants of the Aands. It has Brookhaven National Laborato~, is accredited been the policy of the Department of Ener~ to by the Joint Commission on Accreditation of support the medical program in its efforts to Healthcare Organizations. a nationwide organi- provide primary medical care to these individu- zation that sets standards of performance for als on the basis of humanitarian need and as institutions dispensing medical care and moni- resources permit. tors compliance with those standards, By volun- The medical direction of the Marshall Islands tary participation in the accreditation process, Medical Program and the orgatuzation of the the Marshall Islands Medical Program receives a medical missions to the Marshall Islands are valuable and impanial external review of its centered at Brookhaven National Laboratory. policies and procedures, ss well as an assess- The staff of the program includes a physician- ment of the adequacy of the services it provides. director. an administrator. and a technical spe- Laboratory and radiological services, medical cialist at the Laboratory, and a .Marshallese records, patient satisfaction. pharmaceutical laboratory technician on Ebeye. .+t the time of set-vices, and clinical competence of physicians the missions a variety of physicians are chosen are among the many items reviewed by the Joint for the medical team. They are skilled volun- Commission, Much medical data unreiated to radiation dure used was too insensitive to quantitate exposure is acquired during each medical mls- blood levels of chromium, but during the analv- +ion. Some of this information. from exposed sis it Ivas found that bromine levels were higher and unexposed indi~tiduals. is relevant to health than those reported for any other population care throughout the Marshall Islands. Conse- (Wielopoiski et al.. 1986). The reason for this is quently, public health reports. based on medical unknown: further, the levels of bromine that team observations unrelated to radiation. have were detected fall far short of its known toxic been submitted periodically to the Health Servi- levels. The observation by team ophthalmolo- ces of the Republic of the .Marshall Islands. The gists of large optic disks in many persons topics during this reporting period have included prompted another report to the MarshaUese the following Health Services because the associated increase 1) Serum lipids in Marshallese in disk cupping could be misconstrued by physi- 2} Pediatric growth and development (an cians as representing glaucoma. The high pre- analysis prompted by observations of med- valence of the condition indicates Marshallese ical team physicians that Rongelap child- are unique among all populations in whom such ren, following their transfer to Mejato, measurements have been obtained (Maisel et al., were not maintaining their positions on 1989). charted growth curves ) Procedures: 3) Pediatric audiometry The exposed population. which now numbers 4) DentaI conditions on Rongelap and 163, must be considered at increased risk for Utirik malignant disease as a late complication of 5) Chlamydia infections in Marshallese radiation injury. Therefore. the medical pro- women gram has in place a cancer-oriented annual 6) Large optic disks (a relatively frequent health evaluation. The examination follows the finding by medical team ophthalmologists) ‘guidelines of the Anerican Cancer Society and Some signifkant observations in these and includes a medical history, complete physical earlier public health reports were published in examination, advice on decreasing risk factors medical journals. Moderately elevated serum for cancer, advice on self-detection of lesions, uric acid levels were noted in many Marshallese annual pelvic examinations and Papanicolaou and the frequency of this finding and that of smears, stool testing for blood, blood count, and gout were analyzed (Adams et al.. 1984).Toxo- urinalysis. Several new diagnostic procedures plasmosis was identified as a serious health were incorporated into the medical missions in hazard in the Marshall Islands. with an esti- the past three years. Because of the develop- mated 200 persons being visuaily impaired and ment of x-ray fdms and cassettes that signX]- an inc]dence of chorioretmitis of 273 casesl cantly decrease radiation exposure, annual yearl 100,000 seropositive persons (.Adams et mammography is offered to all exposed women al., 1987). Hepatitis B, the subject of a serological and to alI unexposed women forty years of age survey described in a previous Brookhaven or older. For persons over the age of ffiy years, National Laboratory report (Adams et al., flexible sigmoidoscopy is offered every three 1985), constituted another serious public health years or whenever clinically indicated. An tdtra- problem (Adams et al-, 1986). The prevalence of sound machine has been acquired that greatly anemia in children was described. and normal increases the diagnostic capabilities of the med- ranges for hemoglobin level and erythrocfie ical team, especially in managing acute prob- mean corpuscular volume for ,Marshallese lems seen at the time of team visits. For thyroid children were derived (Duntzy et al.. 1987). The diagnosis, needIe biopsy of selected thyroid latter were found to be identical to those of nodules has been instituted in an effort to avoid children in the United States. Because of the surgery and the subsequent loss of normal thy- devastating effects of diabetes mellitus among roid tissue in patients with benign nodular the Marshallese, an effort was made to deter- lesions. Because of earlier medical program mine if a dietary deficiency of chromium, a trace observations it is known that the exposed are at element that is relevant to glucose tolerance. greater risk for certain endocrine problems and contributed to the problem. The analytic proce- for this reason they receive annual thyroid-
3 500U03 -. -—......
func[lon blooa tests and thyroid examinations noiogies Co.. ~lenna, V.% for hormone assays: by a specialist in endocrinology or thyro]d \lichael Reese Hospitai and Medicai Center (Dr. sun?ery. Other tests are performed on a regular .+. B. Schneider. Department of Endocrinology has~ m an attempt at early detection of malig- and Metabolism ], Chicago, for thyroglobuiin nant nonthyToldal les]ons. There is also ongoing analysis: Medical Microbiology Division. Univer- monitoring for clinical evidence of immune sity of California. Ifine. for chlamydia ctdture competence. for exposed persons may be at and serolo~, and the Eugene L. Saenger Radio- increased risk for unusual manifestations of isotope Laboratory, University of Cincinnati. for infecuous diseases. antimicrosomal and antithyroglobuiin antibody Nedical examinations and services performed testing (Dr. Harry Maxon). during this three-year reporting period were The .Marshall Islands Medical Program is conducted primarily aboard the Liktanur 11and deepiy indebted to the many outstanding physi- the Liktanur 111, vessels chartered from U.S. cians who, despite the inevitable personal Oceanography Exceptions, as in the past. inconvenience. participated in the medical team included the use of Brookhaven National Labor- \isits of 1985-1987. It is fair to say that they are atory facilities on Ebeye and, when necessary, the heart of the program. Drawn from excellent .Marshallese medical dispensaries on Rongelap, medical centers throughout the United States Llink. and Mejato. Laboratory support during and from private practices, these physicians the medical missions is provided by several provide the program with a wide range of up-to- technicians. Routine blood counts are performed date clinical experience and perspective that on a J.T. Baker 5000 electronic particle counter contribute to better patient,care. The physicians and sizer. Leukocyte differentials and phase involved in the 1985-1987 missions are listed in contrast platelet counts are part of each hemo- Appendix A, and represent the following medi- gram. A variety of nonhematological testing ser- cal specialties: \Ices is provided. including bacteriology, stool examination. and urine testing. In the past a Internal Medicine battery of manual clinicai chemistry tests was Pediatrics earned out using commercial spectrophoto- Infectious Disease Cardiology metric kits. Recently, however, Eastman-Kodaks Obstetrics/ Gynecology DT-60 and D’13C analyzers were added to Ophthalmology increase the ~ariety of chemistry tests available Endocrinology in the field and to improve the turn-around time Surgery for results: this has significantly improved Gastroenterology laboratory operation. Fortunately, there have Famdy Practice been few problems associated with transpon. Geriatrics operation, and handling of the new”equipment Allergy/immunology on board ship, even during bad weather. A Dermatology Beckman Electrolyte 2 analyzer is used to mea- Neurology sure sodium and potassium in serum and urine. Pediatric Dentistry Roentgenographic services are performed with The participation of many excellent medical a Bennett standard x-ray unit and mammo- specialists undoubtedly has been a major factor graphy unit. both of which are contained in a in the acceptance of the Marshall Isiands Medi- separate module on the deck of the ship. Serum cal Program by the population it serves. The is usually collected from most exarninees and percent of persons in the exposed and Compari- frozen for subsequent testing. Referral laborato- son groups who appear for the voiuntary exam- ries have included Bio-Science Laboratories and inations remains high. For the current reporting Accupath in Honolulu for special chemistries period the annual acceptance rates were: and serologies: Pathologists’ Laboratories, Inc..
Honolulu, for Papanicolaou smears and other 1985 1986 1987 cytology; Brookhaven National Laborato@ Rongelap 82X 93!Z 95X clinical laboratory for general chemistv and Utirik 92% 92X 90’X} alpha fetoprotein analysis: Hazelton Biotech- Comparison 76% 66%8 72%
4 The percent ot’ the eligible population exam- equivalent medical attention Irom the BNL pro- ]ned on at least one occas]on during the three gram since 1972. and yet. despite the far higher year period \vas: radiation dose received by the Rongeiap group, the Rongelap ‘47”%, su nivai tunes are similar. Utirik : 00:! .Inother factor that contributes to the diffi- Comparison 94’:, culty in interpreting differences in the group survivais in Fig. 1 is that the population used to These figures do not include several persons construct the “’Rongelap unexposed” curve was residing outside the Jlarshall Islands. \fost seiected in 1957. and it is in that year that their exposed persons in this category have medical suntivai is graphed as one-hundred percetm i.e.. examinations arranged through a local physi- data from three years of observation, during cian by the Department of Ener~ or the Mar- which some deaths occurred. had aiready been shall Islands Medical Program. The acceptance acquired from the two exposed populations. rate for mammography among eligible women was 100:{,.For sigmoldoscopy, about 50’YIof age- Causes of Recent Mortalitw eligible persons elect to undergo this procedure The number of deaths occurring in the iast on a regular basis. three years are as foiiows: Rongeiap exposed - 2; Cltirik exposed -9: Comparison group -10. The MEDICAL FINDINGS specific ciinicai situations are described beiow. Overall Survival: Rongelap After thirty-three years there continues to be Subject No. 1. The causes of death iisted on no significant difference in the sunival curves of the death certificate of this” 8 I-year-oid woman the high-exposure Rongelap group, the low- in June 1985 were ““Inanition” and “Senility.” exposure Lkirik group, and the unexposed Ron- When seen in March 1985. she had a normal gelap population followed for the purpose of biood pressure and cardiac examination reveal- comparison (Fig. 1). Estimates of the sum’ival ed “premature beats.” In 1984 she was noted to distribution by the actuarial life table method have cataracts, atriai fibrillation. and complaints \vere analyzed by Mantel-Cox and Breslow sta- of urinary incontinence, some cough, constipa- tistics for testing the equality of the survival tion, and joint pains. Her hemoglobin was 12.7 curves. The “p” values were 0.68 by both tech- g(di. the mean corpuscular voiume was 92 fl, niques. In the Brookhaven National Laboratory and the white biood ceii count was 6,600 per U1 report covering January 1983 through Decem- with a normai differenciai. ber 1984, it was noted that Okajimaet al. (1985) Subject No. 11. This 81-year-oid man died in suggested that medical programs providing 1987 of unknown cause. Diagnoses made during health screening might lead to an underestima- the preceding four years inciuded severe osteo- tion of the effect of radiation on mortality. In arthritis, chronic obstructive pulmonary dis- particular, it was postulated that this couid ease with builous emphysema. macrocWic ane- expiain the iower agespecflc death rates from mia that was being t mated with vitamin B12 ail causes among Nag=aki A-bomb survivors, injections, cataracts, and ‘organic brain syn- compared to a controi population. The effect of drome.” He had declined a medicai examination medicai examinations on the survivai of the when visited at his home in September 1986. but exposed Marshaliese is unknown. On the one did not appear acuteiy iii at that time. hand about 15 percent of the Comparison group seiected in 1957 is no ionger seen because those Utirik individuals have voluntarily foregone examina- Subject No. 2123. This 47-year-oid man died tion. In addition, BNL referrais for the Compari- in December 1986 from biopsy-proven hepato- son group are channeied into the Marshaiiese ceiiuiar carcinoma. His alpha fetoprotein ievei Heaith Services system. whereas seiected medi- was elevated and the serum contained hepatitis cal probiems in the exposed groups can be B surface antigen but no deita antibody. No evi- referred directiy to tertiary care facilities in the dence of tumor was found at his March 1986 United States. On the other hand. the exposed examination. Symptoms related to the tumor populations of Rongeiap and Utirik have received deveioped in June of that year.
5 500[!105 . . .
Subject No. 2125. This patlem died in 1987 Program she was not felt to be a candidate for from carcinoma of the lung ff~th brain metas- diaiysls. and her family agreed to supportive tasis at age 70. He had been referred to a Hono- management. lulu hospital for el’aluatlon of guaiac-poslti~’e Subject No. 2218. The death certificate diag- ~toois in October 1986. A chest x-ray was nega- noms on this 34-year-old woman in September twe at the time of referral. Xo seIYous problems 1985 was “congestive heart failure.” When exa- \vere detected during his Honolulu exammation. mined in March 1985. the only significant but respirato~s~ptoms from the tumor deve- abnormality had been a urinary tract infection loped in January 1987. He had been a cigarette for \vhich she was giveh an antibiotic. although smoker, and was felt to have severe chronic asthma had been noted in the past. The patient obstructive pulmonary disease with recurrent was late in pregnancy at the time of her demise bronchitis. and was, on the basis of history obtained from Subject No. 2128. This 39-year-old woman the 4-Atoll program physicians. probably ec- had diabetes mellitus complicawd by chronic Iamptic. renal failure. severe diabetic retinopathy and Subject No. 2249. This woman died at age 57 neuropathy, and anemia Ihemoglobin 9.4 gjdl in in February 1986 from complications directly October, 1984). She died in a Honoiulu hospital arising from local extension of a “’malignant after emergency air evacuation from Utirik. menmgioma.’”.% description of this patient and Diagnoses made at the hospltai rncluded hypo- the tumor was presented in a previous BNL glycemic and hypoxemlc brain damage. diabetes repon (Adams et al.. 1983) following the o’rigi- mellitus treated with insulin. anemia secondan nal diagnosis in 1982. to renal failure. and sepsis. Comparison group Subject No. 2164. “Postpartum hemorrhage”’ Subject No. 814. The death certificate diag- and ‘“uterine inertia” were listed on the death nosis in June 1985 for this 33-year-old man was certificate of this 42-year-old woman in Febru- pneumococcal meningitis confirmed by culture. aty 1985. Previous problems included obesity He \vorked on Kwajalein and died in Kwajalein and possible gout. A blood count m .March 1984 hospital after being transferred from Ebeye was normal. hospital. His most recent BNL medical examina- Subject No. 2189. This 59-year-old woman tion had been in April 1983. when problems of died in 1987 from chronic renai failure due to smoking and heavy alcohol consumption were diabetes mellitus. Her serum creatinine in noted. His blood count was normal at that time. \larch 1986 was 10.9 mgidl and the hemoglobin Subject No. 821. This 38-vear-old woman died level was 7.7 g:dl. in 1986 from complication of childbirth. her Subject No. 2200. “Inanmon- and “senditv”’ death certificate diagnoms being ‘postpartum were the death certificate diagnoses for this 72- hemorrhage.” When seen in April 1986 she was year-old woman who died in December 1985. A 22 weeks into her thirteenth pregnancy. No sig- thyroid nodule had been noted at least since nificant abnormalities were noted at that time. 1977 but the patient “appeared to be a poor Snbject No. 842. The death certificate diag- surgical risk.” Her hemoglobin Icvei was 11.6 gl dl nosis on this 6 l-year-old man in March 1986 was and the white blood cell count w= 6.200 per u1. “liver failure due to hepatoma.” The only active .%left breast mass had been notd since 1966. problem noted in his last BNL medical examina- but the patient had declined biop~ and surgery. tion in March 1985 was chronic low back pain. A She said the mass had been present since youth. rouIme sigmoidoscopic examination was nor- mal except for the presence of hemorrhoids. Subject No. 2212. This 66-year-old woman Hepatitis B surface antigen was not detected in died in 1987 from chronic renal failure due to his serum. but antibody to the surface antigen diabetes mellitus. She was evaluated at Kwaja- was present. Iein hospital in 1985 and noted to have renal failure. hypertension. and anemia. When evalu- Subject No. 846. This 63-year-old woman ated by physicians of the 4-Atoll Healthcare underwent a bone marrow aspiration in March
SO ON(N 19bn (or cwaluatlon of anemia and leukopema. This diagnosis W= made after she W= referred The f.]]agnosls ot’refractov anemia wmh excess to Majuro for e~”aJuation of a possible abdominal hl~l.; NXMmade and subsequently confirmed in mass detected in June of 1984. IIonolulu at the Straub Clinic (“mvelodyspiastic Laboratory Findings: >>narome !t”ith an evolving acute nonlympno- c}~]c ieukem]a”). She died in 1986. A review of average blood cell counts of the different exposure groups during the three-year Subject No. 928. The cause of death in 1987 of reporting period does not reveai any systematic Ihis 73-year-old woman is unknown. When last differences among groups. Figure 2 is a contin- seen by the BNL medical team in Majuro in uation graph in which the exposed groups are March 1986. no serious medical illnesses. were portrayed in relation to the Comparison group. noted. She had been moderately anemic for sev- Table 1 gives the actual mean counts of formed eral years ( hemoglobin level between 10.5 and blood elements of the different groups and iden- 11.5 g all). and a flexible sigmoidoscopic exami- tifies counts which differed significantly from nation in 1985 was normal. NO gastrointestinal those of the Comparison group. blood loss was documented in recent years. Biochemical test results are iisted by individ- ual identification number in Appendix B. Subject No. 950. This 40-year-old woman died in Kwajalein hospital in August 1985. The death Neopiasms: certlticate diagnoses were essentiai hyperten- Thyroid nodules sion and intracerebral hemorrhage. She had Surgery for palpable th~oid nodules was per- been known to be h~ertensive for 13 years and formed on five persons in 1985 and one person \vas followed in the hypertension program ofrhe in 1986. No new iesions were detected in 1987. Trust Terrnories. The specific diagnoses, determined by an expert “ Subject No. 969. The clinical diagnosis in this panel of pathologists, are listed -in Table Z, and 69-year-old man was either metastic tumor to Table 3 gives a summary of all nodules diag- the lung or puImonary tuberculosis. However. nosed throughout the medical program. The the 1987 death certificate diagnoses were ““con- benign thyroid nodules include adenomak. ade- gestive heart failure”’ and “pneumonia.”.SPutum nomatous nodules, and occult papillary carci- cuh ures for .!4 tuberculosis were negative and nomas. The adenomatous nodules are included [here $vas no clinicai response to antitubercu - in the tabulation even though it is highly debat- ious therapy. able that they are true neopiasms. The occult papillary carcinomas are. \vith rare exceptions, Subject No. 975. When splenomegaly and “harmless tumors” (Sampson. 1976). A recently [hromboc>lopenia were detected in March 1984. reported autopsy series from the Federal [his ti~-year-oid man was referred for further Republic of Germany found occult papihry e~aiuat]on. .% lymph node biopsy in October carcinomas in 6.2% of 10’20 thyroid glands. 1984 showed “atypical lymphoepithelioid cell Almost half of the tumors were multicentric and proliferation of uncertain etiolo~,” possibly a 14’,%had regional lymph node metastasis (Lang l}mphoma. He died in 1985 and details of the et al., 1988). Since there was no predilection for terminal illness could not be obtained. age it was concluded, as in earlier studies, that occult papillary carcinomas have no propensity Subject No. 991. This 78-year-oid woman died to cause clinically apparent thyroid ,disease. in January 1986. Death certificate diagnoses However. controversy continues on how the clin- Inciuded “septicemia. diabetes meilitus. and ical diagnosis of occult papillary carcinoma is to chronic renal failure from diabetic nephro- be made (Schneider et al.. 1980), and some pathv.” She had a mid-calf amputation of the authorities would accept that diagnosis only if right ieg some six years eariier and was being the tumor were an incidental finding at surgery. foliowed at the Ebeye hospital. Her most recent Since some of the purported occult papihry BSL medical examination was m 1981. carcinomas removed from the Marshallese Subject No. 1050. Colon carcinoma with patients presumably were palpable before hepatic metastasis is the death certificate diag- surgety, there may by differing opinions on their noslsin March 1985 for this 50-year-oid woman. clinical. if not histologic, classification.
Sootlm .— .-. . -
‘4EuTROPHILS LYMPHOCYTES
QONGELAP ,31 - 120k ?ONGELAP (b) - — n I lfl - b d 1’ -_l L- rb - -;~L--_ 00- ~+- -_l- I_l -J - -., J- L1 J 80r- i aILINGNAE 1201- AILINGNAE - look n
8o1- b y f 120!- UTIRIK r UTIRIK P-r 1 . 11#- 7 _.-’ : mn 1001 n u Llu ~ ,,, ,, ,,, 901 80 ‘ z 4 6 a IO IZ141618202224262 E30 32 2 4 6 8 IO 12 1416 18 202224262 S3032 YEARSPOST-EXFOSURE YEARS POST-EXPOSURE
PLATELETS-MALES ?LATELETS”-FEMALES ! ,, 1 r 1 RONGELAP (c) - RONGELAP (d] 1
AILINGNAE f AILINGNAE nf
IOOF
801- u
uTIRIK %
, t I Eo~ I 80’ z 4 6 0 1012 14 16 1820222426283032 z 4 6 81012 14161820222426283032 YEARS POST- EXPOSURE YEARS POST- EXFk3SURE
Fig. 2: Annual mean blood cell counts of the different exposure groups (age 5 years or more) expressed = percent of controL beginning two years after exposure. VahIes for both sexes are grouped for neutrophiia and Iymphocnes. Detailed annual observations. including blood cell counts, on the Utirik population did not be@n until 1973. Iakoqne differentmls and Platelet counts were not obtained for six and five of the examinations, respectively, but for graphing purposes the 100% line has not been broken at those years. TABLE 1:
Comparison Rongelap Exposed Utiri.k Exposed
LEUKOCYTES 1985 7392 z 1955 {n=%) 6731 z 1775 (n=48) 7985 z 1957” (n=100) 1986 7438 z 2102 (n=781 7231 z 2060 (n=.54) 7684 z 2023 (n=98) 1987 7690 z 1843 (n=781 7418 z 16~5(n=49) 8$34 = :3195 (n=90)
NEUTROPHILS 1985 :3948 z 1433 3716 z 1524 4606 z 3948* 1986 3786 z 1396 3771 z 1648 4188 z 1570 1987 :3998 z 1427 3825 ~ 1434 4926 * 2984-
LYMPHOCYTES 1985 ?739 z 883 2345 z 860” 2607 * 915 1986 2785 z 1131 2811 z 981 2691 z 927 1987 ‘2972 z 950 ‘2915 z 863 2749 * 1054
MONOCYTES 1985 :309 z 168 229 z 127” :321 2 177 1986 294 z 189 301 z 169 :361 =251 1987 323 z 240 307 = 203 429 =311”
BASOPHIIS 1985 12 f 35 18 & ~~ 12 * 32 1986 40 k 57 47 * 59 ijo * ‘j~ 1987 53 * TO 53 ~ 58 63 & 71
EOSINOPHIXS 1985 261 z 216 2fM * 207 273 & 238 1986 365 z 426 297 t 310 343 ~ 322 1987 310 t 267 293 * 326 ?38 t 239
PMTELETS,MEN 1985 261 t 75(n=:381 ’242 5 57(n=20) 271 z 51 (n—=15) 1986 ’252 z 54 n=:]a) 240 ? 43(n=24) 289 z 66” (n=-13) 1987 266 z 76 n=35) 240 c 54(n=20) 266 z 55(n=41)
PLATELE’T%WOMEN 1985 271 t 61 n=56) 277 * 66(n=28) ~~ * 72S (n=~5) 1986 276 t 71 n=44) 291 + 84(n=30) 328 & 81’(n=55) 1987 273 * 67(n=47) 261 & 51(n=28) 308 & 73”(n=19)
HEMOGLOBIN,MEN 1985 14.5 3 1.4 14.8 & 0.8 14.9 t 1.2 1986 14.9 f 1.6 14.7 t 1.0 15.3 & 1.3 1987 14.4 t 1.1 14.6 t 1.1 15.2 f 1.3”
HEMOGLOBIN, WOMEN 1985 13.0 t 1.2 12.9 t 1.2 12.6 k 1.2* 1986 13.0 f 1.6 13.1 & 1.4 12.8 & 1.6 1987 13.1 t 1.3 13.3 * 0.8 13.0 t 1.2
“Signiflcarttly different, by t-test analysw, from equwalent values of the Comparison group. The only level of s]gniticance tested was p <005. . 9 ---
TABLE 2: THYROID SURGERIES, 1985-1987
Identification Age at Year of Xumber & Group Diagnosis Sex Surgery Consensus Diagnosis-
ti~ - Rongelap 45 F 1985 Papillary follicuiar carcinoma pius occult papillary carcinoma
S22 - Comparison 41 \l [ 985 Normal 2172 - t’tirik 45 F 1985 Follicular adenoma 2172 - Utirik :34 F 1985 Occult papillary carcinoma 2225 - Utirik 39 F 1985 Adenomatous nodule 2251 - ~tirik :37 F 1986 Follicular adenoma plus occult papillary carcinoma
“ !4ajorltv diagnoses. based on interpretations by Dr. L.\’. Ackerman. HeaIth Sciences Center. SUNY. Stony Brook. NY: Dr. W.A. ,Meissner. formerly with New England Deaconess Hospital. Boston. k~ Dr. -~.l-- J’ickery, Massachusetts GeneraI Hospual. Boston. MA: Dr. LB Woolner. .Mavo Clime. Rochester. MN.
TABLE 3: THYROID NODULES DIAGNOSED AT SURGERY THROUGH 1987
Adenomatous Papillary Follictdar occult nodules Adenomas cartcers cancem cancers
Rongelap (67)” 17 .1 .5 1 .%ilingnae ( 19)” 4 1 l-’tink ( 167)- 11 -1 4 1. . . 5
C_omparlson (227)” ● 4 1 2 .>.0=.
NOT INCLUDED are the following unoperated (and therefore unconfirmed) nodules: Rongelap — 1; Ailingttae — 1: Utirik — 1; Comparison — 5. INCLUDED are alf consensus diagnoses of a panel of consultant patholog~ts two different lesions were detected in one person from Rongelap, one from A.i3ingnae. and two from Utirik .- ?Jumber of persons (including those in utmo) who were originally exposed. “” This number includes all persons who have been in the Comparison group since 1957 (see page 18). Some have not been seen for many years others were added as recently as 1976. “”- Equally divided opinion in one case: follicular carcinoma vs. atwcal adenoma. “-”- Majority opinion in one cw+e: occult papdlary carcinoma Js. follicular carcinoma. The same paclent had lyrnphocytlc thyrolditis.
10 Sooullo
. The cumulacm’e experience of ben]gn plus adults I. another interpretation of Fig. 4 is that malignant nodule detreiopment as a funct]on of the time for development of adenomatous age at exposure shows clearly the increased nodules following radiation exposure varies ~usceptlbiiity of the }’oun~er population [o directly wmh age at exposure. nodule indurtion i Fig. 3 L Jlost benw!n nodules Nonthyroidal tumors and all the th>Toid carcinomas have occurred in females. It was noted (Robbins and Adams. During the period 1985 through 1987, deaths 1989) that the prevalence of rh}_roid carcinomas attributable to cancer occurred in three exposed compared to benign nodules ( 15(\,) WZMlower persons. all from Utirik. The types of tumors than that reported follotvmg medical x-ray were: lung cancer, hepatoma. and meningioma therapy (about 30.1,). During the same period there were three cancer- related deaths in the unexposed population, the tumor t}~es being: colon carcinoma. hepatom~ AGE and myeiodysplastic syndrome. RONCiELAP - SIFO % JTIRIK * 954 Additional tumor diagnoses resulted from -. - — -. :!OYR clinical investigation initiated at the time of fi” medical team \lsits. These included a case of = =LPILLARY r ‘.., CER .5 — ‘./ . . . breast carcinoma (detected by mammography) ‘3 LLIC-L.. ~ :ANCER- .-. __ * and a cas-e of colon carcinoma. both diagnosed in exposed LTtirikwomen. Both lesions weresur- “2%}1 gicallyresectedand have a high probability of J“_ being cured. In addition, an epithelioma was removed from the skin of an exposed Rongelap / woman. the site of the lesion being in the ;J . :0-18YR approximate area of a beta burn that developed .? 37%}! Y ‘. soon after the 1954 exposure. This type of lesion, .:. { .5— l– also termed basal cell carcinoma. is very com- mon in the United States and is not included in the detailed cancer statistics published by the >18 YR ~ — American Cancer Society (Silverberg and Lub- era. 19871. However. its frequency in ,Makshal- ‘- W“-” /f “o”:lese is unknown. , The development of two cases of hepatoma among the population served by the medical fEARS A~Eq ‘;54 team requires comment. Two persons. one each from the Utirik and the Comparison groups, Fig. 3: The amrual of cases w?h thyroid nodules and died from this tumor during the period covered thyroid cancer in the exposed Rongelap population by this report.To this number should be added as a function of age at the time of exposure in 1954. the death of another Utirik man who died in The <10 yeargroup includes exposure in urero. ‘Mo 1984 from complications of cirrhosis (Adams et cases of thyrod atrophy wnhout nodule formation (2 al., 1985), for he, like one of the hepatoma Rongelap bo~ <10 years of age) are excluded. (Fig- ure taken from Robbins and Adams. 1989). patients. had hepatitis B surface antigen detected in his serum. Studies have demon- strated an association between hepatitis B sur- It appears that there is an reverse correlation face antigenemia and hepatoma, cirrhosis, and between the radiation dose absorbed by the thy- chronic active hepatitis (Beasley et al., 1981). roid and the time after exposure for develop- Early BNL observations revealed that infection ment of the benign adenomatous nodules (Fig. with hepatitis B virus is nearly universal among -1). However. since the thyro]d-absorbed radia- Marshallese, as it is among many tropical popu- tion dose w-as determined primarily by ageat lations, and that serological evidence of the exposure I children receiving greater doses than infection is common in childhood. In view of the
500WI -— ------
ttvo (atalicies [hat m]ght be causally linked to discussed previously (~dams er al.. 1986). and it hepatitis B \-irus. infect]on with this orgamsm was noted that the prevalence of hepatitis B must he considered a public health problem of surface antitzenemia ws 3.3’’I’Iin the Rongeiap grea[ concern. The JIarshail Islands \ledical ~roup. 1S.8’:’,in the Utirik group. and 10.5% in the f’rogram annually [esrs all persons previously Comparison group. There is evidence suggesting >ho\vn [o be hepatitis B surface antigen -posititie an association between radiation dose and pre- for the presence of alpha-fetoprotein. a tumor valence of cirrhosis. but not hepatoma. in SUI+- marker for hepatoma. Should an elevated level t“ors of the atomic bombings in Japan Ifiano et be detected the affected subject would be al.. 1982). .%suming that two of the three deaths promptly referred for e~’aluation in the hope from hepatoma and cirrhosis in Marshallese [hat early detection might permit curative resulted from chronic hepatitis B infection, the resection of a localized Ie.won [ He.yward et al.. frequency of hepatitis B-related deaths. as per- 1984). cent of hepatitis B surface antigen-positive per- The question arises as to whether the exposed sons is: exposed Rongelap - (W,(O 2): exposed Marshallese are at increased risk for the late Vtiril.i - 9.5% (~~~11; Comparison group - O’X complications of hepatitis B. This problem was (0’ 10).
ADENOMATOUS NODULES AS FUNCTION OF RADIATION DOSE AND TIME
5
9
1
0 o 10 14 18 22 26 30 34
YEARS POST-EXPOSURE
Fig. 4: The time required to develop adenomatous nodules foilowmg radiation exposure appears. m this graph, to be dose-related. However. the thyroid-absorbed radiation dose was highly dependent on the age at exposure.
12 500W2 Autoimrnune thyroid iqjuw disease. but are useful as a screening test. Hypo- thyroidism ISoften quite subtle and difficult to Radiation-induced thyro]a hypofunction. diagnose. and any marker that might identi~ a diagnosed in four[een exposed Rongelap indi- population at risk for subsequent hypothyroi- \lduais. was not found to be increased among dism would be clinically useful. Therefore 231 .Japanese .4-bomb survivors-. This difference Marsh allese sera collected in March 1987 were reflects the larger dose absorbed by thyroids of tested for the presence of antithyroglobulin and ● the Marshallese. a consequence of ingestion of ant]microsomal antibodies in the laboratory of radioiodines. The question arises as to whether Dr. Harry Maxon. Fifty-five sera were from the thyroid hypofunction in the exposed Marshal- Rongelap-exposed. 94 were from Utirik-,exposed, ]ese is a consequence not only of direct radiation and 82 were from the Comparison group. Two injury, but also of immunologic damage. Immu- persons had data consistent with the diagnosis nologic studies by the Radiat]on Effects Research of autoimmune thyroid disease (Table 4), and Foundation found that Japanese A-bomb survi- both were in the Comparison group. One was a vors greater than fifteen years of age at expo- 38-year-old woman who had Grave’s disease sure had a significant decreme in mixed lyre- with hyperthyroidism diagnosed in 1980 that phoc}le culture response that was inversely was treated with 131 I. Her serum contained related to radiation dose (Akiyama et al.. 19871, both types of antibodies in 1980 as well as in and lymphocyte responses to phytohemagglu- 1987.The other person. a 32-year-old woman, tinin decreased more rapldlv with age m per- had an antithyroglobulin antibody level of 35 sons who received more than 200 rad. However. U/l. She has Sheehan’s syndrome, present since the immunological responses of aging Japanese 1975 following postpartum hemorrhage. In . A-bomb survivors do not appear to have been addition, six persons had nondiagnostic but affected by radiation exposure (Bloom et al., slightly elevated levels of a“ntithyroglobulin 1988), nor does there appear to be an increase in antibodies, two from Rongelap and four from diseases associated with autoimmunity in the LTtirik. None have clinical evidence of aut~im. exposed Japanese population. mune thyroid disease, although three have had Immunologic damage to the thyroid is thyroid lobectomies for benign nodules. The lack mediated, in part, by circulating autoantibodies of evidence for an increase in autoimmune thy- that are apparently cytotoxic. Antimicrosornal roid disease among the exposed Marshallese is antibodies are important in the diagnosis of consistent with the findings of Radiation Effects autoimmune thyroid itis. a disease process Research Foundation studies. In a 30-year fol- commonly progressing to hmothyroidism (Frey, 10WUPof persons less than 20 years of age at the 19871. Antithyroglobulin anubodies are far less time of exposure to the atomic bomings in specific an indicaLor of thy~old autolmmune Japan, no difference was detected in the preval-
TABLE 4: ANTITHYROID ANTIBODIES IN THE DIFFERENT RADIATION EXPOSURE GROUPS.
Elevated antithyroglobulin Exposure group(n) antibodies” Percent elevated
Rongelap (551 2 42’! Utirik (94) 4 4’/%’! Comparison (82) Z** 2%
“ The levels ranged between 6 and 11 WI1, with normal levels being= 5 U/1. “” One subject had elevated antlmicrosomal antibodies (35 U/1) and a history of Grave’s dise=e with hyperthyroldism.
13 5004113 ......
ence of antlthyrogiobulin antibodies In unex- tality from radiation exposure is low when posed versus exposed groups {Morlmoto et al.. compared to naturally occurring cancer mortal- 1987). In addition. no difference in the preval- lty it is not surprising that there is no observed ence of chrome th.yroiditis was found in children increase in mortality among the radiation- considered exposed or unexposed to radioac- exposed Marshallese. Nevertheless. much at- tive fallout in Utah and Nevada [Ralhson et al.. tention has been addressed to their cancer risk 1974), Notably, in that study the pre~’alence of On the other hand, limited attention has been “ elevated titers of antithyroglobuIin antibodies in given to morbidity from nonmalignant disease, children with ‘“normal” thyroids was 4.8!’{,.Hypo- principally of the thyroid. as a late consequence th}Toldism is common in aging populations. and of radiation exposure, and yet these lesions m the Framingham Heart Study a clearly ele- have been of great clinical importance (Table 5). vated thyrotropin (TSH) level was found in 4.4’X, .& Thyroid surgery of persons older than 60 years (Sawin et al.. Twenty-six (30 %) of the Rongelap group and 1985a). The prevalence of antimicrosomal anti- eighteen ( 1l%) of the Utirik group have had bodies also increases with age: two-thirds of surgery for thyroid nodules that were ultimately elderly persons with evidence of thyroid hypo- found to be benign. The types of thyroid nodules function had sign~]cant levels of antimicrosomal found in the exposed population since 1963 can antibodies (Sawin et al.. 1985b). The .Marshal- be grouped into cancers, adenomas. and ade- Iese data suggest that autoimmune thyroid dis- nomatous nodules. Cancers and adenomas are ease is not common in that population. regard- neoplasms. Adenomatous nodules, which, like less of a history of radiation exposure. adenomas, are benign, are not propedy catego- rized as neoplasms. HistologicaUy, they’ are NONCANCEROUS THYROID hyperplastic lesions. In the exposed population MORBIDITY IN EXPOSED both benign nodules and thyroid hypofunction MARSHALLESE display a similar correlation with radiation dose t Fig. 5), and, in contrast to thyroid cancer, ade- Thelatesomaticeffectsofexposureto ioniz- nomatous nodules have been very common (see ing radiation have been equated with cancer Table 3). Adenomatous nodules are rarely of induction, the ultimate measure of those effects clinical significance, because they do not evolve being expressed in mortality. Since cancer mor- into carcinoma. Surgery is necessan only to
TABLE 5: I-ATE THYROID MORBIDITY UNREL4TED TO DIAGNOSIS AND TREATMENT OF THYROID CANCER IN 253 RADIATION-EXPOSED MARSHALLESE.
Morbid event Number of cases
Thyroid surgery for benign lesions 44 Hypothyroidism. radiogenlc 15 Hypothyroidism. posts urglcal 21 Hypoparathyroldism. postsurgtcal ~ Recurrent laryngeal nerve palsy 1 Pitunary tumor” ~
Total morbid events 85
‘ Possible association (Adams et al.. 1984).
14 Sooulu exclude that diagnosis. Nevertheless. the clinical C, Hypothyroidism, postsurgical: evaluation required to establish a diagnosis is In 1972 to 1974 it was noted that 11 of 20 associated with its own morbidity. Prominent in exposed persons from Rongelap who under- this morbidity is thyroid surgery itself, a proce- tvent surgenfor removal of thyroid nodules had dure that requmes general anesthesia and elevated levels of thyroid-stimulating hormone results in a cosmetic defect and the unavoidable tTSH). Because this evidence of postsurgical removal of some normal thyroid tissue. hypofunction was more frequent than expected it was surmised that thyroid insufficiency might B. Thyroid hypofunction, radiation-induced: be developing in the exposed Rongelap popula- Overt hypothyroidism was diagnosed in two tion as a whole, rather than being limited to the Rongelap boys who were infants at the time of two hypothyroid children diagnosed some ten exposure (Sutow et al., 1965). In addition. sub- years earlier (Sutow et al., 1965). Such an event clinical hypothyroidism unrelated to thyroid was likely to be clinically inapparent because all surgery was confirmed in twelve other Rongelap of that group had been placed on suppressive persons [Larsen et al., 1982). In 1987 a Utirik doses of thyroxin since 1965 to prevent thyroid man was diagnosed as biochemically hypothy- neoplasia. Therefore, after temporarily discon- roid. He was two years of age at the time of tinuing thyroxin. a survey of thyroid function exposure. and he is the first exposed person was undertaken. and twelve persons were found from Utirik to have this diagnosis. LO have biochemical evidence of thyroid insuffl-
THYROID DISEASE VS. RADIATION DOSE 100
r m BENIGN NODULES 1
z z 50 =
- 0
o 1-250 251-500 501-1000 1001-2000 2001-3000 3001-4000 4001-5000 REM
Fig. 5: Thyroid-absorbed radiation dose VS.benign thyroid nodules. carcinoma. and hypofunction.
5004115 15 (,]ency. Retrospectwe testing of six persons \vho poseiy discontinued before testing. Therefore. had th\Toid h}~ofunction a&er th}Toid surgery except for those relatively few instances in reveaied the h>_pofunctlon had been present ;vhich seiected individuals were asked not to earlier fLarsen et al., 1982). take thyroxin for four to six weeks prior to thy- The development of thyroid hypofunction m roglobulin testing or thyroid scanning, eievated [he exposed indi~lduals continues to be a cause TSH levels were apparent only because of non- for concern. R’bile the routine use of suppressive compliance. Some persons may have had nor- doses of thyroxm should render [his concern mal TSH Ieveis after surgery oniy because they moot. it was noted that. based on medical his- are adhering satisfactorily to the prescribed to~ or results of annual TSH testing, somewhat [hyroxin regimen. more than forty percent of exposed persons It is unlikely that the differences in prevalence who are supposed to be taking thyroxin have of postsurgical thyroid hypofunction among the evidence of irregular or noncompliance with groups resuit from different degrees of com- the prescribed medication regimen (Adams et pliance in taking thyroxin after surgery, Furth- al., 1983). It is desirable to minimtze 10SSof thy- ermore, it is iikeiy that. on the average, the roid tissue at surgery insofar as It is deemed extent of resecIion of thyroid tissue was greater clinically safe to do so: in fact. this has been the ]n the unexposed persons undergoing thyroid practice of the thwoid surgery consultant to the surgery than in exposed individuals because of \larshall Islands Medical Program for almost concern that the iatter were more iikeiy to have [wentv years. Impaired thyroid reserve. As Table 6 shows, this Desp]te efforts to mitigate loss of thyroid concern was weii-founded. “Mthough present tissue. however. there continues to be evidence data are without doubt quantitatively inaccu- of an inordinantly high frequency of postsurgi- rate, they are iikeiy to be qualitatively adequate. cal thyroid hypofunction among the exposed The distinction between these data and those population. Table 6 shows data obtained through of Larsen et ai. ( 1982) is that. whereas thyroid 1987 illustrating this point. An increase in fre- hypofunction was found by the latter group to quency of postsurgical thyToid hypofunction antedate thyroid surgery (as documented by w]th increase in the 1954 thyroid radiation dose retrospective analysis of stored sera collected is apparent, even though all thyroid surgery before institution of thyroxin suppression in the patients were advised to take thyroxin. How- exposed Rongeiap group), the present data ever. the data in Table 6 must represent a min- reveai an inordinantly high frequency of post- imum estimate of the prevalence of postsurgical surgicai thyroid hypofunction in exposed per- thyroid h-ypofunction. In contrast to the study sons with previously normal TSH Ieveis. The by Larsen et al. ( 19821, thyroxm was not pur- Importance of this finding is that there appears
TABLE 6: MARSHALLESE WITH PREVIOUSLY NORMAL TSH LEVELS WHO HAVE DEVELOPED ELEVATED LEVELS FOLLOWING THYROID SURGERY.
Exposure Adult thyroid Number with Number with group dose (rad)” surgery hypothyroidism*” Pement
Rongelap” ● ” 1200 23 14 61 Utirtk 160 25 7 28 Comparison none 11 1 8
“ Average estimated dose for an adult male. - ● Biochemical ewdence of thyroid hypofunction ss indicated by at least two determinations of thyroid stimulat- ing hormone >7.0 uU/ 1. .Norrnal values are less than 6.0 uU/ 1. “•” Routine th~oxin suppression prescribed.
501NHb 16 TObe slgnlficantlv dimmlshea th}’roid reser~’e m In summary. hypothyroidism and subclinical many exposed persons. and. although this dim- thyroid hypothnction. benign thyroid nodule inution ]s not apparent from routine TSH test- formation. thWoid surgew with its attendant ing, it frequently may be made clinically signifi- risks and complications. an excessive preva- cant by thyroid surgery. The extent of the lence of thyroid hypofunction after thyroid problem cannot be accurately assessed with the surgery, and possibly pituitary tumors can be data at hand because ot’the variability in com- considered adverse delayed consequences of pliance with the taking of the prescribed thy- radiation inju~ in the exposed Marshallese. The roxin suppression, and because no clinical tally comes to 85 morbid events in 253 persons. bene!it would accrue to the exposed population In contrast. the only evidence for a “stochastic” from discontinuing thyroxm for the purpose of effect of radiation exposure has been an proving the point. Nevertheless. a 61!7, preval- increase in thyroid cancers in the Rongelap ence of postsurgical thyroid hypofunction is population, none of whom yet have evidence of reason for great concern in tiew of the high residual disease. While several nonthyroidal frequency of benign thyroid nodules in the cancers known to be inducible in humans “by exposed population. external ionizing radiation have been docu- D. Postsurgical hypopsrathyroidism: mented in the exposed population, similar In two thyroid surgery patients transient cancers have occurred in the unexposed Com- postsu rgical hypocaicemia was observed. How- parison population of Marshallese. Therefore, ever. two other Rongelap women developed one may conclude that in the Marsh allese expe- chronic hypoparath.moidism requiring replace- rience the delayed expression of nonmalignant ment therapy since undergoing thyroid surgery. morbidity due to irradiation has indeed been In one the deficiency was diagnosed postopera- great and far exceeds that of malignant disease. tively and has not resolved. In the other the diagnosis was first made. twenty years following REVIEW OF CANCER IN THE surgexy. Both surgeries were performed on COMPARISON POPULATION Guam during the early years of the medical pro- In earlier BNL publications neoplasms of the gram. Postsurgical hypoparathyroldism is not exposed population were compared to those of an unusual complication of extensive thyroid an unexposed “Comparison” population with a surgery, occurring in up to 20Xof patients. How- similar age and sex distribution. However, since, ever, in experienced hands the frequency of the last report. which brought the period of postsurglcal hypoparath.yroidism is much lower. medical coverageup to December 3 lst, 1984, E. Laryngeal neme iqjuw concerns have been voiced about present-day One Rongelap man has a mild but definite safety of habitation on Rongelap island. An impairment in speech resulting from recurrent analysis of the current radiation risk of Ron- laryngeal nerve injury, a well-known complica- gelap habitation is not a function of the Marshall tion of thyroid surgety. This is not a common Islands Medical Program. which is a clinical pro- complication, occurring in perhaps l!% of gram devoted to aspects of health care for per- patients. i% with postsurgical hypoparathyroi- sons acutely exposed to radioactive fallout in dism, its frequency depends greatly on the expe- 1954. Nevertheless, medical information col- rience of the surgeon and the extent of the lected over many years concerning the unex- surgery. posed Rongelap people has been requested by F. Pituit.my tumor formation: different groups who are involved in assessing Two women exposed as young children, one that risk. To assist them and others who may from Rongelap and one from Utirik. have deve- wish to review the medical experience of the loped pituitary tumors. These tumors are usu- Comparison population, a summary of diag- ally benign, causing disease. in part, because of noses of neoplastic disease is presented here. It their expansion inside a rigid structure. There is is essential to realize that whatever radiation no known direct association between radiation risk exists today on Rongelap is quite distinct exposure and development of pituitary tumor, from that incurred by 86 Rongelap inhabitants but there are reasons to suspect that pituitaw and 167 Utirik inhabitants during the two-day tumor formation may be a consequence of thy- exposure to Bravo fallout in 1954. The reasons roid injury (Adams et al.. 1984). for this statement are given below. 5004111 17 The selection of the Comparison woup began persons in the original 1957 Comparison group. in1957at Majuro when the group was initiated The slmilarityof these numbers does not suggest ~rlth .96 individuals matched approximately for the introduction of bias in death rates in subse- sex and age with the exposed group of 86 indl- quent additions in the Comparison population. \~duals, }Iembers of the Comparison group were For the Rongelap exposed population. \vhich exammed periodically thereafter at Rongelap or was statistically similar in age and sex distribu- elsewhere along with members of the exposed tion to the Comparison group when evaluated in Rongeiap population. During 1958-59, after the 1982 (Adams et al.. 1983), this number is return to Rongelap island. the number of per- 234/ 100.000 ( 5 possible cancer deaths in 2139 sons actively enrolled in the Comparison group personi years). The confirmed or presumptive was increased to about 150. During the following cancer diagnoses in the Comparison group are years up to 1974, another 31 persons were given in Table 7, along with cancer deaths in the added. In 1974-76, to make up for more persons exposed Rongelap population. lost to followup or deceased. another 32 persons Table 8 contrasts the distribution of possible were added. No additions to the roster have cancer deaths in the Comparison group accord- been made since that time. When all enrollees ing to years of residence on Rongelap with that are tallied, including those who have discon- oft he exposed population. One of the eight per- tinued their participation in the annuai medical sons dying of possible cancer in the Comparison exammations, 227 persons have been exammed grouP WaS never known to be present on the at one time or another as part of the Compari- island. Furthermore, six of the eight spent only a son group. Although some of the group were lost short time on Rongelap. However. for those six to followup, there were 63 deaths recorded that short time lay between 1958 and 1961, a through 1987. Some deaths may have occurred period when residual radioactivity would have In those lost to followup that were not brought been higher than in subsequent years. One to the attention of the Marshall Islands Medical hundred fifty-one persons in the Comparison Program. Furthermore, the death rate in subse- population were known to be on Rongelap at quently added subgroups may not be the same some time between 1958 and 1961. Of the six as that for persons in 1957. There IS no way to that ultimately died of possible cancer, four determine if there is any bias introduced into were among forty-two who were not on Ron- monality statistics as a consequence of these gelap after 1961, whereas two were among the events which were beyond the control of the one hundred-and-nine that were seen on Ron- program. However. two points can be made. geiap at a later date (Table 9). It is a statistical First. since it is cancer mortality which is specif- oddity that even the latter two individuals were ically in question. cancer deaths can be expres- found on Rongelap only once after 1961. sed in terms of total known deaths. thereby con- There are several points that are relevant for trolling to some extent for uncertainties in the those who would apply an epidem]olog]c analy- determination of total deaths. Therefore, on the sis to these data basis of information made available to the Mar- 1. Since the Marshall Islands Medical Program shall Islands Medical Program. 8 of the 63 has not maintained a year-round medical pres- known deaths ( 13!7,) may have been due to ence on the different atoUs where examinees malignant disease. In the United States cancer may be found. causes of death were obtained in mortality accounts for 22’% of total mortality many instances from records and verbal (Silverberg and Lubera, 1987), and in the accounts of health aides and family members exposed Rongeiap group it accounts for 19X,of living on those atolls and from records and total mortality (5 of 26 deaths). Second, cancer death certflcates at the Ebeye and Majuro hos- deaths can be expressed in personl years of pitals. Autopsies are rarely performed in the obsenation, thereby controlling somewhat for Marshall Islands. persons lost to followup. When this is done the cancer death rate for the 33-year observation 2. Of the eight deaths that clinically may have period is 171/100,000(8 possible cancer deaths been cancer-related. confirmation by tissue in 4669 person lyears) for the Comparison diagnosis is available in only four. In the exposed group overali and 187/ 100,000 (4 possible Rongelap population only three of the five cancer deaths in 2136 personl years) for the 86 deaths attributed to cancer were confirmed.
18 5004118 Table 7 presents Iimlted information relevant to [he present time there is noevidenceof residuai [he diagnosis of the cancers m the Compatuson disease in either of the thyroid cancer patients. group+ but all 8 cases have been desmbed in 6. In attempting to determine whether there :reater detali in this or earlier B!NLreports. has been an increase in cancer deaths in either 3. The mosr frequent lethal cancers m the Uni- the exposed or Comparison poptdation one ted States are lung, breast. colon and leukemia. - should note a Radiation Effects Research Foun- Iymphoma. dation report on the Japanese exposed to atom]c bombing. From 1950 to 1985. there had been 4. Areas where health care is limited often have .5936 cancer deaths among 75991 persons in the increased mortality from noncancerous disease. LSS (Life Span Study) cohort. Three hundred and an increase in cancer incidence has been and forty of the cancer deaths ( 6’Lof the total \tiewed as e]~dence of improved overall health of cancer deaths) are thought to be attributable to some populations because it reflects improve- the 1945 radiation exposure (Preston and ments in longevity. Pierce. 1988). The small size of the exposed and 5. Table 7 lists only cieaths that might have been Comparison Marshallese groups, the smaller related to cancer. There have been two cases of number of cancer deaths, and naturally occur- thyroid cancer that have been diagnosed. The ring fluctuations in disease incidence will make thyroid cancers, discussed elsewhere In this statistical detection of any excess cancer mor- report, have not been a cause of death. and at tality Impossible in these populations.
TABLE 7: POSSIBLE CANCER DEATHS IN THE RONGIXA.P EXPOSED AND COMPARISON (UNEXPOSED) POPULATION
Yeu of Age at Yeara on Cancer
IDU Death Death Rongelap” Type Confirmation
A COMPARISON GROUP 842 1986 61 ~ ? Hepatoma Not avadable S46 1986 63 4 Leukem:a Yes 861 1960 68 ~ Cervix No. Normal pelvic exam in 3/59.
S89 :980 55 ,> Breast yes > 975 1985 65 ‘? Lymphoma “~typical Iymphoeplthelioid proliferation” 1005 19s4 51 2 Lung Yes (Smoker) 1050 1985 50 2Q*. ? Colon No 1571 1982 28 ()*.. Astrocytoma Yes
B. RONGELAP EXPOSED 62 1959 60 2 Yea 30 1962 60 5 Cervix 30 13 1966 71 9 Uterus !VO 54 ~972 19 7 Leukemia Yes 68 1974 64 16 Stomach Yes
“ Years of remdence on Rongelap after rehabitation of RongeIap isiand in 1957, u recorded in the medical records of the .Marshall Island Medical Program or from personal history. “” .4dded to Compar~on group m 1964: did not live on Rongelap between 1957 and 1964 “““ Added to Comparison group m 1976: res]dence prior to 1976 is not recorded.
19 500 UIVJ -. TABLE 8: DISTRIBUTION OF POSSIBLE CANCER DEATHS ACCORDING TO YEARS OF RESIDENCE ON RONGEIAP
Years on Number of Possible Cancer Rongelap Persons Deaths
.+. COMPARISON GROUP 1).~ 135 7 5-9 -$0 () 10-14 20 () 15-19 13 () 20-24 10 1 25-28 9 0 Total ~~7 8 ( 13”,, of recorded deaths)
B. RONGELAP EXPOSED ()-4 9 1) .5-9 10 1) 10-14 12 1 1.5-19 1:3 0 20-24 :30 3 ‘25-28 10 1 Total 83 5 ( 19{, of recorded deaths)
TABLE 9: COMPARISON AND EXPOSED GROUP – CANCER DEATHS
No. in Total Cancer Age at Group Group Deaths Deaths Death
.-!. Comparison ~~7 6:3” 8 ‘28-68
.+.1 Resident on Ron~elap on@ during “57-’61 42 12 4 55-68
.A.2 Resident in ‘57-’61 and for some time thereafter 109 32 ~ 51.63 A.3 Resident oniy am “57-”61 47 5 1 50 A.4 Ne\@r on Rongelap 29 13 1 28
B. Exposed in 1954 86 ~~.. 5 B.1 Like .4.1 8 3 1 60 B.2 Like .+.2 73 ’20 4 19-71 B.3 Like A.3 1 0 0 B.4 Like .+.4 1 0 0
- One death occurred five months after return to Rongelap. -” Three deaths occurred prior COreturn to Rongelap in 1957. REFERENCES
Adams. U’H.. Harper. J.A.. Rittmaster. R.S.. and Grim- In: Radiation Carfl”nogtmesis. Epidemiology and -on. R.S. 1984. Pitu]tarvtumors follow]nz fallout radi Bioicgic Significance. PP 57-71.1301ce..f.D..Jr. and atlon exposure. J. Amer. .Ved. ASSIX. 252:664-6. Fraumem. J.F. (Editors ~.Raven Press inc.. Sew York. .-ldams. \V H.. Harper. J. A.. Rittmaster. R.S.. Heous. Conard. R.A.. Paglia. D.E.. Larsen. P.R.. f?L al. 1980. PM.. and Scott. W.A. 1983. Sfedical Status of’,tfarshal- Review oJ”.\fedical Findings in a Marsha tlesei%pula- lese Aco”den taliy Exposed to 1954 BRAVO Fallout tion T&tq-Six Years After Accidental Exposure to Radiation: January 1980 Through December 1982. Radioactive Fallout. f3NL 51261. BNL 51761. Conard. R.&Cannon. B.. Huggins. C.E.. Richards. J. B.. Adams. W.H.. Fields. H.A., Engle. J. R., Hadler. S.C. 1986. and Lowrey, A. 1957. Medical survey of Marshallese Serologic markers for hepatlcls B among Marshallese LWOyears tier exposure to fallOIJt radiation. ~. Amer. accidentally exposed to fallout radlatlon In 1954. Med. Assoc. 164:1192-7. Radiat. Res. 108:74-9. Conard. R..+.. .Meyer, LX. RalL J.E.. Lowery, A.. Bach, .Idams. W’.H..Harper. J.A.. fieOLIS. P.M.. and Jamner. S.A., Cannon. B., Carter. E.L.. Either, M.. and Hechter, .\,H. 1984. Hyperuricemla in the inhabnants of the H. 1958. .tfa rch 1957 Medical Survey oJ-Rangelap and \larshali Islands. Arthritis Rheum.. 27:713-6. Llin”k Peopie Three Years After Eqasure to Radioa.c- (itv Fa/lou~ BNL 501 (T-1 19). .Idams. W’.H..Engle, JR.. Harper. J..%..Heotls. P.M..and Scott, IV.A. 1985. Medical Status Vi Marshailese Cronkite. E.P.. Bond. \’.P., Conard. R.A.. Shulman. N.R.. .-lccidentally Exposed to 1954 BRA VOFallout Radia- Farr. R.S.. Cohn, S.H.. Dunham. C.L, and Browning, tion: January 198S through December 1984. BSL L.E. 1955. Response of human beings accidentally .51958. exposed to signitlcant falfout radiation. ~. Amer. MA .-lssoc. 159:430-4. .\dams. tV.H.. Kindermann. W’.R.. \Valis. K.~V..Heotls. P.M. 1987. Toxoplasma annbodles and retmochoroi- Cronkite. E.P., Bond. VP.. and Dunham, C.L 1956. ditis in the !larshall Islands and their association Some Efy=ts of Ionizing Radiation on Human with exposure to radioactive fallout. Am. J, Trop. Beings. AEC-TID 5358. .Ifed. H,yg, 36:315-20. DunKv, C.I.. Morgan. B.C.. Heotis. P..M..Branson. H.E.. Akiyama. \f.. Zhou. O-L.. Kusunoki, Y.. Kyoizuml. S.. Adams. \V.H. 1987. Normal hematologic values and Kohno. X.. Akiba. S.. and Delongchamp. R.R. 1987. prevalence of anemia in children living on selected .~ge- and dose-related alteration of in ~ltro mixed Pacific atolls. Acts Haematol. 77:95-100. lymphocyte culture response of blood I}mphocytes Frey, H. 1987. Circulating autoantibodies in thyroid from A-bomb survivors. Radiation Effects Research disease. Actu Med. Stand. 222:289-91. Foundation Tech. Rept. TR-19-87. He~ard. iV L.. Lanier. A.P.. Cartter. M.L.. McMahon. .\sano. \l.. Kate. H.. Yoshimoto, K.. I:akma. S.. Ham- B.J.. and Bender. T.R. In: Wh-ai Hepatitis and Liver ~da. T, and [ijima. S. 1982. Pr]mary Itver carcinoma Disease. \“yas. G.X.. Dienstag, J.1+ and Hoofnagei. J. H.. and liver cmrhosts in atomic bomb surwvors, Hiro- eds. Orlando. Florlda. Grune and Stratton. Inc.. p. shima and Nagasaki, 1961-1975, wnh special refer- 663-4.1984. ence to hepatit:s B surface antigen. J. .Vatl. Cancer Lang W.. Borrusch, H.. and Bauer. L 1988. Occult Inst. 69:1221-1227. carcinomas of the thyroid: Evaluation of 1020 BerAey, R.P.. Hwang, L.-Y.. Lin. C.-C., and Chien, C.-S. sequentmi autopsies. Aw. J. Clin. Pat.hd 9072-6. 1981. Hepatocel]ular carcntoma and hepatitis B virus. Larsen. P.R. Conard. R.& Knudsen. K., Robbins, J., L.ancet 1:1129-32. Wolff. J.. WI, J. E.. ?Jicoioff. J.T., and Dobyns. B.M. Bloom ET.. Akiyama. M.. Kern. E.L. Kusunoki. Y.. 1982. Thyroid hypofunction after exposure to faUout Makmodan. T. 1988. ImmunologIcal responses of from a hydrogen bomb explosion. J. Amer. Med. aging Japanese A-bomb survivors. Radiat. Res. ..kWC.247:1571-5, 116:343-55. Lessard. E.. .Miltenberger, R.. Conard. R.. .Musoiino. S., Bond. \’.P.. Conrad. R.A.. Robertson. J.S. and Weden. Naidu. J.. Moor-thy, A.. and schopfer, C. 1985. l?L@- E.A.. Jr.. .Ifedical Examination of Rongelap PeapLe Absorbed Dose for Pev@ at Rart.geiap, Llink. and Siz .tfonths A@?r Exposure at Fallout. WT.-937. Sifo on March 1, 1954. BNL 51882. Operation Castle Addendum Report 41.A. April 1955. Maisei. J.Jf.. Pearlstein, C.S.. Adams, W,H.. and Heotia, Conard. R,A, 1984 Late radiation effects m Marshall P.M. Large optic disks m the MarshaUese population. [slanders exposed to fallout twenty-eight years ago. Am. J. Oph.#tnlmoL 107:145-1.50.
50041 !!lonmoto. 1.. Yoshimoto. Y.. Sate. K.. Hamilton. H.B.. Sawm-t. CT.. Bigos. S.T.. Land. S,. and Bacharach. P. ‘Kawamoto. S.. Izuml. M.. and Sagataki. S. 1987. Serum 1985a. The aging thyroid: Relauonship between ele- ~H, thyroglobulin. and [hWold disorders in atomic vated serum thy’rotropin level and thyroid antibodies bomb sunwors exposed in vouch: 30-vear follow-up in elderly patients. Amer. J. Jfed. 79:591-5. study. J. .Vucl. Med. 28:1115-22. Sawm. CT.. Casteili. W.P.. Hershman. J.!d.. McNamara. IIkajima. S.. Mine. M,. and Nakamura. T. 1985. Nortal- P.. and Bacharach. P. 1985b. The aging thyroid: ??Ly- ,ty of registered A-bomb surwvors m Nagasaki. Japan. rmd def&iency in the fiamlngham Study. 145:1386-8. 1970-1984. Radiat. Res. 103:419-31.
Preston, D.L and Pierce. D.A. 1988. The effect of Schneider. AIL, Favus. M.J.. and Frohman, LA. 1980. changes in dosimetry on cancer monality risk esti- Nodules in irradiated thyroids. .V. Engl. J. Med. matesin the atomic bomb surwvors. Rad. Reseamh 302:1148-9. 114:437-66. Rallison. M.L, Dobyns, B.M., Keating. F.R.. Rafl. J. E., Silverberg, E., and Lubera. J. 1987. Cancer ,statiatics. and ~ler. F.H. 1974. Thyroid disease m children: A 1987. Ca-A Cancer JoumalJor Clinicians. 372-19. survey of subjects potentially exposed to fallout radi- ation. Aw. J. Med. 56:457-63. Sutow, W.W.. Conard. R.A.. and Griffith. K.M. 1965. Growth status of children exposed to fallout radia- Robbins. J.. and Adams, W.H. 1989. Radiation effects tion on Marshall Islands. Pediatrics 36:721-31. m the Marshafl Islands. Elsemer Publishing Co.. m press. Wlelopolski. L.. Adams. W.H.. and Heous. P.M. 1986. Sampson. R.J. !detastatic occult follicular thyroid Blood bromine levels in a Pacific atoll population. carctttomz 1976. J. Aw. .!fed. Assoc. 236:1693. Envtron. Rx+. 41:91-8.
.>.9 .- 5004122 APPENDIX A PROFESSION& STAFF PARTICIPATING IN THE 1985-87 MARSHALL ISLANDS SURVEYS
PARTICIPATING NAME SURVEY SPECL4LTY AFPHJATION
Adams. \V.H. 3,85. 985. 3 86 Internal Medicine Brookhaven Natl. Lab. 9/86. 587. 987 (Hematolo~J Upton. NY 11973 .+nderson. J. 5/87 Internal Medicine NY Bellevue Div. of (Geriatrics) Geriatric Medicine NY. NY 11016 Arelong, T. 3,’85, 9’85. 387 Nurse Armer Ishoda Memorial Hosp., Majuro. Ml 96960 Barclay, P. 5i87 Internal Medicine Central General Hosp. (AIlergylmmun. I Plainvtew. NY 11803 LDirector, Emergency Physicians) Benes. S Ophthalmolow Ohio State University Medical School Columbus, OH 43210 %evcioun. S 3/’86 Obstetrics; G:n. Univ. of Miami School of Medicine MiarnLFL 33101 Bliss, M. :3T85, 9’87 Internal Med]cme Boston City Hospital (Gastroenteroiogy) Boston. ,MA02118 (’heatham. if” 3 86 Internal !dedlcme Walter Reed Army (Endocrlnolow ) Medical Center Washington, D.C. 20012 Dec. W’ :1 86 Internal \ledlc]ne Harvard Medical School (Cardiology ) Mass. Gen. Hospital Boston. MA 0211-1 [)obvns. R .1 85 Surgery Case \Vestern Resene L_nw. Cleveland Gen. Hospital Cleveland. OH 44109 Engle. J 3/85. 9{85, 3 86 Famdy Pracuce Vet. Adm. Med. Center Martinsburg, W’ 25401 . . (tormeriy BNL Resident Physician stationed at Kwajalein ) Ferguson. F. 9’85 Pediatr]c Dentistry School of Dental Medicine State Univ. of Sew }“ork at Stony Brook. NY 11791 Giorglo. R :) 85, .5 67 G-yn. Surge~ Private Practice Pearl City, H] 96782 Giorg]o. L. 3.’85 Nurse Peari City, HI 96782 Greene. G. 9/85 Pediatrics Univ. of California Irvine .Medical Center Orange, CA 92668
23 500$123 PARTICIPATING NAME st.m7zY SPECLALTY AFFILIATION
Harper. J. 9 66 Famliv Pracr[ce Private Pract]ce Portland. XIE 04103 (formerly BNL Resident Physician sratloned at Kwajalein } Jacobs. D. 3 86 Surse .\rmer Ishoda ,Mem. Hospital. Xlajuro, MI 96960 Jensen. L.P. :3 85 Obstetrics/Gyn. University of Miami School of Medicine %liami,FL33101 Kabua. J. 3, 85. 985. 3)’86 Yurse Ebeye 9/86. 5 87. 986 .Marshall Islands, 96960 iiehne. S. :3 85. :3 86 Internal Medicine Boston City Hospital (Pediatric Neurolo~) Boston, MA 02118 - Kindermann. R. :3 85 Ophthalmology Private Pratt ice Cherry Hill. NJ 08003 Lakshmanan. M. 3/ 86. 5 87 Internal Medicine Natl. Institutes of Health Bethesda MD 20892 Landsberger, E. 386 Obstetrics/Gyn. Albert Einstein College of Medicine, Bronx, NY 10461 Langrme, H.. 3,85. 985. 3)’86 Nurse Armer Ishoda Mere. Hospital, Majuro. MI 96960 MacKay, D. 5/87 Internal Medicine Dartmouth-Hitchcock (Infectious Diseases) Medical Center Hanover, NH 03756 WiseL J. 3/85 Ophthalmology State Univ. of New York at Stony Brook NY 11791 !4axon. H. 5/87 Internal Medicine University of Cincinnati (Nuclear Medicine Medical Center Thyroldology) Cincinnati. OH 45267 McClintock. C. 3,85 Internal Medicine Boston City Hospital (Gastroenteroiogy) Boston, MA 02118 .Melkonlan, R. 5/87 Obstetrics/Gym. Stony Brook Univ. Hospital SUNY at Stony Brook NY 11791 MelIan. M. 5/87 Nurse Armer Ishoda Mere. Hosp. Majuro, Mashall 1s.,96960 Pacifico, A. 5i87 Internal Medicine Baylor College of Medicine (Cardiology) Houston. TX 77030 . Panebianco. R. 3/’85 Internal Medicine Private Practice Southampton, NY 11968 Rittmaster, R. 3/’85 Internal Medicine Natl. Institutes of Health . (Endocrinology) Bethesda MD 20892 (Formerly BNL Resident Physician stationed at Kwajalein)
,- 500!/24 PARTICIPATING SAME SURVEY SPECIALTY AFFILIATION
$[e\vart, D. 9 8.5 Pediatrics Univers]tv of California [r\ine Medical Center Orange, CA 92668 Symes, D. .5 87 Ophthalmology Pritate Pratt ice Tucson. AZ 85718 1“golini. 1“ .5 87 Internal Medicine University of Texas (Cardiology) - !%uthwestern Medical Ctr. Dallas. TX 75235 \Verth. \’. 3 86 Internal Medicine New York Uni\w-sity (Dermatology) Dept. of Dermatology NY. NY 10017
UWams. K. 3’86 [nternal .Medicine Cornell LTniversny Department of Medicine NY. NY 10032
.
500! 125 TECHNICAL SPECIALISTS PARTICIPATING IN THE 1985-87 MM?SHALL ISLANDS SURVEYS
P.4RTICIPATIXG SAME SURVEY AFFILIATION
.Idams. Diana :1 85 Medical Department Brookhaven National Laboratory Upton. .NY 11973 Anklen. Risong .1 85. 5 87 Armer Ishoda Memorial Hospital Majuro. Marshall Islands 96960 Boyd. Lindora 9 85 Medicai Department Brookhaven Nationai Laboratory Upton. NY 11973
Bulbs. James Jr. .1 86 Medical Department Brookhaven National Laboratory Upton. NY 11973 defhum. Reynoid .1 85. 9 85. 3 S6 U.S. Depanment of Energy 9 86. 5 87, 9 87 Majuro. Marshall Islands 96960 Duhaime, Susan 5 87 Stony Brook University Hospital State University of Sew York at Stony Brook, NY 11791 Emos. Helmer 3 85. 985. 3 86 Medical Department 986. 5’87, 987 Brookhaven National Laboratory Stationed at Ebeye, Marshall Islands Gideon. Kalman .1 86 Armer Ishoda Memorial Hospital Majuro. Marshall Islands 96960 Heotis. Peter .3 85. 9 85, 3 86 Medical Department 9 86. 5 87. 9 87 Brookhaven National Laboraton Upton. NY 11973
Heinrlchs. John 5 87 Medical Department Brookhaven ?Jatlonal Laboratory L’pton. XY 11973
Jacob, Stanley’ 1 85. 3 86 Ebeye Hospital Ebeye, Marshall Islands 96960 Lehman. l!’i]li~ 9/86, 5:87, 9/87 Medical Department Brookhaven National Laboratory Upton, NY 11973 Saul. Joe 3;85, 9/85. 3’86 Armer Ishoda Memorial Hospital !’vlajuro. ,Marshall Islands 96960 Scott, Wiiiam 3/85, 9/85. 3;86 Medical Department .5,’87. 9187 Brookhaven National Laboratory Upton. NY 11973
Shonlber. Sebio 1 85 9 85, 587 Armer Ishoda Memorial Hospital Majuro. Marshall Islands 96960 Stra%lno. Michaei :3 85. 9 85, 3 86 Medical Department (Retired) Brookhaven National Laboratory Upton. NY 11973
Tommy. Morris 5 87. 9 87 Armer [shoda Memor]al Hospital Majuro. Marshall Islands 96960 APPENDIX B lndii~dual Marsnallese Iaboratorvdata collected durm~ the 1985.1986. and 1987 medical surveys. ( Idenuficatlon numbers i to bti belong to exposed persons 01 Roneelap and Ailingnae. numbers begmnmc at 21(P belong to the 1“[irlk exposed numbers t’rom 805 through 1.578 belong to the Comparison group).
.+bbreviations:
[’ID = EWookhaven National Laboratory Identllicatlon number sEX = 1 - Male: 2- Female .-lGE = years
W13C = leukocyte countl PI PMN = neutrophii countt PI BAND = band formsj p] L134PH = Iymphocvesjul MONO = monocytesl PI EOS = eosinophiis/ pl BASO = basophils/ PI f’LT = platelet count x 1(Y MI Ha = percent RBC = e~hrocytes x 10~‘d )1(X’ = mean corpuscular volume In fl HGB = hemoglobin level in g d] TSH = thyroid stimulating hormone level m ~U I
PRL = serum prolactin m ng: ml T4 = thyroxine in ~g/ dl TPR = total protein in g d] .4LB = albumin in g) dl GLOB = globulin in g~dl .4/G = albumin jglobuiin ratio CAL = calcium in mg/dl FBS = fasting blood sugar In me dl HBAIC = glycosylated hemoglobin A 1C in percent
27 Cn COtiPUTER LISTING OF 1986 ltAW DATA m PID SEX AGE NBC PnN BANDLYMPH HONO E08 IIASO PLT HCT RBC MCV IIGB TSH Pul. ‘r4 a 2 7000 4808 168 2133 316 310 70 224 42.9 4.45 96 15.0 16.60 45 10.4 l-- -. .- 4 ; % 9800 emo 90 aeeo 870 190 95 11344f3.1 6.a6 88 14.9 0.20 2.2 — I 33 6100 2Bea O 2989 a44 308 O 201 42.7 4.6\ 96 14.1 6.00 23 : I 00 6.80 11.9 r-a 9 1 6a 0000 3033 2001 828 138 270 O 246 43.6 4.46 98 15.2 3.20 6.2 CD 1 66 10BOO 7a4B 106 2416 62B aio 0 270 48.4 8.30 84 14.8 2.00 3.0 :: a 40 7600 3408 70 W& aaa 304 0 410 40.3 4.a7 94 13.2 6.10 a.7 14 a 60 6100 a860 81 204 308 o aae 34.3 3.49 ee 11.7 0.30 a.e 16 a 39 0000 3@le 0 4s39 3B6 89 0 300 4a.1 4.40 04 13.8 36.00 21.7 10 1 71 4000 a484 138 1010 3aa 40 0 320 43.8 8.88 74 13.9 17.00 0.3 2 36 8400 3770 266 179a 384 la8 (I4 190 40.0 6.04 93 la.9 a.60 18.1 :: a 93 6700 3078 171 1707 28B 399 0 313 30.6 4.31 92 la.7 0.90 15.0 1 37 7300 46a0 73 ao44 ::: 438 0 202 48.1 6.98 76 14.3 t)8.00 12.9 3.9 :: I 38 aaoo 6088 aa 2a96 0 0 292 B1.1 B.78 aa 16.4 8.20 4.8 7.9 ai a 34 4300 a0a3 43 ]03a I 72 430 oaao 41.1 B.04 8a 13.7 260 17 2 aa a 47 0100 2748 12a 2f104 i2a 4a7 O 2t31 4~.6 6.80 90 12..9 0.30 13.0 23 1 36 24 a 48 7400 3700 0 aala 200 618 $’4202 38.7 4.24 91 13.8 2.90 3.1 27 7800 362B 2a6 aQaD aa6 Bae 76 a43 43a 4.s6 99 14.8 3.10 1.3 34 : % 7800 4080 390 2416 I 60 1BO o a39 34.3 3.48 98 11.7 10.60 11 1 36 1 30 Oaoo 3600 180 1984 372 03 0 27a 47.3 4.69 101 16.6 6.00 43 B.(I 37 1 8a 4100 aoeo 41 1470 410 8a aoo 39.3 4.10 90 13.8 6.70 30 : .4: eaoo 3348 0 2294 3:: I 80 Iae 3ao 40.4 4.a7 93 la.4 6.00 40 4000 1 ma 40 a84a 08 49 0 208 42.4 4.63 94 13.9 3.90 6,0 41 1 73 eBoo 3770 0 ao80 130 0ao 0 186 44.0 4.01 9B 13.9 e.oo 4.6 [A 4a 3.10 1.0 14.2 CD a 34 7700 4488 0 a096 308 a31 o a31 4e.7 6.11 91 16.a 1 36 6000 a700 100 ao60 100 60 0 280 46.8 B.40 86 14.8 0.20 3.2 9.4 :: a 4a 0400 a40e 04 3072 320 448 0 a44 43.8 4.81 91 13.4 0.00 4.3 01 a 40 7400 3330 0 39aa 148 0 0 388 41.2 4.68 90 13.7 3B.00 N 83 a 07 6800 333a ao4 ao40 1186 o am 39.0 4.a4 94 13.1 4.00 3.8 08 a 33 4000 2406 48 la80 i 9: 338 48 200 33.6 i.’?3 90 10.8 108.00 30.3 00 a 61 0800 3468 ao4 a86a ao4 a72 o a41 38.7 4.ao 9a ia.7 10.30 39 07 a 4S 7000 41e7 316 300 I 7s 160 o aon 41.1 4.ao 98 13.3 3,ao 6,0 11.() 71 a 88 7000 aaoo 0 3300 380 4s0 o lee 38.7 4.}9 @a 13,0 8.60 6.3 7a a 3@ 7eoo 6016 0 1900 380 304 O 396 39.7 4.39 90 13.0, 3.80 2a.3 13.8 ?4 a 47 0900 a7eo 89 3460 34B 207 W 304 47.6 6.30 90 16.1 3.40 18.8 76 a 43 11400 aaoa 34a a608 a28 114 0 a48 41.9 4.60 93 i3.a 13.10 ::: 0.9 70 I 4a 6000 1800 o a700 aoo aeo 60 1B6 43.6 4.41 99 14.8 3.30 6.1 7? I 60 B400 3684 lea 1608 84 0 334 40.3 4,a4 95 13.a 4.00 4.9 ’78 a e7 7800 3120 4368 :: 234 o 3ao 40.0 4.03 09 13.3 3.00 4.7 70 1 71 7900 46aa 7: a44t3 3QB 390 0 148 47.8 B.14 93 16.8 4.00 4.9 83 I aa 6400 a60a 0 ao6a 3a4 3a4 O 206 46.7 4.78 98 10.B a.80 4.3 0.6 86 1 31 0000 4044 0 36a6 344 86 0 346 48.0 6.14 96 14.8 88 a 31 7000 6040 360 1190 140 280 0 a3a 31.1 3.3a 9a 10.8 4.00 8 a 33 1 I 000 8010 330 1210 0 860 0 ale 31.B 3.82 87 10.0 l:.?: 69.9 46 a 03 4800 a340 13B 130B a26 4B0 4B a98 34.7 3.0’7 06 Ia.1 6.a a 30 0000 3306 a904 198 132 o 300 43.4 4.01 04 14.3 9:80 12.1 % a 48 3600 2a7B : 980 140 10s 0 all 36.0 4.a4 86 la.3 3.BO 6.7 12.4 al a 41 4aoo 2004 4a I 3oa I ae I ae 0 400 38.7 4.31 90 13.0 6,30 10.4 0.2 84 1 30 4800 2004 ] oa 1776 1oa 670 0 199 60.0 6.28 96 16.0 3.00 2ioa I 4a 0400 4630 o 3270 604 0 84 380 48.6 4.92 00 16.8 1.60 2103 1 75 0700 8402 a91 24a6 388 1@4 0 281 43.7 4.48 98 13.8 3.90 alo4 a.B5 6.40 aloe 1 ?7 i 1600 7360 0 a990 346 a 30 0 310 41.a 4.68 90 13.1 3.90 2100 1 30. Iaeoo 6790 28a 6410 768 370 0 313 49.8 6.79 M 16.9 COMPUTER LISTING OF 1S85 RAW DATA PID 6EX ! WBC PMN BAND LYNPII MONO EOfi BASO PLT ilCT RBC MCV tlGB TSU PRL T’1
alo7 a Iaeoo 7aee 78a 3008 3B4 384 o aoa 4a.e 4.77 00 13.7 1.30 2108 1 7aoo 403a 144 a808 o ale 0 333 43.3 4.81 90 16.I 1.30 2110 7800 4680 I Be aaea 3ia 390 0 a44 30.9 3.07 Iol ia.8 6.40 all] : 8QO0 0340 o acwo 440 448 0 ael 30.8 4.87 ma 13.1 3.00 at13 a eaoo ea40 0 aa14 410 aae 0 34s 38.9 4.90 79 13.6 4.00 al14 8400 a77a aee S040 laa lea MI a.e a.oo aile 0600 :::: ~j:~ p] .6 9117 I ,Cmo 4990 80 ao?e 4a@ Saa # 14 .0 a]ie m 8400 3948 aefiw 4ao a8a o a38 40:4 4.6e 08 13.4 a.80 alas I eooo aaoo % a)eo I ao o o ao4 47.1 4.88 97 16.e 3.ao ala4 I 8800 4ee4 88 3344 ele 0 a84 48.8 e.3e 01 le.o 3.ao alao 0700 3a83 3149 I 34 I:: o aao 47.1 4.eJ4 97 18.1 4.10 alae : eaoo 3834 e: ao4e 37a ea o aeo 41.a 4.61 91 13.I 3.10 ala9 a 8000 ::~ a3ao 6eo 880 0 4al 40.7 6.00 al 13.a 4.10 a]30 a 0100 :: Iaal a44 1aa 0 ao4 34.8 3.8e ee 11.4 e.oo 2134 a 8700 1740 87 8608 348 eiaa o 308 39.3 3.00 90 la.3 3.40 alm 1 aaoo 418a 0 a64a 3aa 40a 8a a36 4e.4 4.80 oe 14.3 4.30 ai37 0000 3300 0 aa80 I ao 300 0 a3e 48.9 6.11 90 14.4 3.80 a13e : 10800 0016 0 aaoo alo 1470 0 4e8 40.4 4.el 88 la.a 3.ao ai39 a 8800 3380 86 a408 aeo 300 o 304 37.0 4.01 96 ta.a 6.ao ai40 6400 4090 0 179a 3ao 0 0 a14 40.1 4.17 ee la.8 6.60 a14a I I aoo 7108 Ila 347a IIa 3 se 0 aoe 61,0 3.ao e7 le.4 4.ao a143 0400 33a8 a304 384 384 o 408 41.0 4.77 80 la.e 7.40 a146 0100 aeaa 1a: aaol a44 a44 0 a87 41.8 4.30 01 la.7 6.40 a147 8300 1aoa 83 3180 189 1oe 0 358 41.7 4.e9 se 14.7 a.40 .a148 @BOO eaa6 380 34ao am 1Qo o a44 4a.a 4.40 96 13.7 4.70 a]49 B800 aoltl a430 a90 88 0 aee 38,a 4.33 88 11.4 4.40 aleo 9300 6080 18: a883 I ae 4e0 0 aoe 40.8 e.114 80 Ie.a 4.60 aiaa 8600 3080 68 1880 330 aao 50 aee 43.8 4.ee 93 14.7 a.oo 2183 4000 3470 49 1078 147 147 o aee 4e,4 6.81 e4 13.a aiee eaoo awm 0 310a 37a :;: 0 ae4 48.? 6.78 84 ie.1 3.eo aloe 0400 3004 0 ao48 3ao 0 a7a 48.4 4,0e ea 14.e 3.00 a188 7000 4830 0 1810 4ao 140 o a70 3e.e 4.al ea 13.0 4.10 aleo 8100 s4a7 a43 aloe 3a4 el o 304 43.1 4.e7 9a 13.8 4.70 aleo 8000 Baoo aao 1440 480 6eo o a9e 46.0 4.70 94 14.0 e.oo alea ?400 4014 148 aaao aoe aaa 0 399 36.e 4.oa 89 11.4 e.30 aiee 7800 3000 78 3888 31a 1ue O aaQ 43.6 4.94 8S 14.6 3.40 alee 7800 3060 af3e4 4e8 64e 78 aea 4e.6 4.74 ,98 13.9 6.60 altn 7800 3744 3:: 3198 4ee 78 0 all 4e.9 6.3a 88 16.3 3.ao a}71 0800 6016 4a8 aalo” 170 595 06 abo 41.a 4.eo 90 la:o a.eo a17a 7100 6041 14a 1633 14a I 4a O 330 37.4 4.06 ea la.6 3.30 a174 8800 0330 le7a 440 ae4 88 a80 61.6 6.76 ee 16.9 4.40 a17e 0800 31a8 0: 3400 ao4 0 a33 44.0 4.ee ee 14.e 4.80 al?e 8100 ;;:: 0 ae7s. 408 I ei o aazi t51.o e.aa el Ie.e 3.00 alaa 4000 0 a67e I 3e @a o 37a 34.e 3.74 93 11.e 4.eo a188 8800 4400 178 aaie eao 440 80 1S1 64.7 6,91 93 lee 4.30 aleo : 8400 ema 108 76e 33e 804 e4 ale 31.7 3.4e 9a 10.3 3.70 a193 a 6900 4130 a06 1475 o 0 o 300 40.1 4.30 93 13.O 4.80 alcm a 0700 3484 07 a747 ao 1 e7 0 388 40.0 4.80 ea 13.4 4.70 a]ee a 0800 aaeo 66 318S 3a6 ea 0 ao4 41.6 4.70 ea 13.a a7. 00 a197 a 0300 3160 03 a487 aaa 318 63 171, 33.1 3.73 89 10.9 4.70 aaoo a eaoo 36.8 3.7e 94 11.e aaoe 1 eaoo 4784 3e80 4eo 164 o a9i 43.7 4.Oe 06 13.7 3.90 aao8 1 0200 4608 1:: 3t38e a7e I 04 ea a40 4?.0 6.13 9a 14.6 a,40 aao7 1 Ioloo 6069 404 3a3a 303 Iol 101 30Q 47.e 6.eo 86 14.9 3.30 iz
A a n.
20 Ooooooooomoeoooo 000000000000:00 00000;0000;;00 Oocaago:ooo Q2 v mm m
n aaaaaaaaaaaa aaaaaa-----a -a-aa-aaaa-a ----maa-a-m- -aa-a.- :
:31 500UNI cm CD
C3 COMPUTER L18TING OF 1986 RAW —DATA.. PID 881 AGE VBC PMU BAND LTMPH IIONO PLT JiCT RBC WCV I(GB PRI, T4 -1= E08 BA60 TSH
-- 83a a 4a 0600 3316 o a730 130 3a8 a61 30.7 4.Ba la.a 033 4100 bJ : le4 18.4 834 I 81 7eoct M M 300$ 4b “o alw 1::! 1::; Ia.11 — 030 a em I oeoo 6ela 108 4a40 4a4 100 o aoo 4a.6 4.4e 14.6 038 1 84 8800 4T6a 170 3344 38a 170 0 a40 63.3 6.46 le.1 839 a M 7800 aaea 78 4788 64e 166 0 3a 1 47.1 4.ee 14.a 840 1 00 10000 4670 ale 6460 640 109 0 3ee 46.0 6.6a 14.9 841 a 63 8400 4068 aia4 4ao 76e 0 a6a 43.1 4.4@ 13.a 842 1 el etmo aoa4 I:: 34e8 I 3e I 3e 0 144 44.3 4.el 13.9 843 a 07 6eoo aaao 1 la aeao Ila 336 0 3a3 30.0 4.03 la.7 044 a 07 T400 4688 74 a3e8 aaa 146 0 a41 S7.6 4.04 Ia.o 84e 1 06 0700 ao4a 308a 4e0 aol 0 ai7 4a.o 4.e6 13.a 848 a 83 3700 em 14: a400 Ill 37 0 n3a 34.6 3.e4 il.e 881 a ?0 0100 a86e 61 1e3a 387 ao4 0 alo 30.4 4.02 12.1 ee4 1 60 7eoo a344 37a4 aae a2a 0 227 43a 4.81 ia.9 805 a ea 0300 474s a7; 3tea 668 668 0 a79 43.e 4.47 14!0 6.90 887 a s’? 10800 48eo 43a 48eo ale 432 0 336 44.8 6.00 16.2 a.80 808 1 ea 4400 8080 1760 80 80 40 a16 43.0 4.6e 14.e 879 a So 8800 6186 aeoo 340 88 0 306 4e.e 6.47 lao6 880 1 83 1aooo 7800 eo; aveo eoo a40 0 all 48.3 4.47 13.s 881 1 03 eaoo S740 ea a684 408 0 aaa 4e.e 8.14 14.7 88a 1 aa e400 s77e o a3e8 0 aeg 0 a44 47.4 0.70 14.e 890 a 40 eeoo 33e4 a3a 107a a3a 0 a61 40.7 4.67 13.6 011 a 33 8800 4ooa 174 1460 66 11: 0 aeo aa.a 3.36 11.0 91’7 1 es 8000 6aoo 80 a400 a40 80 0 aa4 3e.6 4.a7 11.7 e.ao 019 ) 38 8300 8366 a438 ala ala 0 ;;: 36.7 4.19 la.o w to Oao 1 04 8300 ao14 1 % a644 ala 371 0 46.0 4.07 14.0 Oaa a m 8!?00 aaa3 67 aeo7 171 34a 0 aoo 43.3 4.eo ia.4 Das a w woo 69a6 a86 ao90 ee6 4’?6 0 aoa 38.e 4.40 la.6 Qaa a 73 eaoo 3036 310 I eaa a48 eaa 0 1 ee 3a.4 3.31 lo.a 031 1 m 8eoo 4816 a 3364 344 ae 0 438 46.3 6.11 16.7 03a a 01 e400 39e8 17a8 e7e 0 3a7 38.8 a.7e 11.8 034 a 61 eioo ae64 1:: aoas 1:: 1 aa 0 a46 4a.o 4.88 la.a 038 a 83 10000 6600 Too a800 eoo aoo aoo 179 40.1 4.64 14.D 3.30 041 a m 8000 6440 a660 170 340 o a44 37.4 4.oa Ia.e e4a a 71 7eoo 4040 40: 1000 460 aaa 7e ao6 40.7 4.aa la.9 a.oo 043 1 Be oaoo 467e 184 a300 73e eao 184 410 43.? 4.37 14..6 044 1 61 9100 4660 a73 aela e37 16a aae 4e.6 6.4a 16.0 a.ao 060 a 30 i ) 800 e138 600 4484 364 am : 333 46.3 6.a4 16.1 068 a w 10400 e8e4 aoa aeoo 8ao aoe 0 aa4 30.8 4.ae Ia.7 086 a 77 eeoo 3380 o a340 466 3a6 n a84 3e.6 a,ae 11.6 909 a w 8000 a8eo aao ao36 a78 110 ii 3ai 41,a 4.ee as la.6 000 a 34 11800 8860 118 1888 600 364 o aea a6.a a.8e 91 11.4 Oea 1 m 8000 31a7 118 ala4 a06 aim o a4e 41.8 4.60 ea ]a.1 906 a 4a 8300 4731 ee4 a168 33a 33a 83 366 3?,7 4.a6 69 ta.1 000 ) 84 8800 a806 o ao36 110 496 66 a4t3 43.4 4.37 09 la.6 000 ) 00 I aooo 8376 600 a760 600 600 0 41a 37.0 a.ea 07 10.4 070 a 73 8600 4846 0 3146 426 o a84 a4.e a,ea 04 lo,e 971 1 43 aeoo a6ae 0 4at4 sle 3:: o a91 41.4 4.7a e7 14.1 07? a 40 6700 aeo? 67 a337 ae6 114 o 197 a9.7 4.49 88 Ia.o 080 a 33 7400 4e0a 0 aa04 aoe 146 0 a48 4].e 4.ea .:: ~:.; 901 I aa 7400 4aea 0 aoeo 148 O a48 64.7 6.89 99(I a 88 8000 aa40 1000 I e: 0 106 a7,6 4.19 89 tale 1001 8 em 7600 4104 18: S040 304 0 a7a 41.0 4.90 ea la.e 1007 1 78 6000 a744 60 a3aa lea ae~ 0 101 4].0 4.08 89 Ia.e 2.eo Cn C2 C3 -r=
LIJ I-.3
OF 1980 RAW DATA PID SEX AGE WBC PUN BAND LYMPH MONO EOS BASO PLT XCT RBC MCV tlGB TSII PRL T4
1030 a 34 8000 4000 80 3440 480 o o 4ae 4a.7 4.74 00 14.8 1043 a 00 e 300 180 44.8 tI.a3 00 11.0 1800 ; :: 6700 3819 134 aall 4oa I 34 o 280 30.3 a.08 91 11.7 I 608 3.20 1018 1 43 7700 431a 154 atwo 4ea 77 o aae ea.a 6.49 90 ie.a 1820 a se 7aoo 430a 144 aa3a 360 ?a 0 L3a4 44.0 0.11 Be 14.0 1630 a W 3000 aoe7 117 loea 78 540 0 140 40.8 4.88 89 1S.8 1841 a 68 6800 aooo o aaea 348 aoo 0 17a ae.a 4.a7 ea 13.1 1843 a 33 8400 3oa4 a8a 448a 4ao aea o a86 40.0 6.80 80 16.8 1040 1 ?a 6800 3185 8s 3a80 o 0 lea 01.1 0.41 es 10.8 1848 a 44 I afroo 74ea aol 3ea7 ad 636 0 3a8 a8.1 4.]0 ea Ia.a 1849 1 aa 0800 aoea 08 aleo 470 08 o ae4 44.0 4.88 91 14.7 166a 1 M 7100 4970 71 1’7’?8 a84 0 0 300 43.1 4.77 90 14.3 1863 1 34 6400 ae70 84 law ale 64 0 208 46.0 4.ve :; ;:.: 1680 a 43 8100 41.8 6.86 1660 a 41 Baoo ae40 3s 18a4 114 0 ai3 44.8 4.34 09 la:8 1068 a se eooo 4080 480 amo JJ I eo 0 a61 36.0 4.3a aa ia.a 4.20 1069 a as 8000 a440 o a870 774 o aea 4a.4 e.aa 81 la.8 1800 a ea oaoo aaao 184 8000 044 o aoe 44.0 4.01 97 14.8 1601 a 00 0700 a747 0 ao8a 1:: 070 07 300 ao.1 4.01 98 13.0 1803 1 80 7000 3’780 o aOOo 4ao 140 0 a84 45.8 4.?3 90 14.8 18t34 a 37 0000 3480 o aloe a7e o aa7 41.a 4.07 88 13.4 a.70 1600 a ii I 0800 3740 o a618 408 1:: 0 aoe 38.0 4.ae 91 Isa 1670 a 06 8800 3996 o a8as ;;: 170 o aaa 4a.o 4.88 08 14.3 167a I aa eaoo ame ea alaa I 80 0 a14 49.8 8.40 91 )0.3 1873 1 30 8800 47ea 88 38a0 88 38a 0 40.0 6.a3 98 10.6 3.00 1 B77 a 36 Oeoo 48@e 00 a840 480 a88 o 307 a8.7 4.al ea la.a 1878 a 81 9300 0046 a79 a3a6 858 @a o aea 4e.a 6.a9 80 14.6 COMPUTER LISTING OF 198(3 RAW DATA PID SEX AGE VBC PMII BAND LYMPU MONO E08 BA80 PLT llCT RBC 14CV MGB TSH PRL T4 TPR AI.B GLOB AfG CAL
1 0400 a6eo 64 3204 128 384 O sell 46.0 4.00 00 14.8 0.00 a.a 4.20 4.0 1.0 10.2 I :: 11700 eem a34 3510’ 468 819 0 236 40.7 8.10 90 16.0 a44.00 30.4 0.8 8.3 4.00 4.3 ,007 I 71 7600 3116 0 3876 304 304 0 300 48.8 4,90 02 10.6 4.ao 8.1 4.10 4.0 1.0 88 I 34 8900 a419 0 an37 364 47a IIa a70 iw.a 4.2a ’93 13.3 3a. 10 0.0 7.2 3.00 3.3 1.2 1 e’? 4300 1160 o 1849 a68 a6a a6a aoo 40.3 4.40 9a 13.0 . ao 7.6 8.1 3.30 4.8 .7 0.5 1 63 0000 3381 0 3030 ao7 138 130 183 46.0 4.78 90 14.7 a.70 1.6 7.6 4.10 3.4 1.2 10.0 1 80 0700 4aal 67 1870 336 07 134 ale 4a.a 6.08 83 14.3 0.00 7.7 3.00 3.8 1.0 10.0 a 4Q 8aoo 49ao 0 a870 104 a4e 0 a70 38.0 4.a8 90 13.4 3.00 7.6 3.00 3.0 1.1 0.4 a 67 6LIO0 30B6 o aea6 J 06 aeo en aao 37.4 3.87 97 la,a 4.ao 7<6 3.00 3.0 1.0 9a a 40 11300 8703 113 4407 791 113 113 400 43.3 4.70 aa 13.3 .30 a,l 3.80 4.3 .9 9.3 I 7a 8300 a78e 0 aoe7 371 83 e3 a48 4a.8 6.70 79 13.0 a 30 8400 twaa 84 1848 ao2 588 0 186 43.0 4.89 93 13.3 7.0 3.80 3.a 1.0 8.6 a 64 7400 34?8 0 3330 aaa am 74 418 40.8 4.83 B9 14.0 4.40 18.3 7.4 7.0 4.20 3.0 I.a 9.B 1 38 4800 31ao 1104 a40 338 240 48.6 6.07 78 ]4.a 0.80 I 30 13700 11608 0 la33 .tlml a74 0 a68 40.0 6.74 80 16.8 3.40 8.] 4.ao 3.9 1.0 10.2 a 38 0000 3033 o aeel 00 09 0 a83 36.7 4.8a 81 la.3 la.7 7.3 4.00 3.6 1.1 6.7 a 48 e800 3186 o atiea aeo 300 o 3a6 30.6 4.04 96 13.0 3.BO 7.(? 3.60 4.3 .8 0.S a 48 6100 3819 81 1173 250 102 0 aao 44a 4.7s 93 14.4 4.80 6.0 3.00 4.4 .0 o.a 10800 3888 0 e160 648 I 08 o a88 49.1 4.91 100 17.0 .00 :.: ;.;: :.: .8 9.8 : :: 8800 431a 88 3784 sea ae4 0 338 40.8 4.ae Be 13.4 01.00 14.9 .8 9.4 a 77 8300 a304 340a 318 1ae ao3 38.0 3.88 03 II.(I 6.ao 7:8 3:40 4:4 .8 0.0 1 46 4600 a7eo o 1360 180 180 0 aao 44.3 4.40 01 10!1 0.00 4.6 7.6 4.00 3.4 l.a 9.3 1 40 7700 4158 0 3080 a31 0 0 a43 40.7 4.04 01 14.7 4.00 1.8 8400 aeea 84 a37e o 43a 0 ao8 4a.3 4.aa 00 13.6 a.oo 1.6 7.6 7.a 3.ao 3.4 .1.1 0 7 : % 0000 ae40 o ae70 3@e o 6a8 30.1 4.01 e4 13.3 0.60 a.a 3.00 4.0 .8 0.5 I aa 0000 aaao o aaao a40 e: 00 308 43a 4.84 w 1s.0 3.60’ e,l 3.40 3.a 1.1 0.a I 74 8300 S601 O 9673 83 83 0 a70 37.9 3.86 90 Ia.e 3.40 e,e a.a 3.60 4.7 .7 0.0 a 38 8aoo 4810 0 3108 a48 a40 0 ao3 43.3 4.3a :: ;:.: 8.0 3.00 4.a .9 9.7 1 37 6800 3000 0 1060 466 ]30 aio 40.0 6.00 a.ao ta.a v.7 3.70 4.0 .0 0.2 I 41 0000 ae40 0 a6ao 180 3: ea 103 46.0 4.48 oa 16:6 3.60 4.0 8.0 4.10 4.6 .9 10.1 a 49 6800 )488 o 3676 110 a76 86 300 41.4 4.74 87 13.8 a.eo 0.4 8.8 4.10 4.7 .0 a 41 aaoo 3090 0 377a 164 674 0 a43 43a 4.ea 04 14.8 Ia.eo 7.1 3.00 3.6 1.0 96 a 08 7000 3010 o 3430 aao alo 70 103 40.9 4.30 08 13.7 1.30 7.3 3,70 3.0 I.O lo.] 2 83 4700 4ooa a41e 414 1s7 33.0 3.43 90 11.3 .70 3.3 10.0 7.6 3.00 4.a .B 9.6 a 34 4700 3431 840 a% 94 ii3 aa.i i.4e ea 46.80 7.7 7.3 3.ao 4.1 .8 8.6 a ea 7000 aa40 0 3990 alo 4% 70 a3e 38.7 4.17 03 1:::0.60 0.0 7,0 3.00 4.0 .9 9.1 67 a 40 7aoo 3000 0 3108 604 144 144 306 39.4 4.34 01 13.0 7.6 3.60 3.7 1.0 9.4 ’71 a 80 8000 3070 0 4300 80 344 0 a13 3e.a 4.03 06 13.s 4.00 8.a 3.70 4.6 .8 9.1 72 a 40 @700 oeae 07 aelo 388 68a 97 380 37.6 3.91 90 11.8 10.00 7.8 3,ao 4.0 10.1 73 61 8900 a419 89 300Q 413 o 0 a38 46.8 4.96 @3 14.7 .40 4.a 16.3 7.7 4.00 3.7 1.1 9.4 74 ; 49 aloo 340a al 3078 408 1134 0 310 46.9 6.aa ]e.a 7.9 3.80 4.4 .a 9.I 78 a 44 I31OO 7860 131 3144 6a4 1834 131 aee 40.6 4.43 :: 13.0 11.00 8.3 3.80 4.8 .8 9.5 70 1 43 0000 ao40 3a40 a40 480 0 180 46.1 4.04 07 14.8 4.40 3.3 77 87 7800 4788 o iaa4 700 aaa 0 a6a 47.0 6.ae 16.1 4.60 8.0 3.40 4.(3 ‘r 10.() ?8 : 08 ‘?400 3700 o 3404 14a 74 O 406 40.0 3.90 1% 13.9 0.40 8.1 4.00 4.1 1:0 79 I 0300 4410 ‘o 1440 316 63 03 178 49.4 6.ao 06 18.6 a.70 0.8 7.4 3.80 3.0 1.0 8.9 86 1 H 8000 490a a838 616 344 a38 40.6 4.96 04 16.6 a.oo 8e a 3a 8600 3oa8 o ao90 a20 110 66 a76 33.7 4.10 aa 10.9 3.00 7.0 3.90 3.7 1.1 0 1 34 6900 3a49 o a301 230 118 0 333 4a.o 4.41 96 14.3 3.40 8.a 4.403.6 “1.1 9.4 i! a 34 aaoo 3620 8a 3864 164 4oa aa a80 40.0 4.40 93 13.6 .10 a4.6 7.6 3.80 4.0 .9 9.8 46 a en 6400 aae8 Ion a3aa 3a4 3a4 0 316 30.0 3.88 Q3 la.a 7.7 3.60 4.a .0 0.9 48 a 38 0400 3778 64 ao48 3ao 04 Iao ale 41.1 4.17 99 13.3 3.80 ;.; ~.;; ~.; I.o 9.a 63 a 40 0400 461a o 43a4 4ao 04 8’73 43.9 4.88 00 14.9 e.ao lea .0 0.8 70 a 49 6400 a430 o 1990 a70 (34: 64 a30 ae.a 4.61 87 13.0 8:3 4:00 4:3 .9 9.8 u-l COMPUTER LISTING OF 1988 RAU DATA PID BEX wBc Pun C3 BAND LYHPE Mono E08 BA80 PLT EC’? RBC MCV IIGB TSH PRL T4 TPR ALE GLOB AIG CAL c) 2102 6900 me? 0 a02a 483 em ttao 60.8 5.ao 97 le.o 7.3 4.00 3.3 1.2 aio3 -“ 0100 317a 306 lf+na 300 3% o aao 41.7 4.aa 09 )3.6 7.0 3.00 4.0 .9 alo4 4800 10aO 0 a400 330 48 a@8 38.1 3.Q3 97 la.3 e.40 8.0 4.00 3.4 1.4 aloe 8000 eeoa a781 7a I 1% 103 4fM 40.0 4.BQ 88 14.3 0.1 4.10 4.0 1.1 aloe 0700 10886 I e7 4178 Iooa 801 o aoo 40.1 8.08 87 10.4 2107 4400 7770 4808 I008 870 144 a40 44.1 4.80 01 13.7 0.8 4.70 4.1 1.1 2110 0900 3303 : 1888 384 aoo 104 Iaoa 7.8 3.90 3.0 1.0 alii 0800 0184 918 3880 t oee t!a4 10: !% 1::s ;::: :: ::.! 9.4 4.60 4.~ al13 0000 3480 00 1800 a40 300 00 383 41.9 O.la 7.6 3.90 3.0 I:! 2114 0400 3840 I ae I wa 3ao aee o aee 40.0 8.30 87 14:4 8.3 4.00 4.3 .O ali7 0100 8187 o aela 304 937 0 310 49.0 0.10 00 14.7 8.8 4.ao 4.3 1.0 alio 0300 3408 0 at4a aaa 3?8 03 a08 43.8 4.84 00 14.1 8.1 4.10 1.0 ala3 7aoo alla 0 Iala see mea 0 aa3 46.0 4.ea 99 14.4 8,a4.10 4.1 I .0 alaa 8400 a7e4. 0 17a8 004 ale 108 aee 46.0 4.7a 90 16.a 3.00 alaa 7300 37a3 Soee 14e aea 73 318 3Q.9 4.44 00 i3.a 7.e 4.20 3.4 1.2 ala9 a 0700 ai44 0! 3010 070 804 0 3etI 40.0 s.00 80 13.4 a130 a 36 0300 3034 o a883 00 I aa3a o ao8 30.7 4.00 00 ia.1 8.44. 104.3 1.0 a13a a 33 4800 a746 46 lale 130 300 0 a73 4a.4 4.94 80 13.3 ai34 a 33 6300 eaao 88 a4eo I 00 ma 0 S18 41.6 4.04 80 13.7 7.e 3.70 3.9 .9 alw 1 37 7aoo 3810 0 a89a 43a 300 0 308 47.4 4.8@ 97 10.0 7.0 3.90 3.i I.a a137 I 4e 0100 3000 1709 308 300 o aa8 40.8 6.38 91 16.0 8.7 4.00 4.1 1.1 a138 0300 0180 10: ae78 309 103 0 438 37.8 4.16 91 13.0 8.8 4.20 4.3 1.0 a130 : % 0400 1819 0 maa 448 1 la 0 348 43.6 3.88 9B 13.8 8.eo 7.6 4.00 3.8 1.1 a140 a 7@ 7aoo 4774 ao79 a31 308 S08 188 30.0 3.38 9a 10.0 7.a 3.eo ,3.e 1.0 a14a 1.0 u 1 3e 0000 0807 3379 100 a18 aia aea 47.3 4.oa :: ;:.: 7.a 3.70 3.8 u! a14s 1 3e 6700 3s01 8; l18a 480 114 87 305 44.6 8.10 7.7 4.00 3.7 1.1 ai44 1 11400 4300 o aela 4ao 0 0 180 8a.7 8.47 08 17:1 7.9 4.40 3.6 1.3 a14e 1 :: 0400 3a04 0 1488 43a lea 04 300 4a.e 4.33 08 la.O a.oo 7.9 4.00 3.9 1.0 a147 a 37 7300 407a 0 aae3 aoa 73 0 313 40,7 4.80 8S 1S.7 7.7 4.00 3.7 II a14a 1 77 aloo 4131 0 Srlso 010 a43 at aa3 39.3 4.17 04 Isa 3 00 77 4.00 3.7 1.1 a140 41 0700 aei3 Wleo aot 4oa 134 aeo 30.0 4.14 04 ia.8 7.7 3.00 3.8 1.0 aieo 46 8300 6003 a8aa a40 I ee 0 a18 4?.1 8.43 e7 14.8 1.00 alaa eo IJaoo aais I 378 a76 408 0 300 40.0 s.oe 00 18.0 8.6 4.40 4.1 1.1 aiee 0300 0130 a?eo 03 a70 o 380 4Q.a e.ea ee Ie.e 7.9 4.00 3.s 1.4 aloe 8aoo 3030 104 yltl: 410 o o a30 66.7 0.70 7.0 4.10 a.o 1.4 2108 6000 aa40 0 tee 80 60 310 3Q.8 4,40 % !!:: 8.4 4.10 4.3 .0 aim 7000 sa7e a064 3 Bo 300 0 410 4a.0 4.00 83 14.3 7.8 4.ao 3.0 l.a aleo 8ih0 aaea a4e4 ago 080 0 370 40.4 6.04 90 14.9 e.io 8.a 4.10 4.1 1.0 alea oaoo 3ee4 4140 o 1104 0 376 40.8 4.68 09 11.e 4.10 8.9 3.00 8.3 a)ea eaoo 3444 39s0 874 104 33a 44.4 8.00 eta i4.e 8.3 4.30 4.0 I :: abtte 8000 3040 1344 a80 3:; 0 aa3 41.I 4.38 ee 13.0 3.10 7.a 3.00 3.0 1,0 aie7 7100 3470 aoll a84 a84 71 313 43.8 4.81 91 16.5 7.4 4.00 3.4 i.a a171 a eaoo e41a aa14 a4e saa 0 a78 4a.3 4.08 91 13.4 .80 7.e a.eo 4.0 al?a a 4e 0900 3804 a683 ao7 ao7 00 403 44.9 4.0a 01 13.7 a.30 7.0 3.00 4.0 .9 I.a ai74 1 33 eeoo eaeo 1848 1080 0]0 o 370 40.3 6.30 ea 10.6 8.0 4.40 3.8 i.a 2170 43 eeoo 3004 a884 470 ao4 0 360 4?.9 4.87 ee 14.e l.ao 9.0 8.80 4.a 1.0 alaa : e8 6300 a173 a8t3a aea 0 aos 37.8 4.oa 94 la.1 a.tlo 8.8 4.60 4.3 2188 1 30 8700 aeoe lw& 084 eat 114 aoo 00.3 8.80 91 10.3 7.2 3,30 3.0 alw a 66 e400 0300 840 108 0 330 al.9 a.34 94 7.7 l:; a)m 04 8000 3080 1024 60 aa4 a83 31.8 3.34 94 10.4 a.eo 7.3 3,80 3.6 7.6 4.20 3.3 1.3 ales e7 eBoo 3040 130 aa7a I 30 aeo 06 343 41.a 4.00 ee 13.8 a.lo all)e 71 0000 3300 0 a310 I oe 79a 0 a18 40.0 4.40 90 13.4 10.00 8.3 4.40 3.9 1.1 1.1 a197 34 7aoo ml: 7a aiee aee 7a i44 aee 30.8 4.40 89 ta.e 4.00 7.9 4.20 3.7 7.4 3.70 3.7 1.0 aaoe ea @800 o 4780 aee o 0 330 47.9 6.48 en 13.7 u-l CD C3 . r-. . --