Indian Health Service Indian Health Service RotationRotation

Natalie BranaganNatalie Branagan

August 28August 28thth, 2007, 2007

HPIHPI

►72 yo man referred to the Radiation 72 yo man referred to the Radiation Exposure Screening and Education Exposure Screening and Education Program clinic for positive review of Program clinic for positive review of systems on hospital screening – systems on hospital screening – reported shortness of breath and has a reported shortness of breath and has a history of working in the uranium history of working in the uranium mines. mines.

HPIHPI

►The patient reports that he has had The patient reports that he has had shortness of breath beginning about 9 shortness of breath beginning about 9 months ago.months ago.

►Unable to walk greater then 50 feet.Unable to walk greater then 50 feet.►No orthopnea, no lower extremity No orthopnea, no lower extremity

edemaedema►Reports occasional chest painReports occasional chest pain►No cough, no fevers or chillsNo cough, no fevers or chills

HPIHPI

►Worked in two uranium mines from 1958 – Worked in two uranium mines from 1958 – 19591959 Worked underground and above ground dumping Worked underground and above ground dumping

mining waste materialmining waste material Sometimes wore a maskSometimes wore a mask Stopped mining after falling at work – sustained Stopped mining after falling at work – sustained

a fracture to right arm and hit his heada fracture to right arm and hit his head Recounts how electricity was lost for Recounts how electricity was lost for

approximately one hour while working in mines approximately one hour while working in mines once – mechanical ventilator and elevators once – mechanical ventilator and elevators stopped working during that time.stopped working during that time.

Past medical historyPast medical history

►Coronary artery disease Coronary artery disease Status post CABG 11/06Status post CABG 11/06

►HypertensionHypertension►CVA in 10/06 CVA in 10/06

Residual left sided hemianopsia and Residual left sided hemianopsia and difficulty speaking clearlydifficulty speaking clearly

►Bilateral carotid bruits diagnosed 2000Bilateral carotid bruits diagnosed 2000 Refused workup at that timeRefused workup at that time

MedicationsMedications

►Aspirin 325 mg dailyAspirin 325 mg daily►Atenolol 25 mg dailyAtenolol 25 mg daily►MultivitaminMultivitamin

►Allergies: NKDAAllergies: NKDA

Family historyFamily history

►Mother and father deceased of Mother and father deceased of unknown causes in their 80’sunknown causes in their 80’s

►No known family history of No known family history of hypertension, diabetes, CVA or hypertension, diabetes, CVA or myocardial infarctionmyocardial infarction

Social historySocial history

►Lives with wifeLives with wife►Retired currentlyRetired currently►Worked as a bus driver after working Worked as a bus driver after working

in mines up until about 1 year agoin mines up until about 1 year ago►Owns sheep and cattleOwns sheep and cattle►Denies smoking, alcohol or drug useDenies smoking, alcohol or drug use

Review of systemsReview of systems

►Reports unable to see out of left eye Reports unable to see out of left eye since CVAsince CVA

►Also reports difficulty with memory Also reports difficulty with memory ever since falling and hitting head in ever since falling and hitting head in the minesthe mines

►Occasional palpitationsOccasional palpitations►No abdominal pain, nausea, vomiting, No abdominal pain, nausea, vomiting,

dysuriadysuria

Physical examPhysical exam► Vitals: T 98.0, P 82, BP 164/96, RR 16, 94% on room air, Vitals: T 98.0, P 82, BP 164/96, RR 16, 94% on room air,

weight 77.7 kg, height 65 inchesweight 77.7 kg, height 65 inches► Gen: elderly appearing Native American man in no acute Gen: elderly appearing Native American man in no acute

distressdistress► HEENT: PERRL, mucus membranes moist, no lesionsHEENT: PERRL, mucus membranes moist, no lesions► Neck: no jugular venous distention, no cervical nodesNeck: no jugular venous distention, no cervical nodes► c/v: regular rate and rhythm, normal s1 and s2, no murmurs, c/v: regular rate and rhythm, normal s1 and s2, no murmurs,

rubs or gallupsrubs or gallups► Pulm: fine crackles at bases bilaterally, no dullness to Pulm: fine crackles at bases bilaterally, no dullness to

percussionpercussion► Abd: soft, not tender, not distended, no hepatosplenomegaly, Abd: soft, not tender, not distended, no hepatosplenomegaly,

normoactive bowel soundsnormoactive bowel sounds► Extremities: no cyanosis, clubbing or edema, 2+ peripheral Extremities: no cyanosis, clubbing or edema, 2+ peripheral

pulsespulses

Labs and studiesLabs and studies

► ABG 7.42/34/51/-1.6/21.7/85.4% with FI02 of ABG 7.42/34/51/-1.6/21.7/85.4% with FI02 of 21%21%

► PFTsPFTs FVC 3.72 Liters (54%)FVC 3.72 Liters (54%) FEV1 2.89 Liters (61%)FEV1 2.89 Liters (61%) FEV1/FVC 0.78 (113%)FEV1/FVC 0.78 (113%) FEF 25% 6.50 (91%)FEF 25% 6.50 (91%) FEF 75% 1.02 L (100%)FEF 75% 1.02 L (100%) FEF 25-75% 2.77 (86%)FEF 25-75% 2.77 (86%) FEF max 7.07 89%FEF max 7.07 89% Hgb 15.7 g/dLHgb 15.7 g/dL

Chest x-rayChest x-ray

►s/p CABG, slight cardiomegaly, s/p CABG, slight cardiomegaly, pulmonary vasculature normal, no pulmonary vasculature normal, no infiltrate or pleural effusion, infiltrate or pleural effusion, degenerative changes in the spinedegenerative changes in the spine

Uranium mining and the Uranium mining and the Navajo experienceNavajo experience

UraniumUranium

►Found at low concentrations naturally Found at low concentrations naturally in soil, round, surface water and in soil, round, surface water and ground waterground water

►RadioactiveRadioactive►Several isotopes, however USeveral isotopes, however U238238 is is

predominant isotope in naturally predominant isotope in naturally occurring uraniumoccurring uranium

►Half-life of UHalf-life of U238238 is 4.5 billion years is 4.5 billion years

UraniumUranium

►Primary use is as fuel in nuclear power Primary use is as fuel in nuclear power reactors to make electricityreactors to make electricity

►Highly enriched uranium is a Highly enriched uranium is a component of nuclear weaponscomponent of nuclear weapons

►Uranium ore is usually found in hard Uranium ore is usually found in hard rock or sandstonerock or sandstone

Uranium mining historyUranium mining history

►1948 the US Atomic Energy Commission 1948 the US Atomic Energy Commission began to purchase all uranium mined in began to purchase all uranium mined in the USthe US

►Uranium mining became a large Uranium mining became a large industry in Utah, Arizona, New Mexico industry in Utah, Arizona, New Mexico and Coloradoand Colorado

►Uranium mining peaked in the 1950’s Uranium mining peaked in the 1950’s with over 750 mines operatingwith over 750 mines operating

►Approximately 3,000 uranium miners Approximately 3,000 uranium miners were Navajowere Navajo

Uranium mines on Navajo Uranium mines on Navajo landland

Uranium demand increasingUranium demand increasing

Western World Uranium Production and Demand 1945-Western World Uranium Production and Demand 1945-20042004

www.uic.com

Uranium miningUranium mining

►Underground miningUnderground mining Involves drilling of shafts into sandstone, Involves drilling of shafts into sandstone,

blasting, loading ore into bins and blasting, loading ore into bins and transporting ore up via elevatorstransporting ore up via elevators

Miners were exposed to large amounts of Miners were exposed to large amounts of dust and smoke after re-entering the dust and smoke after re-entering the mines after blastingmines after blasting

Brugge, D. Am J Public Health 2002;92:1410-1419

Uranium mining and millingUranium mining and milling

►Uranium ore contains between 0.5 -2% Uranium ore contains between 0.5 -2% of uranium oxideof uranium oxide

►Milling is the process in which uranium Milling is the process in which uranium oxide is extracted from the uranium oreoxide is extracted from the uranium ore Involves crushing the mined ore, mixing it Involves crushing the mined ore, mixing it

with water and adding chemicals such as with water and adding chemicals such as sulfuric acid to separate out of the uranium sulfuric acid to separate out of the uranium ore, the liquid is then filtered from the rest ore, the liquid is then filtered from the rest of the material, and is concentrated by of the material, and is concentrated by precipitation and then dried.precipitation and then dried.

Health effects of uranium Health effects of uranium miningmining

►Degenerative joint diseaseDegenerative joint disease From repetitive motionFrom repetitive motion

► TraumaTrauma As result of crush injuries from heavy equipment As result of crush injuries from heavy equipment

or falling rockor falling rock►Hearing impairmentHearing impairment

From drilling and blastingFrom drilling and blasting►Diseases of the lungsDiseases of the lungs

Exposure to dusts, fumes and gases can cause Exposure to dusts, fumes and gases can cause malignant and nonmalignant diseasesmalignant and nonmalignant diseases

Mulloy, K et. al. Environmental Health Perspectives 2001;305-309

Nonmalignant lung processesNonmalignant lung processes

► PneumoconiosisPneumoconiosis Lung diseases caused by the inhalation of dustLung diseases caused by the inhalation of dust

► SilicosisSilicosis Pulmonary diseases caused by the inhalation of Pulmonary diseases caused by the inhalation of

silicasilica

►Diffuse fibrotic lung diseaseDiffuse fibrotic lung disease► Pulmonary fibrosisPulmonary fibrosis►Obstructive lung diseaseObstructive lung disease► TuberculosisTuberculosis

Mulloy, K et. al. Environmental Health Perspectives 2001;305-309

Malignant lung processesMalignant lung processes

►Carcinogens suspected or known to Carcinogens suspected or known to cause lung cancercause lung cancer Arsenic, silica dust, diesel exhaust, radonArsenic, silica dust, diesel exhaust, radon

RadonRadon

►Radon exposure poses one of the Radon exposure poses one of the greatest risk for developing lung cancer greatest risk for developing lung cancer among the other exposures listed among the other exposures listed previouslypreviously

►Clear odorless gasClear odorless gas►Produced from breakdown of uraniumProduced from breakdown of uranium►Causes production of radon daughters Causes production of radon daughters

which emit alpha particleswhich emit alpha particles►Exposure to alpha particles cause Exposure to alpha particles cause

mutations in DNAmutations in DNAwww.lungusa.org

RadonRadon

►Exposure to radon measured in working Exposure to radon measured in working level months (WLM)level months (WLM)

►A working level is 130,000 MeV of A working level is 130,000 MeV of potential alpha energy that is released potential alpha energy that is released from an amount of radon decay product from an amount of radon decay product in one liter of airin one liter of air

►1 working level month is one working 1 working level month is one working level exposure for a period of 170 hours level exposure for a period of 170 hours (average number of hours a miner (average number of hours a miner would work)would work)

www.ma.utexas.edu

WLMWLM

► In an average homeIn an average home Annual WLM is 0.2Annual WLM is 0.2 Lifetime exposure 10-20 WLMLifetime exposure 10-20 WLM

► In one study of Colorado Plateau In one study of Colorado Plateau underground uranium miners working underground uranium miners working before 1974before 1974 WLM ranged between 465 to 16,467 WLM ranged between 465 to 16,467

Mulloy, K et. al. Environmental Health Perspectives 2001;305-309

Lung cancer attributed to radon Lung cancer attributed to radon exposure in uranium miningexposure in uranium mining

►Estimated that ~ 70% of all lung Estimated that ~ 70% of all lung cancer deaths in nonsmoking miners cancer deaths in nonsmoking miners are due to exposure to radon are due to exposure to radon daughtersdaughters

►Approximately 40% of all lung cancer Approximately 40% of all lung cancer deaths in smoking miners are due to deaths in smoking miners are due to exposure to radon daughtersexposure to radon daughters

Lubin JH, et al. J Natl Cancer Inst 1995 87:817-27.

Mechanism of action of damage Mechanism of action of damage to lungto lung

► Radon daughters are inhaled with mine dustRadon daughters are inhaled with mine dust► Alpha particles that pass through cell nuclei Alpha particles that pass through cell nuclei

induce damage to DNAinduce damage to DNA► Radiation damages cell membranes and Radiation damages cell membranes and

blood vesselsblood vessels► Alpha particles cause water molecules to Alpha particles cause water molecules to

dissociate into free radicals which interact dissociate into free radicals which interact with biological moleculeswith biological molecules

► Radiation causes a disruption in collagen Radiation causes a disruption in collagen metabolismmetabolism

Archer V, et al. JOEM 1998;40:460-74.

CompensationCompensation

►Radiation Exposure Compensation Radiation Exposure Compensation Program (RECA)Program (RECA) Enacted in 1990Enacted in 1990 Purpose: to provide compensation for Purpose: to provide compensation for

people who developed particular cancers people who developed particular cancers or diseases related to exposure to or diseases related to exposure to radiation from either working in the radiation from either working in the uranium mining industry or exposed via uranium mining industry or exposed via above ground nuclear weapon testing above ground nuclear weapon testing

Compensation for minersCompensation for miners► Must have worked for at least one year or been exposed to 40

or more working level months (WLMs) of radiation in above or underground uranium mines in Arizona, Colorado, New Mexico, Wyoming, South Dakota, Washington, Idaho, North Dakota, Oregon, Texas, or Utah between 1942 and 1971.

► AND► Must have developed at least one of these diseases

Primary cancer of the lung, trachea or bronchus One of the following nonmalignant respiratory diseases Pulmonary fibrosis or fibrosis of the lung Cor pulmonale related to fibrosis of the lung Silicosis Pneumoconiosis

► Payment amount: $100,000

www.bu.edu/formerworker

Compensation for millersCompensation for millers► 1) Must have worked for at least one year in a uranium mill or

transporting uranium ore or vanadium-uranium ore from mines or mills located in Arizona, Colorado, New Mexico, Wyoming, South Dakota, Washington, Idaho, North Dakota, Oregon, Texas, or Utah between 1942 and 1971.

► AND► Must have developed at least one of these diseases

Primary cancer of the lung, trachea or bronchus Renal cancer or other chronic renal diseases, including nephritis

and kidney tubal tissue injury One of the following nonmalignant respiratory diseases

► Pulmonary fibrosis or fibrosis of the lung► Cor pulmonale related to fibrosis of the lung► Silicosis► Pneumoconiosis

► Payment amount: $100,000

www.bu.edu/formerworker

RESEPRESEP

► The Radiation Exposure Screening and The Radiation Exposure Screening and Education ProgramEducation Program sponsored by the U.S. Department of Health and sponsored by the U.S. Department of Health and

Human Services Division of Primary Health CareHuman Services Division of Primary Health Care Came about as a result of the RECA amendment Came about as a result of the RECA amendment

of 2002of 2002►““it should be the responsibility of Federal Government it should be the responsibility of Federal Government

in partnership with State and local governments and in partnership with State and local governments and appropriate healthcare organizations, to initiate and appropriate healthcare organizations, to initiate and support programs designed for the early detection, support programs designed for the early detection, prevention and education on radiogenic diseases”prevention and education on radiogenic diseases”

http://books.nap.edu

RESEP screening servicesRESEP screening services

►Health screening Health screening History, physical exam, obtaining appropriate History, physical exam, obtaining appropriate

medical testsmedical tests► Education Education

Detection and prevention of disease linked to Detection and prevention of disease linked to exposure to radiation exposure to radiation

► Referral Referral for treatment for treatment

► RECA counselingRECA counseling Help with compensation claims Help with compensation claims

RESEP Screening protocolsRESEP Screening protocols

►History History must include date of exposure, place, duration of must include date of exposure, place, duration of

employment and tobacco useemployment and tobacco use► Physical examPhysical exam

emphasis on pulmonary, cardiac and renal examemphasis on pulmonary, cardiac and renal exam► Chest radiography Chest radiography

standard posterior-anterior view chest standard posterior-anterior view chest radiograph for presence of radiologic fibrosis, radiograph for presence of radiologic fibrosis, silicosis or pneumoconiosissilicosis or pneumoconiosis

► Pulmonary Function testingPulmonary Function testing as needed including spirometry, lung volumes, as needed including spirometry, lung volumes,

arterial blood gases and a DLCOarterial blood gases and a DLCO

Eligible for compensationEligible for compensation

►Nonmalignant diseaseNonmalignant disease Biopsy or chest imaging documentationBiopsy or chest imaging documentation Chest x-rays are interpreted by two readersChest x-rays are interpreted by two readers spirometryspirometry

►FEV1 FEV1 << 80% or FVC 80% or FVC << 80% 80%

ABGABG►pCO2 30 mmHG and pO2 pCO2 30 mmHG and pO2 << 70 for an altitude of 70 for an altitude of >>

3,000 feet or pO2 3,000 feet or pO2 << 75 for an altitude < 3,000 feet 75 for an altitude < 3,000 feet

►Malignant disease Malignant disease Written documentationWritten documentation

Mulloy, K. Environmental Health Perspectives 2001;109:305-9

CaseCase

► CXR s/p CABG, slight cardiomegaly, pulmonary CXR s/p CABG, slight cardiomegaly, pulmonary vasculature normal, no infiltrate or pleural effusion, vasculature normal, no infiltrate or pleural effusion, degenerative changes in the spinedegenerative changes in the spine

► ABG 7.42/34/51/-1.6/21.7/85.4% with FI02 of 21%ABG 7.42/34/51/-1.6/21.7/85.4% with FI02 of 21%► PFTsPFTs

FVC 3.72 Liters (54%)FVC 3.72 Liters (54%) FEV1 2.89 Liters (61%)FEV1 2.89 Liters (61%) FEV1/FVC 0.78 (113%)FEV1/FVC 0.78 (113%) FEF 25% 6.50 (91%)FEF 25% 6.50 (91%) FEF 75% 1.02 L (100%)FEF 75% 1.02 L (100%) FEF 25-75% 2.77 (86%)FEF 25-75% 2.77 (86%) FEF max 7.07 89%FEF max 7.07 89% Hgb 15.7 g/dLHgb 15.7 g/dL

RESEP screening protocolRESEP screening protocol

► If an abnormality is noted with the If an abnormality is noted with the initial screening then further testing is initial screening then further testing is waranted.waranted. Includes high-resolution CT scans, Includes high-resolution CT scans,

bronchoscopy, V/Q scans, pulmonary bronchoscopy, V/Q scans, pulmonary angiography and thoracentesis, pleural angiography and thoracentesis, pleural bx, MRI and PET scanning, 24 hour urine bx, MRI and PET scanning, 24 hour urine testing, renal ultrasound, tissue biopsy or testing, renal ultrasound, tissue biopsy or aspiration, endoscopyaspiration, endoscopy

RESEP follow upRESEP follow up

►Follow up for nonmalignant cases Follow up for nonmalignant cases includes periodic re-evaluationincludes periodic re-evaluation

►Follow up for malignant cases includes Follow up for malignant cases includes involving a case manager to help involving a case manager to help facilitate the process of documentation facilitate the process of documentation and follow upand follow up

CompensationCompensation

►Amount of compensation $100,000Amount of compensation $100,000►Difficulties encountered with Difficulties encountered with

compensation claimscompensation claims Often times it is difficult to document Often times it is difficult to document

exposure to radonexposure to radon Access to diagnostic resources can be Access to diagnostic resources can be

difficultdifficult Difficult to recognize the diseasesDifficult to recognize the diseases

Mulloy, K. Environmental Health Perspectives 2001;109:305-9

PreventionPrevention

► Clean Air ActClean Air Act Maximum uranium dose is 10 millirem from the airMaximum uranium dose is 10 millirem from the air

►Sets standards for site clean-upSets standards for site clean-up A person’s risk for developing cancer must not be increased A person’s risk for developing cancer must not be increased

to greater than 1 in 10,000to greater than 1 in 10,000

► Safe Drinking Water ActSafe Drinking Water Act Limits contamination of water from uranium to no Limits contamination of water from uranium to no

more than 30 micrograms per liter of watermore than 30 micrograms per liter of water► Uranium Mill Tailings Radiation ActUranium Mill Tailings Radiation Act

Directs the EPA to set standards for clean up and Directs the EPA to set standards for clean up and disposal of contaminantsdisposal of contaminants►Limits air emissions and soil and groundwater Limits air emissions and soil and groundwater

contamination contamination www.epa.gov

ReferencesReferences► Assessment of the scientific information for the radiation exposure and

screening and education program 2005. Accessed on 12/16/07 at http://books.nap.edu/openbook.php?record_id=11279&page=10

► Archer V, Renzetti A, Doggett R, et al. Chronic diffuse interstitial fibrosis of the lung in uranium miners. JOEM 1998;40:460-74.

► Brugge D, Goble R. The history of uranium mining and the Navajo people. Am J Public Health 2002;92:1410-1419.

► Gilliland F, Hunt WC, Pardilla M, et. al. Uranium mining and lung cancer experience among Navajo men in Arizona and New Mexico, 1969 to 1993. J Occup Environ Med 2000;42:278-83

► Lubin JH, Boice JD, Edling C, et al. Lung cancer in radon-exposed miners and the estimate of risk from indoor exposure. J Natl Cancer Inst 1995 87:817-27.

► Mulloy K, James D, Mohs K, et. al. Lung cancer in a nonsmoking underground uranium miner. Environmental Health Perspectives 2001;305-309

► Radiation exposure compensation program. June 2006, accessed on 12/16/07 at http://www.bu.edu/formerworker/RECP_Factsheet.pdfhttp://www.bu.edu/formerworker/RECP_Factsheet.pdf

► Uranium. Human Health Factsheet. August 2005, accessed on 12/15/07 at Uranium. Human Health Factsheet. August 2005, accessed on 12/15/07 at http://www.ead.anl.gov/pub/doc/Uranium.pdfhttp://www.ead.anl.gov/pub/doc/Uranium.pdf

► World Uranium Mining World Uranium Mining Nuclear Issues Briefing Paper 41 accessed on Nuclear Issues Briefing Paper 41 accessed on 12/15/07 at http://www.uic.com.au/nip41.htm12/15/07 at http://www.uic.com.au/nip41.htm