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ATSDR’s
Case Studies in Environmental
Medicine:
Polychlorinated Biphenyl (PCB) Toxicity
is being
updated. It will be available on the Internet
at www.atsdr.cdc.gov/HEC/CSEM/
and in print (see
contact information, page 2).
The
case studies series is a key part of the agency’s
health professional education
strategy. They are available
at
no cost to educate and inform health professionals and
the
general public about hazardous substances. The case
studies are accredited and offer
continuing education
credits.
For a print version of the revised
PCB case study when it becomes available, write to or fax the continuing
education coordinator (Continuing
Education Coordinator,
DHEP, ATSDR, 1600 Clifton Road, NE (MS
F-32), Atlanta, GA 30333, or 770-488-4178).
[Table
of Contents]
The
Revised PCB Toxicological Profile
Obaid M. Faroon, PhD, DVM, Division of Toxicology, Agency for Toxic
Substances and Disease Registry
Neurodevelopmental Studies
Immunologic Studies
New Intermediate
Oral Minimal Risk Level
New Endocrine Disruption
Section
New Child Health Section
Request for Toxicological
Profile
ATSDR prepares toxicological
profiles on the hazardous substances most commonly found at
National Priorities List sites
and on those substances that pose the most significant potential threat
to human health. ATSDR reviews the profiles every 3 years to determine
if revisions and updates are warranted. The overall goal in updating
the profiles is to enhance the risk assessment process to the greatest
possible extent.
 The
Toxicological Profile for Polychlorinated Biphenyls was updated
extensively in 2000, from 450 pages to more than 900 pages, and it has
been reformatted for easier use. The profile is organized by health
end points, includes a running title and an index, and is hardbound.
Following is a summary of the new information included in the updated
profile.
Recent findings from the Michigan Mother-Child Study, the Oswego Newborn
and Infant Development Project, the Lake Michigan Aging Population Study,
the Dutch Mother-Child Study, and the European Background PCB Study
were summarized, representing over 10 articles. The studies found that
background exposure levels to PCB, was measured by cord and/or maternal
serum levels, induced neurobehavioral alterations in newborns.
The Dutch Mother-Child and the Inuit Infant Studies found that infants
born to PCB-exposed mothers had an increased number of middle ear and
respiratory infections at a PCB level of 0.45 parts per billion (ppb)
in cord plasma and/or at a PCB level of 620 ppb in breast milk (fat basis).
The dose of 7.5 micrograms per kilogram per day was identified as the
lowest observable adverse effect level in infant monkeys after a 20-week
exposure to a PCB mixture simulating 80% of the congeners mostly found
in the breast milk of Canadian women. The infant monkeys had decreased
learning and performing abilities.
New research and health discussions have focused on the potential harmful
effects of endocrine disruptors, which are able to mimic, block, and modify
the normal function of the endocrine system. Some scientists believe that
these chemicals have potential adverse health effects in humans and animals.
The endocrine disruption section outlines the effects of PCBs on breast
cancer, estrogenic and antiestrogenic activity, the reproductive system,
and thyroid glands.
Many studies indicate that children can have different susceptibilities
to toxic chemicals than adults. These differences are probably due to
behavior, pharmacokinetics, developmental stages, and body fat content.
Information on neurobehavioral deficits, reduction in immunity, and endocrine
effects of PCBs in children are discussed in sections 1.6 (How Can
PCBs Affect Children?), 1.7 (How Can Families Reduce the Risk of Exposure
to PCBs?), 2.7 (Children's Susceptibility), and 5.6 (Exposure of Children).
ATSDR's Toxicological Profile for Polychlorinated Biphenyls is
now available. If you qualify for a free copy,* contact
ATSDR, Division of Toxicology, 1600 Clifton Road, NE (MS E29), Atlanta,
GA 30333 (telephone: 1-888-42-ATSDR or 1-888-422-8737; fax: 404-498-0093;
email: atsdric@cdc.gov).
If you do not qualify for a free copy,
you can purchase one from the National Technical Information Service
(NTIS). Contact NTIS at 5285 Port Royal Road, Springfield, VA 22161
(telephone: 1-800-553-6847 or 703-605-6000; NTIS Web site: www.ntis.gov).
* Congress requires ATSDR to (1) provide
toxicological profiles to state health and environmental agencies and
(2) make them available to other interested parties.
[Table of Contents]
A
Tale of Two Cities: PCBs in Rome and Anniston
Howard Frumkin, MD, DrPH, Professor and
Chair, Environmental and Occupational Health; Director, Southeast Pediatric
Environmental Health Specialty Unit; Rollins School of Public Health
of Emory University, Atlanta, Georgia
Anniston
Rome
Similarities and Differences
PEHSU Involvement
Summary
 Pediatric
Environmental Health Specialty Units (PEHSUs) are supported by ATSDR,
the Association of Occupational and
Environmental Clinics,
and the U.S. Environmental Protection
Agency.
PEHSUs are a national resource for pediatricians, other health care
providers, and communities. The program is designed to reduce environmental
health threats to children, improve access to expertise in pediatric
environmental medicine, and strengthen public health prevention capacity.
The key focus areas of the PEHSUs are medical education and training,
clinical consultation, and clinical specialty referral for children
who may have been exposed to hazardous substances in the environment.
Eleven PEHSUs are now in operation. For more information about the PEHSU
program, contact Chris Rosheim (cxr5@cdc.gov).
The Southeast PEHSU at Emory
University
recently worked with two PCB-contaminated communities. This article
will (a) introduce the two communities, (b) compare and contrast them,
(c) describe our activities in each community, and (d) offer conclusions
about the value of PEHSU involvement at the community level.
Anniston is the county seat of Calhoun County, Alabama. Although there
is some industry and agriculture in the area, and a medical center serving
the northeast part of the state, Anniston's economy has been heavily dependent
on two large military bases. (One of these, Fort McClellan, recently closed;
the Anniston Army Depot is still operational.) From 1929 to 1971, the
Monsanto (now known as Solutia Inc.) plant manufactured PCBs (one of two
U.S. facilities that did so). The plant is on the west side of Anniston
in a low-income, mixed-race area. Considerable environmental PCB contamination
has been documented near the plant. Since the early 1990s, community-based
environmental justice groups have been active in Anniston, pursuing environmental
sampling, public education, research by government agencies, litigation,
and other initiatives.
Rome is the county seat of Floyd County, Georgia. It has a diversified
economy, with sizeable manufacturers of container board and other paper
products, wire, aluminum products, carpets, poultry products, and machine
tools; a regional medical center; and three small colleges. From the 1950s
until the 1990s, General Electric (GE) operated a medium transformer manufacturing
facility in Rome. The facility used PCBs until the 1970s. The plant is
on the northern side of Rome, in an area of light industry and predominantly
white, middle-class neighborhoods. In the 1970s, PCB contamination was
discovered on the GE site and in nearby waterways. The Georgia Environmental
Protection Division issued fish advisories and began regulating the facility's
waste stream. Environmental levels of PCBs began to decline. In 2000,
the citizens' group, Citizens Action Network (CAN), was formed, and it
has focused considerable public attention on PCB contamination since its
formation.
In some ways the Rome and Anniston areas are similar. In other ways they
are quite different. Among these differences are duration of community
concern and activism, history of litigation, profile of "key players,"
medical infrastructure, and data available on both environmental
contamination and human levels of PCBs.
Widespread community attention to PCBs has a 10-year history in Anniston;
in Rome it is more recent. As a result, Anniston has defined the problem
in greater detail, and has pursued a range of remedies. In Rome, agency
officials and citizens are still assessing the extent of the problem.
In Anniston, much litigation has occurred and is ongoing. Two large settlements
have been reached; one included the relocation of several families. In
Rome, no major litigation has been launched.
Key players in each city include community and environmental organizations;
local, state, and federal health and environmental agencies; the facilities
themselves; the medical community; the business community; local and county
elected officials; school systems; and others. (A full analysis of each
city, and a comparison of the two, are beyond the scope of this article.)
The medical infrastructures of the two cities are similar. Anniston's
medical community is centered at the 372-bed
Northeast Alabama Regional Medical Center;
a smaller hospital (Stringfellow
Memorial,
with 125 beds) and numerous small private medical practices also exist.
Rome has two hospitals, Floyd Medical
Center (304 beds)
and Redmond Regional Medical
Center (201 beds),
and several large multispecialty practices. Both cities are regional medical
centers for their parts of the state, and both have family practice residencies.
The Anniston medical community has remained largely detached from the
PCB issue, whereas the Rome medical community has been eager to address
patient concerns and to learn more about PCBs in continuing medical education
sessions. The reasons for this difference are unclear.
Extensive environmental sampling in Anniston has defined the areas of
contamination, and blood testing of almost 3,000 people—most by plaintiffs'
attorneys, and the remainder by ATSDR—has documented the community's
biological uptake. In Rome, in contrast, most available environmental
sampling is from the plant site itself, and results from off-site properties
are only now becoming available. Biological monitoring has yet to
be conducted.
This brief comparison provides a partial picture of the communities encountered
when PEHSU became involved with the sites. PEHSU was asked to become involved
in Anniston by the U.S. Environmental
Protection Agency's Region IV office
and in Rome by the
Georgia Environmental Protection Division.
In Anniston, the primary focus was physician education; in Rome,
it included both physician education and health information for the community.
However, in both communities, PEHSU initiated dialogue with community
and environmental groups, local officials, and others, in an attempt to
understand the situations more fully and to provide more responsive, relevant
information. PEHSU offered itself as an impartial, health-oriented resource
in both communities.
In Anniston, the major health concern was child development and behavior.
Both physicians and members of the community believed that too many children
were hyperactive, inattentive, withdrawn, and/or had behavioral and learning
difficulties. PEHSU therefore suggested addressing this concern directly,
with a program of early detection of developmental and learning difficulties
and early intervention. Although it is virtually impossible to prove that
a child's learning difficulties have been caused by PCB exposure, it is
possible to develop early intervention programs in a city where PCB exposure
is common and where children might, as a group, be at risk. Discussions
about this program—how to design, implement, and fund it—are underway
with the school systems, community groups, the medical community, and
others in Anniston. Because of its expertise in developmental pediatrics,
PEHSU is assisting in these discussions.
In contrast to health concerns in Anniston, what emerged in Rome was a
need for fuller information on PCB contamination. Although there is reason
to suspect excessive levels of PCBs in the soil and waterways of Rome,
environmental sampling data remain fairly limited, and biological data
are unavailable. Accordingly, PEHSU suggested a program of blood testing
to determine whether citizens in Rome have elevated body levels of PCBs.
If some levels are elevated, PEHSU will attempt to identify the risk factors,
such as a history of employment in the GE facility, residence near the
plant, or residence near waterways that drain the plant area. In
particular, elevated levels among children could indicate ongoing absorption
of PCBs long after the cessation of PCB use at the GE plant. Discussion
of the blood testing program—how to design and implement it, who should
be screened, which laboratory should be used, and how to fund it—are
underway, led by a broad coalition of local elected officials, the health
department, CAN, and the business and medical communities.
Several conclusions can be drawn from these two projects.
- Careful "diagnosis" of the community—including a thorough history,
a physical examination (multiple visits to the community, time spent
with key people, and visits to the sites of contamination), and a
review of laboratory data—is essential. This time-consuming process
is necessary because no two communities are alike.
- Trust-building is essential, both to be able to elicit a complete
history of the community and to be credible when offering solutions.
- Appreciating underlying tensions and needs is essential. Just as
a patient who presents with hypertension may be struggling with family,
job, and social problems that need to be addressed, a community presenting
with chemical exposure may be struggling with economic challenges,
discrimination, and marginalization. Without appreciating and addressing
these issues, it is difficult to "treat" the presenting problem effectively.
Moreover, when these underlying tensions and needs erupt in a noisy
public forum, a tense private meeting, or an off-target newspaper
article, that is as much a part of the process as an emotional interaction
with a physician—something to be respected and handled sensitively,
not feared or avoided.
- Just as a primary care physician must do the difficult work of
remaining in contact with a variety of specialists on a complicated
case, physicians who want to help at the community level must communicate
regularly with numerous agencies, officials, and organizations to
contribute to effective solutions rather than contradictory recommendations
and even chaos.
In both Anniston and Rome, many professionals, mostly from government
agencies and the manufacturers, had been active before PEHSU involvement
began. Nevertheless, many doors were opened to PEHSU. We believe this
resulted from our impartial medical input, the link with an academic
medical center, and the technical expertise without a vested interest
or local history. We believe PEHSU is "part of the solution" in both
Anniston and Rome, and that these projects provide a model for PEHSU
activity throughout the region.
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This page last updated on
April 17, 2002
Contact Name: Wilma López/ WLópez@cdc.gov
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