Indian Health Service Rotation

1
Indian Health Service Rotation

• Natalie Branagan
• August 28th, 2007

2
HPI

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

3
HPI

• The patient reports that he has had shortness of
  breath beginning about 9 months ago.
• Unable to walk greater then 50 feet.
• No orthopnea, no lower extremity edema
• Reports occasional chest pain
• No cough, no fevers or chills

4
HPI

• Worked in two uranium mines from 1958 1959
• Worked underground and above ground dumping
  mining waste material
• Sometimes wore a mask
• Stopped mining after falling at work sustained
  a fracture to right arm and hit his head
• Recounts how electricity was lost for
  approximately one hour while working in mines
  once mechanical ventilator and elevators
  stopped working during that time.

5
Past medical history

• Coronary artery disease
• Status post CABG 11/06
• Hypertension
• CVA in 10/06
• Residual left sided hemianopsia and difficulty
  speaking clearly
• Bilateral carotid bruits diagnosed 2000
• Refused workup at that time

6
Medications

• Aspirin 325 mg daily
• Atenolol 25 mg daily
• Multivitamin
• Allergies NKDA

7
Family history

• Mother and father deceased of unknown causes in
  their 80s
• No known family history of hypertension,
  diabetes, CVA or myocardial infarction

8
Social history

• Lives with wife
• Retired currently
• Worked as a bus driver after working in mines up
  until about 1 year ago
• Owns sheep and cattle
• Denies smoking, alcohol or drug use

9
Review of systems

• Reports unable to see out of left eye since CVA
• Also reports difficulty with memory ever since
  falling and hitting head in the mines
• Occasional palpitations
• No abdominal pain, nausea, vomiting, dysuria

10
Physical exam

• Vitals T 98.0, P 82, BP 164/96, RR 16, 94 on
  room air, weight 77.7 kg, height 65 inches
• Gen elderly appearing Native American man in no
  acute distress
• HEENT PERRL, mucus membranes moist, no lesions
• Neck no jugular venous distention, no cervical
  nodes
• c/v regular rate and rhythm, normal s1 and s2,
  no murmurs, rubs or gallups
• Pulm fine crackles at bases bilaterally, no
  dullness to percussion
• Abd soft, not tender, not distended, no
  hepatosplenomegaly, normoactive bowel sounds
• Extremities no cyanosis, clubbing or edema, 2
  peripheral pulses

11
Labs and studies

• ABG 7.42/34/51/-1.6/21.7/85.4 with FI02 of 21
• PFTs
• FVC 3.72 Liters (54)
• FEV1 2.89 Liters (61)
• FEV1/FVC 0.78 (113)
• FEF 25 6.50 (91)
• FEF 75 1.02 L (100)
• FEF 25-75 2.77 (86)
• FEF max 7.07 89
• Hgb 15.7 g/dL

12
Chest x-ray

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

13
Uranium mining and the Navajo experience
14
Uranium

• Found at low concentrations naturally in soil,
  round, surface water and ground water
• Radioactive
• Several isotopes, however U238 is predominant
  isotope in naturally occurring uranium
• Half-life of U238 is 4.5 billion years

15
Uranium

• Primary use is as fuel in nuclear power reactors
  to make electricity
• Highly enriched uranium is a component of nuclear
  weapons
• Uranium ore is usually found in hard rock or
  sandstone

16
Uranium mining history

• 1948 the US Atomic Energy Commission began to
  purchase all uranium mined in the US
• Uranium mining became a large industry in Utah,
  Arizona, New Mexico and Colorado
• Uranium mining peaked in the 1950s with over 750
  mines operating
• Approximately 3,000 uranium miners were Navajo

17
Uranium mines on Navajo land
18
Uranium demand increasing
Western World Uranium Production and Demand
1945-2004

www.uic.com
19
Uranium mining

• Underground mining
• Involves drilling of shafts into sandstone,
  blasting, loading ore into bins and transporting
  ore up via elevators
• Miners were exposed to large amounts of dust and
  smoke after re-entering the mines after blasting

20
Brugge, D. Am J Public Health 2002921410-1419
21
Uranium mining and milling

• Uranium ore contains between 0.5 -2 of uranium
  oxide
• Milling is the process in which uranium oxide is
  extracted from the uranium ore
• Involves crushing the mined ore, mixing it with
  water and adding chemicals such as sulfuric acid
  to separate out of the uranium ore, the liquid is
  then filtered from the rest of the material, and
  is concentrated by precipitation and then dried.

22
Health effects of uranium mining

• Degenerative joint disease
• From repetitive motion
• Trauma
• As result of crush injuries from heavy equipment
  or falling rock
• Hearing impairment
• From drilling and blasting
• Diseases of the lungs
• Exposure to dusts, fumes and gases can cause
  malignant and nonmalignant diseases

Mulloy, K et. al. Environmental Health
Perspectives 2001305-309
23
Nonmalignant lung processes

• Pneumoconiosis
• Lung diseases caused by the inhalation of dust
• Silicosis
• Pulmonary diseases caused by the inhalation of
  silica
• Diffuse fibrotic lung disease
• Pulmonary fibrosis
• Obstructive lung disease
• Tuberculosis

Mulloy, K et. al. Environmental Health
Perspectives 2001305-309
24
Malignant lung processes

• Carcinogens suspected or known to cause lung
  cancer
• Arsenic, silica dust, diesel exhaust, radon

25
Radon

• Radon exposure poses one of the greatest risk for
  developing lung cancer among the other exposures
  listed previously
• Clear odorless gas
• Produced from breakdown of uranium
• Causes production of radon daughters which emit
  alpha particles
• Exposure to alpha particles cause mutations in DNA

www.lungusa.org
26
Radon

• Exposure to radon measured in working level
  months (WLM)
• A working level is 130,000 MeV of potential alpha
  energy that is released from an amount of radon
  decay product in one liter of air
• 1 working level month is one working level
  exposure for a period of 170 hours (average
  number of hours a miner would work)

www.ma.utexas.edu
27
WLM

• In an average home
• Annual WLM is 0.2
• Lifetime exposure 10-20 WLM
• In one study of Colorado Plateau underground
  uranium miners working before 1974
• WLM ranged between 465 to 16,467

Mulloy, K et. al. Environmental Health
Perspectives 2001305-309
28
Lung cancer attributed to radon exposure in
uranium mining

• Estimated that 70 of all lung cancer deaths in
  nonsmoking miners are due to exposure to radon
  daughters
• Approximately 40 of all lung cancer deaths in
  smoking miners are due to exposure to radon
  daughters

Lubin JH, et al. J Natl Cancer Inst 1995
87817-27.
29
Mechanism of action of damage to lung

• Radon daughters are inhaled with mine dust
• Alpha particles that pass through cell nuclei
  induce damage to DNA
• Radiation damages cell membranes and blood
  vessels
• Alpha particles cause water molecules to
  dissociate into free radicals which interact with
  biological molecules
• Radiation causes a disruption in collagen
  metabolism

Archer V, et al. JOEM 199840460-74.
30
Compensation

• Radiation Exposure Compensation Program (RECA)
• Enacted in 1990
• Purpose to provide compensation for people who
  developed particular cancers or diseases related
  to exposure to radiation from either working in
  the uranium mining industry or exposed via above
  ground nuclear weapon testing

31
Compensation 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
32
Compensation 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
33
RESEP

• The Radiation Exposure Screening and Education
  Program
• sponsored by the U.S. Department of Health and
  Human Services Division of Primary Health Care
• Came about as a result of the RECA amendment of
  2002
• it should be the responsibility of Federal
  Government in partnership with State and local
  governments and appropriate healthcare
  organizations, to initiate and support programs
  designed for the early detection, prevention and
  education on radiogenic diseases

http//books.nap.edu
34
RESEP screening services

• Health screening
• History, physical exam, obtaining appropriate
  medical tests
• Education
• Detection and prevention of disease linked to
  exposure to radiation
• Referral
• for treatment
• RECA counseling
• Help with compensation claims

35
RESEP Screening protocols

• History
• must include date of exposure, place, duration of
  employment and tobacco use
• Physical exam
• emphasis on pulmonary, cardiac and renal exam
• Chest radiography
• standard posterior-anterior view chest radiograph
  for presence of radiologic fibrosis, silicosis or
  pneumoconiosis
• Pulmonary Function testing
• as needed including spirometry, lung volumes,
  arterial blood gases and a DLCO

36
Eligible for compensation

• Nonmalignant disease
• Biopsy or chest imaging documentation
• Chest x-rays are interpreted by two readers
• spirometry
• FEV1 lt 80 or FVC lt 80
• ABG
• pCO2 30 mmHG and pO2 lt 70 for an altitude of gt
  3,000 feet or pO2 lt 75 for an altitude lt 3,000
  feet
• Malignant disease
• Written documentation

Mulloy, K. Environmental Health Perspectives
2001109305-9
37
Case

• CXR s/p CABG, slight cardiomegaly, pulmonary
  vasculature normal, no infiltrate or pleural
  effusion, degenerative changes in the spine
• ABG 7.42/34/51/-1.6/21.7/85.4 with FI02 of 21
• PFTs
• FVC 3.72 Liters (54)
• FEV1 2.89 Liters (61)
• FEV1/FVC 0.78 (113)
• FEF 25 6.50 (91)
• FEF 75 1.02 L (100)
• FEF 25-75 2.77 (86)
• FEF max 7.07 89
• Hgb 15.7 g/dL

38
RESEP screening protocol

• If an abnormality is noted with the initial
  screening then further testing is waranted.
• Includes high-resolution CT scans, bronchoscopy,
  V/Q scans, pulmonary angiography and
  thoracentesis, pleural bx, MRI and PET scanning,
  24 hour urine testing, renal ultrasound, tissue
  biopsy or aspiration, endoscopy

39
RESEP follow up

• Follow up for nonmalignant cases includes
  periodic re-evaluation
• Follow up for malignant cases includes involving
  a case manager to help facilitate the process of
  documentation and follow up

40
Compensation

• Amount of compensation 100,000
• Difficulties encountered with compensation claims
• Often times it is difficult to document exposure
  to radon
• Access to diagnostic resources can be difficult
• Difficult to recognize the diseases

Mulloy, K. Environmental Health Perspectives
2001109305-9
41
Prevention

• Clean Air Act
• Maximum uranium dose is 10 millirem from the air
• Sets standards for site clean-up
• A persons risk for developing cancer must not be
  increased to greater than 1 in 10,000
• Safe Drinking Water Act
• Limits contamination of water from uranium to no
  more than 30 micrograms per liter of water
• Uranium Mill Tailings Radiation Act
• Directs the EPA to set standards for clean up and
  disposal of contaminants
• Limits air emissions and soil and groundwater
  contamination

www.epa.gov
42
References

• 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_id11279
  page10
• Archer V, Renzetti A, Doggett R, et al. Chronic
  diffuse interstitial fibrosis of the lung in
  uranium miners. JOEM 199840460-74.
• Brugge D, Goble R. The history of uranium mining
  and the Navajo people. Am J Public Health
  2002921410-1419.
• 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 200042278-83
• 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
  87817-27.
• Mulloy K, James D, Mohs K, et. al. Lung cancer in
  a nonsmoking underground uranium miner.
  Environmental Health Perspectives 2001305-309
• Radiation exposure compensation program. June
  2006, accessed on 12/16/07 at http//www.bu.edu/fo
  rmerworker/RECP_Factsheet.pdf
• Uranium. Human Health Factsheet. August 2005,
  accessed on 12/15/07 at http//www.ead.anl.gov/pub
  /doc/Uranium.pdf
• World Uranium Mining Nuclear Issues Briefing
  Paper 41 accessed on 12/15/07 at
  http//www.uic.com.au/nip41.htm