Survey of Childhood Cancers and Birth Defects at USMC Camp Lejeune (Full Report) (July 2003)
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Survey of Specific Childhood Cancers
and Birth Defects Among Children Whose Mothers Were Pregnant While
Living at U.S. Marine Corps Base Camp Lejeune, North Carolina,
1968-1985
U.S. Department of
Health and Human Services
Agency for Toxic Substances
and Disease Registry
Division of Health
Studies
Atlanta, Georgia 30333
July 2003
EXECUTIVE SUMMARY
In 1982, testing of drinking
water began at U.S. Marine Corps (USMC) Base Camp Lejeune, North Carolina.
The tests showed pollution in the drinking water at some base housing.
The water had chemicals called volatile organic compounds (VOCs).
VOCs are used to clean machinery and weapons and in dry cleaning.
The Agency for Toxic
Substances and Disease Registry (ATSDR) released a health assessment
of the base in 1997. This assessment stated that exposure to VOCs
probably would not cause health problems in adults. It also said
a study was needed to see if such exposure at Camp Lejeune posed
a threat to fetuses and infants.
ATSDR then studied Camp
Lejeune to see if infants whose mothers were exposed to drinking
water with VOCs were at risk for being "small for gestational age"
(weighing less than the 10th percentile). This study found such
a link with a subgroup of the births.
ATSDR is now moving
toward a full study of specific birth defects and childhood cancers
at Camp Lejeune. The first step was to choose which birth defects
and childhood cancers to study. Existing studies and other factors
were considered. ATSDR decided to focus on these conditions:
- Childhood leukemia
- Childhood non-Hodgkin's
lymphoma
- Spina bifida
- Anencephaly
- Cleft lip
- Cleft palate
The second step was to
identify the children eligible for the study by doing a telephone
survey. ATSDR decided on children born to women who were pregnant
with them while living on the base during 1968 - 1985. The year 1968
is the starting point because that year North Carolina began computerizing
its birth records. These records were used to identify children for
the study. The end point is 1985 because the tainted wells were shut
down that year.
The survey began in
September 1999 and ended in January 2002. ATSDR surveyed by telephone
the parents of 12,598 eligible children. This number was about 80%
of the estimated total. Parents were asked if the child had had
a birth defect or had developed a childhood cancer. A total of 103
cases were reported.
The third step was to
confirm the children's health problem(s). ATSDR asked the parents
who said their children had health problems of interest (or the
children if they were now over 18) for access to their child's health
records. These records are now under review. ATSDR has received
records for 46 of the 103 children so far and has confirmed about
80%.
The final step will
be to conduct a full study. This study will include all confirmed
cases of the birth defects and childhood cancers which are the focus
of the study. The study will also include modeling of the
water system to see which mothers did and did not receive the water
with VOCs. Currently we do not know which mothers received
the water with VOCs.
In summary, ATSDR has
finished the survey and is now confirming the cases. These steps
were needed to prepare for the larger study. There is enough information
to proceed with the full study. Only the full study can establish
whether VOC-tainted drinking water may cause the childhood health
problems being studied.
INTRODUCTION
U.S. Marine Corps (USMC)
Base Camp Lejeune covers an area of approximately 233 square miles
in the City of Jacksonville, Onslow County, North Carolina. In the
mid-1980s, groundwater contamination was found in wells that provided
drinking water to base-housing areas on Camp Lejeune. The contamination
was caused by both on- and off-base sources. The on-base sources
included the following:
- leaking underground
storage tanks containing trichloroethylene (TCE)
- spills from operations
at the vehicle maintenance area
- drum disposal at
sites 6, 9, and 82, and
- associated storage
lots at operating unit 2 (ATSDR 1997).
The off-base sources
consisted of a leaking, above-ground tetrachloroethylene (PCE) storage
tank and solvent-disposal practices at ABC One-Hour Cleaners, a
dry-cleaning establishment (ATSDR 1990). The public health assessment
(PHA) for Camp Lejeune found that PCE was the primary contaminant
at the dry cleaners (ATSDR 1997). PCE and other solvents from the
dry-cleaning establishment had contaminated a nearby well on Camp
Lejeune property; this well had provided drinking water to the Tarawa
Terrace base housing complex. Both Camp Lejeune and ABC One-Hour
Cleaners were listed as Superfund sites in 1989.
The 1997 PHA for Camp
Lejeune determined that exposures to the levels of drinking water
contaminants from the dry-cleaning establishment and the on-base
sources would most likely not result in adverse health effects to
adults (ATSDR 1997). However, because of information about how these
chemicals might affect a fetus or child, the levels of the contaminants
in the drinking water, and the findings from previous studies conducted
in other states, the PHA recommended that an epidemiologic study
be performed at Camp Lejeune.
The study would evaluate
whether mothers exposed during pregnancy to chlorinated solvents
(e.g., PCE and TCE) in drinking water had a higher risk of giving
birth to a child with a birth defect or a childhood cancer. As a
first response to this recommendation, ATSDR conducted a study of
births occurring at Camp Lejeune during 1968-1985. The study evaluated
whether having a small-for-gestational age (SGA) infant at Camp
Lejeune was associated with exposures to water supplies from Tarawa
Terrace that were contaminated with PCE and water supplies from
Hadnot Point that were contaminated with TCE and 1,2-dichloroethylene
(ATSDR 1998; Sonnenfeld 2001).
Exposure to Hadnot Point
water was associated with an elevated risk for SGA only among male
infants (odds ratio [OR] = 3.9, 90% confidence interval [CI]: 1.1,
11.9) (ATSDR 1998). Exposure to Tarawa Terrace water was associated
with elevated risk for SGA among infants born to mothers aged >35
years (OR=2.1, 90% CI: 0.9, 4.9) and among mothers with two or more
prior fetal losses (OR=2.5, 90% CI: 1.5, 4.3) (Sonnenfeld 2001).
BACKGROUND
Three water distribution
systems provided water for Camp Lejeune's base housing areas: the
Tarawa Terrace, Holcomb Boulevard, and Hadnot Point systems. Because
it was not known when the contamination started in each of the distribution
systems, chemicals could have been present in the systems for many
years before their initial discovery in 1982. Table 1 provides the
maximum levels that were measured at the tap in each of the three
water distribution systems (ATSDR 1997).
Tarawa Terrace
Contamination
in the Tarawa Terrace water system occurred as a result of disposal
practices at ABC One-Hour Cleaners, which opened in 1954 and was
located just outside Camp Lejeune's gate. As a practice, the establishment
disposed of waste solvent by draining it into a septic tank or by
releasing it onto the ground. In 1958, the USMC drilled an on-base
drinking-water supply well located 900 feet from the dry cleaner.
This well was probably contaminated soon after it was drilled because
of its proximity to ABC One-Hour Cleaners and the high permeability
of soils in the area (ATSDR 1998). In May 1982, sampling of the
finished water at the Tarawa Terrace system was done, and high levels
of PCE, a dry cleaning solvent, were found (76 - 104 parts per billion
[ppb]). One sample taken in 1985 before the contaminated wells were
shut down indicated a PCE level of 215 ppb was found. TCE, a degreaser,
and 1,2-dichloroethylene (DCE), a breakdown product of PCE, also
were detected in this sample. The contaminated wells were closed
in February 1985 (ATSDR 1997).
Hadnot Point
The Hadnot
Point water distribution system supplied water primarily for industrial
purposes at the base, but it also supplied drinking water to the
Hospital Point housing area. High levels of TCE (a maximum of 1,400
ppb) were detected during sampling in 1982. High levels of TCE and
DCE were found during the routine testing of the drinking water
system in 1984 and 1985. The Hadnot Point system had 39 operational
wells, although only approximately 20 wells were used at any one
time. The contamination was linked to leaking on-base underground
storage tanks.
Holcomb Boulevard
In 1972, the
Holcomb Boulevard water distribution system went on-line and served
the Midway Park, Berkeley Manor, Watkins Village, and Paradise Point
base-housing areas. Before 1972, the Holcomb area was served by
the Hadnot Point water distribution system. In early 1985, a fuel
line burst at the Holcomb Boulevard water distribution system, releasing
fuel into the water supply. An emergency line from the Hadnot Point
water system temporarily supplied water to the Holcomb Boulevard
system service area over a 12-day period beginning January 27. During
this period, the Holcomb area base housing received contaminated
water from the Hadnot Point system. Once the fuel line was repaired,
the emergency hookup from Hadnot Point was disconnected, and the
Holcomb Boulevard system resumed service to its designated housing
areas.
OBJECTIVES
The primary objective of
the health survey was to identify and confirm all cases of specific
birth defects and childhood cancers among children exposed in utero
to drinking water contaminated with TCE, PCE, and other chlorinated
solvents. The specific group investigated was composed of children
who were conceived or carried in utero while their mothers lived in
on-base housing at Camp Lejeune during 1968 - 1985.
METHODS
Definition of Eligible Children
and Recruitment Practices
Children eligible for the
health survey were those born at >28 weeks gestation to mothers who
were pregnant while they lived in base housing at Camp Lejeune from
1968 through 1985. Eligible children included those born to mothers
who had transferred off the base at the time of delivery as well as
those born to mothers who lived on the base at the time of delivery.
Because 1968 was the first year that birth certificates were computerized
in the state, the year was chosen as the start of the study period
in both the previous SGA study and the current survey. The year 1985
was chosen as the end date of the study because the contaminated wells
were shut down that year.
ATSDR attempted to locate
and contact the parents of each eligible child to elicit information
on the child's health as well as to confirm that the mother was
a resident at the base at some point during the pregnancy. Eligible
children were identified in two ways. First, the survey used the
birth certificate information from the previous Camp Lejeune study
of SGA (ATSDR 1998). A total of 12,493 birth certificates were obtained
for children born from 1968 through 1985 to mothers who lived in
base housing at the time of delivery.
Second, children born
from 1968 through 1985 to mothers whose pregnancies occurred while
they lived in base housing but who lived off the base at the time
of delivery were identified primarily by word-of-mouth (e.g., parent
groups), by referrals from other parents during their interviews,
or by parents prompted by media information about the survey to
contact ATSDR or the USMC. Birth certificates were not obtained
for these children. The number of pregnancies that occurred at base
housing during the study period and that resulted in live births
to mothers who lived off the base at the time of delivery is unknown.
However, staff of the Camp Lejeune Naval Hospital estimated that
about one third of mothers receiving prenatal care at the hospital
were transferred from Camp Lejeune before delivery. Based
on this information, ATSDR estimated that between 3,500 and 4,500
mothers were transferred from Camp Lejeune before delivery.
Therefore, an estimated total of 16,000 to 17,000 births occurred
among women who were pregnant while living at Camp Lejeune during
the study period.
Because many of the
parents were no longer in the military, several locating methods
were used. The primary approach used to identify the current addresses
and/or telephone numbers of parents was to obtain the parents' names
and social security numbers and send this information to Lexus-Nexus,
a private-sector locating firm. The names of the parents were obtained
from birth certificates. Two sources were used to obtain the parents'
social security numbers: (a) birth medical records of children born
at the Camp Lejeune Naval Hospital; and (b) data from the Defense
Manpower Data center matched to the parents' names.
To identify current
addresses of parents for whom social security numbers were unavailable,
USMC personnel matched the parents' names to information contained
in the databases of the USMC records system. In addition, ATSDR
searched the membership directory of the USMC Association to identify
current addresses for the parents. The USMC also prompted families
to contact ATSDR by distributing a military administrative memo
(MARADMIN 394/00) describing the survey to Marine Corps newsletters
and newspapers as well as through the USMC e-mail system (USMC 2000).
The memo was initially released September 12, 2000, and re-released
in early 2001. The USMC also promoted the survey by conducting a
nationwide television, newspaper, and radio campaign after the initial
media releases from CNN and FOX networks in November 2000. The USMC
also sent an e-mail message to current marines asking if they had
been conceived or carried in utero during the study period while
their mothers lived in Camp Lejeune on-base housing.
For births that occurred
off the base, the names of parents were identified primarily by
word-of-mouth (e.g., from parents groups) or by referrals from other
parents during their interviews. In addition, communications from
the USMC in the form of memos, e-mails, and media information releases
prompted some parents of eligible children (or the eligible children
themselves who were now adults) to contact ATSDR or the USMC for
information on the survey.
Survey Questionnaire
The survey questionnaire
was administered to the parent (most often the mother) using a computer-assisted
telephone interviewing (CATI) system, and answers were entered directly
into the computer. The average length of time to complete the telephone
survey was 15 minutes. The interviews were conducted from September
15, 1999, through January 26, 2002. The survey confirmed the eligibility
of the child by asking the parent(s) about where and when they resided
during the pregnancy. The survey also asked for information on the
current vital status and residence of the child.
In addition, the parent
was asked if the eligible child had been diagnosed by a physician
as having a birth defect or a childhood cancer. A childhood cancer
was defined as a cancer diagnosed before the age of 20 years for
those children born during 1968-1980. Because those born after
1980 would not have attained the age of 19 when the survey began,
a childhood cancer was defined as a cancer diagnosed at any age
for those born during 1981-1985. If the parent stated that
the eligible child had been diagnosed by a physician as having a
birth defect or childhood cancer, then the parent was asked for
the specific type of birth defect or cancer. Many of the parents
were able to give the names of the specific types of birth defects
or cancers. If the parent could not name the specific type of birth
defect or cancer, he or she was asked to describe the condition
and symptoms.
Verification of the
Health Outcomes Of Interest
Once all the surveys were
completed, the next step was to verify the specific birth defects
and childhood cancers of interest by obtaining and reviewing the children's
medical records. The birth defects of interest were spina bifida and
anencephaly, which are neural tube defects of the central nervous
system oral clefts, that is, cleft lip and cleft palate.
The childhood cancers
of interest included non-Hodgkin's lymphoma (NHL) and leukemia,
particularly acute lymphocytic leukemia (ALL). The decision to focus
on these specific birth defects and childhood cancers was based
on the evidence from the scientific literature as well as the ability
of the survey to identify reliably and completely all the cases
of these diseases.
The first task was to
identify from the parent interviews all the eligible children who
were diagnosed by a physician as having the specific birth defects
and childhood cancers of interest. Because the birth defects and
childhood cancers were "self-reported" (i.e., reported by the parents
and not identified directly from medical records), it was necessary
to verify the birth defects and childhood cancers of interest that
were reported by the parents. The review of a child's medical records
was necessary to verify that the child had the birth defect or childhood
cancer of interest. If a parent reported the name of the specific
birth defect or childhood cancer of interest, then the parent was
asked to sign a medical records release form granting ATSDR permission
to obtain the child's medical record from the child's health care
provider. If the child was now ?18 years of age, he or she was contacted
and asked to sign a medical records release form.
Some parents, however,
could not provide the names of the specific types of birth defects
that their children had. Instead, they provided only descriptions
of the birth defects (e.g., a parent might describe what the birth
defect looked like). Some parents did not report that their children
had a birth defect, but during other parts of the interview they
provided descriptions of their children's health problems that seemed
to indicate the children might have had a birth defect. Because
the objective was to identify all potential cases of the birth defects
of interest, it was necessary to evaluate the descriptions provided
by the parents to reduce the likelihood of missing potential cases.
Therefore, a dysmorphologist from the Centers for Disease Control
and Prevention (CDC) reviewed the descriptions provided by the parents
and determined whether the children were likely to have the birth
defects of interest. If the dysmorphologist determined from the
parent's description that the child was likely to have a birth defect
of interest, then the parent was asked to give ATSDR permission
to obtain the child's medical record from the child's health care
provider.
PROGRESS TO DATE
Information on 12,598 eligible
children was obtained through the survey. This total includes numbers
for the both groups of eligible children. Group 1 (N=10,040) includes
children born inside Onslow County at either the base or county hospital.
Group 2 children (N=2,558) were those born outside the county.
For Group 1 children,
whose computerized birth certificate information was available from
the NC Department of Health, an accurate participation rate can
be calculated because the total number of eligible children is known
(N=12,493). The participation rate for Group 1 children was 80.4%.
How many eligible children were born outside Onslow County is not
known, however, so the participation rate for Group 2 children is
uncertain. On the basis of information provided by the Camp Lejeune
Naval Hospital, ATSDR estimated that about 3500 - 4000 eligible children
were born outside of Onslow County. Given this estimate, the participation
rate for Group 2 children would range from 64% to 73%. Therefore,
the overall participation rate for the survey ranges from 76% to
79%.
The survey also noted
descriptive data for the eligible children whose parents completed
the survey (Table 2). About 73.5% of the children were white, 17.3%
were African American, and 7.9% were Hispanic. The frequency of
the outcomes of interest based on the parents' survey responses
was also documented. The parents' responses to the survey identified
74 children with potential birth defects of interest and 29 children
with potential cancers of interest. (Table 3).
FUTURE DIRECTIONS
The objectives of this
survey were to (a) identify all potential cases of the specific birth
defects and childhood cancers of interest and then (b) confirm the
diagnoses of these cases. At present, ATSDR has obtained medical records
for about 45% (46 of 103) of the potential cases (Table 3). Of the
46 medical records that ATSDR was able to review, the diagnoses were
confirmed for about 80% (36 of 46) of the children. Most of the disconfirmed
diagnoses were conditions that were related to the birth defects and
childhood cancers of interest (e.g., central nervous system defects
other than neural tube defects, and blood disorders other than leukemia).
Therefore, the information provided by the parents has been reliable,
and we expect to be able to confirm most of the reported cases.
The verification process will continue until the diagnoses for the
potential cases are either confirmed or not confirmed.
Only confirmed cases
can be analyzed in an epidemiologic study. Therefore, confirming
as many potential cases as possible will be crucial to the success
of the study.
Although the survey
continues to provide information, an epidemiological study is necessary
to determine whether maternal exposure to the contaminated drinking
water at Camp Lejeune is associated with increased risks of specific
birth defects and childhood cancers. Such a study seems warranted
for several reasons:
- High levels of the
contaminants were found in the drinking water;
- Findings in the scientific
literature indicate that such exposures increase the risks of
specific birth defects (Bove 2002) and childhood cancers (Cohn
1994; Costas 2002; NJDHSS 2003);
- The high participation
rate of the survey (approximately 80%); and
- The high percentage
of these potential cases that have been confirmed to date.
The planning for the epidemiologic
study has begun. A draft of the protocol for the study has been
completed, and ATSDR will be seeking input on the draft protocol from
concerned citizens as well as scientists outside the government.
Once all comments have been received, the protocol will be revised
in response. In addition, a "control group" will be selected by conducting
a random sample of the eligible children (i.e., who were born to mothers
who were pregnant while they lived in base housing at Camp Lejeune
during 1968 - 1985). This type of study is also called a "case-control
study."
The epidemiologic study
will also require computer modeling of the drinking water system
at Camp Lejeune for 1968 - 1985 to determine which mothers were probably
exposed to VOCs in the drinking water during their pregnancy and
which mothers were not.
ATSDR has extensive
experience in the modeling of drinking water systems. For example,
as part of a study of childhood cancers conducted in Dover Township,
New Jersey, ATSDR successfully developed a drinking water system
model. This model was precise enough to allow ATSDR to estimate
the percentage of water from contaminated public wells delivered
to any location in the town for each month from January 1962 - December
1996 (Maslia et al. 2001, NJDHSS 2003). These estimates were
then applied to the residences of the cases and controls.
The Dover Township drinking water system model was based on field-data
collection of the present-day system operations and a historical
reconstruction of fate and transport of contaminants within the
water system, using historical information available from the water
company.
A similar approach will
be used for the epidemiologic study at Camp Lejeune. The drinking
water distribution system model will be based on current and historical
information on the base water system as well as historical information
on the sources of the contamination. ATSDR is in the process of
gathering these data. The results of the model will enable
the epidemiologic study to establish whether the mothers of the
children with birth defects or cancers of interest were more likely
to have been exposed during their pregnancy to the drinking water
contaminants than were the mothers of the controls.
CONCLUSION
ATSDR is planning an
epidemiologic study to determine whether exposure to contaminated
drinking water at Camp Lejeune was associated with excess rates
of the specific birth defects or childhood cancers of interest.
This plan is based on four principal factors:
- The high levels of
contamination found in the drinking water at Camp Lejeune during
testing in 1982 - 1985
- The likelihood that
the drinking water was contaminated in prior years
- The scientific literature
on the adverse health conditions of interest, and
- The potential number
of confirmed cases of these conditions of interest.
The health survey and the
process of confirming the cases of birth defects and childhood cancers
have been critical steps in preparation for conducting the epidemiologic
study. The high participation rate supports the likelihood that most
birth defects and childhood cancers among the eligible children have
been identified. The key issue now is whether the diagnoses can be
confirmed for most, if not all, of the potential cases of the birth
defects and childhood cancers of interest that were identified by
this survey.
REFERENCES
Agency for Toxic Substances
and Disease Registry (ATSDR). 1990. ATSDR preliminary public health
assessment for ABC One-Hour Cleaners. Atlanta: US Department of Health
and Human Services.
Agency for Toxic Substances
and Disease Registry (ATSDR). 1997. Public health assessment: U.S.
Marine Corps Camp Lejeune, Onslow County, North Carolina. Atlanta:
US Department of Health and Human Services.
Agency for Toxic Substances
and Disease Registry (ATSDR). 1998. Volatile organic compounds in
drinking water and adverse pregnancy outcomes: U.S. Marine Corps
Camp Lejeune, Onslow County, North Carolina. Atlanta: US Department
of Health and Human Services.
Bove F, Shim Y, Zeitz
P. 2002. Drinking water contaminants and adverse pregnancy outcomes:
a review. Environ Health Perspect 110(suppl 1):61 - 74.
Cohn P, Klotz J, Bove
F, Fagliano J. 1994. Drinking water contamination and the incidence
of leukemia and non-Hodgkin's lymphoma. Environ Health Perspec 102:556
- 61.
Costas K, Knorr RS,
Condon SK. A case-control study of childhood leukemia in Woburn,
Massachusetts: the relationship between leukemia incidence and exposure
to public drinking water. Sci Total Environ 2002;300:23 - 35.
MARADMIN, Military Administrative
Memo, U.S. Marine Corps, September 12, 2000.
Maslia, ML, Sautner,
JB, Aral, MM, Gillig, RE, Reyes, JJ, and Williams, RC. 2001. Historical
reconstruction of the water-distribution system serving the Dover
Township area, New Jersey: January 1962 - December 1996. Atlanta,
Georgia: Agency for Toxic Substances and Disease Registry.
New Jersey Department
of Health and Senior Services (NJDHSS). 2003. Case-control study
of childhood cancers in Dover Township (Ocean Country), New Jersey.
Trenton, New Jersey: New Jersey Department of Health and Senior
Services.
Sonnenfeld N, Hertz-Picciotto
I, Kaye WE. 2001. Tetrachloroethylene in drinking water and birth
outcomes at the US Marine Corps base at Camp Lejeune, North Carolina.
Am J Epidemiol 154(10):902 - 8.
Table 1. Maximum Concentration (Ppb)
of Contaminants in Drinking Water at The Tap - Camp Lejeune, North
Carolina, 1982 - 1985.
Chemical
|
Maximum Concentration
by Distribution
System
|
US Drinking
Water Maximum Contaminant Level Standard
|
Hadnot Point
|
Tarawa Terrace
|
Holcomb Boulevard
|
Trichloroethylene (TCE)
|
1,400
|
8
|
1,148
|
5
|
1,2-Dichloroethylene (DCE)
|
407
|
12
|
407
|
70
|
Tetrachloroethylene (PCE)
|
ND
|
215
|
ND
|
5
|
Methylene chloride
|
54
|
ND
|
ND
|
5
|
Vinyl chloride
|
3*
|
ND
|
ND
|
2
|
*
Estimated value.
ND = None detected.
Table 2. Selected characteristics
of eligible children whose parents completed the survey - Camp Lejeune,
North Carolina
|
|
|
Category |
Frequency |
Percentage |
Sex
Male
Female
Unknown/Refusal |
6,371
6,223
4 |
50.6
49.4
0.0 |
Race
White
Black/African American
Native Hawaiian/Pacific Islander
Asian
American Indian/Alaska Native
Other
Unknown/Refusal |
9,257
2,177
87
86
86
822
83
|
73.5
17.3
0.7
0.7
0.7
6.5
0.7
|
Hispanic Ethnicity
Yes
No
Unknown/Refusal |
997
11,576
25 |
7.9
91.9
0.2 |
Total |
12,598 |
100.0 |
Table 3. Number of cases of
birth defects and childhood cancers of interest, and number of children
for whom medical records have been obtained - Camp Lejeune, North
Carolina.
Outcome of Interest |
Number Reported |
Medical Records Obtained
(NumberConfirmed) |
Number in Process |
Number Unavailable |
Neural tube defects |
33 |
16 (11) |
15 |
2 |
Oral clefts |
41 |
13 (12) |
25 |
3 |
Childhood leukemia |
22 |
15 (11) |
7 |
0 |
Childhood lymphoma |
7 |
2 (2) |
3 |
2 |
Total |
103 |
46 (36) |
50 |
7 |
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