PCBs, Pollution and Detoxification

Conclusions

The story of Semic follows a script which could be drawn from almost any of the increasing number of occupational and environmental pollution incidents. The sequence of events, aimed at cleaning up the environment, ensuring economic viability of the region, and preventing a reoccurrence of the incident, followed the course outlined in the introduction. To this scenario, we add a new tool. Detoxification is demonstrated to be a positive medical intervention, capable of markedly aiding the occupationally exposed, symptomatic, worker. This treatment has been shown to be equally beneficial in cases involving inadvertently exposed individuals (Root et al., 1985; Schnare et al., 1984).

Our suggestions for sites where toxic materials and their by-products are in evidence focus on environmental and occupational health issues. Surveillance and amelioration should include an immediate well-designed cross-sectional survey of the community and a longitudinal survey of the affected population, followed by patient screening and, where indicated, detoxification treatment. In our opinion, the value of such measures to the workers and the affected community outweighs the costs.

Acknowledgements

We would like to acknowledge Slava Stupar, M.D., of Ljubljana who made the initial evaluation and Megan Shields, M.D. and James Dahlgren, M.D. who further evaluated and treated the female worker in Los Angeles with the assistance of Michael Wisner. We would also like to acknowledge Robert Graves, M.S., who was critical for the planning and delivery of the pilot study, David E. Root, M.D., M.P.H., Ruzica Slivnik, M.D., Ellen Edmundson, R.N., and Stasa Cujes, R.N., who, along with Ziga Tretjak, M.D., delivered the program, and thank all of the staff at the Rogaska Slatina health resort for their full support in this undertaking.

The ongoing support of Dinko Leskosek, M.D., Minister of Health for Slovenia; Igor Krizman, M.D., Ph.D., Head of the Medical Department of Gastroenterology at the University of Ljubljana; and Samo Modic, M.D., Ph.D., Head of the Institute of Occupational, Traffic, and Sports Medicine at the University of Ljubljana contributed to the successful approval and completion of this study. We thank Prof. Ch. Schlatter, Ph.D. and Fritz Bühler, Ph.D., Institut fur Toxikologie, University and Technical Faculty of Zurich, who volunteered their expertise for the analyses of blood samples for PCBs, PCDDS, and PCDFS. Our thanks also to Anton Sebenik, Ph.D. and Crt Volavsek, M.D. of Ljubljana for their NMR and chromosome analyses of samples.

Appendix A

Pilot Study Summary: Detoxification of Occupationally Exposed Workers

The goal of the study was to assess the overall clinical value of the detoxification treatment for individuals exposed to PCBs and related chemicals. Eleven workers with readily identifiable symptoms were selected for treatment from a group of twenty-four male volunteers. The remaining thirteen served as a control group.

For these twenty-four participants, the clinical picture, standard biochemical tests, and the PCB and PCDF levels in serum and fat were taken 1 to 4 days before treatment began and compared to these same measurements on the day of treatment completion (approximately one month later), and at a four month follow-up presentation. The treated workers also had a skin test to assess the status of their cellmediated immune system before and after treatment.

For comparative purposes the PCB levels were determined in thirteen women from Semic (9 factory workers and 4 residents), a farmer residing 24 Km (15 miles) from the town, and in four unexposed individuals not residing in the polluted area. During the study no complications were encountered which could be attributed to either the tests or the treatment.

i) Body burdens

Total PCB, in our study, represents the sum total of 18 reliably detected low and high chlorinated congeners. Concentrations of these PCBs in both serum and fat were elevated in all persons from the polluted region. In contrast, for the unexposed individuals, both fat and serum PCB levels were well in the range we all acquire due to the ubiquitous presence of these compounds (Chase et al., 1982; Kimbrough, 1980; Lawton et al., 1985; Sahl et al., 1985). The PCB concentrations in serum and fat for the persons participating in this study are given in Table A-1 and fat values are shown in Figure A-1.

No difference could be determined between the PCB levels in the small samples of occupationally exposed and inadvertently exposed women from Semic. PCB levels in the farmer living distant from Semic were in the lower range of the exposed group (Figure A- 1).

PCB levels in the twenty-four exposed workers were the highest. As noted in the 1984 health-survey study (Crnivec et al., 1986) and similarly reported by others (Kimbrough, 1980; Lawton et al., 1985; Safe, 1984), the ranges of PCB levels found in these workers overlapped with those of the inadvertently exposed residents (Figure A-1). Fat levels correlated well with the length of direct exposure to PCBs.

The PCBs in persons from Semic had a distinct pattern of congener distribution, including enhanced levels of the less highly chlorinated isomers and one hepta-chloro biphenyl (2,3,5,6,2',3',4'- CB), while unexposed persons from outside Semic had a different pattern with only traces of these PCB congeners. This pattern was especially evident in serum. The PCB pattern from the farmer is interesting in that it includes the less highly chlorinated congeners found in samples from Semic residents. (Figure A-2)

ii) Detoxification

The detoxification program mobilizes and removes fat-stored xenobiotics. It is a medically supervised regimen involving exercise, sauna sweat-out, and nutritional supplements within a regular daily schedule. A detailed description has been published elsewhere (Hubbard, 1980).

iii) Post-Treatment Evaluation of PCB and PCDF Levels

The treated patients were selected based on initial severity of symptoms. It was, therefore, not surprising that some of these patients had organic diseases in addition to chemical exposure. For the purposes of data evaluation, the treated patients were divided into those exhibiting symptoms only (7 patients) and those with both symptoms and organic disease (4 patients). The diseases present in these four patients - diabetes mellitus; peptic ulcer disease biliary stones; and prostatitis with calcifications and irritable bowel syndrome necessitated that their detoxification programs be individually adjusted. Their outcomes might also have been influenced by the addition of other treatments indicated by their respective clinical problems during detoxification.

Following treatment, the PCB levels in fat for six of the seven patients without organic disease had decreased by an average of 20.5 percent, representing a statistically significant reduction. Samples from one of these patients were lost. In the four treated patients with organic disease, the PCB levels had decreased by an average of 7.9 percent, a statistically non-significant change. In the control group, one patient was excluded due to an acute exposure to PCBs while assisting in cleanup operations. At the time of the post-treatment evaluation, PCB levels in the remaining twelve workers of the control group were higher than their initial levels by a statistically non-significant 1.3 percent (Figure A-3b and Table A-I). A follow-up evaluation was done four months after the conclusion of the treatment program. The. mean PCB levels in fat for both groups were elevated some 15 percent at this time, with the levels for the treated group still less than initially measured (Figure A-3).

The explanation that this was solely due to renewed exposure may be discounted; this magnitude of increase would not be expected in a group where long-term exposure is the probable source for high body burdens. Samples had been analyzed in two batches due the project's requirement for interim reports; one immediately after the conclusion of the treatment, the other after the follow-up evaluations. The parallel increase in PCB measurements at followup is probably due to the variance between batch analyses found in this type of work (Holden, 1988). The Institut fur Toxikologie, University and Technical Faculty of Zurich, offered to analyze some samples for PCB, polychlorinated dibenzofuran (PCDF) and dibenzo-p-dioxin (PCDD) content. Level. of these compounds were determined for six treated patients. PCDF and PCDD levels were at the limits of detection considering the available sample quantities.

The initial PCB concentrations in whole blood determined at this laboratory were comparable to those obtained in serum by the U.S. laboratory. Dibenzo-p-dioxin levels were below the level of detection (less than 0.2 picograms/g). The mean initial PCDF values (given as the sum of 2378 TCDF, 12378 PECDF, 23478 PECDF and 123478 HXCDF congeners) were slightly elevated, having an average content of 1.43 picograms/g (pg/g), ranging from 0.26 to 1.69 pg/g. The post-treatment concentrations were lower, with an average content of 0.59 pg/g. At follow-up, the mean PCDF content in this group was 0.86 pg/g.

iv) Clinical improvements

The treatment resulted in a marked improvement in symptoms of the patients while the clinical picture of the control group remained unchanged (Figure A-4). Though both PCB levels and the severity of symptoms were high prior to treatment, the amelioration of symptoms in the treated group was greater than anticipated given the level of PCB reduction. This suggests that elimination f other accumulated chemicals might have accounted for some of these improvements.

The skin tests for cellular hypersensitivity in the treated patients revealed an abnormally low immune response at initial evaluation. At the post-treatment evaluation, however, these patients showed a normalization of their immune response (Tretjak et al., in preparation).

Figure A-2 : PCB Congener Profiles. From left to right, IUPAC PCB congener assignments for congeners 1 to 18 are (28/31, 74, 66, 68, 99, 144, 153, 138, 175, 159, 174, 178, 177, 188, 196, 201, 195, and 194), respectively. Mean concentrations for each congener are presented. Black = Unexposed controls (n=4), ° = Farmer (n=1), — = Factory workers (n=22). (a) Fat, (b) Serum.

Figure A-3 : Changes in PCB Levels in Fat During Pilot Study. Pre = Pretreatment; Post = Post-Treatment; F-up = Follow-up. (—) = Mean concentration for group. (a) Treated Patients (n = 6), (b) Untreated Controls (n = 12).

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