Item ID Number °0671

Author

Corporate Author

Report/Article Title RePort on Survey MDL/2: Prospective LongitudinalEpidemiological Survey of Clean-Up Workers at Workfrom 1980 in High-Contaminated A Zone

Journal/Book Title

Ysar °°00

Month/Day

Color D

Number of Images 112

DOSOriptOn Notes Alvin ^- Young filed this item under the category"Human Exposure to Phenoxy Herbicides and TCDD"

Tuesday, February 20, 2001 Page 671 of 680

SURVEY frDL/2

PROSPECTIVE LONGITUDINAL EPIDBMIOLOGICAL SURVEY OF

CLEAN-UP WORKERS AT WORK FROM 1980 IN HIGH-CONTAMINATED

A ZONE

Research team:

I .Gilessi (coordinator}

G.AsseimatoP.BraaibillaP.CanziateiliL.MeaszaF.Merlo?.MocarelIiF.Sicarello

SSPOST ON STT2VEY MDL/2

PROSPECTIVE LONGITUDINAL EPIDEMIOLOGICAL SZJ2VBY OF ..CLEAN-UP

WORKERS AT WORK FROM 1980 IN HIGH-CONTAMINATED A ZONE.

INTRODUCTION

In A zone contaminated by high level of TCDD following the ICMESA

accident the clean-up operations started in the stammer

of 1980. The existence of a real risk for clean-up workers is

demonstrated by the experience accumulated in the last years

as a result of similar operations at various European industrial

plants in Europe.

Four years after the contamination episode at the Badische und

Soda Fabrik (3A5F) ( two years after the reopening of the plant

a new case of poisoning occurred in a worker who had been repair-

ing an autoclave; during the operation he had several tines lift-

ed his protective mask to wipe off the sweat. Four days later1

dermatological manifestations and neurological symptoms appeared;

six months later he was admitted to hospital for pancreatitis ind

hepatomegaly; nine months later he died; pancreatic necrosis,

liver abscesses and chloracne on the trunk were found at necropsy

The Clean-up procedures at the Coalite plant in England were

inadequate: after the clean-up,79 cases of chloracne occurred

in workers not e:eposed at the time of the accident.

Numerous cases of chloracne developed among workers engaged 021 t±

initial clean-up at the Philips plant in Holland. In the subse-

quent dismantling of the plant strict personal protection was

enforced among the workers, who had to wear ventilated overalls,

and * clinical surveill.ar.ce program was set up centered on the ova

lutation of biochemical parameters before the event and subsequently.at re-ju

iar intervals. Wo major deviations from normal values were ob-

served in the ten workers who complied consistently with the

prevention procedures. In two other workers who had been sent

to the contaminated zone to dilute the contents of some tanks

with water and who had worn on the overalls correctly one

or more liver function parameters were found to be abnormal

eleven weeks later; the values slowly normalised in the weeks

that followed. In no case were there dermatological manifes-

tations. The Philips researchers concluded that the working

methods were effective in preventing exposure to TCDD.

Notwithstanding the vast quantity of data on TCDD that has accu-

lated since the Philips episode, a public health surveillance

program still has to be based on the observation of biological

parameters whose behavior may indirectly reveal exposure to the

poison by showing its early effects (early effect indicators).

Direct monitoring of the intake of the poison (dose indicator),

up to now imply the biopsy of adipose tissue and it is not proposa

ble as a continuous nonitoring of groups of active workers in a

plan of public health surveillance.

2 - M3TEGDS

2.1 Objectives

The general objective of the survey 7;as to gauge the effi-

ciency of tlie safety sieasrares taken during the clean-u? of

areas A*-A3. Tlie safety measures rere taken, to prevent any

significant exposure to the poison but, going by previous

experience, possible e::posure could not be excluded.

2.2 General desicn of the study

The design v/as that of a prospective controlled study (almost

lilce a trial) comparing clean-up -workers and reference groups.

The parameters of interest (essentially clinical signs and

symptoms, biochemical parameters) were measured before, during

and after the period of potential exposure, in both groups

(Fig. 1).

2.3 Population under study

The groups under study vere selected at the .^replacement

examination. The subjects vere sent by the firm handling :.hs

clean-up to Desio Hospital. None had previously been engaged

en clean-up operations.

The preplacement examination took place in trsro stages: first

35 clean-up workers vere selected and then a month later

another 37 subjects rere chosen, 36" as controls and 1 as a

clean-up worker.

2.4 Preplacement examination. Data collection.

For every subject the preplacement examination included:

2.4.1 In t ervi ev-cuest ionary

2.4.2 History and physical examination

2.4.3 Laboratory tests

2.4.4 Lung function test

2.4.5 Neurological examination, nerve conduction velocityaad Electromyography (EMG)

2.4.6 Electrocardiogram (ECG)

2.4.7 Chest X-ray

2.4.1 Int ervi e -ques t.ionary

The main purpose was to obtain informations for the

comparision of the clean-up workers with the controls.

The interviesz-questionary was administered, by two trained

interviewers at the time o£ the medical examination. The

questions included:universal variables(like years of

schooling, marital status, telephone, working history),

habit (drinking, smoking-), drugs intake,

family history and personal history with special reference

to liver disease and skin diseases.

A copy of the questionary form is attached in Appendix A.

2.4.2 The history was taken and the physical examination done by

occupational health specialists of the Occupational Health

Service of Desio Hospital.

A copy of the case record form used is attached in Appen<Sc B

2.4.3 Laboratory tests

The following tests were done:

1 - Glutamic oxalacetic transaminase (SGOT or AST)

2 - Glutamic pyruvic transaminase (SGFT'or ALT)

3 - Alkaline phosphatase-(AP)

4 - Gamma glutamyl transpeptidase (GGT)5 - Bilirubin

£ _ Cholesterol

7 _ Triglycerides

o „ Surface antigen of hepatitis B Virus (HBsA.g)

9 - Electrophoresis of serum proteins

10 _ Blood cells count plus platelets and differential

11 - Total urinary porphyrins

12 - Urinary dejta-aninolevulinic acid (ALA-U)

Most of the parameters were chosen because TCDD is hepa

totoxic and affects the lipid metabolism. An increase

in SGOT-SGPT is to be regarded., as an indicator of cyto-

lysis-, an increase in GGT as an indicator of enzyme in

duction and an increase in AP as an indicator

of biliary stasis.

The urinary porphyrins vere determined because TCDD

is known to exert a porphyrogenic effect.

2.4.4 Lung function test

2.4.5. Neurological examination, nerve conduction velocity,

EMG2.4.5 Slectrocardiographic examination

2.4.7 Cliest X-ray examination

2.5 Selection of groups of clean-up workers and controls

The criterium of eligibility was the fitness of the followingparameters:

1 Males between 18 and 55 years old

2 JTo clinical signs of acute or chronic diseases such as

viral hepatitis, diabetes, chronic liver disease, skin dis

ease, etc.,

3 Results within the normal range for the following laboratory

tests: SGOT,SGPT,GGT,AP,Serum bilirubin,RBC,hematocritfher--i

globin,WBC and differential counts,platelets,urinary porphjyr

4 Ho clinical or instrumental signs of peripheral hervous~sys

5 Normal ventilatory function test.Out of 112 candidates only 72 were found eligible for

the clean-up work and entered the study.Grounds for exclusion <jrere medical problems (Irver disease( a

normal values in laboratory tests), problems relating to the

nature of the u'ork (abnormalities of ventilatory function -/it!

reduced tolerance to the wearing of a mask).

2.5 periodic examinations

According to the protocol, svery subject had to be examined

every 6 months. Moreover, b~ regional lav the clean-up vor^e

had to be examined every 3C working days un~il the end cf the

job. The periodic examinations included physical examination

and laboratory test as required for the preplacement exami-

nation. '

2.7 Final tests

The final tests were done 6 and 12 months after completion

of the clean-up job.

2.8 Data analysis

Given the sample size the power of the tests used was estima-

ted and proved to be adequate for the design of the study.

The frequency distribution for the demographic and other

variables (Table 1) was reported. For comparing this distri-

bution the chi-squared test for independent samples was used.

For the comparison of the continuous variates (Figs. 3-26) one-

and two-way variance analysis was used, by group (clean-up and

reference workers) and by, test (tests done at successive exami-

nations), using the SPSS program. All tests were rated signif-

icant if the probability depending on chance was less than

0.05* (with two tails).

Discriminant analysis was done with a program developed by Da-

vies. The logic of the discrimisnt approach lies in the fact

tjiat significant differences could be identified for the entire

battery of -rests used, where for a single test no significant

difference emerges.

HS3ULTS

The results of the replacement examination and of the firs- 4

periodic examinations are reported here. The results will also

be shOwT. for the subset of incividvials wich underwent all the

periodic tests.

The data are also presented according to the number of hours

worked. The time trend of six selected parameters for each

worker is also indicated.

3.1 Response

The outline of the study design and follow-up response aresho\..i in Fig. 1 .During the follow-up two of the exposed workers died in aroad accident. One missed out after the first follow-upand yet anotherone after the second Another four failed to

attend for the fourth follow-up.

In the reference group the response rate was low: five failedto attend for the first follow-up, seven for the second andthird and another six for the last (response rate « 65%).Among the clean-up workers the response rate was 100% of thosepresent on the job, who needed to comply with periodical controland to be passed fit to continue working;.

_ The fail in the response" rate at the last follow-upwas due to ex clean-up workers (those who had for various r-s*sons given up working- in the zone) . In tha reference croupthe low response rate was due to distance from tha place cfresidence or to emigration to other areas. One control subjeafter the first follow-up was included among the clean-up "/or!ers and from that date ha was s:ccludec from the data analysis

2.2 Base data

3.2.1 Int erview-cues t ior.ary

One of the clean-up workers and four -of the controls were

not interviewed, tnter-croup comparability in respec" cf

certain characteristics is indicated in Table 1 . Age, sc

ucation, marital status, smoking, drinking, previous ex-

posure to heparotcxic substances and liistorv of skin cis-

ease presented fairly similar distributions in the two

groups. Significant differences were found in respect

of history of liver disease and possession of a telephone

at home, which proved to be more frequent in the reference

group.

3.2.2 Laboratory data

Of the laboratory tests done those most relevant for sta-

tistical analysis are the ones that, according to the sci-

entific literature, seem to be correlated with exposxire to

TCDD, viz.'urinary porphyrins, liver enzymes, serum cho-

lesterol and triglycerides. The results of the WBC, plate-

let, serum protein, albumin and gamma globulin tests are

also presented. At the preplacernent examination no sig-

nificant difference was found in the variables studied,

except for alkaline phosphatase, the mean value of which

was higher in the reference group.

3.3 Follow-up results

kDuring the follow-up period nine workers left the job for reasons

unrelated to health. Five workers were rated no longer fit and

r/ere dismissed. The grounds for unfitness were:

1 - in siibject 12 abnormal SCOT (42 mU/ml) and SCOT (75 aU/ial}

values in t /o tests, in October and December 193*!: tiiese

values returned to normal in subsequent tests.

2 - in subject 13 severe hypertension (135-125 rnmKc).

3 - in subject 14 a slight increase in GGT.

4 - in subject 15 persistent presence of H3sAg.

5 - in subject 27 use cf antiepiieptic drugs.

These subjects continued to attend for follor-up examinations

according -c the program for ex clean-up workers. Another sub-

ject cave up tl:e job a fev; days after starting because he cculc

not stand the mask and was lost to follow-up.

3.3.2 Clinical evaluation

No case of skin or neurological disease occurred. Clinical

examination revealed nothing noteworthy. The percentage

of subjects with hepatomegaly did not differ significantl

in the two groups; the higher percentage among the clean-

up workers might be due to the fact that the doctors were

not "blind" (Fig. 2). Mo significant difference emerged

in respect of weight variations.

3..3.3 Laboratory data

The analysis was dene separately for all the cases in the

follow-up period and for a subset of subjects whose data

were available for all the periodic examinations (except

the last).

Dispersion charts for 10 out of 14 laboratory tests in th;

first four examinations are shown in Figs. 3-26 together

with the means and standard deviations.

3.3.3.1 Urinary porphyrins (Figs. 3 and 4)

ITo significant difference was found between the t

groups at successive tests but a significant c:-/f

ence was found for both croxips between tests dens

successive times. But the values were within r:.or

limits, well below threshold values. The same re

suits appeared for the subset of subjects air/ays

present.

3 1 1 o <;r'i",r^ CPS*** f V-t~s *. £. *? o ^* J . J • £. i Urvj A. — a«jr"i \ ~ - CS . 3 , O f / f O , '

Mo significant difference was found, except fcr 3

at third follow-up, when the mean value cf t«s *:••:

posed (17.75 iBC/ml) was higher than in the r.cr. e:-:;

posed (14.28): this difference ~-as also sicr.ifica

within the subgroup of ever-present subjects.

10

3.3.3.3 Alkaline phosphatase (Figs. 9-10)

The significant difference observed in the baseline

test disappeared in subsequent tests.

3.3.3.4 Gamma GT (Figs. 11-12)

No significant difference was found between the two

groups in the successive tests but a significant

difference did emerge for both groups between suc-

cessive tests.

3.3.3.5 Bilirubin (Figs. 13-14)

Serum total bilirubin behaved in the same way as GGT.

3.3.3.5 ALA-U (Figs. 15-16)

The same applies to ALA-U.

3.3.3.7 Cholesterol and triglycerides (Figs.17-18-19-20)

Ho difference was observed.

3.3.3.8 Other laboratory tests* !

A significantly lower vTBC count was found in the

clean-up workers at first follow-up (Figs. 21 and 22)

and the same applies to platelets (Fig. 23). -The

serum total protein value was higher than in the con-

trols (Fig. 24) and a lower mean serum albumin (Fig.

25^ in the .clean-up workers in the.preplacemeat exam-

ination only in the subgroup of the ever-present.

A significantly higher gamma globulin value (Fie.26)

was found in the clean-up workers at second follow-

up.

3.3.3.9 Analysis of the biliary data

In order to identify deviations from the normal val-

ues, some variables were converted into binary data,

above or below the threshold used at tl:e ^replacement

examination. The frequency of ovitside range values

was too low'for statistical analysis: r.o r.orercrt.v-<$•' 6 ••

11

3.3.3.10 Discriminant analysis

The dispersion chart of the scores obtained by

discriminant analysis of the values of eleven

laboratory tests is show, in Fig. 37. Mo sig-

nificant discriminant function was identified.

3.4 On-job hours and laboratory tests

The clean-up workers were divided into three subgroups by the

number of hours worked in zone A at the time of the second

follow-up. Seven had worked less than 200 h, nine from 201 *o

400 h and twenty more than 400 h. JTo significant difference i-

in the mean values of the lab tests was found at the first and

second follow-up (Table 2N-.

3.5 Individual assessment of the clean-up workers

It must be stressed that, while the program of tests for the

reference group envisaged an examination every six months, the

clean-up workers und'ertrent medical checks every 30 days as lor

they continued on the job. The number of examinations of th:« •-

group was between 2 and 20 (mean 12.41). In the foregoing*'•'-, *analysis we have considered only the five for which the controdata are also available. Figs. 38 to 73 show the time trer;-*-.of six selected parameters (porphyrins, 5GCT, A?, GGT, cholest-erol and triglycerid.es) for each worker.

The analysis of the test shows that in ten cases (nos. 4,10,1620,22,23,27,37,32 and 35) 210 variables increased by more than100% of the baseline value curing the follow-up period; in thiteen cases (nos. 1 ,2 ,3 ,3 ,6 ,14,15,13,19,25,29,30 ar.d 33) f:erewas an increase of more than iCCf. in at least one parameter bvialways within the normal rar.ee. In another thir-eer. cases ''-i3 ,3 ,11 ,1 2,: 3,17, 21,24, 26, 2S, 34,36) there was an increase of .,-,cthan 1 CC'= in at laast ons sarsnister wi~h values bevond the ?.c~*

12

range: in six cases the increase was in the triglycerides, in

three in alkaline phosphatase, in one the urinary porpliyrins

and triglycerides, in one case transaminase and triglycerides

and in one case GGT.

CONCLUSIONS

The program of surveillance for the clean-up workers in area Al-

A5 of Seveso was undertaken to check the efficiency of the safety

measures taken during the clean-up operation started in May 1930.

The principal conclusions are:

1. During the follow-up period no case of clear clinical disease

that, could be attributed to TCDD (chloracne, peripheral neurop-

athy, liver disease, etc.) occurred.

2. Of the five workers rated unfit after the commencement of the

job one had abnormal liver enzyme values in two tests, which

subsequently normalised. There was no known cause of the in-

crease and so a transient effect of TCDD exposure cannot be ex-

cluded, 'although the contemporaneous weight gain (more than 15

kg) may suggest nutritional causes.

3. Mo definite difference between clean-up workers and controls

was found in respect of the laboratory tests. The .same con-

clusion was reached when the data were treated as binary data

and discriminant analysis was applied to i3 lab test variables.

4. The analysis of the time trends of six variables in the clean-

up workers shows that some variations occurred in the trigly-

cerides: these are, however, :r.ore likely to be due to biologi-

cal variability or to insufficient precision in analysis.

In sum, the survey failed to show biologically significant features

13

such as to suggest that the workers engaged on the clean-up

operations in the highly contaminated zones can have absorbed

TCDJ5. The safety measures adopted seeni to have provided

effective protection for the v/orkers.

Desio, 30 July 1983.

TABLE 1. Distribution of Detaographic and Other Variablesin Clean-up and Reference Groups

Characteristics

Mean Age

Education(Tears completed)0-56-910+

Marital Status

Never MarriedMarriedSeparated, DivorcedWidowed

*

Smoking Habit(Cigarettes /day)

Non-smokerEx-smokerLess than 2020 or more

Alcohol Consumption(cc./day)0Less than 4040 or more

Previous Exposure to

Clean-upWorkers

31.2C-.74

13157

Ch£ s<? j|'59

13-152

Chi sq.-j3.54£u£

11

2.1111

Chi sq.-2.56

7919

Chi sq.-l.13

ReferenceWorkers

32.. 7

19103

-19100.

35712

61214

Hepatotoxic Substances

YesNo

332

725

Chi sqf-|.33

•i TA3LZ 1. Distribution of Desographic and Other Variables, ' (Continued) in Clean-up and Reference Groups

Characteristics Clean-up ReferenceWorkers Workers

Telephone at Horns

Yes ' 13 21No 22 . 11

History of Dermatitis

Yes 6 9No 29 23

Chi .

History of LiverEnlargement

Yes 4- 12No '29 23"

Chi sq,-$.25~

Past ?hysician*sWarning on Liver Disease

Yes 4 4No 32 28

Chi s

' Significant at ? less than .05

f 1

!-..i? »esulls of various laboratory tests (mean and afrwJW (tt\»latio») at the ^re-employment examination, after 3 and !) monllts inuorkorSt^lvidetl according to the number oMiours spent in AT, A2 zones"

Number ofhours

Total urinaryporphyrlne(^icj/cj.crcat.)

SCOT (U/l.)

SGPI (U/ l )

Alka l ine|»hosfaUse(U/L)

Uaiiima-GI (U/l.)

TotalD i l l nib ln(Mj/dl)

I'M (sue)

llciuoijlouin (y/dl)

HIC (xl03/«»u3)

I'laltilcts(xlO3/™3)

Al lHMln(g/d l )

(i.iiiiua-GlobuUne(<|/dl)

Cholesterol Scrumlevel (my/Mllt

I t lij]y«:«!r idc^f HHI/j l l )

pre-uN|>l.ex.

71.17(24. 19)

20.71(LSI)

23.71III. 32 )

23.06(&.03)

30.00(10.07)

.73(.13)

27.25(2.43)

15.1)0(.ifl).»

6.46(1.60)

216.14(47.34)

4.00(.220

1.021.12)

242.43(60.30)

1-U5.43, .....

less than 2003"1 mnrith ex.

09.20(47, 26)

10.03(6.06)

20.33(3.67)

34.03(a. la)

31.67 '(J2.14)

.50(.16)

27, 511(3.22)

. 15.93j (.34)

7.15 /p5.4fi)

230.17(43.06)

4.97(.45)

.96(.12) .

223.50ft 7. 60 j

155.17

9l" month ex.

60.43(IG.67)

10.29(4. |»fl)

19.14(fi. ?2)

27,71(5.02;

26.29(fO.97)

.67(.IB)

29.67(3.2?)

16.31f . f i f f )

6.06(I.flfi)

222.00(40. 0fi)

4.9U(.3C J

.94(.11)

215.71(63.&0)

131.1)0

fp|re-eiM|il.ex,

93.57(S4.&&)

15.66(2, 70)

16.70(&.V3)

34.67(IJ.2B)

10,70(12,36)

.66(,ie)

27.06((. ?D

16.06(.00)

6.73(1.30)

200. U9(42. If)

4.62(.33)

1.22(.17)

ID4.7U(33.2fc)

i?2 .G6jJ /.1/J.H.SI

m 201 to 4003rd month ex.

75.09(3f.$*j

14.67(2.J2)

14.09(3. 10)

37.11(6.4&)

23.11(12.00)

.62(,J7)

26.29(2.2r;

16.01(.02)

6.67(3.2SJ

209.56(44. U)

4.96(.«)

1.17(.22)

J92.70(30. 00)

109.66

/40.&£<;

9ln month ex.

01.00(2T.O&)

12.67(3.24)

12.00(2.00)

33.56(7.04)

20.56( 7.62)

.69(.16)

29.59(2.57)

16.51(.9.1)

6.ni(I. 72)

200.71)(36.77)

4.29(.16)

1.15(.12)

192.09(20.55)

r U C . S f c "

•; * ±..42*

(iru-cutpl.ex.

96.44(44.20)

15.20(3.02)

17.70(4.07)

27.20(fi. 71)

17.95(0.0 J )

.66(.13)

25.55(2.33)

15.64(.73)

6.09(1. 10)

193.25(34. GO)

4.70(.33)

1.21(.20J

174.11( 25.22)

101.37

( 42.3fi)

more than 400

3 Mionlh ex.

70.55(38.01)

14.75(*.,'.«)

19.35(ii.Oi.)

32.15(7.61)

20.115(7.2J);

.65(.12)

26. GU(2.00)

15.65(.7G)

6.'J/(J.lrt)

206.20f<i7.3&)

.4.70(•36)

I .H)(.20)

179.60^23. 61)

'b.y

Ulii.Zll)

9 ' HKHitl

C6.9f>(2/.

13.60(3.D.

16.110(a. ;

2U.70(/.

in. us(x./

.67(.7;

20.77(/-

lu.16( . 1*

6 . i r >('•'

I'Jfi.ifO(3«

5.05(-1

1.16<"-J

ID3. no( 2'

134.30

(•'••

'IG. 1 OUTLINE OF TEE STUDY DESIGN AND r'OLLOW-Oi'CLEAN-U? AND REFERENCE GROUPS

List o Workers

Eligible (n-72)

Clean-up Workers (n«36)

Non-Eligible (n*41)

Controls (n*36)

PreplacsmenrExamination

lesDoncents Non-ResVxondents Pvescondents Non-Respondents

1s u Follow-un

•* _ , i2 Fbllow-un

3rd FoUow-UD

4 Follow-ID

FIG.2 PROPORTION OF LIVER ENLARGEMENTAMONG CLEAN-UP AND CONTROLS.

CLEAN-UPYORKERS

CONTROLS

X Llvor F.nlnrrjniiiQntG cm. orO.

5

1 1-

JAM1 1 1 1

JAM JAN

F i g. 3 • URINARY PORPHYRINS VALUESIn cloan-up and refGrQnco groups

(mcg/1) C R U 11 R

10

o0

,,.*"•J

i-i

i-i

* *•i

Tf i*M-

i•i-

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if,*

EXAM

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^ i

; . - ,'•• 1 ' i j r

qmx* icloan-up

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F i g./4 .URI NARY PORPHYRINS (mean' sd)in cloan-up and reference groups

EXAH | EXAH 2 EXAH 3 ,!ii|Mii If leant betwucii-bxautt mena d

HXAH 4 EXAH 'J

VCllUQSFig. 5 S G Uin clean-up and reference groups

1.U./B.1 'C* -f K R R R

0

10

in

o

.,.(09)

titt

(51)

i i

i

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EXAM• i • •

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CROUP IctiCHT-ynIZZZ3GROUP 2reference[XXX]

Fig, 6 S, G, 0, L GnQan+sd)in clean-up and referenca groups

EXAM I

i: Hcnut

EXAM 2 EXAM 3

a inetm

EXAH 4 EXAH 5

m

0l .U./ml

V'* .•'*:

Fig.7 S G P T valuesin clean-up and reference groups ,'

— ,'/••,

a /. ((64)

0

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10

t

r||-

Hl

* trf

fc

I1 1

t*V v• -1- :t

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EXAM• i • »

:?&••Fig.S ALKAL PHOSPHATASE valuQ

in clean-Up and reference groups

o1.U./1 K R R C H

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10

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+

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0

S. G. P, T,ir» clean~up and refer once groups

EXAM 1 EXAM EXAH3 EXAM 4 L'XAH 5

.WJP Iaon-Mp

ZZJ-2

foroncQ

''10

0

F i g:10ALKAL, PHOSPHATASE (mean+sa;in cjQan-up and reference groups

l.tk/1

EXAM 1.- EXAM 2 EXAM 3

Hi|;nt.fleant l>etuceu~^&-o|i|ia |iiona*difference.

EXAH 4 EXAH 5

-..-•** «•-

•pi

n

Fig.tl G G T P vciluQsin clQcnvup and rQfQrQncQ groups

LU./I c R c ' n-1 1 (55) +(51)

1 . 1 +•l- -f -I- -|-

-1-

•I- 1-•1- •!•.•-,. .•.,.

•1- -1-

** ;: •* f"1** *l* "1* *•*

h t -H- -1^II. 1. fl- If

1 i1! ' r"1 't I *

i 1- •!• -f- T*H-.'I fo tt.- *+| J t „

•1- T

-|-|.

1 1

1

*

C ft . 'C R

H+(b7)-l-(b1) +(52)

' t4

-II--1-+ *'"T i•1-

•|* 'K.1. " 1

1 '., +f.,. ., f ^ r .,. ,.

1 t \-II 4- ^ 114- -I-

A w \ If

V + • +1 tit+ + *]> i

H-'I,•1-

i i

EXAM• • I •

cJucuruo

CROUP 2rafaranoBfXXX)

I.U./l

40

0

Fig. 12 G,G.T,P. (rnean+sd)in claan-up and rcfGrenco groups

EXAM S

,n if Scant

EXAM 2 EXAM 3 EXAM 4 EXAH

vu i

in cloan-up and rGforence groups

.4

1.2

1.0

.0

.0

MCJ R R R

.2

0.0

l

•il-l

•I-H-

•H-f

l-l-

•I-

III

II

III-

h

II-

I

•i-i-

•n-

1 1

•in-

•H-l-

f +

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•i-i-i-•in-

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ii

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ii h

EXAM

. .*&,S//7V/-

• V-Vt

J t *.— J tiH .

IcJorrt/)t//)

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Fig.14BILlRUBIN (moan+sd)in clean-up and PQfaronce groups

L-XAH 1 EXAM 2

inn 3 f leant l>ctwcun-exjuii«0

EXAM 3 EXAH

(Ufterejice.

EXAM 5

Fig. 15 U - ALA valuesin clQan-up and rQfQrQncQ groups

•g/1 R 11 (t

G I

t

ll-l-

f|

II

*•*

•It

f14t\ -II-

-I-

*

'tf*

4t++t

ft

0

EXAM• i » i

-). i: i I J :*- 3 -

cjaorrwiIZZZ1

2rafarancaIXXX1

o

Fig. 16 U - A L A dnean^sd)in clQarrup and rcfenQncQ groups

EXAM I

8 i I'M i. if leant

EXAM 2 EXAH 3

mean

EXAH 4 EXAM 5

Fig.,17 CHOLESTEROL valuesin clean-up and reference groups

A

t»•t

**

*+*Tt*

»

t

K+ •

nEXAM

i = ! t- J L.:. j u i «- 1 L. I' i. 1 l.

IZZCROUP 2

IXXX1

F i g, 16 CHOLESTEROL (inean-«-sd)in clQQn~up and raferonco groups

300ng

200

100

0CXAH I EXAM 2 CXAH 3 EXAM

\

CXAH 5

0

F i g. 19 TRIGLYCERIDES valuesin clQan-up and refQrQncQ groups

U it R K

•I" «. -f-

I ... +*' *

1

... *+ t'1= + 1

+ t** «... t *1 + 1- Til t.i. "•"<"•i.1 4

i ! *, -*? tit / ft-J-. -j'H' -f . '.|:|-:j: J :|'+ I] -|-.|;|.:' M ,;|; ^ *1, ':| +*+ tl*t * **

1 1

^.(6/0) ^.( 329) 4. (300)

•I-

1

H '+ '' 1t

*i **f t + t*

a. * *I I*iL'l* J'l fc *

- .. *4.r-(- -t+tr 4:|- I-* *!• aL « * 1_*/ l '; '»

. ; . + '<t •« ' •

i i

EXAM

GliOUP IcluarvpI7-771

GROUP 2referanctiKXX]

Fig;2QTRIGt¥GERIDES (niQan+sd)in clQarrup and reference groups

300

wo -

0HXAM 1 EXAM 3 EXAM 4 EXAM S

> Fig.21 LEUKOCYTES valuesin clean-up and reference groups

/ MtttQ K \\ H R

•i-i+

H:|:i::

\ *.

*

•it

ti '•it

*h

+1-

*.t

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V

4*;.

o oEXAM

i £~:.; « -. j ;

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F i g.22 LEUKOCYTES (mean'sd)in c)Qan~up and. reference groups

EXAM f EXAH ^

Hi I'.ni ficnuL iiel:wccii-Biioui>B

EXAM 3 EXAM 4 EXAH 5

CTrtJW* IcJanrrt/p

177712

rtiforoncQIxxxi

400/•mo

200

0

F i g.23 PLATELETS (meon+ed)in cloan-up and roferonce groups

EXAM i EXAM 2 EXAM 3 EXAM 4 EXAMS

" SI I mi If tcnnt liQ|.wiicn~exaroa menu difference,

, . 1.. .. . ; - ' - • t""J .-- .; L. , .

CROUP 2roller oncafXXXI

o

Fig..24 SERUM PROTEINS (mean+sd)in clean-up and rofo^QncQ groups

EXAM 1 F-XAH ^ EXAM 3 EXAM 4 EXAM 5

GROUP ic hum-up

EZZJGROUP 2

rnfnronca

100

00

20

0EXAM 1

Fig.25 ALBUMIN (mean+sd>in clecm-up and reference groups

EXAH2 EXAM 3 EXAM 4 EXAM S

1. i

GROUP 2rnfttrflncoV77777A

F i g. 26 -GLOBULINS (mean-'-sd)in cloan-up and pQferencu grou|i9

i

l-XAH i EXAM 2 EXAH 9

. '«i i>nifleant j>ct:wecn-ftroupa nieiuf (Difference.

l-XAH 4 EXAM 5

Fig,27 PORPIIYRIN PATTERN IN CLEANUP ANDCONTROLS, DY EXAM (CUT-OFF=250)

CUE/UNI'HOUHAI.

ci r.AN-in»AIJNOKMAI.

NURHAI.

IZZZJ

ADMOHMM

50NllMHiR «: SUBJECTS

30

20

10

0EXAM I EXAM 2 EXAM 3 EXAM 4

I "3 f I . I I

CMIAN-lf*NMIMAL

AN II'

MOfvHAL

CONIROLSM1HOHHM.

fiq.28 SCOT PATTERN IN CLEAN-UP ANDCONTROLS, BY EXAM (CUT-OFFMO)

50NUMUBl OF SUUI£CTr>

30

20

10

KXXX sxxx

CXAM I EXAM 2 EXAM 3 I-XAM 4

in*mm[IIIZlCLEAN UPADMOIIMM.

CONIHOLSNURHAL

\ZZZ\

CQMIROL8ADIJOHMM.

fig.29.SGPT PATTERN IN CLEAN-UP ANDCONTROLS, BY EXAM (CUT-OFFM2)

50NUMBER (H:

40

30

10

0 l-EXAH 1 EXAM 2 EXAM 3 EXAM 4

J . 1 . I v'~1

Cf£AN-U>NORMAL

IZZZICLFAN Ul»AI1NOUMAI.

CONIKOI.SNURHAI.

\ZZ73

COHntOLSADIIOHHAI.

50

30

20

10

0

Fig.30 A.P. PATTERN IN CLEANUPAND CONTROLS, BY EXAM(CUT-QFF=50)

mm OF

IIXAM 1

• [7

EXAM 2

IXXXXl

EXAM 3 EXAM 4

QJNJFJUHJPHW.

CI.KANUI'ADNOUMAL

CONIROISNORMAL

IZZZJCl)WIU)L!>AONOiiMAI.

Fig:3t GGTP-PATTERN IN CLEANUPAND COMTROLSrOY EXAM(CUT-OFF-50)

50NUHOtlt OF SUBJECT?}

30

10

/ 0

JXXXX

EXAM 1

IXXXX

EXAM 2 EXAM 3 l-XAH 4

(LEAN-UPNORMAL

I |

CLEAN-UPADNOHHAL

COMllfflLSNORMALizzziCONVBOLSADNQKHAL

50

20

10

0

Fig.3.2 BILIRUBIN IN CLEAN-UP ANDCONTROLS, BY EXAM <CUT-QFF=M)

NUHOER OF SUBJECT

EXAM I EXAH 2 EXAH3 EXAH 4

C1.EAN-UI1AHNOUMAI.

COMTROLSMDRHM,

IZZZ]

CONIHOLSADHOIJHAL

Fig.33 WBC PATTERN IN CLEAN-UPAND CONTROLS, OY EXAM (CUTOFFS. 5)

50NUHIER OF SUOJECTp

30

20

10

0

xxxx

EXAM 1 EXAM 2 TiXAM 3 EXAM 4

i J

• \

NORMAL

Cl I AN WADNOHMAL

com iaiisNORMAL

IZZZJCONTROLSAONOIiMAI.

f\g.34 U - A14 PATTERN IN CLEAN-UP AND• CONTROLS, OY EXAM (CUT-OFF=6)

MUHI)L:II (M: SUDJECTS

30

10

sxxx;

CXAH I I :XAH2 EXAM 3 UXAM 4

EAfH»>

CIITJCII:AN IH»ADHOIJHAl.

CONIHOLHORMM.

IZZZICONTHOI. SABtiOHMM.

FigJ35 CHOLESTEROL IN CLEANUPAND CONTROLS. OY EXAM(CUTOFF=270)

50NUMfO OF SUBJECT?

30

20

10

0

tin

EXAM 1 F.XAH 2 EXAM 3 EXAM 4

NORMAL

Cl.nAN-UPAIMUIHAI.

CONIUUl.SNORMAL

CONTKOLSAOHOKHAL

50

30

20

10

0

Fig.36 TRIGLYC. IN CLEAN-UP ANDCONTROLS, BY'EXAM <CUT-OFF=1GO)

OF

I:XAM EXAM 2 EXAM 3 EXAM 4

OH 13 1J\IK)HATOUY TESTS IN CI.EAN-UI* AND REFERENCE GROWS. BY EXAM.

CLEAN-UPVOKKERS

REFERENCE

u

0

0

1 + 1I tt.

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JMHSP.33

C.T.I*.i l l . H P 10

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Fin. 40 TIME TRENDS OF 6 PARAMETERSJ CLEAN-UP WORKER #3i V. F., 39 yrs

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V Variation

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Fin,47 TIME TRENDS OF 6 PARAMETERSJ CLEAN-UP WORKER fflOiF.L.39 yra.

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X Variation

100

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Fin48 TIME TRENDS OF 6 PARAMETERS INCLEAN-UP WORKER //11«L. A., 30 yra.

X Variation200

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X Variation

JAN JANFoUow~ii(» (Kirlocl (3-00/J2-02)

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io.50 TIME TRENDS OF 6 PARAMETERS INCLEAN-UP WORKER //13? A.F., 46 yrs.

X Variation

1IYIUN5

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TIME TRENDS OF 6 PARAMETERSCLEAN-UP WORKER //M:G.C.,<I4 yrs.

IN

JAN , • JANFol 1 ow-up por I (id (3-00/12-02)

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fin.52 TIME TRENDS OF 6 PARAMETERS INJ CLEAN-UP WORKER //15, S, G.. 24 yrs.

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Fia 53 1 1 ME TRENDS OF 6CLEAN-UP WORKER //16«E.P,,30 yre.

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Fin.54 TIME TRENDS OF 6 PARAMETERS INJ CLEAN-UP WORKER #17iG.R.,35 yrs.

Variation

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Fiq.55. TIME TRENDS OF 6 PAKAMtlhKb INw f^i r~ i ii t ir\ t.ir\r\i/r~r\ 111 f\ i r* *\ MCLEAN-UP WORKER //lOsA.C.,34X Variation

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Fiq.56 TIME TRENDS OF 6 PARAMETERS INCLEAN-UP WORKER //19: $. C., 23 yrs.

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X Variation

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CIIOI,oollnQ=107

1IUGLYC.iuullim:>225

Fin.72'TIME TRENDS OF 6 PARAMETERSCLEAN-UP WORKER //35a T. C., 33 yrs

IN

X Variation200

-100JAN JAN

Fntlow-un narinct (3-QQ / 12~02)

mm

J.T.

lim-41

T. I1.

IOL

CI.YC.llmHM

R.q.75 TIME TRENDS Uh b lJAKAMtihKbJ CLEAN-UP WORKER //36i A. S., 23 yrs* Variation

i.i.i—i_J—i—i—i 1 . 1 , 1 i—i—i—<—i-100JAM JAH - , JAN

FoJJoir-tyj period (3-BO / 12-1)2)

APPENDIX A

FACSIMILE OF INTERVIEW QUESTIONARY

Study en the surveillance of the cLean-up workers in the TCDD/decontamination/ Seveso, Italy.

Date of the interview

Starting time

Interviewer's number

Interview number

A - Personal Data

Al - "What is- your full name?"

A2 -"When were you born?" (Specify day, month and year)

A3 - "Where were you born?" (Specify Town and Province)

A4 -"What is your address?" (Specify street., number. Town,, nrov. , •<postal code)

AS- "Do you have a telephone?"

Yes ..... /___/

No /__/

I don11 Know / /

JTo answers / /

If YES, go to A6else, go to A7

A6- "What is your telephone number?"

I den11 knew / /

A7 - "Vfhat is your present civil status?"

Single ............... . /__/

Married ..... .......... / _ /

Separated ............. / _ /

Divorced .............. / /

Widow/er ........ . ..... /_/

Other (specify) ...........

answers ............ / _ /

A8 - "What is the highest educational record you have got?"

University degree ............. . . / _ /

High School ..................... / _ /m-

Secondary School .......... ^ ..... / _ /

Primary School ............. ..... / _ /

Other ( specify). ..... ............. / _ /

No records ..... ^ ................ / _ /

I don ' t know ...... ......... .'„... / _ /

No answers ....... ............... / _ /

A9 - "Did you do the military service?"

NO .. .......... . ---- /_ _/

I DON'T KNOW ....... '/ _ /

NO ANSWEHS ......... / _ /

OTHER (Specify) ---- / _ /

If NO, go to A10

else, go to A12

A10 -"Why did you net do the military service?"

Health reasons / /

Family reasons / /

Other (Soecifv) / /

All - "In the last month, have you been smoking cigarettes?"

YES /__/

I. CANNOT REMEMBER / /

NO ANSWERS / /

OTHER / /

If YES, go to A12

else, go to A17

A12 - "How many a day?"

A13 - "At what age did you start smoking?

I cannot remember . ... / /

No answers ........... / _ /

A14 - "How long have you been smoking?"

YEARS ............... /__/_/

1 CANNOT REMEMBER . /. / _ /

A15. - "Over the last five years, the number of cigarettes you

smoke- a day hast

INCREASED -.. .............. / _ /

DECREASED ............... / _ /

THE SAMS ............... / _ /

I DON ' T KNOW .... ......... / _ /

OTHER (Specify) ....... . .......

In case of increase or

decrease, go to A16, ej.

Se, co to A17.

A16 - "Why?" (Specify)

Go to A21

A17 - "Have you ever smoked in the past?"

If yes, go to 1£else, go to A21

A18 - "How old were you when you smoked the first cigarette?"

AGE /__/I CANNOT REMEMBER / /

AlSbis - "Have you smoked more than 5 packets of cigarettes inyour life?"

If yes, go to Al9 YES .,, . . / /fc „, NO I. .. / /

else, go to Dl ' —

A19 - "For how many years have' you been smoking?" / / /

A20 - "Kow many cigarettes a day were you smoking in that period?"

NUMBER OF CIGARETTES . . ..... / _ /^I CANNOT REMEMBER .......... / _ /"

ALCOHOL

31 - "Have you ever drunk alcoholic drinks like wine, licuors, beer?

YES ................... / _ .NO .................... /__I DON ' T KNOW .......... / _OTHER (Specify) ........

NO ANSWERS ............ /

If YES, go to 32else, ao co Cl

32 - "At what age did you start drinking aLcohcLic beverages?"

YEARS ...... .............I DON ' T. KNOW ............NO ANSWERS .............. /OTHER (Specify) .......... .

S3 - "At present, are you drinking alcoholic beverages?

YES .................... /__,NO .....................I DON ' T KNOW ...........NO ANSWERS .............

YES, go to B6

else, go to 34

34 - "At what age did you. give:, up drinking alcoholic beverages:

YEARS /I DON'T KNOW /NO ANSWERS v . . /__

\BS - "Why did, you give- up drinking alcoholic beverages?"

I DON' T KNOW /mNO ANSWERS -''

Note for the interviewer: —•"*- read DRINKS if yes at D2, else read DRINKEO

/

26 - "Could you specify what kind of alcoholic beverages you usual"

WINE ..... .............. /BEER ................... /OTHER (Specify)

REGULARLY DURING MEALS /_REGULARLY DURING AMDBETWEEN1 MEALS . . .* /_REGULARLY BETWEEN MEALS /_I DON <T KNO:; /~NO ANSWERS /_

20 - "On these occasions, how much do you drink?" i•

WINE /__/1-2 glasses a day / /Two fflaases to half a liter a day / /Half a liter to one liter a day / /More than one liter a day / /I don' t know / /No answers / /

BEER /__/1-2 glasses a day ~ / /Two classes to half a liter a day / /Half a liter to one liter a day / /More than one liter a day / /I don' t know ..*».., /• /No answers * / /

32 - "Have you been drinking these drinks in the last week?:vrh i sky t Br andy, Bitt er s, et c. ? "

YES / /NO /_/I DON'T.IOTO:: / /HO ANSWERS ... / /

If YES, go to 310else go to Cl

BIO - "What kind of hard liquors have you

ALCOHOLIC APERITIFS /_BITTERS-DIGESTIVES /"KAU-DS-VI2. . /"COGNAC /"WIIISKY /COFFFT: WITH LIQUEUR /OTHER.' "

7)

•311 - "You usually drink these drinks:

OGCASIOKALLY / /REGULARLY BEFORE . OR AFTER MEALS / /RSGULARLY BETWEEN MEALS / /REGULARLY DOTH ON AND BETWEEN MEALS / /

I?-12 - "On these occasions, how Tiuch do you drink?"

ONE TO TWO LIQUEUR GLASSES A DAY / /THREE TO FuUIl LIQUEUR GLASSES A DAY /__/MORE THAiT FOUR LIQUEUR GLASSES A -DAY /_/

Cl - "In the last two months from today, have you been taking medipills, suppositories, syrups., etc.

YES .,,....NO /__/I DON'T Ktfow / /NO ANSWERS / /

If YES, go to C2t

else/ go to Dl.\ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ • • • • •• •• •I M BI MB MB M MI ™ ™™ *

\\

12 - "Would you please tell the names of the medicines you have

1)2) ; .3)4) .

Eor. each medicine at C2,

go to the cuestions C3,C4,C5

C3 - "Have you been taking I) ,.2), 3), 41 for more than one week?"

YES 1} /__/ 2 /__/ 3 /_/ ^ /"NO /___/ /__/ /__/ /I DON' T KNOW /__/ / / / / /.\T0 ANSWERS / / / / / / /

8)

C4 - "What troubles caused you to take 1), 2), 3), 4)?"Note: Specify the type of trouble for each medicine

CS

1}2)3) iA] '

- "Did the physician prescribe the mpriicine 1), 2), 3), 1)?"

1) /_/ 2) /__/ 2) /__/

Y E S / / / / / /

I DON'T KNOW1TO ANSWERS ..

CS - "For how long have you been taking the medicine i), 2), 3), 4)?'

1) YEARS / / / MONTHS / / /

2) /_/_/ /— /— /3)- /_/__/ /__/__/

Dl - MEDICAL HISTORY

"Have you ever suffered frotn any of the following trou'-.las ordiseases?"

YES NO I DON'T REM. I DON'T KHO'.: VTAll OF 3

Acne /__/ /__/ /__/ /_/ /__/Soils /__/ /__/ /_/ /_/ /_/Viral hepatitis /__/ / / / / / /• / /Chronic hepatitis /__/ / / / / /__/ / /Hepatic cirrhosis / / / / / / / / / /Epilepsy /___/ /__/ /__/ /_/ /___/Gail-bladder and/orbiliary ducts stones / / / / / / / / / /Diabetes /__/ /___/ /__/ /'___/ /__/

For each YZ3 at Dl, ask for D2 and fill in the above cclu~n, elsec:o to D3

D2 - "When dirt it start ...... (read the disease)?",

D3 - "Have you ever been hospital -zed?"

YES .......................... /__/NO ............ ............... /_/i DON ' T KNO;; ................. / _ /NO ANSWERS ................... /__/

If YES go to D4, else go to D9

D4 - "liow -nany ti-aes have you been l-ospitaLized?"

Number of ti-ru?s / /

D5 - For each time, write th<? disease, tlie year, t'.ie Hospital name and the town where it is.

"For what disease have you been hospitalized t'-te (1st,2nd, 3rd) time?

D6 - "When did it happen?" (year)

D7 - ' "What is the na-.e of the Hospital?"

D8 - "Where is the Hospital?" (town)Number of Year of

Disease _ cIoapita^izationa-.HoapitaJLization nosrital £Ta-*r~ "

D9 - "Please/ tell us the name and the address of your physician1

DlO - "Have your physician ever told you that your liver is iconditions?"

YES /_/NO /__/i DON'T :-:sow / /I DC17' T XEMEM2E?. / /

10)

Dll - "In th •» last two years, have you ever lost Tiore* than 5 :'ilos1 without being on a special diet?"

YES .: /__/NO /__/I DOT' T KNOW /_/I DON'T REMEMBER / /

If YES go to 012, else go to D13

D13 - "Why did you lose weight?

D13 - "In the last t\ o years have you rvrr been under treatment againanaemia?"

*.

YES /__/NO /__/I DON'T KKO»: / /I DON-T REMEMBER / /NO ANSWERS / /

If YES specify* tee treatment

D14 - "Have you ever suffered from skin troubles because of exposuresunbeams?"

YES /__/NO /__/I DON * T KNOW / / •NO AN5:vEi1S / /

If YES go to D15 else go to El

D15 - "Please describe these troubles"

Dlo - "Do these troubles reappear after each exposure to sun1"cans "

YES .... .................. /__/NO .... ................... /___/I DON • T KNOW ............. / /

ENDING TI::E OF T"nr QUESTIONNAIRE / / / / /

El - " la the interviewed hard of hearing?"

YES /__/NO /__/I DON ' T KNOW / /

E2T - "Can the interviewed speak and understand Italian correctly?"

VES /__/NO /__/I DON'T . K2JOW ./ /

E3 - "In which day of the week was the interview made?"*

Monday / / _Tuesday / /Wednecday / /Thursday / /Friday / /

APPENDIX 3

CASE SHEET USED F02 MEDICAL EXAMINATION"

DE3IO HOSPITAL

OCCUPATIONAL HEALTH SS2VICS

Chief Physician: Prof. I.Gaessi

CLINICO-SPIDEMIOLOGICAL SURVEY

MDL - 1 ICM3SAMDL - 2 CLSAN-U? "C25C

Desio Hospital

Surname and name

place of birth date

Registered residence tel.

Usual address

Marital status

married unmarried nridower separated divorced

Occupation

Exposed control

Treating physician

Examining physician

f iW^T V *-~ O'rAi'iiijI .~_o_

FatherMotherC T 7 -' v> (»<;

PHYSIOLOGICAL HISTORY

Birth at tern premature

Delivery normal dystocic twin

Development normal precocious late

Schooling1 compulsory high school university

Military service:

yes force

no health reasons :

yes

no

•

Marriage: no

yes at ... years

no. children

no. abortions

Present occupation

Previous "

'for risks see cuesticnarv^• «» '

smoking (see questionary) } only

drinking (see cv.estionary) C

drugs (see questionary • )

Diet

poor • normal plentiful

Digestion: normal yes

no why

Bowel movements: normal constipated loose

Urine output: normal yes

no

Sex life:

reported normal

reported abnormal since which year

why

PAST HISTORY: (supplemented by cuestionary)

Diseases:

Hospital admissions

Accidents

Allergies

*

PSBSEHT HIS.TOKY: (past year)

Visual apparatus

disturbances

diseases

Auditory apparatus

disturbances

diseases

Respiratory system

disturbances

diseases

Heart

disturbances

diseases

Digestive tract

disturbances

diseases

Urinary system

disturbances

diseases

Limbs

disturbances

diseases

Masculosksletal systemdisturbances

diseases

Skin

disturbances

diseases

Nervous 33/31 em

disturbances

diseases

PHYSICAL EXAMINATION

Height Weight kg Usual veight

Constitution:

longilineal normal brevilineal athletic

thin medium fat obese

3P max min Heart rate

Slcin: normal

abnormal

specialist examination

Subcutaneo\is tissue. Abnormal findings

no •

yes wh

Lymph nodes. Abnormal findings

no

yes specify

i-tisculature. Abnormal findings

no

ves specify

Skeletal system. Abnormal findings

no

yes specify

Head: mobility ache yes

no

eyes abnormal findings no

yes

ears: abnormal findings nonose: yes

mouth: oropharynx abnormal findings no

yes

teeth abnormal findings no

yes

Neck: abnormal findings no

yes

Respiratory System: abnormal findings no

yes

if yes: chest deformity

"F.V.T. (fremitus - vocal - tactile)

: percussion

auscultation

Mammary Glands: abnormal findings no

yes

Heart: abnormal findins no es

Abdomen: abnormal findings no

yes

Liver: normal findings yes no

in any case: :

- upper limit on the right midclavicular line:

intercostal space or rib

- lower limit (cm from tlie costal arch on rightmidclavicular line):

. at end of normal inspiration

palpation

percussion

. in max forced inspiration

palpation

percussion

- margin and surface

- consistency

- tenderness

Spleen: normal findings yes no

Other Findings Abdominal Organs

Genitourinary System

Sidneys: abnormal findings no

Bladder: abnormal findincs no

yes

•res

3xterr.al gsnitalia: abnormal findings r.o -es

Limbs: abnormal findings no 753

upper•

lower

varices no yes

peripheral pulses (radial, posterior tibial, dorsal arteryof foot)

abnormal findings

no yes

if yes:

Nervous System And Psyche

abnormal findings no yes

Remarks: