MEDICAL EVALUATION OF THE BILLERICA STREET RESIDENTS Prepared by the Environmental Health Section Boston University School of Public Health David Ozonoff, MD, MPH Clifford Mitchell, MD, SM Patricia Coogan, MPH March 10, 1989 FOR PUBLIC RELEASE Acknowladeement We would like to extend our appreciation to the subjects of this evaluation who subjected themselves to the lengthy examinations and interviews for the sake of the study. We would also like to thank Dr. Robert Knorr, the project supervisor for the Massachusetts Department of Public Health, who was extremely helpful to us in %any ways as this complex project proceeded. support for this project was provided by the massachusetts Department of Environmental Quality Engineerinq and the Department of Public Health. However the views in the report are our own and do not necessarily represent the views of either agency. -A PARTICIPATING PERSONNEL AND ORGANIZATIONS John Bernardo, MD Allergy Clinic Boston City Hospital Cheryl Caswell, MS Shiela McGuire, DDS New England Research Institute, Inc. Robert Feldman, MD Clyde Niles, MD Roberta White, PhD Department of Neurology Boston University School of Medicine John Graef, MD Lead and Toxicology Clinic Childrens Hospital Medical Center Edwin J. Mikkelsen, MD Associate Professor of Psychiatry Massachusetts Mental Health Center Harvard Medical School Patricia Coogan, MPH Clifford S. Mitchell, SM, MD* David Ozonoff, MD, MPH Environmental Health Section Boston University School of Public Health * Department of Internal Medicine, Francis Scott Key Medical Center, Baltimore, Maryland Joseph Stokes III, MD BU-Framingham Study Boston University School of Medicine The clinical impressions and overall interpretations of the study are those of Drs. Ozonoff and Mitchell. We express our appreciation to all of the study participants and the collaborating specialists for their cooperation. LIST OF TABLES Table 1 List of Residents -- Omitted Table 2 Symptom Prevalence in Billerica Street Residents Table 3 Billerica/Silresim Rate Ratios Table 4 Frequent Symptoms and Reasons for Medical Visits in the Billerica Street Residents Table 5 Cardiac Risk Profiles -- Comparison of Lowell and Framingham Residents Table 6 Holter Monitor Results for Adult Residents Table 7 Pulmonary System: Symptoms and Pulmonary Function Table 8 Hematologic/Immune System: Test Results Table 9 Summary of Liver Function Tests Table 10 Neurophysiologic Testing: Nerve Conduction Studies Table 11 Neurophysiologic Testing: Blink Reflex Studies EXECUTIVE SUMMARY This Report presents a detailed medical evaluation of the 25 residents of the 93 Billerica Street site in Lowell, Massachusetts. In January of 1988 these residents were moved to temporary housing to allow a complete environmental assessment of their property which had been found to be contaminated with hazardous substances. The evaluations reported here took place in the Fall of 1988. The first of the eight families occupied their new condominium homes on the contaminated site in 1979, with the other families following at various intervals. While living there they complained of a variety of health problems, especially respiratory problems and frequent infections. When the residents discovered in 1987 that the site was contaminated they requested from health authorities a more detailed evaluation of their health in relation to the contamination. In response the Massachusetts Department of Public Health moved to obtain outside contractors to perform a health status investigation. At the same time the Department of Environmental Quality Engineering began a more extensive evaluation of the site. While the environmental and health investigations were conducted independently, they can be used together to provide a better picture of the site and the health of the individuals who lived on it. 1. We asked the residents themselves about their health, the health of their children, and factors in their lives that might affect their health. To accomplish this we administered a structured questionnaire to each adult that inquired about a variety of health related issues, including an occupational, social and residential history. Most of the questions were the same as those used in a previous study of another, nearby Lowell neighborhood allowing a comparison with a geographically similar population. In addition, clinical histories were taken during the neurological examinations and the cardiopulmonary examinations (see below). 2. We reviewed existing medical records (doctor visits and hospitalizations) for the periods when individuals lived on the site, before they lived on the site, and in some cases, after they were relocated from the site. We asked each adult to provide a list of all hospitalizations and doctor visits that they could recall. Copies of the records were then requested. At the time of this report, we had received over 70% of requested records. A certified medical records technician then abstracted the records and summarized the results. 3. We arranged for routine laboratory testing and for specialists to perform selected clinical examinations on specific organ systems. We collected blood samples which were then sent to a clinical laboratory for routine blood counts and chemistries. We also obtained thiocyanate levels, PCB levels and blood lead levels because of the presence of cyanides, PCBs and lead on the site. In addition, a set of clinical examinations was performed by Boston-area specialists. Three organ systems were specifically studied: the neurological system, the immune system and the cardiopulmonary system. These organ systems were selected for both theoretical, and empirical reasons. The information from these three sources was then combined and looked at from two different points of view: 1. We considered the clinical history and exam results of each resident and evaluated it in relation to the possibility that any signs or symptoms were a result of exposure to contamination from the site. When such a possibility existed, we compared it to alternative explanations, for example, an occupational exposure or a pre-existing medical condition. 2. We looked at the Billerica Street residents as a group to see if they were different in some respect from what we might expect of a similar group that did not share the common experience of living on a contaminated waste site. Finally, we took one additional step in an effort to understand the results as fully as possible. Each family underwent an extensive interview with a clinician familiar with the psychosocial dimension of toxic exposure episodes. The results of these interviews were then synthesized into an overall description of the psychosocial processes that are characteristic of such situations. This was done because it is clear that the impact of living on a contaminated property cannot properly be understood by reference only to laboratory values and clinical descriptions but must take into account the many ways that such an experience affects the life of an individual and a family. The findings of our evaluation can be summarized as follows: (1) In symptoms reported, the residents experienced significantly more rashes or skin irritation, burning or irritation of the eyes or nose, acne, swollen glands, bowel complaints, persistent colds, frequent headaches, nervousness, irregular heartbeat and fatigue than a control population. (2) Physical exam findings included only one case of a psoriatic rash. (3) Laboratory findings included three people with mild elevations of total and indirect bilirubin and a different person with a minimally elevated GGT, one adult with a slightly elevated white blood cell count and 4% eosinophilia, and one child with an elevated white cell count and 10% eosinophilia. (4) Neurophysiologic exams revealed four people judged to have "subclinical neuropathies." Although some residents complained of "pins and needles," and had abnormal neurophysiologic exams, all of the residents had normal neurological exams. (5) A variety of minor deficits were seen on neuropsychologic testing, but in the judgment of the neuropsychologist no pattern emerged suggestive of a common toxic exposure. (6) Three individuals had abnormal cardiac rhythms. Two individuals had 24 hour Holter monitor results that showed ventricular tachycardia, a potentially serious cardiac rhythm disturbance. Two individuals also had considerable ventricular ectopy throughout the 24 hours. All three also had "subclinical neuropathies;" their durations of exposure on the site varied widely. They had no obvious risk factors for coronary artery disease. (7) One child had reactive airway disease which was new in onset while he was living at the site and has since improved. All other pulmonary function tests were normal. (8) The psychosocial evaluation of the families found, "higher levels of generalized anxiety and depression than one would expect in a population of similar background and size." These results could plausibly be looked at from two different perspectives. (1) The Billerica Street residents present with a variety of health complaints, similar to those found at other toxic waste sites, and to a degree more than one would expect in an unexposed population. The lack of objective findings in physical and laboratory exams notwithstanding, this could be taken as evidence of an effect from living on the site. Moreover, the fact that three residents had an unusual combination of potentially serious cardiac rhythm disturbances and subtle subclinical neuropathies and that two residents