Article

Residential proximity to petroleum storage tanks and associated cancer risks: Double Kernel Density approach vs. zonal estimates

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Abstract

Background and aims: The relationship between exposure to petroleum products and cancer is well-established in occupational studies carried out among employees of transportation and oil-producing industries. However, question remains whether living near petroleum storage facilities may represent a cancer risk. In the present study, we examined cancer incidence rates associated with residential proximity to the Kiryat Haim industrial zone in Northern Israel, using different analytical techniques and adjusting for several potential confounders, such as road proximity, population density, smoking rates and socio-demographic attributes. Methods: Both traditional zonal approaches and more recently developed Double Kernel Density (DKD) tools were used to estimate relative risks of lung and NHL cancers attributed to residential proximity to the petroleum storage site. Results: Zonal approaches based on comparing ASRs across small census areas (SCAs) did not detect any significant association between residential proximity to the industrial zone and the two types of cancers under study (P>0.2). In contrast, the DKD approach revealed that the relative density of both lung and NHL cancers declined in line with distances from the industrial zone, especially among the elderly (Lung: t>-12.0; P<0.01; NHL: t>-9.0; P<0.01), adjusted for proximity to main roads, population density, smoking rate, average income, and several other potential confounders. Conclusions: Living near petroleum storage sites may represent significant cancer risk which cannot always be detected by traditional zonal approaches commonly used in epidemiological studies, especially if the number of census areas available for the analysis is small.

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... In recent studies , Kloog et al 2009, Zusman et al 2012, a refinement of the KD method, termed the Double Kernel Density (DKD) technique, was proposed. ...
... The DKD technique is based on the transformation of continuous KD surfaces into discrete observations, suitable for multivariate analysis. In these empirical studies, kernel smoothing was used to analyze the concentration of lung cancer cases , breast cancer cases (Kloog et al 2009) and lung and NHL cancers (Zusman et al 2012), and to associate the observed morbidity with underlying environmental causes, such as air pollution, nighttime artificial illumination or residential proximity to petroleum storage tanks. According to these studies, the DKD technique helped to provide better assessment results than traditional zonal approaches, based on aerial aggregation of original observations into predefined areal units, especially if the number of geographic units available for the analysis was small. ...
... Therefore, after a KD surface is calculated, normalization is the next step. For instance, the observed density of disease patients in each point of space can be divided by the total number of people living in the same location (Kloog et al 2009, Shi 2010, Zusman et al 2012. An additional benefit of this technique, also known as the Double Kernel Density (DKD) estimate, is that it helps to minimize the aforementioned "edge" effect: ...
... Four types of point estimates were reported in the selected studies: odds ratio (OR), relative risk (RR), standardized incidence ratio (SIR), and age-standardized rate ratio (ASRR). SIR or ASRR represent a comparison of the observed incidence in a studied group to the expected incidence in an age-and sex-adjusted standard population (Axelsson et al., 2010;Fazzo et al., 2016;Zusman et al., 2012). OR, ASRR, and SIR can be interpreted and analyzed as approximates of RR (Symons and Taulbee, 1981). ...
... For studies that did not report either 95% CI or standard error (SE) (Kaldor et al., 1984;Zusman et al., 2012;Fares and Masri, 2012), we estimated variances and SE of lnRR using the following equation: ...
... Supplementary Section 3 and Section 4 list details of quality assessment for the five cohort studies and one case-control study, respectively. Zusman's study received maximal N-O scores (Zusman et al., 2012), as did the only case-control study. The lowest N-O score of all cohort studies was seven out of nine (Axelsson et al., 2010;Hurtig and San Sebastian, 2002;Bulat et al., 2011), and its low score was due to losing stars on the items "selection of the non-exposed cohort" in the selection category and "adequacy of follow up of cohort" in the outcome category (Supplementary Table S1). ...
Article
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Background: Lung cancer is one of the most common cancers in the world. Higher incidence of lung cancer may be associated with residential proximity to a petrochemical industrial complex (PIC) due to exposure to various carcinogens, although results from previous epidemiologic studies remain inconclusive. Because disease burden due to residential inequality is a public health and societal concern, this study analyzed published data to estimate lung cancer incidence in association with residential proximity to PICs. Methods: We performed a meta-analysis on selected epidemiologic studies that met the following criteria: lung cancer incidence was coded by the International Classification of Diseases; exposure groups were clearly defined as residents living near PICs; and confidence intervals were available or calculable from original articles. We further applied a population attributable factor (PAF) method to estimate disease burden attributable to living near PICs in 22 European Union (EU) countries. Results: Meta-analysis included six studies with a total of 466,066 residents living near PICs in six countries. Residents living near PICs had a 19% higher risk of lung cancer compared to those who lived farther away (95% CI = 1.06-1.32). By sex, risks were higher and more significant for females (RR = 1.29; 95% CI = 1.09-1.54; P = 0.004) than males (RR = 1.12; 95% CI = 0.95-1.33; P = 0.173). By location, only groups in Europe had a significantly greater risk of lung cancer with exposure to PICs (95% CI = 1.03-1.33; P = 0.019), although groups in other locations showed similar trends. By bona fide observation, observation of residents for at least seven years provided sufficient latency to estimate risk (RR = 1.25; 95% CI = 1.17-1.34; P < 0.001). Regarding burden of lung cancer in 22 EU countries, 494 males and 478 females were attributed to living in the vicinity of a PIC annually. Conclusions: Lung cancer incidence is significantly higher in individuals living near PICs. This result provides strong epidemiologic evidence for further policy to regulate potential pollutants near PICs. Highlights: Higher incident rates of lung cancer for residents living close to petrochemical industry complex.
... Applying different investigation techniques to a study of the same health phenomenon may be justified by the fact that risk assessments provided by different estimation methods may differ due to information loss associated with data aggregation and processing (Jarup, 2004;Jerrett et al., 2005Wong, 2004;Portnov et al., 2007). Thus, morbidity risk estimates, based on pre-established statistical divisions (such as census blocks, small census areas and census tracts) are commonly used in epidemiological studies (Zusman et al., 2012;Lavigne et al., 2016;Gotway and Young, 2002;Openshow, 1984), including studies of adverse birth effects (Luo et al., 2006;Simonet et al., 2011). However, the way, in which the boundaries of geographical units are demarcated, can result in the modifiable areal units problem (MAUP), according to which the choice of areal units used for data aggregation may lead to different results and affect hypothesis testing (Wong, 2004;Portnov et al., 2007;Wong and Fotheringthem, 1991). ...
... An alternative technique for the analysis of adverse health outcomes is based on data smoothing into continuous surfaces, differentiating between areas of different relative risk of a disease (Bithell, 1990;Shi, 2010;Zusman, 2012;Anderson, 2009;Svechkina et al., 2017). Advantages of this approach, compared to zonal estimates, are that the former method does not require an a priori delineation of areal units for data aggregation (Kloog et al, 2009;Portnov et al., 2007). ...
... According to several studies (cf. inter alia, Grubesic and Matisziw, 2005;Beale et al., 2008;Zusman et al., 2012), this approach is especially effective if the number of geographic units available for data aggregation and analysis is small. ...
Article
Background: Low birth weight (LBW) is known to be associated with infant mortality and postnatal health complications. Previous studies revealed strong relationships between LBW rate and several socio-demographic factors, including ethnicity, maternal age, and family income. However, studies of association between LBW rate and environmental risk factors remain infrequent. Study methods: We retrieved a geo-referenced data set, containing 7216 individual records of children born in 2015 in the Haifa Bay Area in Israel. Using this dataset, we analysed factors affecting LBW prevalence by applying two alternative techniques: analysis of LBW rates in small census area (SCAs) and more recently developed double kernel density (DKD) relative risk (RR) estimates. Results: In the SCA models, LBW rate was found to be associated with proximity to petrochemical industries (B=-0.26, 95%CI=-0.30, -0.22), road density (B=0.05, 95%CI=0.02, 0.08), distance to the seashore (B=0.17, 95%CI=0.14, 0.22), PM2.5 (B=0.06, 95%CI=0.04, 0.09) and NOx (B=0.10, 95%CI=0.06, 0.13) exposure estimates. Although similar factors emerged in the DKD models as well, in most cases, the effects of these factors in the latter models were found to be stronger: proximity to petrochemical industries (B=-0.48, 95%CI= -0.51, -0.30), road density (B=0.05, 95%CI=0.02, 0.08), distance to the seashore (B=0.24, 95%CI=0.21, 0.27), PM2.5 (B=0.08, 95%CI=0.05, 0.10) and NOx (B=0.20, 95%CI=0.17, 0.23) exposure estimates. In addition, elevation above the sea level was found to be statistically significant in spatial dependence models estimated for both DKD and SCA rates (P < 0.01). Conclusion: The analysis revealed an excess LBW rate in residential areas located close to petrochemical industries and a protective effect of seashore proximity and elevation above the sea level on the LBW rate. We attribute the latter finding to the moderating effect of elevated seashore locations on outdoor temperatures during the hot summer season.
... By contrast, the second group of methods uses aerial proximities to pre-identified health hazards as proxies for unknown (or unmeasured) concentrations of air pollutants. In recent empirical studies, this approach, also known as the distance gradient method or DGM, was used for the investigation of health effects associated with various sources of exposure, including thoroughfare roads, power stations, and various industrial facilities (Gatrell et al., 1996;Neidell, 2004;McConnell et al., 2006;Gordian et al., 2006;Wichmann and Fernando, 2009;Marco de et al., 2010;Brender et al., 2011;Rava et al., 2012;Marchetti et al., 2014;Paz et al., 2009;Zusman et al., 2012;Rosser et al., 2014;Moshe et al., 2015;Ramis et al., 2015;Eldeirawi et al., 2016). ...
... According to this analytical method, aerial density of the observed events (e.g., residential locations of asthma patients) is calculated for each geographic location, by counting the number of the events of interest with a predefined search radius, also known as the kernel bandwidth, and then normalizing by the overall density of population in which the events of interest occur (Bithell, 1990;Shi, 2010;Portnov and Zusman, 2014). In several recent empirical studies, DKD technique was used for the analysis of cancer incidence Kloog et al., 2009;Zusman et al., 2012;Lemke et al., 2015), acute undifferentiated fever and diabetes (Kauhl et al., 2015(Kauhl et al., , 2016, and autism prevalence (Bakian et al., 2015). We created the DKD surface of the year-2014 asthma incidence rates (see Fig. 3) in the following steps. ...
... In the present study, we extend the distance gradient method (DGM), commonly used in empirical studies (cf., inter alia, Neidell, 2004;McConnell et al., 2006;Gordian et al., 2006;Wichmann and Fernando, 2009;Marco de et al., 2010;Rava et al., 2012;Marchetti et al., 2014;Paz et al., 2009;Zusman et al., 2012;Moshe et al., 2015;Eldeirawi et al., 2016), to the spatial identification of a priori unknown health hazards associated with childhood asthma. We applied the 1 Considering the program memory limitations, the analysis was run for 553 residential locations of children diagnosed with asthma in 2014, and not for all children in the sample. ...
Article
Research background: Childhood asthma is a chronic disease, known to be linked to prolonged exposure to air pollution. However, the identification of specific health hazards, associated with childhood asthma is not always straightforward, due to the presence of multiple sources of air pollution in urban areas. In this study, we test a novel approach to the spatial identification of environmental hazards that have the highest probability of association with the observed asthma morbidity patterns. Methods: The effect of a particular health hazard on population morbidity is expected to weaken with distance. To account for this effect, we rank potential health hazards based on the strength of association between the observed morbidity patterns and wind-direction weighted proximities to these locations. We validate this approach by applying it to a study of spatial patterns of childhood asthma in the Greater Haifa Metropolitan Area (GHMA) in Israel, characterised by multiple health hazards. Results: We identified a spot in the local industrial zone as the primary risk source for the observed asthma morbidity patterns. Multivariate regressions, controlling for socio-economic and geographic variables, revealed that the observed incidence rates of asthma tend to decline as a function of distance from the identified industrial location. Conclusion: The proposed identification approach uses disease patterns as its main input, and can be used by researches as a preliminary risk assessment tool, in cases in which specific sources of locally elevated morbidity are unclear or cannot be identified by traditional methods.
... Air pollution from motor traffic and industrial facilities is known to be linked to respiratory, cardiovascular and cancer morbidity [1][2][3][4][5][6][7][8][9]. However, since urban areas are often characterized by multiple sources of air pollution, the identification of specific environmental hazards associated with the observed morbidity patterns is not always straightforward [10][11][12][13]. ...
... The proposed method is based on an expectation that the morbidity effect of a particular health hazard weakens with distance [9,[27][28][29]. As a result, people living in a close proximity to a morbidity source, are expected to exhibit, ceteris paribus, a higher rate of morbidity than those living at a distance from that source [11,30]. To account for this effect, we estimate distance decay gradients of morbidity for alternative potential "source" locations and then rank these locations based on the strength of association between the observed morbidity patterns and wind-direction weighted proximities to these locations. ...
... Zusman et al. [11] used proximity to an oil storage site, as a proxy for residential exposure to unknown levels of emissions of volatile and semi-volatile organic compounds from the site. As the study revealed, the rates of lung and non-Hodgkin lymphoma (NHL) cancers declined in line with distance from the storage site, especially among the elderly (P < 0.01). ...
Article
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Background and aimsLarge metropolitan areas often exhibit multiple morbidity hotspots. However, the identification of specific health hazards, associated with the observed morbidity patterns, is not always straightforward. In this study, we suggest an empirical approach to the identification of specific health hazards, which have the highest probability of association with the observed morbidity patterns. Methods The morbidity effect of a particular health hazard is expected to weaken with distance. To account for this effect, we estimate distance decay gradients for alternative locations and then rank these locations based on the strength of association between the observed morbidity and wind-direction weighted proximities to these locations. To validate this approach, we use both theoretical examples and a case study of the Greater Haifa Metropolitan Area (GHMA) in Israel, which is characterized by multiple health hazards. ResultsIn our theoretical examples, the proposed approach helped to identify correctly the predefined locations of health hazards, while in the real-world case study, the main health hazard was identified as a spot in the industrial zone, which hosts several petrochemical facilities. Conclusion The proposed approach does not require extensive input information and can be used as a preliminary risk assessment tool in a wide range of environmental settings, helping to identify potential environmental risk factors behind the observed population morbidity patterns.
... An alternative technique for the analysis of disease incidence in urban areas is based on the so called 'double kernel density' (DKD) approach Kloog et al., 2009;Zusman et al., 2012). This technique is a nonparametric method that calculates the areal density of 'health outcome events' within a given search radius from a moving 'target' point and then normalizes the obtained event density by the density of background population in which the events of interest occurred ). ...
... In the case study, described in the following subsections, we aim to investigate the association between air pollution and cancer morbidity by comparing two analytical techniques: the traditional zonal approach (Boyle and Parkin, 1991;Curtin and Klein, 1995) and more recently developed Double Kernel Density (DKD) tools Zusman et al., 2012;Chakraborty, 2012). The study's results can be beneficial for disease risk analyses in other urban areas, in which relatively small numbers of new cancer cases are recorded annually or only few internal subdivisions are available for incidence rate calculation and comparison. ...
... Several studies carried out in the Haifa sub-district and in the Greater Haifa Metropolitan Area (GHMA) revealed associations between cancer morbidity and ambient air pollution, although findings of these studies were not always consistent (Paz et al., 2009;Portnov et al., 2009;Rottenberg et al., 2013;Zusman et al., 2012). ...
... However, such aggregation may result in a modifiable areal unit problem (MAUP), according to which different strength of statistical association may emerge from the analysis of data based on different units of spatial resolution (Openshaw 1984;Portnov et al. 2009;Swift et al. 2014). An additional problem may also arise if the events of interest are highly concentrated in space, and the overall number of areal units, available for aggregation is small, leading to inconclusive results and low statistical power (Li and Lian 2010;Zusman et al. 2012). ...
... In recent studies Kloog et al. 2009;Zusman et al. 2012), a refinement of the KD method, termed the Double Kernel Density (DKD) technique, was proposed. The DKD technique is based on the transformation of continuous KD surfaces into discrete observations, suitable for multivariate analysis. ...
... The DKD technique is based on the transformation of continuous KD surfaces into discrete observations, suitable for multivariate analysis. In these empirical studies, kernel smoothing was used to analyze the concentration of lung cancer cases ), breast cancer cases (Kloog et al. 2009) and lung and NHL cancers (Zusman et al. 2012), and to associate the observed morbidity with underlying environmental causes, such as air pollution, nighttime artificial illumination or residential proximity to petroleum storage tanks. According to these studies, the DKD technique helped to provide better assessment results than traditional zonal approaches, based on aerial aggregation of original observations into predefined areal units, especially if the number of geographic units available for the analysis was small. ...
Article
Full-text available
Attributeless event point datasets (AEPDs) are datasets composed of discrete events or observations defined by their geographical location only and lacking any other additional attributes. Examples of such datasets include spotted criminal events, road accidents and residential locations of disease patients. A commonly used approach to the analysis of such datasets involves their aggregation into predefined areal units, such as neighborhoods or census tracts. However, this approach does not perform effectively when the events of interests are geographically localized and the number of areal units available for aggregation is small. An alternative approach to the analysis of AEPDs is based on double kernel density (DKD) smoothing, according to which events of interest are transformed into continuous density surfaces and then normalized by the density of the entire population from which the events of interest are drawn. In the present study, the applicability of the DKD approach to multivariate analysis is tested for estimation consistency, sensitivity to the number of input observations and potential bias attributed to the spatial dependency of neighboring observations. Our analysis indicates that the DKD approach provides reasonably stable and consistent estimates, if the following three preconditions are met: (a) the kernel estimation parameters are properly defined, (b) the number of reference points, used for transformation of continuous DKD surfaces into discrete observations, is sufficiently large, and (c) the spatial dependency of neighboring observations is taken into account using spatial analysis tools.
... Previous epidemiological studies mainly used variations of ecological study designs, in which both exposures and outcomes were assessed using aggregated measures, without any individual-level data [15][16][17][18][19]. One exception for this design is a study on cancer incidence in adults, in which individual-level cancer incidence data was used, but no exposure assessment was made [20]. ...
... However, this exposure assessment lacks temporal variability, characterization of the relevant pollutants, and direct measures of these pollutants-components that would have improved it had they been available. Prior studies characterized HBA exposure on either distance from the industrial area, measurement of criteria pollutants, or merely comparing HBA to non-HBA residents [15][16][17][18]20]. We have used a new approach to categorize the HBA population by levels of exposure to HBA-IAP, and think that this approach is better than the other available assessment method of historical HBA-IAP unmeasured pollutants. ...
Article
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Haifa Bay Area (HBA) contains Israel’s principal industrial area, and there are substantial public concerns about health effects from its emissions. We aimed to examine associations between exposure to air pollution from HBA industrial area with prevalent asthma and other atopic diseases at age 17. This is a cross-sectional study. The study population included all adolescents born in Israel and whose medical status was evaluated for mandatory military recruitment by the Israeli medical corps during 1967–2017. We analyzed prevalent asthma, allergic rhinitis, atopic dermatitis, and rhinoconjunctivitis. We estimated exposure to industrial air pollution by a kriging interpolation of historical SO2 observations and adjusted the associations to the year of birth, SES, school orientation, and traffic pollution. The study population included n = 2,523,745 adolescents, among which 5.9% had prevalent asthma and 4.6% had allergic rhinitis. Residency in HBA was associated with a higher adjusted risk of asthma, compared with non-HBA residency. Still, this association was limited to the three lowest exposure categories, while the highest exposure group had the lowest adjusted risk. Sensitivity analyses and other atopic diseases presented similar results. These results do not provide support for causal relationships between HBA industry-related emissions and prevalent atopic diseases.
... Four studies [54][55][56][57] only provide information on the observed (O) number of incident cases in the exposed group and the expected (E) number of cases based on a reference population, to calculate the SIR where O/E. The 95% confidence intervals of these studies were estimated by regarding O as a Poisson variable, with upper (O U ) and lower (O L ) distribution table values that are to be divided by E [58]. ...
... The systematic review identified 16 unique studies, which collectively record the incidence of haematological malignancies across 187,585 residents living close to a petrochemical operation (see Table 3) [6,48,[54][55][56][57][67][68][69][70][71][72][73][74][75][76]. In terms of geographical coverage, 11 studies were conducted in Europe, 3 in North America and 2 in Asia. ...
Article
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Background: The petrochemical industry is a major source of hazardous and toxic air pollutants that are recognised to have mutagenic and carcinogenic properties. A wealth of occupational epidemiology literature exists around the petrochemical industry, with adverse haematological effects identified in employees exposed to 'low' concentrations of aromatic hydrocarbons (benzene, toluene, ethylbenzene, and xylene). Releases from the petrochemical industry are also thought to increase the risk of cancer incidence in fenceline communities. However, this emerging and at times inconclusive evidence base remains fragmented. The present study's aim was to conduct a systematic review and meta-analysis of epidemiological studies investigating the association between incidences of haematological malignancy and residential exposure to the petrochemical industry. Methods: Epidemiological studies reporting the risk of haematological malignancies (Leukaemia, Hodgkin's lymphoma, Non-Hodgkin's lymphoma, and Multiple myeloma) were included where the following criteria were met: (i) Cancer incidence is diagnosed by a medical professional and coded in accordance to the International Classification of Diseases; (ii) A clear definition of fenceline communities is provided, indicating the proximity between exposed residents and petrochemical activities; and (iii) Exposure is representative of normal operating conditions, not emergency events. Two investigators independently extracted information on study characteristics and outcomes in accordance with PRISMA and MOOSE guidelines. Relative risks and their 95% confidence intervals were pooled across studies for the four categories of haematological malignancy, using a random effects meta-analysis. Results: The systematic review identified 16 unique studies, which collectively record the incidence of haematological malignancies across 187,585 residents living close to a petrochemical operation. Residents from fenceline communities, less than 5 km from a petrochemical facility (refinery or manufacturer of commercial chemicals), had a 30% higher risk of developing Leukaemia than residents from communities with no petrochemical activity. Meanwhile, the association between exposure and rarer forms of haematological malignancy remains uncertain, with further research required. Conclusions: The risk of developing Leukaemia appears higher in individuals living near a petrochemical facility. This highlights the need for further policy to regulate the release of carcinogens by industry.
... Since multivariable regression analysis cannot directly be applied to continuous surfaces, PM air pollution and sVOCs soil contamination maps (see Subsection 3.4) were converted into discrete point data. For this purpose, 1000 randomly distributed "reference" points were generated according to the methodological approach, suggested in Zusman et al. (2012). In particular, after the layer of reference points was generated using Hawth's Analysis Tool in ArcGIS10.xÔ ...
... In particular, after the layer of reference points was generated using Hawth's Analysis Tool in ArcGIS10.xÔ (ESRI, 2012) (see the Supplement materials section e Fig. S-1), the reference points were linked to the PM 2.5 and sVOCs contours, with each reference point received the value from the contour being closest to that particular point (for more detail on this procedure, see Zusman et al., 2012). The calculation was performed in ArcGIS10.xÔ ...
... Kernel Density (KD) analysis was used to determine the intensity of AFS in the studied region. This spatial statistical approach can be used to produce a quantitative assessment of the density or concentration of falajs throughout a geographic region [47]. The generated KD surface showed regions with greater or lower densities, providing information about the geographical distribution and strength of the falajs. ...
Article
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This study investigates the spatial distribution patterns and environmental factors influencing the Aini Falaj system in a specific study area. The research findings are presented through the lens of the following four categories: collinearity diagnostics, spatial autocorrelation analysis, kernel density (KD) findings, and multivariate geographically weighted regression (MGWR) analysis. The collinearity diagnostics were applied to examine the interrelationships among 18 independent environmental variables. The results indicate the absence of significant multicollinearity concerns, with most variables showing values below the critical threshold of five for variance inflation factors (VIFs). The selected variables indicate minimal intercorrelation, suggesting that researchers should be confident utilizing them in subsequent modelling or regression analyses. A spatial autocorrelation analysis using Moran’s Index revealed positive spatial autocorrelation and significant clustering patterns in the distribution of live and non-functional Aini Falajs. High concentrations of live or dead Falajs tended to be surrounded by neighbouring areas with similar characteristics. These findings provide insights into the ecological preferences and habitat associations of Aini Falajs, thereby aiding conservation strategies and targeted studies. The kernel density (KD) analysis depicted distribution patterns of live and dry Aini Falajs through hotspots and cold spots. Specific regions exhibited high-density areas of live Falajs, indicating favourable environmental conditions or historical factors contributing to their concentrated distribution. Identifying these high-density zones can enhance our understanding of the spatial patterns and potential factors influencing the prevalence and sustainability of Aini Falajs. The multivariate geographically weighted regression (MGWR) models revealed strong associations between the live or dead status of Aini Falajs and environmental factors. The precipitation, topographic wetness index (TWI), aspect and slope exerted positive impacts on the live status, while evaporation, solar radiation, distance to drains and drain density exerted negative influences. Similar associations were observed for the dead status, emphasising the importance of controlling evaporation, shading mechanisms, proper drainage planning and sustainable land-use practices. This study provides valuable insights into the spatial distributions and factors influencing the live and dead status of Aini Falajs, thereby contributing to our understanding of their ecological dynamics and guiding conservation efforts and management strategies.
... Each of these ports is located adjacent to a highly populated area; approximately 550,000 and 250,000 inhabitants live within 10 km of these ports, respectively [50][51][52]. The elevated levels of air pollution around the Haifa-bay area are considered a well-known public issue, and some studies have also correlated the latter with increased risk of adverse health effects in specific areas around the bay [53][54][55]. ...
Article
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Marine air pollution is a major contributor to seaports and coastal air pollution, and Israel has yet to seriously confront this issue. This study aimed to update previous marine air pollution estimations in Israel’s two major ports: Haifa and Ashdod. The objectives were to examine technical and regulatory measures to address the problem, to propose mitigation targets and to estimate their potential benefits. Based on a model of emission-calculations that relies on an updated ship-inventory data as well as real-time ships’ location and movement tools, the combined marine NOx, SOx and PM2.5 annual emissions in these ports were found to be 18,415, 15,128 and 1453 tons, respectively. These values are considerably higher than previous estimates, are comparable to the constant pollution emitted at ground level from a 1000-MW coal powered city power plant and are 3–20 times higher than the industrial and land transportation sectors in these cities. Relatively high nickel concentration in PM was found in Israel only relatively adjacent to the Haifa and Ashdod ports. Since high nickel concentration in PM is today mainly associated with marine air pollution, this finding supports the hypothesis that marine air pollution worsens the air quality in these cities. SOx and PM2.5 emissions can be reduced by 78% and 27%, respectively, if Israel enforces the revised International Convention for the Prevention of Pollution from Ships (MARPOL) Annex VI regulations in its territorial waters. While the latter step can achieve external benefits of NIS 518.4 million/year (EUR 132 million/year), additional mitigation actions and local regulations are suggested, focusing on NOx emissions but also on other pollutant criteria. Such actions can achieve further benefits of NIS 274.3 million/year (EUR 70 million/year). Achieving the suggested targets is challenging yet attainable, and their potential benefits will probably outweigh their costs.
... We found a tendency of higher risk for the NHL subtype FL and lower risk for the DLBCL subtype in association with most of the PM constituents. Previous studies have investigated associations between risk of NHL and different crude measures of exposure to air pollution including residential proximity to industrial facilities (De Roos et al., 2010), dioxin emitting cement factories (Pronk et al., 2013), metal industries (Zheng et al., 2002), petroleum refinery (Zusman et al., 2012), solid waste incinerator (Viel et al., 2011), andtraffic (Raaschou-Nielsen et al., 2011), providing mixed results. Workplace air pollution exposure in metallurgy (Fritschi et al., 2005b), gas industry (Kane and Newton, 2010) and transport (Smith et al., 2007) have been associated with the risk of NHL. ...
Article
Background; Particulate matter (PM) air pollution is a complex mixture and the various PM constituents likely affect health differently. The literature on the relationships among specific PM constituents and the risk of cancer is sparse. In this study, we aimed to evaluate the association of PM2.5 and its constituents with the incidence of non-Hodgkin lymphoma (NHL) and the two main NHL subtypes. Methods We undertook a nationwide register-based case-control study including 20,847 cases registered in the Danish Cancer Registry with NHL between 1989 and 2014. Among the entire Danish population, we selected 41,749 age and sex-matched controls randomly from the Civil Registration System. We assessed modelled outdoor PM concentrations at addresses of cases and controls with a state-of-the-art multi scale air pollution modelling system and used conditional logistic regression to estimate odds ratios (ORs) adjusted for individual and neighborhood level socio-demographic variables. Results The 10-year time-weighted average concentrations of PM2.5, primary carbonaceous particles (BC/OC), secondary inorganic aerosols (SIA), secondary organic aerosols (SOA) and sea salt were 17.4, 2.3, 7.8, 0.3, and 4.1 μg/m³, respectively among controls. The results showed higher risk for NHL in association with exposure to BC/OC (OR=1.03; 95% CI: 1.00, 1.07, per interquartile range (IQR)) and SOA (OR=1.54; 95% CI: 1.13, 2.09, per IQR). The results indicated a higher risk for follicular lymphoma in association with several PM components. Including PM2.5 (OR=1.16; 95% CI: 0.98 – 1.38), BC/OC (OR=1.05; 95% CI: 0.97 – 1.14), SIA (OR=1.44; 95% CI: 0.80 – 1.08), SOA (OR= 4.52; 95% CI: 0.86 – 23.83) per IQR. Conclusion This is the first study on PM constituents and the risk of NHL. The results indicated an association with primary carbonaceous and secondary organic PM. The results need replication in other settings before any firm conclusion can be reached.
... Recently, increasing evidence has shown associations between living near industrially contaminated sites or being exposed to industrial air pollution and increased total cancer incidence and mortality [27][28][29][30]. Although the main focus has been on lung cancer [28,29,31,32], the increased risks have also been documented for kidney [33,34], bladder [31][32][33][34], and breast cancer [35][36][37] as well as leukaemia [33,[38][39][40] and non-Hodgkin's lymphoma [33,41,42]. Less evidence has been reported on prostate [43], colorectal [44], liver [31], and paediatric cancer risk [45,46]. ...
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Large oil shale resources are found in Eastern Estonia, where the mineral resource is mined, excavated, and used for electricity generation and shale oil extraction. During industrial activities in the last 100 years, pollutants have been emitted in large amounts, some of which are toxic and carcinogenic. The current study aims to analyse time trends in cancer incidence in the oil shale industry-affected areas and compare them with overall cancer incidence rates and trends in Estonia. We analysed Estonian Cancer Registry data on selected cancer sites that have been previously indicated to have relationships with industrial activities like oil shale extraction. We included lung cancer, kidney cancer, urinary bladder cancer, leukaemia, breast cancer, and non-Hodgkin’s lymphoma. A statistically significantly higher lung cancer age-standardized incidence rate (ASIR) was found during the study period (1992—2015) only in males in the oil shale areas as compared to males in Estonia overall: 133.6 and 95.5 per 100,000, respectively. However, there appeared to be a statistically significant (p < 0.05) decrease in the lung cancer ASIR in males in the oil shale areas (overall decrease 28.9%), whereas at the same time, there was a significant increase (p < 0.05) in non-oil shale areas (13.3%) and in Estonia overall (1.5%). Other cancer sites did not show higher ASIRs in the oil shale industrial areas compared to other areas in Estonia. Possible explanations could be improved environmental quality, socio-economic factors, and other morbidities.
... 8 A study by Zusman et al. reported a small increase in the risk of NHL with decreasing distance between the residence and an industrial zone in Northern Israel. 9 A Danish study found a weak association between traffic-related air pollution at residential addresses and risk for NHL based on 200 NHL cases. 10 A case-control study from the USA reported no increased risk of NHL with residential proximity to industrial facilities. ...
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There is limited evidence regarding a possible association between exposure to ambient air pollutants and the risk of non‐Hodgkin lymphoma (NHL). Previous epidemiological studies have relied on crude estimations for air pollution exposure and/or small numbers of NHL cases. The objective of our study was to analyze this association based on air pollution modeled at the address level and NHL cases identified from the nationwide Danish Cancer Registry. We identified 20,874 incident NHL cases diagnosed between 1989 and 2014 and randomly selected 41,749 controls matched on age and gender among the entire Danish population. We used conditional logistic regression to estimate odds ratios (ORs) and adjusted for individual and neighborhood level sociodemographic variables. There was no association between exposure to PM2.5, BC, O3, SO2 or NO2 and overall risk of NHL but several air pollutants were associated with higher risk of follicular lymphoma, but statistically insignificant, for example, PM2.5 (OR = 1.15 per 5 μg/m³; 95% CI: 0.98–1.34) and lower risk for diffuse large B‐cell lymphoma (OR = 0.92 per 5 μg/m³; 95% CI: 0.82–1.03). In this population‐based study, we did not observe any convincing evidence of a higher overall risk for NHL with higher exposure to ambient air pollutants.
... Carcinogenic effects of crude oil exposure in humans Several studies have investigated the incidence of cancers in populations living close to petrochemical industries. The majority have revealed an increased risk of certain types of cancers, predominantly hematological cancers (Belli et al. 2004;Yu et al. 2006;Weng et al. 2008;Barregard et al. 2009;Axelsson et al. 2010;Ana et al. 2010;DeRoos et al. 2010;Zusman et al. 2012;Cirera et al. 2013;Micheli et al. 2014). ...
Article
People who reside near oil exploration activities may be exposed to toxins from gas flares or oil spills. The impact of such exposures on the human immune system has not been fully investigated. In this review, research investigating the effects of crude oil on the immune system is evaluated. The aim was to obtain a greater understanding of the possible immunological impact of living near oil exploration activities. In animals, the effect of exposure to crude oil on the immune system depends on the species, dose, exposure route, and type of oil. Important observations included; hematological changes resulting in anemia and alterations in white blood cell numbers, lymph node and splenic atrophy, genotoxicity in immune cells, modulation of cytokine gene expression and increased susceptibility to infectious diseases. In humans, there are reports that exposure to crude oil can increase the risk of developing certain types of cancer and cause immunomodulation.
... An alternative approach to the spatial identification of potential environmental hazards in urban areas is based on the distance gradient method (DGM) that uses aerial proximities from potential air pollution sources, such as heavy roads and chemical and power plants, as proxies for unknown exposures. If the observed disease rates decline as the distance from a particular hazard increase, a conclusion is reached that proximity to the hazard in question is associated with morbidity in surrounding areas (see inter alia Moore and Carpenter 1999;McKenzie et al. 2012;Sermage-Faure et al. 2012;Paz et al. 2009;Zusman et al. 2012). ...
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Reduced birth weight (RBW) and reduced head circumference (RHC) are adverse birth outcomes (ABOs), often linked to environmental exposures. However, spatial identification of specific health hazards, associated with these ABOs, is not always straightforward due to presence of multiple health hazards and sources of air pollution in urban areas. In this study, we test a novel empirical approach to the spatial identification of environmental health hazards potentially associated with the observed RHC and RBW patterns. The proposed approach is implemented as a systematic search, according to which alternative candidate locations are ranked based on the strength of association with the observed birth outcome patterns. For empirical validation, we apply this approach to the Haifa Bay Area (HBA) in Israel, which is characterized by multiple health hazards and numerous sources of air pollution. We identified a spot in the local industrial zone as the main risk source associated with the observed RHC and RBW patterns. Multivariate regressions, controlling for personal, neighborhood, and geographic factors, revealed that the relative risks of RHC and RBW tend to decline, other things being equal, as a function of distance from the identified industrial spot. We recommend the proposed identification approach as a preliminary risk assessment tool for environmental health studies, in which detailed information on specific sources of air pollution and air pollution dispersion patterns is unavailable due to limited reporting or insufficient monitoring.
... To eliminate the confines of arbitrary administrative boundaries, we followed the double kernel density (DKD) method [43][44][45][46][47][48] to calculate distributions of SGA and LBWT, normalized by all births. DKD involves kernel density estimation-a non-parametric method that spreads point values across a surface by calculating the magnitude-per-unit area from points (representing the counts of birth events), fitted to a smoothly tapered function that spreads the values within a specified distance (25 km for this study) around each point [49]. ...
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Background The geography of where pregnant mothers live is important for understanding outdoor environmental habitat that may result in adverse birth outcomes. We investigated whether more babies were born small for gestational age or low birth weight at term to mothers living in environments with a higher accumulation of outdoor hazards. Methods Live singleton births from the Alberta Perinatal Health Program, 2006–2012, were classified according to birth outcome, and used in a double kernel density estimation to determine ratios of each outcome per total births. Individual and overlay indices of spatial models of 136 air emissions and 18 land variables were correlated with the small for gestational age and low birth weight at term, for the entire province and sub-provincially. ResultsThere were 24 air substances and land sources correlated with both small for gestational age and low birth weight at term density ratios. On the provincial scale, there were 13 air substances and 2 land factors; sub-provincial analysis found 8 additional air substances and 1 land source. Conclusion This study used a combination of multiple outdoor variables over a large geographic area in an objective model, which may be repeated over time or in other study areas. The air substance-weighted index best identified where mothers having abnormally small newborns lived within areas of potential outdoor hazards. However, individual air substances and the weighted index provide complementary information.
... Their results are very similar to wilkinson's, because they showed that lung cancer and non-Hodgkin lymphoma incidence tended to decrease as the distance to storage facilities increased, especially among the elderly. 29 another important health effect on the population living near reineries is the rise in the incidence of premature births. Regarding this issue, in Taiwan they evaluated its incidence in infants born within 3 towns located 3 Km from oil reineries. ...
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Introduction: Polycyclic aromatic hydrocarbons (PaH) are a group of semi-volatile organic compounds composed of 2 or more aromatic rings, generated during incomplete combustion of organic matter. These compounds have been considered as major air pollutants, and also, there is evidence of potential mutagenic and carcinogenic effects in some of them. One of the most important sources of these compounds is industry, and particularly, in processes such as aluminium or coke production, waste incineration and petrochemical and oil reining. This last process is the subject of this article, whose aim is to review the health effects in persons potentially exposed to PAH generated during petroleum reining. Methods: a descriptive review of the available literature was performed, in which PubMed was used as an information source. The following search descriptors were used: refinery, PaH, health, health impact assessment, air pollutants and environmental, as well as their translations in Spanish. Results: eleven articles were included, and most of them correspond to epidemiological studies in which a high incidence of cancer is reported. Conclusions: The reviewed studies concur that there is a signiicant relationship between the presence of oil reineries and the increase of adverse health effects of workers and people living in areas that are close to these industries, particularly, respiratory diseases and cancer. However , it is important to develop studies that simultaneously evaluate the effects on human health and the concentration of these substances in the environment, in order to establish a more direct relationship between the 2 variables.
... Consequences of a fuel leak can be considered both in ecological ( Jenkins, Guignet, & Walsh, 2014; and economical terms ( Jenkins et al., 2014;Simons, Bowen, & Sementelli, 1997;. When hazardous and flammable liquid escapes from its container, it soaks into soil and aquifers, causing a significant threat to wildlife and human beings ( Rasekh & Brumbelow, 2015;Zusman, Dubnov, Barchana, & Portnov, 2012 ). ...
Article
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Leaks and spills of hazardous fluids like petroleum endanger the environment, while remediation costs and penalties imposed when petroleum contaminates the ecosystem affect economics heavily. Therefore, it is crucial to detect any possible symptoms of a leak as soon as possible. Most of existing leak detection techniques require specialized equipment to be used, while purely software-based methods rely solely on data analysis and are very desirable since they can be deployed on petrol stations without any changes to the existing infrastructure. Moreover, such techniques can be considered as complementary to the hardware leak detection systems, as they provide additional security level. In this paper we present the TUBE algorithm, which detects fuel leaks from underground storage tanks, using only standard measurements that are normally registered on petrol stations, i.e. the amount of stored, sold, and delivered fuel. The TUBE algorithm is an autonomous solution capable of making decisions independently as well as supporting human-made decisions and thus can be considered as an expert leak detection system. The TUBE algorithm introduces a new data mining technique for trend detection and cleaning data over time series, which can be easily adapted to any other problem domain. A trend detection technique, called tubes, created for the TUBE algorithm is a novel data analysis method that allows to envelop uncertainties and oscillations in data and produce stable trends. Trend interpretation technique described in this paper has been designed especially for fuel leak detection purposes using our industrial experience. This paper includes a step-by-step usage example of the TUBE algorithm and its evaluation according to the United States Environmental Protection Agency requirements for leakage detection systems (the EPA SIR standard). Such an evaluation involves calculating the probability of detection and the probability of false alarm. The TUBE algorithm has obtained 98.84% probability of detection and 0.07% probability of false alarm while rejecting 42.22% of analyzed datasets due to their uncertainty. Rejecting datasets from analysis is compliant with the EPA SIR standard; however, rejection rate higher than 20% is not acceptable. Therefore we have evaluated the two-phase filtering stage of the algorithm in order to find the best combination of filters as means of data cleaning. Moreover, we have discussed the results pointing at the overall data quality problem, since it is the main cause of rejecting some datasets from the analysis. Finally, the TUBE algorithm has obtained 93.11% probability of detection and 0.73% probability of false alarm for the best combination of all parameters with 15.56% rejection rate, which is acceptable by the EPA SIR standard. The value of probability of detection is not fully compliant with the EPA SIR standard where 95% probability of detection with probability of false alarm lower than 5% is required. We have found that the requirements for the aforementioned probabilities have been completely fulfilled for datasets representing manifolded tank systems but not for single tank datasets. Such a situation was unexpected since manifolded tank systems are generally claimed to be more complex for analysis as they are in fact systems of multiple single tanks directly connected. In this paper we have also measured the time and memory complexity of the TUBE algorithm as well as discussed the issues connected to the TUBE algorithm deployment on petrol stations using our industrial experience in the topic.
... Simply put, distance matters: proximity to primary or secondary toxin sources increases the risk of adverse health outcomes (Zota et al., 2011). For example, Zusman et al. (2012) examined cancer incidence rates linked to residential proximity at the Kiryat Haim industrial zone in Northern Israel and demonstrated statistically significant correlations for both lung and non-Hodgkin lymphoma patients with distancing from the industrial zone. ...
... Also, the introduction of bromide constituents from hydraulic fracturing wastewater into drinking water sources could increase the subsequent, downstream formation of carcinogenic disinfection byproducts and increase the risk of cancer, such as bladder cancer (Regli et al., 2015). Further, agents released from other components of oil and gas infrastructure, such as petroleum storage tanks (Zusman et al., 2012), petrochemical plants (Yu et al., 2006), and petrol stations (Brosselin et al., 2009;Harrison et al., 1999;Steffen et al., 2004) could pose a leukemia risk. This analysis has several limitations. ...
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The widespread distribution of unconventional oil and gas (UO&G) wells and other facilities in the United States potentially exposes millions of people to air and water pollutants, including known or suspected carcinogens. Childhood leukemia is a particular concern because of the disease severity, vulnerable population, and short disease latency. A comprehensive review of carcinogens and leukemogens associated with UO&G development is not available and could inform future exposure monitoring studies and human health assessments. The objective of this analysis was to assess the evidence of carcinogenicity of water contaminants and air pollutants related to UO&G development. We obtained a list of 1177 chemicals in hydraulic fracturing fluids and wastewater from the U.S. Environmental Protection Agency and constructed a list of 143 UO&G-related air pollutants through a review of scientific papers published through 2015 using PubMed and ProQuest databases. We assessed carcinogenicity and evidence of increased risk for leukemia/lymphoma of these chemicals using International Agency for Research on Cancer (IARC) monographs. The majority of compounds (> 80%) were not evaluated by IARC and therefore could not be reviewed. Of the 111 potential water contaminants and 29 potential air pollutants evaluated by IARC (119 unique compounds), 49 water and 20 air pollutants were known, probable, or possible human carcinogens (55 unique compounds). A total of 17 water and 11 air pollutants (20 unique compounds) had evidence of increased risk for leukemia/lymphoma, including benzene, 1,3-butadiene, cadmium, diesel exhaust, and several polycyclic aromatic hydrocarbons. Though information on the carcinogenicity of compounds associated with UO&G development was limited, our assessment identified 20 known or suspected carcinogens that could be measured in future studies to advance exposure and risk assessments of cancer-causing agents. Our findings support the need for investigation into the relationship between UO&G development and risk of cancer in general and childhood leukemia in particular.
... This finding indicates that non-exposed individuals residing in proximity to an oil spill should also be monitored due a probable increased risk of cancer in relation to the general population. The present hypothesis is supported by the increase of cancer, especially leukemia, in people living in close proximity to oil refineries [41,42] and in proximity to petroleum storage tanks [43]. ...
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Background: The identification of breakpoints involved in chromosomal damage could help to detect genes involved in genetic disorders, most notably cancer. Until now, only one published study, carried out by our group, has identified chromosome bands affected by exposure to oil from an oil spill. In that study, which was performed two years after the initial oil exposure in individuals who had participated in clean-up tasks following the wreck of the Prestige, three chromosomal bands (2q21, 3q27, 5q31) were found to be especially prone to breakage. A recent follow-up study, performed on the same individuals, revealed that the genotoxic damage had persisted six years after oil exposure. Objectives: To determine whether there exist chromosome bands which are especially prone to breakages and to know if there is some correlation with those detected in the previous study. In addition, to investigate if the DNA repair problems detected previously persist in the present study. Design: Follow-up study performed six years after the Prestige oil spill. Setting: Fishermen cooperatives in coastal villages. Participants: Fishermen highly exposed to oil spill who participated in previous genotoxic study six years after the oil. Measurements: Chromosome damage in peripheral lymphocytes. For accurate identification of the breakpoints involved in chromosome damage of circulating lymphocytes, a sequential stain/G-banding technique was employed. To determine the most break-prone chromosome bands, two statistical methods, the Fragile Site Multinomial and the chi-square tests (where the bands were corrected by their length) were used. To compare the chromosome lesions, structural chromosome alterations and gaps/breaks between two groups of individuals we used the GEE test which takes into account a possible within-individual correlation. Dysfunctions in DNA repair mechanisms, expressed as chromosome damage, were assessed in cultures with aphidicolin by the GEE test. Results: Cytogenetic analyses were performed in 47 exposed individuals. A total of 251 breakpoints in exposed individuals) were identified, showing a non-uniform distribution in the human ideogram. Ten chromosome bands were found to be especially prone to breakage through both statistical methods. By comparing these bands with those observed in certain exposed individuals who had already participated the previous study, it was found in both studies that four bands (2q21, 3q27, 5q31 and 17p11.2) are particularly sensitive to breakage. Additionally, the dysfunction in DNA repair mechanisms was not significantly higher in oil-exposed individuals than in non-exposed individuals. Limitations: The sample size and the possibility of some kind of selection bias should be considered. Genotoxic results cannot be extrapolated to the high number of individuals who participated occasionally in clean-up tasks. Conclusion: Our findings show the existence of at least four target bands (2q21, 3q27, 5q31 and 17p11.2) with a greater propensity to break over time after an acute exposure to oil. The breaks in these bands, which are commonly involved in hematological cancer, may explain the increase of cancer risk reported in chronically benzene-exposed individuals. In addition, a more efficiency of the DNA repair mechanisms has been detected six years after in fishermen who were highly exposed to the oil spill. To date, only this study, performed by our group on the previous and present genotoxic effects, has analyzed the chromosomal regions affected by breakage after an acute oil exposure.
... There is general agreement, though, that an evaluation of sufficient evidence of causality cannot be formulated, the exception being pleural mesothelioma and residence near asbestos mines or asbestos industries, such as asbestos-cement plants. Recently, increasing evidence has been provided for associations between residence near: i) processing and storage facilities and lung cancer and Non Hodgkin lymphoma [13,14]; ii) refineries, thermal power plants, steel and pulp mills and breast cancer [15]; iii) metal industries and prostate cancer [16] and digestive tract cancer [17]; iv) sites contaminated by toxic waste dumps and bladder and kidney cancer [18]. Increased incidence of haematological cancers, was observed in ZIP codes containing benzene waste sites [19]. ...
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Introduction: The incidence of cancer among residents in sites contaminated by pollutants with a possible health impact is not adequately studied. In Italy, SENTIERI Project (Epidemiological study of residents in National Priority Contaminated Sites, NPCSs) was implemented to study major health outcomes for residents in 44 NPCSs. Methods: The Italian Association of Cancer Registries (AIRTUM) records cancer incidence in 23 NPCSs. For each NPCSs, the incidence of all malignant cancers combined and 35 cancer sites (coded according to ICD-10), was analysed (1996-2005). The observed cases were compared to the expected based on age (5-year period, 18 classes), gender, calendar period (1996-2000; 2001-2005), geographical area (North-Centre and Centre-South) and cancer sites specific rates. Standardized Incidence Ratios (SIR) with 90% Confidence Intervals were computed. Results: In both genders an excess was observed for overall cancer incidence (9% in men and 7% in women) as well as for specific cancer sites (colon and rectum, liver, gallbladder, pancreas, lung, skin melanoma, bladder and Non Hodgkin lymphoma). Deficits were observed for gastric cancer in both genders, chronic lymphoid leukemia (men), malignant thyroid neoplasms, corpus uteri and connective and soft-tissue tumours and sarcomas (women). Discussion: This report is, to our knowledge, the first one on cancer risk of residents in NPCSs. The study, although not aiming to estimate the cancer burden attributable to the environment as compared to occupation or life-style, supports the credibility of an etiologic role of environmental exposures in contaminated sites. Ongoing analyses focus on the interpretation of risk factors for excesses of specific cancer types overall and in specific NPCSs in relation to the presence of carcinogenic pollutants.
... There is general agreement, though, that an evaluation of sufficient evidence of causality cannot be formulated, the exception being pleural mesothelioma and residence near asbestos mines or asbestos industries, such as asbestos-cement plants. Recently, increasing evidence has been provided for associations between residence near: i) processing and storage facilities and lung cancer and Non Hodgkin lymphoma [13,14]; ii) refineries, thermal power plants, steel and pulp mills and breast cancer [15]; iii) metal industries and prostate cancer [16] and digestive tract cancer [17]; iv) sites contaminated by toxic waste dumps and bladder and kidney cancer [18]. Increased incidence of haematological cancers, was observed in ZIP codes containing benzene waste sites [19]. ...
Article
Full-text available
Introduction: The incidence of cancer among residents in sites contaminated by pollutants with a possible health impact is not adequately studied. In Italy, SENTIERI Project (Epidemiological study of residents in National Priority Contaminated Sites, NPCSs) was implemented to study major health outcomes for residents in 44 NPCSs. Methods: The Italian Association of Cancer Registries (AIRTUM) records cancer incidence in 23 NPCSs. For each NPCSs, the incidence of all malignant cancers combined and 35 cancer sites (coded according to ICD-10), was analysed (1996-2005). The observed cases were compared to the expected based on age (5-year period,18 classes), gender, calendar period (1996-2000; 2001-2005), geographical area (North-Centre and Centre-South) and cancer sites specific rates. Standardized Incidence Ratios (SIR) with 90% Confidence Intervals were computed. Results: In both genders an excess was observed for overall cancer incidence (9% in men and 7% in women) as well as for specific cancer sites (colon and rectum, liver, gallblad-der, pancreas, lung, skin melanoma, bladder and Non Hodgkin lymphoma). Deficits were observed for gastric cancer in both genders, chronic lymphoid leukemia (men), malignant thyroid neoplasms, corpus uteri and connective and soft-tissue tumours and sarcomas (women). Discussion: This report is, to our knowledge, the first one on cancer risk of residents in NPCSs. The study, although not aiming to estimate the cancer burden attributable to the environment as compared to occupation or life-style, supports the credibility of an etiologic role of environmental exposures in contaminated sites. Ongoing analyses focus on the interpretation of risk factors for excesses of specific cancer types overall and in specific NPCSs in relation to the presence of carcinogenic pollutants.
... 2. Although developing the discussion in this direction is out of the scope of this article, it is worth noticing that the health risks of such proximity are object of specific literature. See, for example , Zusman et al. (2012), De Roos et al. (2010) and Brender et al. (2008). ...
Article
The rejection of siting controversial facilities in urban areas periodically resurrects the discussion regarding site-specific technologies that pose risks characterised by severe impacts and extremely low probabilities. This article discusses this topic from an ethics perspective, focusing on the problematic evaluation of minimum safe distances that should be established between potential accidents and exposed residents. Two different approaches to the assessment of such ‘spatial safety’ measures – namely, the probabilistic and deterministic approaches – are compared. The scope of this article is to unveil these approaches’ implicit ethical assumptions and – more generally – facilitate a considered choice between different approaches towards planning ‘risky’ land uses.
... The incidence of leukemia in our study showed that Eastern Region ranked second which is might be due to presence of ARAMKO, the largest oil company around the world and Jubail Industrial City, global city for chemical industries. Many reports revealed that Exposure to petroleum, petrochemicals and petroleum oil was strongly associated with leukemia 6,7,8,9 however, further studies are needed to determine whether if this association also occurs in Saudi Arabia. Moreover, there was seldom r eports about the incidence of leukemia in specific region which is Northern region reporting that leukemia ranked sixth among all types of cancers by 26 cases registered in 2002. ...
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Objectives: Leukemia is a type of the cancers that needs careful registration and reporting among Saudi hospitals. Leukemia is defined as neoplastic proliferation of abnormal white blood cells (WBCs). Methods:This study was conducted to investigate the incidence of leukemia in the Kingdom of Saudi Arabia, to determine which age group leukemia most commonly affects and also to identify which region in Saudi Arabia is mostly targeted by leukemia. A quantitative observational retrospective cross sectional analysis of the reported cases of leukemia was conducted based on the reports of Saudi Cancer Registry (SCR) in the Ministry of Health (MOH) at Saudi Arabia about leukemia in all regions from the period of January to December 2009. A P-value < 0.05 was considered statistically significant with confidence interval (CI) of 95%. Results:619 cases of leukemia were reported. Males are slightly more affected with leukemia by 343 cases (55.4%) than females by 276 cases (44.6%). Patients who are 75+ old of age are the commonly affected age group with leukemia by 20.8 per 100,000 for males and 10.3 per 100,000 for females. Najran was the commonly affected region with leukemia by 7.3 per 100,000 for males and 5.9 per 100,000 for females. The commonly morphological distribution of leukemia was acute lymphoblastic leukemia (ALL) by 133 cases (39%) for males and 108 cases (39%) for females. Conclusion:Further studies and reports are needed to identify the risk factors targeting a specific age group and specific region in Saudi Arabia with leukemia. Keywords:Incidence, Leukemia, and Kingdom of Saudi Arabia.
... Branches of these two companies are distributed throughout the major cities of the Eastern region. Empirical studies have highlighted that exposure to petroleum emissions and petrochemicals and proximity to the petroleum oil industry are associated with leukemia, NHL and lung cancer [48][49][50][51][52][53]; however, further investigation is needed to determine whether this association also occurs in Saudi Arabia. One study has shown an increased risk of liver cancer in people with a father and brother diagnosed with prostate cancer. ...
Article
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Little is known about the geographic distribution of common cancers in Saudi Arabia. We explored the spatial incidence patterns of common cancers in Saudi Arabia using spatial autocorrelation analyses, employing the global Moran's I and Anselin's local Moran's I statistics to detect nonrandom incidence patterns. Global ordinary least squares (OLS) regression and local geographically-weighted regression (GWR) were applied to examine the spatial correlation of cancer incidences at the city level. Population-based records of cancers diagnosed between 1998 and 2004 were used. Male lung cancer and female breast cancer exhibited positive statistically significant global Moran's I index values, indicating a tendency toward clustering. The Anselin's local Moran's I analyses revealed small significant clusters of lung cancer, prostate cancer and Hodgkin's disease among males in the Eastern region and significant clusters of thyroid cancers in females in the Eastern and Riyadh regions. Additionally, both regression methods found significant associations among various cancers. For example, OLS and GWR revealed significant spatial associations among NHL, leukemia and Hodgkin's disease (r² = 0.49-0.67 using OLS and r² = 0.52-0.68 using GWR) and between breast and prostate cancer (r² = 0.53 OLS and 0.57 GWR) in Saudi Arabian cities. These findings may help to generate etiologic hypotheses of cancer causation and identify spatial anomalies in cancer incidence in Saudi Arabia. Our findings should stimulate further research on the possible causes underlying these clusters and associations.
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There is substantial public concern about the health risks of proximity to petrochemical industries. In the Haifa Bay Area (HBA), which contains Israel’s densest industrial area, these concerns have been strengthened by elevated cancer mortality rates since the late 1960s. We studied the association between adolescent exposure to industrial air pollution in the HBA and adult-onset cancer. This is a historical cohort study. The study population comprised 2,187,317 subjects, using the Israeli medical corps data linked to the Israel National Cancer Registry with follow-up of up to 45 years. Exposure assessments were estimated by a spatial kriging interpolation model of SO2, serving as a marker for the dispersion of air pollution emitted from the complex during the study period. We found increased crude (HR = 1.23, 95%CI= 1.17 to 1.29) and adjusted (HR = 1.16, 95%CI = 1.10 to 1.21) risk of cancer with increased exposure to air pollution in HBA. The associations remained robust in analyses stratified by decade and socio-economic status. We found evidence of monotonically increased risk in five of 13 cancer categories (leukemia, melanoma, female breast, central nervous system, and thyroid tumors). Our findings strengthen the hypothesis that this exposure posed a carcinogenic risk during the study period.
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The article presents general recommendations for the calculation of steel tanks for gas and petroleum products storage. The analysis of the existing structural forms of tanks is carried out and their classification is provided. The paper analyzes the main types and features of tanks. Optimal dimensions and parameters of steel tanks are given. The article presents coefficients of working conditions for the calculation of vertical cylindrical tanks elements. The article details calculation of the tank wall and negative tolerances on the thickness of the steel sheet. The stress–strain state of the tanks is estimated according to the theory of shell calculation. This assessment takes into account only the ring and meridional stresses, operational snow and wind loads, temperature and aggressive effects. Negative trends of reducing the indicators of bearing capacity, operational reliability and durability of steel tanks were revealed. A variant of calculated diagram of the fluid pressure on the tank wall is presented. Calculation proposals based on the experience of designing steel tanks are formed. An example of calculation of a steel vertical tank is considered. The formula of calculation of the tank wall belt from condition of strength provision (according to the first group of limit states) is presented. The formula for checking the stresses in the lower zone of the tank wall taking into account the action of the boundary moment is also obtained.
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Link to Summary Table on Progress and Challenges is available at http://www.ehf.org.il/magazines/en/EnvHealthIsrael2017/140/
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Introduction: A brief review is presented in the field of petroleum carcinogenesis. Epidemiological surveys in occupationally exposed populations postulate that long exposure to polycyclic aromatic hydrocarbons (PAHs) is carcinogenic. Several novel surfactants were investigated by Badawi and his collaborators on regulation of cancer growth. Other investigators recorded the role of cationic surfactants and pegylation. Materials: Germanium-based surfactants. Tin-based surfactants. Metallosurfactants. Copper- or cobalt-based surfactants. Sulfonamide-based surfactants. Isothiouronium quaternary surfactants. Polymeric surfactants. Benzethonium chloride surfactant. Liposomal doxorubicin. Clinical trials. Key Findings: Amino acid germinate surfactants provided sufficient immune responses to cancer diseases. Germanium-amino acid surfactant complexes showed antitumor potency related to possible osmotic balance disturbance. Cationic germanium-based surfactants displayed significant cytotoxicity in tumor cells. Cationic tin-based surfactants showed effective antitumor potency possibly due to disturbing the osmotic balance between the tumor cells and the medium. Metallosurfactants like copper cetyltrimethylammonium bromide (Cu-CTAB) surfactant loaded cyclodextrin nano-analogue displayed significant in vitro antitumor activity against human breast cancer cells (MCF-7), cervix cancer cells (Hela), and colon cancer cells (HCT-116) and in vivo effective antitumor activity against Ehrlich ascites carcinoma tumor in mice. Another metal-based surfactant as cobalt or copper dodecylammonium hydrogen selenite revealed high cytotoxicity against human tumor cell lines, H460 lung carcinoma, breast carcinoma MCF, and colon carcinoma HCT116. Testing novel substituted sulfonamide based-surfactants showed that N-{4[(laurylamino)sulfonyl] phenyl}acetamide has the best surface activity and exhibited the highest cytotoxicity on liver carcinoma cell line (HEPG2). Another different biphenyl-4,4\-disulfonamide surfactant showed that its copper complex exhibited the highest cytotoxicity on liver carcinoma cell line (HEPG2). Sulfonamide tetrachlorometallate surfactants showed significant in vitro cytotoxic activity against colon HCT human cell line. Screening new isothiouronium and quaternary surfactants reflected promising in vitro antileukemic activity. Surface-active polymeric micelles with covalently entrapped doxorubicin were a system with high promise for the target delivery of cytotoxic agents. Evaluation of benzethonium chloride cationic surfactant revealed broad-range antitumor activity inducing apoptosis and activated capsis. Randomized multicenter phase III trial evaluated the role of maintenance therapy with surface-active regulated liposomal doxorubicin (PLD) after induction of chemotherapy in patients with metastatic breast cancer. Conclusion: Surfactants play a great role in regulation of cancer growth.
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The examination of size frequency distributions with time helps to analyze some useful parameters in the study of population dynamics. In this paper, we present the use of Kernel Density Estimators (KDE's) as a modern tool to examine length-frequency distributions of fish larvae with the case of Pholis gunnellus larvae as an example. Data were taken from a previous published work carried out at two hydrographically different sites in the Gulf of Maine, USA. At each site, sampling was performed from late winter to early summer during 1979 and 1980, at weekly intervals. Fish larvae were measured to the nearest 0.5 mm total length. As we only knew the number of larvae in each millimeter interval (from 9 to 30), we added random numbers around each discrete value in order to obtain a set of continuous data. The size distribution of each sample was analyzed by means of kernel density estimators, using a Gaussian function with the optimal bandwidth. The resulting distributions were decomposed in their Gaussian components with a computerized version of the Bhattacharya's method. Each component's means (corresponding to dominant modes) were plotted against time to follow the average growth of fish larvae. These values were fitted to a logistic function by means of a nonlinear least squares procedure. These analyses showed that mean size of larvae remains relatively constant during late winter samplings, suggesting a con-tinuous larvae hatching and mortality. At spring establishment, when environmental conditions are more favorable for the survival of fish larvae, body size increases following a logistic function. Results indicated a short time lag (16 days) in larvae growth between the sites only in 1980. Hence, with this we illustrate that the use of KDE's, followed by the Bhattacharya's identification of Gaussian distribution components, and the analysis of main modes versus time, provide a more precise way to study length-frequency distributions than length-frequency tables alone.
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This paper shows how kernel density estimation may be used to estimate flexibly the geographic distribution of customers in a market. In addition it shows how a density-based product positioning methodology may be applied to site selection, using the estimated geographic customer density to help locate a new or (relocated) store or distribution center. This application provides a conceptual basis for more complicated site selection and spatial demand models which might involve several predictor variables.
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The minimum size of subjects required for the research on human health, thermal comfort and productivity is a frequently asked question. In this paper the idea of power analysis, which helps to determine required sample size as well as to interpret research results, is introduced in order to promote good practice of power analysis in the context of human and building environment relationship research. How to calculate effect size from published article or experimental data is presented with plenty of examples. The effect sizes of several physiological and psychological measurements indicating the effect of indoor environment quality on human health, thermal comfort and productivity are presented, which could be worked as references when researchers planning their own studies. How to determine required sample size when planning a study and how to interpret the research results with power analysis are also illustrated step by step with samples. Finally how to make decisions when evaluating the study results is summarized. It is expected that these examples and the summary could help researchers to better apply power analysis in indoor environment quality (IEQ) studies. Some statistical terms used in this paper, such as power analysis, effect size, and t-test, etc., are explained in detail in the Appendix.
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To examine the incidence of lymphohaematopoietic malignancy around industrial complexes that include major oil refineries in Great Britain after recent public and scientific concern of possible carcinogenic hazards of emissions from the petrochemical industry. Small area study of the incidence of lymphohaematopoietic malignancies, 1974-91, within 7.5 km of all 11 oil refineries (grouped into seven sites) in Great Britain that were operational by the early 1970s and processed more than two million tonnes of crude oil in 1993. Combined analysis of data from all seven sites showed no significant (p < 0.05) increase in risk of these malignancies within 2 km or 7.5 km. Hodgkin's lymphoma, but no other malignancy, showed evidence (p = 0.02) of a decline in risk with distance from refineries, but there was an apparent deficit of cases of multiple myeloma near the refineries (p = 0.04). There was no evidence of association between residence near oil refineries and leukaemias, or non-Hodgkin's lymphoma. A weak positive association was found between risk of Hodgkin's disease and proximity to major petrochemical industry, and a negative association with multiple myeloma, which may be chance findings within the context of multiple statistical testing.
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Geographic information systems have advanced the ability to both visualize and analyze point data. While point-based maps can be aggregated to differing areal units and examined at varying resolutions, two problems arise 1) the modifiable areal unit problem and 2) any corresponding data must be available both at the scale of analysis and in the same geographic units. Kernel density estimation (KDE) produces a smooth, continuous surface where each location in the study area is assigned a density value irrespective of arbitrary administrative boundaries. We review KDE, and introduce the technique of utilizing an adaptive bandwidth to address the underlying heterogeneous population distributions common in public health research. The density of occurrences should not be interpreted without knowledge of the underlying population distribution. When the effect of the background population is successfully accounted for, differences in point patterns in similar population areas are more discernible; it is generally these variations that are of most interest. A static bandwidth KDE does not distinguish the spatial extents of interesting areas, nor does it expose patterns above and beyond those due to geographic variations in the density of the underlying population. An adaptive bandwidth method uses background population data to calculate a kernel of varying size for each individual case. This limits the influence of a single case to a small spatial extent where the population density is high as the bandwidth is small. If the primary concern is distance, a static bandwidth is preferable because it may be better to define the "neighborhood" or exposure risk based on distance. If the primary concern is differences in exposure across the population, a bandwidth adapting to the population is preferred. Kernel density estimation is a useful way to consider exposure at any point within a spatial frame, irrespective of administrative boundaries. Utilization of an adaptive bandwidth may be particularly useful in comparing two similarly populated areas when studying health disparities or other issues comparing populations in public health.
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Cryptosporidium parvum is one of the most important biological contaminants in drinking water that produces life threatening infection in people with compromised immune systems. Dairy calves are thought to be the primary source of C. parvum contamination in watersheds. Understanding the spatial and temporal variation in the risk of C. parvum infection in dairy cattle is essential for designing cost-effective watershed management strategies to protect drinking water sources. Crude and Bayesian seasonal risk estimates for Cryptosporidium in dairy calves were used to investigate the spatio-temporal dynamics of C. parvum infection on dairy farms in the New York City watershed. Both global (Global Moran's I) and specific (SaTScan) cluster analysis methods revealed a significant (p < 0.05) elliptical spatial cluster in the winter with a relative risk of 5.8, but not in other seasons. There was a two-fold increase in the risk of C. parvum infection in all herds in the summer (p = 0.002), compared to the rest of the year. Bayesian estimates did not show significant spatial autocorrelation in any season. Although we were not able to identify seasonal clusters using Bayesian approach, crude estimates highlighted both temporal and spatial clusters of C. parvum infection in dairy herds in a major watershed. We recommend that further studies focus on the factors that may lead to the presence of C. parvum clusters within the watershed, so that monitoring and prevention practices such as stream monitoring, riparian buffers, fencing and manure management can be prioritized and improved, to protect drinking water supplies and public health.
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This paper reports incidence of cancer in employees of the Australian petroleum industry from 1981 to 1989. Two surveys by personal interview incorporated more than 15,000 employees, representing 92% of the eligible population. Subjects were included in the analysis after completing five years of service in the industry. At the time of this report the cohort did not include sufficiently large numbers of women for useful analysis; results presented are restricted to the men. On 31 December 1989, 50,254 person-years of observation had accumulated in the men with 152 incident cancers reported. The standardised incidence ratio (SIR) analysis showed overall cancer rates close to those of the national population. Whereas deficits were seen in some cancer sites, notably lung cancer (SIR 0.5, 95% confidence internal (95% CI) 0.3-0.9), incidence rates for some other cancer sites suggested increased risk. An excess of observed over expected cases was present in all subcategories of lymphohaematopoietic cancer except Hodgkin's disease (no cases), and was most apparent in myeloid leukaemia (SIR 4.0, 95% CI 1.6-8.2). The other major site with a raised number of cases observed over expected was melanoma (SIR 1.4, 95% CI 0.8-2.1).
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To estimate the risk of cancer due to occupational exposure to petroleum products in the Swedish transport and refinery industries. In a retrospective cohort study the cancer incidence in 4128 men and 191 women, who had worked for at least one year in the petroleum industry, was compared with the incidence in the general population. The job titles and employment times for each person were found in personal files in the industries. The men had on average worked in jobs exposed to petroleum for 11.6 years at the end of the observation period. The cases of cancer were identified by record linkage with the Swedish cancer register. In total there were 146 cases of cancer v 157.6 expected (standardised mortality ratio (SMR) 0.93 90% confidence interval (90% CI) 0.80 to 1.1). Operators at refineries had an increased risk of leukaemia (6 cases v 1.7 expected, 90% CI of relative risk (RR) 1.5 to 7.0). Five of the six cases had started to work at the refineries in the 1950s or later. No other significantly increased risk of cancer was found. Distribution workers had a decreased incidence of lung cancer (no cases, 90% CI of RR 0 to 0.4). Operators at Swedish refineries had an increased risk of leukaemia. A possible cause is exposure to benzene. There was no increased risk of leukaemia in distribution workers. Distribution workers had a decreased risk of lung cancer.
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The aim of the present study is to investigate cancer mortality and residence in the neighbourhood of the petrochemical plant located in Brindisi, South-eastern Italy. Cases were all subjects resident in Brindisi and in three neighbouring municipalities who died in the study area in 1996-1997 from lung cancer, pleural neoplasm, bladder cancer and lymphohematopoietic malignancies. Controls were subjects resident in the same area and deceased in 1996-1997 for any cause except those listed for the cases. Next of kin's of all study subjects were visited by an interviewer who collected anamnestic information. The main residence of each subject, defined as the longest held residence with exclusion of the last 10 years, was reported on a digitalized map of the study area (MapInfo). The study included 144 cases and 176 controls; response rate was 98%. Residence within 2 km from the centre of the petrochemical plant was associated with a 3 fold increase of the Odds ratios (OR) for lung cancer, which did not reach statistical significance. Living close to the petrochemical plant was associated with moderate increases of OR for bladder cancer and lymphohematopoietic neoplasms which did not reach statistical significance. In conclusion the present study has shown moderate increases in risk for lung, bladder and lymphohematopoietic neoplasms in the population resident within 2 km from the centre of the petrochemical plant in Brindisi. These figures were confirmed after adjusting for smoking habit, occupation and school level. Random misclassification may have somehow resulted in risk underestimation.
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Comments on the original article "The impact of chief executive officer personality on top management team dynamics: One mechanism by which leadership affects organizational performance", by R. S. Peterson et al.. This comment illustrates how small sample sizes, when combined with many statistical tests, can generate unstable parameter estimates and invalid inferences. Although statistical power for 1 test in a small-sample context is too low, the experimentwise power is often high when many tests are conducted, thus leading to Type I errors that will not replicate when retested. This comment's results show how radically the specific conclusions and inferences in R. S. Peterson, D. B. Smith, P. V. Martorana, and P. D. Owens's (2003) study changed with the inclusion or exclusion of 1 data point. When a more appropriate experimentwise statistical test was applied, the instability in the inferences was eliminated, but all the inferences become nonsignificant, thus changing the positive conclusions.
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The authors conducted a population-based, case-control study in Kaohsiung, southern Taiwan, Republic of China, to investigate the association between residential petrochemical exposure and leukemia risk among subjects 29 years of age and younger. Between November 1997 and June 2003, 171 cases and 410 controls matched for age and sex were recruited. Since assessment of petrochemical impacts depends on accurate exposure estimates, the authors developed a procedure using geographic information system tools to assign subjects' exposure. The resulting individual-level exposure estimates (the exposure opportunity score) are an integrated exposure measure that accounts for subjects' mobility, length of stay at each residence, distance to petrochemical plant(s), monthly prevailing wind direction, and multiple petrochemical pollution sources. Different conditional logistic regression models were fitted for subjects aged 0-19 and 20-29 years to evaluate separately childhood versus adulthood leukemia. No overall association was observed for the younger age group. However, residential petrochemical exposure was a significant risk factor for leukemia for the older age group. For one unit of increase in the log-transformed exposure opportunity score, the adjusted odds ratio was 1.54 (95 percent confidence interval: 1.14, 2.09). This study illustrates the utility of geographic information system tools for providing refined exposure estimates for residential exposure to petrochemical pollution.
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What do we currently know about the occupational and environmental causes of cancer? As of 2007, the International Agency for Research on Cancer (IARC) identified 415 known or suspected carcinogens. Cancer arises through an extremely complicated web of multiple causes, and we will likely never know the full range of agents or combinations of agents. We do know that preventing exposure to individual carcinogens prevents the disease. Declines in cancer rates-such as the drop in male lung cancer cases from the reduction in tobacco smoking or the drop in bladder cancer among cohorts of dye workers from the elimination of exposure to specific aromatic amines-provides evidence that preventing cancer is possible when we act on what we know. Although the overall age-adjusted cancer incidence rates in the United States among both men and women have declined in the last decade, the rates of several types of cancers are on the rise; some of which are linked to environmental and occupational exposures. This report chronicles the most recent epidemiologic evidence linking occupational and environmental exposures with cancer. Peer-reviewed scientific studies published from January 2005 to June 2007 were reviewed, supplementing our state-of-the-evidence report published in September 2005. Despite weaknesses in certain individual studies, we consider the evidence linking the increased risk of several types of cancer with specific exposures somewhat strengthened by recent publications, among them brain cancer from exposure to non-ionizing radiation, particularly radiofrequency fields emitted by mobile telephones; breast cancer from exposure to the pesticide dichlorodiphenyltrichloroethane (DDT) before puberty; leukemia from exposure to 1,3-butadiene; lung cancer from exposure to air pollution; non-Hodgkin's lymphoma (NHL) from exposure to pesticides and solvents; and prostate cancer from exposure to pesticides, polyaromatic hydrocarbons (PAHs), and metal working fluids or mineral oils. In addition to NHL and prostate cancer, early findings from the National Institutes of Health Agricultural Health Study suggest that several additional cancers may be linked to a variety of pesticides. Our report also briefly describes the toxicological evidence related to the carcinogenic effect of specific chemicals and mechanisms that are difficult to study in humans, namely exposures to bis-phenol A and epigenetic, trans-generational effects. To underscore the multi-factorial, multi-stage nature of cancer, we also present a technical description of cancer causation summarizing current knowledge in molecular biology. We argue for a new cancer prevention paradigm, one based on an understanding that cancer is ultimately caused by multiple interacting factors rather than a paradigm based on dubious attributable fractions. This new cancer prevention paradigm demands that we limit exposure to avoidable environmental and occupational carcinogens, in combination with additional important risk factors like diet and lifestyle. The research literature related to environmental and occupational causes of cancer is constantly growing, and future updates will be carried out in light of new biological understanding of the mechanisms and new methods for studying exposures in human populations. The current state of knowledge is sufficient to compel us to act on what we know. We repeat the call of ecologist Sandra Steingraber: "From the right to know and the duty to inquire flows the obligation to act."
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This study examines the impact of the precision of address geocoding on the estimated density of crime locations in a large urban area of Japan. The data consist of two separate sets of the same Penal Code offenses known to the police that occurred during a nine-month period of April 1, 2001 through December 31, 2001 in the central 23 wards of Tokyo. These two data sets are derived from older and newer recording system of the Tokyo Metropolitan Police Department (TMPD), which revised its crime reporting system in that year so that more precise location information than the previous years could be recorded. Each of these data sets was address-geocoded onto a large-scale digital map, using our hierarchical address-geocoding schema, and was examined how such differences in the precision of address information and the resulting differences in address-geocoded incidence locations affect the patterns in kernel density maps.An analysis using 11,096 pairs of incidences of residential burglary (each pair consists of the same incidents geocoded using older and newer address information, respectively) indicates that the kernel density estimation with a cell size of 25×25m and a bandwidth of 500m may work quite well in absorbing the poorer precision of geocoded locations based on data from older recording system, whereas in several areas where older recording system resulted in very poor precision level, the inaccuracy of incident locations may produce artifactitious and potentially misleading patterns in kernel density maps.
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Simulations are necessary to assess the performance of home-range estimators because the true distribution of empirical data is unknown, but we must question whether that performance applies to empirical data. Some studies have used empirically based simulations, randomly selecting subsets of data to evaluate estimator performance, but animals do not move randomly within a home range. We created an empirically based simulation using a behavioral model, generated a probability distribution from those data, and randomly selected locations from that distribution in a chronological sequence as the simulated individual moved through its home range. Thus, we examined the influence of temporal patterns of space use and determined the effects of smoothing, number of locations, and autocorrelation on kernel estimates. Additionally, home-range estimators were designed to evaluate species that use space with few restrictions, traveling almost anywhere on the landscape. Many species, however, confine their movements to a geographical feature that conforms to a relatively linear pattern. Consequently, conventional analysis techniques may overestimate home ranges. We used simulations based upon coastal river otters (Lontra canadensis), a species that primarily uses the aquatic-terrestrial interface, to evaluate the efficacy of fixed and adaptive kernel estimates with various smoothing parameters. Measures of shoreline length within contours from fixed kernel analyses and the reference smoothing parameter were best for estimates of 95% home ranges, because smoothing with least squares cross validation (LSCV) often resulted in inconsistent results, excessive fragmentation, and marked underestimates of linear home ranges. Core areas (50% density contours) were best defined with fixed kernel LSCV estimates. Fewer locations underestimated linear home ranges, and there was a subtle positive relation between home-range size and autocorrelation. Generally, as location numbers increased, autocorrelation increased, but differences from the "true" home range decreased. Results were similar for our simulations and empirical data from 13 river otters. Examination of empirical data revealed that data with high positive autocorrelation illustrated seasonal reproductive activities. Because autocorrelation does not negatively influence estimates of linear home ranges, assessment of independence between data points may be more appropriately viewed as a means to identify important behavioral information, rather than as a hindrance.
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The kernel density (KD) function estimates the intensity of events across a surface by calculating the overall number of cases situated within a given search radius from a target point. To form a continuous surface from individual observations, the KD technique does not require the presence of a parameter’s value in a given location (e.g., the incidence rate of a disease). This feature of KD smoothing is especially beneficial for empirical studies in which individual observations are represented by geographic coordinates only and have no other attributes, required by more commonly used smoothing techniques, such as spline and kriging. In the present study, we illustrate the use of KD technique for a study of association between the geographical distributions of breast cancer cases and exposure to artificial illumination during nighttime (light-at-night or LAN) in the city of Haifa, Israel.
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A standard planar Kernel Density Estimation (KDE) aims to produce a smooth density surface of spatial point events over a 2-D geographic space. However, the planar KDE may not be suited for characterizing certain point events, such as traffic accidents, which usually occur inside a 1-D linear space, the roadway network. This paper presents a novel network KDE approach to estimating the density of such spatial point events. One key feature of the new approach is that the network space is represented with basic linear units of equal network length, termed lixel (linear pixel), and related network topology. The use of lixel not only facilitates the systematic selection of a set of regularly spaced locations along a network for density estimation, but also makes the practical application of the network KDE feasible by significantly improving the computation efficiency. The approach is implemented in the ESRI ArcGIS environment and tested with the year 2005 traffic accident data and a road network in the Bowling Green, Kentucky area. The test results indicate that the new network KDE is more appropriate than standard planar KDE for density estimation of traffic accidents, since the latter covers space beyond the event context (network space) and is likely to overestimate the density values. The study also investigates the impacts on density calculation from two kernel functions, lixel lengths, and search bandwidths. It is found that the kernel function is least important in structuring the density pattern over network space, whereas the lixel length critically impacts the local variation details of the spatial density pattern. The search bandwidth imposes the highest influence by controlling the smoothness of the spatial pattern, showing local effects at a narrow bandwidth and revealing “hot spots” at larger or global scales with a wider bandwidth. More significantly, the idea of representing a linear network by a network system of equal-length lixels may potentially lead the way to developing a suite of other network related spatial analysis and modeling methods.
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Abstract For an effective interpretation of spatio-temporal patterns of crime clusters/hotspots, we explore the possibility of three-dimensional mapping of crime events in a space-time cube with the aid of space-time variants of kernel density estimation and scan statistics. Using the crime occurrence dataset of snatch-and-run offences in Kyoto City from 2003 to 2004, we confirm that the proposed methodology enables simultaneous visualisation of the geographical extent and duration of crime clusters, by which stable and transient space-time crime clusters can be intuitively differentiated. Also, the combined use of the two statistical techniques revealed temporal inter-cluster associations showing that transient clusters alternatively appeared in a pair of hotspot regions, suggesting a new type of “displacement” phenomenon of crime. Highlighting the complementary aspects of the two space-time statistical approaches, we conclude that combining these approaches in a space-time cube display is particularly valuable for a spatio-temporal exploratory data analysis of clusters to extract new knowledge of crime epidemiology from a data set of space-time crime events.
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In the absence of patient-specific data, composite level data are often used in epidemiological studies. However, since individual exposure levels cannot accurately be inferred from aggregate data, such an approach may lead to erroneous estimates of health effects of potential environmental risk factors. In the present study, we attempt to address this information-loss problem by using the "kernel density function", which estimates the intensity of events across a surface, by calculating the overall number of cases situated within a given search radius from a target point. The present paper illustrates the use of this analytical technique for a study of association between the geographical distributions of lung cancer cases and SO2 air pollution estimates in the Greater Haifa Metropolitan Area (GHMA). In the analysis, the results obtained by kernel smoothing are contrasted with those obtained by areal aggregation techniques more commonly used in empirical studies.
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Industrial pollution has been suspected as a cause of non-Hodgkin lymphoma (NHL), based on associations with chemical exposures in occupational studies. We conducted a case-control study of NHL in four SEER regions of the United States, in which residential locations of 864 cases and 684 controls during the 10 years before recruitment were used to characterize proximity to industrial facilities reporting chemical releases to the Environmental Protection Agency's Toxics Release Inventory (TRI). For each of 15 types of industry (by 2-digit SIC code), we evaluated the risk of NHL associated with having lived within 2 miles of a facility, the distance to the nearest facility (miles categories of < or =0.5, >0.5-1.0, >1.0-2.0, >2 [referent]), and the duration of residence within 2miles (years categories of 10, 1-9, 0 [referent]), using logistic regression. Increased risk of NHL was observed in relation to lumber and wood products facilities (SIC 24) for the shortest distance of residential proximity (< or =0.5 mile: odds ratio [OR]=2.2, 95% confidence interval [CI]: 0.4-11.8) or the longest duration (10 years: OR=1.9, 95% CI: 0.8-4.8); the association with lumber facilities was more apparent for diffuse large B-cell lymphoma (lived within 2 miles: OR=1.7, 95% CI: 1.0-3.0) than for follicular lymphoma (OR=1.1, 95% CI: 0.5-2.2). We also observed elevated ORs for the chemical (SIC 28, 10 years: OR=1.5, 95% CI: 1.1-2.0), petroleum (SIC 29, 10 years: OR=1.9, 95% CI: 1.0-3.6), rubber/miscellaneous plastics products (SIC 30, < or =0.5mile: OR=2.7, 95% CI: 1.0-7.4), and primary metal (SIC 33, lived within 2miles: OR=1.3, 95% CI: 1.0-1.6) industries; however, patterns of risk were inconsistent between distance and duration metrics. This study does not provide strong evidence that living near manufacturing industries increases NHL risk. However, future studies designed to include greater numbers of persons living near specific types of industries, along with fate-transport modeling of chemical releases, would be informative.
Article
The linkage between NHL morbidity and residence near heavy roads is analyzed among the Jewish population of the Haifa Metropolis, Israel. The addresses of 1436 patients (94.5% of all cases, 1995-2004) were geocoded. The geographic distribution of NHL patients was adjusted by the overall density of population in the study area. The analysis indicates steady decline in the "density adjusted" numbers of patients as a function of increasing road distances (P<0.01). Differences between genders/age groups were not found. The much higher occurrence of NHL in areas near main roads may be indicative of disease risks.
Article
To investigate the relationship between petrochemical air pollution and risk of death due to bladder cancer, studies were conducted using a matched cancer case-control model based upon deaths that occurred in Taiwan from 1995 through 2005. Data on all eligible bladder cancer deaths were obtained from the Bureau of Vital Statistics of the Taiwan Provincial Department of Health. The control group consisted of individuals who died from causes other than neoplasms or diseases associated with genitourinary problems. The controls were pair matched to the cases by gender, year of birth, and year of death. Each matched control was selected randomly from the set of possible controls for each case. The proportion of a municipality's total population employed in the petrochemical industry in a municipality was used as an indicator of a resident's exposure to air emissions from the petrochemical industry. The subjects were divided into three levels (< or =25th percentile; 25th-50th percentile; >50th percentile). Subjects who lived in the group of municipalities characterized by the high levels of petrochemical air pollution had a significantly higher risk of death attributed to bladder cancer than subjects in the group that lived in municipalities with the lowest petrochemical air pollution levels, after controlling for possible confounders. The findings of this study warrant further investigation of the role of petrochemical air pollution in the etiology of bladder cancer.
Article
Exposure assessment is an integral part of health risk characterization. Exposure assessments typically address three critical aspects of exposure: the number of people exposed to the environmental toxicant, at specific concentrations, for the time period of interest; the resulting dose; and the relative contribution of important sources and pathways to exposure/dose. Because historically both "point-of-contact" measurements and information about dose and related pharmacokinetic processes have been lacking, exposure assessments have had to rely on construction of "scenarios" to estimate exposure and dose. This could change, however, as advances in development of biologic markers of exposure and dose make it possible to measure and interpret toxicant concentrations in accessible human tissues. The increasing availability of "biomarkers," coupled with improvements in pharmacokinetic understanding, present opportunities to estimate ("reconstruct") exposure from measurements of dose and knowledge of intake and uptake parameters. Human tissue monitoring, however, is not a substitute for more traditional methods of measuring exposure, but rather a complementary approach. A combination of exposure measurements and dose measurements provides the most credible scientific basis for exposure assessment.
Article
We have collected data on the cancer deaths of children and adolescents 0-19 yr old living in a residential area near 3 large petroleum and petrochemical complexes in and near Kaohsiung city (petrochemical industrial districts, PIDs) in the period of 1971-1990 and compared these with the cancer deaths of children and adolescents 0-19 yr old among the entire population of Taiwan (national reference) and among the residents of 26 administrative districts, comprising all of Kaohsiung city and Kaohsiung county (local reference), except for 8 sparsely populated, rural districts. Having scrutinized all cancer death certificates, we have identified various statistically significant excess deaths, as compared with the national and local reference, due to cancers at all sites. Cancer of the bone, brain, and bladder in boys and girls 0-9 yr and 10-19 yr of age in the 1981-1990 decade that followed the establishment of petrochemical production in the PIDs was studied. However, excess cancer deaths seemed to have clustered in the 10-19 yr age group, who had been potentially exposed to the petrochemical pollutants for the longest period of time from the youngest age. Almost all bone, brain, and bladder cancer deaths registered were within 3 km of the 3 complexes. Bone and brain cancers in particular occurred in girls in the PIDs more frequently than in boys, even though these are believed to occur more in males than females elsewhere.
Article
An ecologic study design was used to investigate the relationship between cancer risks and residence in communities adjacent to petrochemical industrial counties (PICs). Directly age-adjusted mortality rates for cancer during 1982-1991 among 16 counties characterized by a heavy concentration of petrochemical industries were compared to rates among 16 matched counties with similar concentration of nonpetrochemical manufacturing industries, urbanization level, and demographic characteristics. An excess rate for liver cancer among males was found in the so-called PICs. The correlation could not be explained by confounding variables such as urbanization, socioeconomic class, or employment in nonpetrochemical industries. No other increased cancer risks were found to be associated with residence near petrochemical industries.
Article
The risk for several cancers is higher in urban than in rural areas. The gradient has seldom been studied in southern Europe. The geographical pattern of mortality for different cancers and all causes was studied in the Campania Region (about 5.6 million inhabitants), whose largest town is Naples. The key variables were residence in urban/rural and coastal/inland municipalities. Relative risks of death and corresponding 95% confidence intervals by residence were evaluated by means of Poisson log-linear regression models. Significantly increased mortality rates in urban compared to rural municipalities were found for several cancer causes of death. In particular, in both sexes, excesses in the order of 30-50% were observed for tobacco-related neoplasms (i.e., larynx, lung, and bladder) and cancers of the intestine, liver, brain, multiple myeloma and non-Hodgkin's lymphoma, in addition to all-cancer, and all-cause mortality. In females, specific excesses were also noticed for cancer of the gallbladder, pancreas, breast and uterus (corpus and cervix). Conversely, significantly decreased mortality rates in urban with respect to rural municipalities were observed for cancer of the oral cavity and pharynx in males. Coastal location and degree of urbanization were strongly correlated, thus showing similar associations with most causes of death. However, a significant excess of cancer of the pleura in males was restricted to coastal municipalities. Anti-smoking campaigns, sanitation improvements, hepatitis B vaccination, and a decrease in obesity emerge as high priorities with respect to cancer control strategies in the Campania Region, particularly in overpopulated, underprivileged urban areas.
Article
To investigate the relationship between petrochemical air pollution and female lung cancer, we conducted a matched case-control study among women who had died in Taiwan from 1990 through 1994. Data about all eligible female lung cancer deaths were obtained from the Bureau of Vital Statistics of the Taiwan Provincial Department of Health. The control group included women who died from nonneoplasms and diseases that were not associated with respiratory problems. We pair-matched the controls to the cases by sex, year of birth, and year of death. Each matched control was selected randomly from the set of possible controls for each case. We used the proportion of a municipality's total population employed in the petrochemical manufacturing industry as an indicator of a resident's exposure to air emissions from the petrochemical manufacturing industry. The subjects were divided into tertiles according to the above indicator. Women who lived in the 2 groups of municipalities characterized by higher levels of petrochemical pollution had a statistically significant higher risk of developing lung cancer than the group that lived in municipalities with the lowest petrochemical air pollution levels (after controlling for possible confounders). The linear trend was also statistically significant (p < .05). The results of this study shed important light on the relationship between the Taiwan petrochemical industry and the resulting risk to human health.
Article
Research into the relationship between housing and health has frequently been narrowly focused, fragmented, and of marginal practical relevance to either housing or health policy. From an extensive review of the literature, this paper reports on the current state of knowledge about the relationship between housing and health. The research falls into four distinct categories: (1) specific physical or chemical exposures; (2) specific biological exposures; (3) physical characteristics of the house; and (4) social, economic, and cultural characteristics of housing. Much of the general literature on the effects of housing on health cites previous studies and then proceeds to advocate housing policies and strategies that are aimed at improving population health. Studies providing original data on the relationship, which is the vast majority of the literature, focus on very specific physical, chemical, and biological exposures with a known or suspected effect on health within the house, or they focus on the social, economic, and cultural characteristics of the house. The mechanisms through which specific aspects of housing affect health are extremely complicated, but they do exist. Researchers have made a great deal of progress in clarifying some of these mechanisms. A large gap still exists in our knowledge about the links and pathways between housing, socio-economic status and health status.
Article
The objective of this study was to quantify the total number of lung cancer deaths attributable to chronic exposure to fine particles (pm2.5) among adult populations of four French urban populations (Grenoble, Rouen, Paris, and Strasbourg). A geographic information system (GIS) was used to extrapolate personal average exposures to the total population of each metropolitan area across three sectors contrasted in terms of local sources of pollutants. We followed a health impact assessment approach by using the risk estimates in the CSP II study. The annual number of lung cancer cases attributable to pm2.5 chronic exposure ranged from 12 to 404 according to the city. Among these deaths, up to 60% occurred, in the Paris metropolitan area in the urban sector most exposed to traffic emissions. The health impact of chronic exposures to urban air pollution in metropolitan areas of developed countries warrants further efforts to abate sources of toxicants and to reduce exposure. Traffic emissions still contribute significantly to the total lung cancer burden in France.
Article
The Tranguch Gasoline Spill leaked 50,000-900,000 gallons of gasoline from underground storage tanks, potentially exposing an area of Hazle Township and Hazleton, Pennsylvania, to chronic low levels of benzene since at least 1990. A retrospective cohort study of 663 individuals representing 275 households assessed whether affected residents were at increased risk for cancer from 1990-2000 compared with the Pennsylvania populace. Age-adjusted standard incidence ratios (SIRs) were calculated using Pennsylvania rates to determine expected numbers. The age-adjusted SIR for the gasoline-affected area was 4.40 (95% confidence interval: 1.09-10.24) for leukemia. These results suggest an association between living within the area affected by the Tranguch Gasoline Spill and increased risk for leukemia.
Article
Using geographical information systems (GIS) tools, the present study analyzed the association between children's lung function development and their long-term exposure to air pollution. The study covered the cohort of 1492 schoolchildren living in the vicinity of a major coal-fired power station in the Hadera sub-district of Israel. In 1996 and 1999, the children underwent subsequent pulmonary function tests (PFT) (forced vital capacity (FVC) and forced expiratory volume during the first second (FEV(1))), and the children's parents completed a detailed questionnaire on their health status and household characteristics. A negative association was found between changes in the results of PFT and the estimated individual levels of air pollution. A sensitivity test revealed a FEV(1) decline from -4.3% for the average pollution level to -10.2% for the high air pollution level. The results of a sensitivity test for FVC were found to be similar. Association with the reported health status was found to be insignificant. As we conclude, air pollution from a coal-fired power station, although not exceeding local pollution standards, had a negative effect on children's lung function development. As argued, previous studies carried out in the region failed to show the above association because they were based on zone approaches that assign average concentration levels of air pollutants to all individuals in each zone, leading to a misclassification bias of individual exposure.
Article
The Tranguch Gasoline Spill leaked 50,000–900,000 gallons of gasoline from underground storage tanks, potentially exposing an area of Hazle Township and Hazleton, Pennsylvania, to chronic low levels of benzene since at least 1990. A retrospective cohort study of 663 individuals representing 275 households assessed whether affected residents were at increased risk for cancer from 1990–2000 compared with the Pennsylvania populace. Age-adjusted standard incidence ratios (SIRs) were calculated using Pennsylvania rates to determine expected numbers. The age-adjusted SIR for the gasoline-affected area was 4.40 (95% confidence interval: 1.09–10.24) for leukemia. These results suggest an association between living within the area affected by the Tranguch Gasoline Spill and increased risk for leukemia.
Article
Learning Objectives After completing this course, the reader will be able to: Discuss the evolving changes in the following cancer-related measures: median age at diagnosis, incidence rate, death rate, lifetime risk, survival, and prevalence.Explain important concepts affecting occurrence of multiple primary cancers at various cancer sites.Describe the impact of the growing and aging population on the future number of cancer cases by age at diagnosis. CME Access and take the CME test online and receive 1 AMA PRA Category 1 Credit™ at CME.TheOncologist.com
Article
Benzene exposure has been shown to be related to acute myelogenous leukemia, while the association with multiple myeloma and non-Hodgkin lymphoma has been a much-debated issue. We performed a historical cohort study to investigate whether workers employed in Norway's upstream petroleum industry exposed to crude oil and other products containing benzene have an increased risk of developing various subtypes of hematologic neoplasms. Using the Norwegian Registry of Employers and Employees we included all 27,919 offshore workers registered from 1981 to 2003 and 366,114 referents from the general working population matched by gender, age, and community of residence. The cohort was linked to the Cancer Registry of Norway. Workers in the job category "upstream operator offshore", having the most extensive contact with crude oil, had an excess risk of hematologic neoplasms (blood and bone marrow) (rate ratio (RR) 1.90, 95% confidence interval (95% CI): 1.19-3.02). This was ascribed to an increased risk of acute myelogenous leukemia (RR 2.89, 95% CI: 1.25-6.67) and multiple myeloma (RR 2.49, 95% CI: 1.21-5.13). There were no statistical differences between the groups in respect to non-Hodgkin lymphoma. The results suggest that benzene exposure, which most probably caused the increased risk of acute myelogenous leukemia, also resulted in an increased risk of multiple myeloma.
Article
Combustion emissions account for over half of the fine particle (PM2.5) air pollution and most of the primary particulate organic matter. Human exposure to combustion emissions including the associated airborne fine particles and mutagenic and carcinogenic constituents (e.g., polycyclic aromatic compounds (PAC), nitro-PAC) have been studied in populations in Europe, America, Asia, and increasingly in third-world counties. Bioassay-directed fractionation studies of particulate organic air pollution have identified mutagenic and carcinogenic polycyclic aromatic hydrocarbons (PAH), nitrated PAH, nitro-lactones, and lower molecular weight compounds from cooking. A number of these components are significant sources of human exposure to mutagenic and carcinogenic chemicals that may also cause oxidative and DNA damage that can lead to reproductive and cardiovascular effects. Chemical and physical tracers have been used to apportion outdoor and indoor and personal exposures to airborne particles between various combustion emissions and other sources. These sources include vehicles (e.g., diesel and gasoline vehicles), heating and power sources (e.g., including coal, oil, and biomass), indoor sources (e.g., cooking, heating, and tobacco smoke), as well as secondary organic aerosols and pollutants derived from long-range transport.
Article
To investigate the relationship between petrochemical air pollution and brain cancer (29 yr of age or younger), the authors conducted a matched case-control study using deaths that occurred in Taiwan from 1995 through 2005. Data on all eligible brain cancer deaths were obtained from the Bureau of Vital Statistics of the Taiwan Provincial Department of Health. The control group consisted of subjects who died from causes other than neoplasms or diseases that were not associated with respiratory problems. The controls were pair matched to the cases by sex, year of birth, and year of death. Each matched control was selected randomly from the set of possible controls for each case. The proportion of a municipality's total population employed in the petrochemical industry in a municipality was used as an indicator of a resident's exposure to air emissions from the petrochemical industry. The subjects were divided into tertiles according to the levels of the index just described. Subjects who lived in the group of municipalities characterized by the highest levels of petrochemical air pollution had a statistically significant higher risk of developing brain cancer than the group that lived in municipalities with the lowest petrochemical air pollution levels after controlling for possible confounders (OR = 1.65, 95% CI = 1.00-2.73). The findings of this study warrant further investigation of the role of petrochemical air pollution in the etiology of brain cancer.
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Age standardization of rates: a new WHO standard. World Health Organization: Geneva; 2001. Agency for Toxic Substances and Disease Registry [Internet]. Public Health Statement for Total Petroleum Hydrocarbons (TPH)
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Geographical mapping of malignant diseases in Israel 2001-2005. Israel National Cancer Registry: Jerusalem
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Hyattsville: Maryland: National Center for Health Statistics
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Curtin LR, Klein RJ. Direct standardization (age-adjusted death rates). Hyattsville: Maryland: National Center for Health Statistics; 1995 [Statistical Notes; No.6].
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