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8
Conclusions

In this chapter, the committee further evaluates the peer-reviewed published literature to draw conclusions about the long-term human health outcomes associated with exposure to natural uranium (as occurred in uranium-processing mills and other facilities and in residences) or depleted uranium (as occurred in the Gulf War). The discussion is organized according to cancer (or malignant) and noncancer (or nonmalignant) health outcome. Tables included at the end of this chapter contain results from the studies on which the committee bases its conclusions.

The traditional 5% level of statistical significance is used in describing the committee’s conclusions regarding associations. Associations that did not reach the 5% level of statistical significance are described below as nonsignificant.

CANCER OUTCOMES

This section presents the strength of associations between exposure to natural or depleted uranium and particular cancer outcomes. It draws on the information from the many studies that were described in Chapter 7 and on Gulf War and Health, Volume 1: Depleted Uranium, Pyridostigmine Bromide, Sarin, Vaccines (IOM, 2000; hereafter referred to as Volume 1). The committee focused on the following sites: leukemias, lymphomas, and cancers of the lung, bone, kidney, bladder, stomach, central nervous system, prostate, and testis.

Most of the studies examined cancer mortality, but several studies of UK Gulf War veterans, Balkans veterans, and the Finnish drinking-water cohort also investigated cancer incidence. Because several cancers of interest are associated



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8 Conclusions I n this chapter, the committee further evaluates the peer-reviewed published literature to draw conclusions about the long-term human health outcomes as- sociated with exposure to natural uranium (as occurred in uranium-processing mills and other facilities and in residences) or depleted uranium (as occurred in the Gulf War). The discussion is organized according to cancer (or malignant) and noncancer (or nonmalignant) health outcome. Tables included at the end of this chapter contain results from the studies on which the committee bases its conclusions. The traditional 5% level of statistical significance is used in describing the committee’s conclusions regarding associations. Associations that did not reach the 5% level of statistical significance are described below as nonsignificant. CANCER OuTCOMES This section presents the strength of associations between exposure to natural or depleted uranium and particular cancer outcomes. It draws on the information from the many studies that were described in Chapter 7 and on Gulf war and Health, volume 1: Depleted Uranium, Pyridostigmine Bromide, sarin, vaccines (IOM, 2000; hereafter referred to as volume 1). The committee focused on the following sites: leukemias, lymphomas, and cancers of the lung, bone, kidney, bladder, stomach, central nervous system, prostate, and testis. Most of the studies examined cancer mortality, but several studies of UK Gulf War veterans, Balkans veterans, and the Finnish drinking-water cohort also investigated cancer incidence. Because several cancers of interest are associated 1

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1 UPDateD literatUre review oF DePleteD UraniUm with a generally good chance of survival, cancer incidence (ascertainable from cancer-registration programs) is a better indicator of cancer risk than cancer- related mortality. Results of cancer studies conducted in animal models are inconsistent (see Chapter 3). Several studies reported positive findings with respect to the devel- opment of a variety of cancers (including lung and renal cancers, leukemia, and sarcoma) in animals exposed by inhalation of uranium-ore dust or uranium dioxide, intratracheal injection of 235U (as tetravalent or hexavalent uranium), or implantation of depleted-uranium pellets (Leach et al., 1973; Filippova et al., 1978; Mitchel et al., 1999; Hahn et al., 2002; Miller et al., 2005). However, other studies reported no increase in tumor development in animals exposed by inha- lation of uranium-ore dust or ingestion of uranium (Maynard and Hodge, 1949; Cross et al., 1981; ATSDR, 1999). Lung Cancer Twenty-three studies of uranium-processing workers examined the associa- tion between exposure to uranium and lung cancer, as did three studies of military populations and three studies of residents (see Table 8-1). Four of the uranium- processing studies reported statistically significantly increased standardized mor- tality ratios (SMR) (that is, above 100). All four of those studies involved the same cohort of Oak Ridge, Tennessee, and all included employees of the Y-12 plant (see Table 8-2). The specific study populations overlapped, but each study took a different approach and examined a different timeframe. The most recent study of the cohort, by Richardson and Wing (2006), did not demonstrate a statis- tically significant increase in lung-cancer mortality in any dose stratum. However, when assessing the dose-response relationship with a 5-year lag assumption, they found a dose-response trend between external exposure and lung-cancer mortality (due largely to a small number of excess deaths among those who accumulated an external dose of 50 mSv or more) but did not find a similar trend for internal exposure. Analyses of the joint effects of external and internal exposures found that compared to the referent group (defined as less than 10 mSv external and internal dose), the rate ratio estimates were increased for each group defined by higher cumulative concentrations of internal and/or external dose; however, the results were not statistically significant and a dose-response trend was not observed. One major limitation of the uranium-processing worker studies is the lack of control for smoking, a major risk factor for lung cancer. Contrary to the Y-12 cohort finding, a UK study of processors found sig- nificant reductions in both mortality from lung cancer (SMR, 85; p < 0.05) and incidence of lung cancer (standardized incidence ratio [SIR], 75; p < 0.001) but is limited by having only external-exposure data (McGeoghegan and Binks, 2000b). Beral et al. (1988) also reported a significant deficit in lung-cancer mortality (SMR, 64; p < 0.01) in employees of UK atomic-weapons research establish-

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1 ConClUsions ments with radiation records but found a significant positive association between cumulative exposure and lung-cancer mortality in a test for trend. One study of residents living near former nuclear-material processing plants found a significant reduction in risk of lung-cancer death (relative risk [RR], 0.95; 95% confidence interval [CI], 0.93-0.98) (Boice et al., 2003b); this study is limited by imprecise and incomplete data on exposure and information on risk factors. Ritz (1999) found a weak dose-response relationship with a 15-year lag per 100 mSv of external dose in workers in a uranium-processing plant. Cragle et al. (1988) reported a nonsignificant increase in lung cancer mortality (8 deaths) for salaried and hourly nuclear-fuels production-plant workers (SMR 152) but lower SMRs (also nonsignificant) for only hourly or only salaried workers. The study lacks exposure data. Pinkerton et al. (2004) reported a statistically nonsignificant increase in lung cancer mortality among uranium millers (SMR, 113; 95% CI, 89-141, compared to US referent rates) that was not found in earlier studies of this cohort. When compared to regional referent rates, the increase reached statistical significance (SMR, 151; 95% CI, 119-189). This study is limited by lack of assessment of individual exposure to uranium and other substances in the milling environment. In summary, there is no consistent evidence of an effect of exposure to natural or depleted uranium on lung-cancer incidence in the studies reviewed. The finding is unchanged when one considers evidence from the studies with the strongest designs, for example, with measurement of cumulative exposure at the individual level, internal controls, a large study population, long followup, and controlling for confounders. The pattern among studies is varied: some studies show increases in risk of lung cancer, and others show decreases. A major short- coming of the studies is the lack of individual data on smoking, a primary risk factor for lung cancer. The committee concludes that there is inadequate/insufficient evidence to determine whether an association between exposure to uranium and lung cancer exists. This conclusion on lung cancer differs from the one in volume 1. The previous committee concluded that there is limited/suggestive evidence of no association between exposure to uranium and lung cancer at cumulative internal doses lower than 200 mSv and that there is inadequate/insufficient evidence to determine whether an association between exposure to uranium and lung cancer exists at higher cumulative exposure (> 200 mSv). The present committee did not place quantitative limits on the dose for the following reasons: • There is substantial uncertainty in the measurement of uranium exposure in the studies reviewed. • The types of quantitative measure vary widely from study to study, from individual biomonitoring data to external or internal exposure measurements

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16 UPDateD literatUre review oF DePleteD UraniUm (often lacking data on many study subjects) to group estimates based on job title to a general category of years of employment. Furthermore, different dose- reconstruction methods were used to estimate dosage, and different cut-points were often used to categorize the dose in the data analysis, so it was difficult to draw a conclusion. • Some studies of lung cancer that reported dose had small samples and often did not adjust for risk factors, such as smoking. Because inhaled uranium dust remains in lung tissues and hilar lymph-node tissues for several years, they are potential targets for uranium radiation. Fur- thermore, lung cancer is a common malignancy and the leading cause of cancer death; even a modest effect could result in a meaningful increase in the number of cases of lung cancer (that is, an increase in an exposed group compared to an unexposed group might be detectable given the frequency of lung cancer occur- rence). Therefore, the committee assigns high priority to continuing to monitor a possible association between exposure to depleted uranium and lung cancer. Leukemias The results of only one of the 23 studies reviewed by the committee achieved statistical significance: a residential study by Boice et al. (2003b) (see Table 8-3). The authors reported a reduction in mortality from leukemia (RR [computed by comparing SMRs from the study counties with control counties], 0.91; 95% CI, 0.86-0.97). However, that study is limited by a lack of exposure data and infor- mation on other risk factors. The remaining 22 studies showed both increases and decreases in risk associated with exposure to uranium, all of which were nonsignificant. There was no consistent evidence of effect, and the pattern among studies was highly varied. The same pattern was observed after restriction of consideration to the “larger studies” (those with a sample population of about 10,000 or more or with more than 10 cases). The committee concludes that there is inadequate/insufficient evidence to determine whether an association between exposure to uranium and leukemias exists. Leukemia is a relatively uncommon malignancy, so large study populations are generally needed to demonstrate any significant moderate effects. The studies reviewed by the committee generally did not have adequate sample size. Earlier studies were complicated by the broad grouping of and changes in classification for leukemia. On the basis of the evidence to date, the committee would assign a low priority to additional study of an association between exposure to depleted uranium and leukemias.

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1 ConClUsions Lymphomas This section includes discussion of two types of lymphoma: Hodgkin lym- phoma (also known as Hodgkin’s disease) and non-Hodgkin lymphoma (NHL). The risk of lymphatic malignancy is of particular interest because uranium is known to accumulate in lymph-nodel tissues. Study results are summarized in Tables 8-4 and 8-5. Hodgkin Lymphoma The studies considered (see Table 8-4), split virtually evenly between show- ing an increase in risk of Hodgkin lymphoma associated with exposure to natural or depleted uranium and showing no change or a decrease in risk of Hodgkin lymphoma associated with uranium exposure. The same pattern was observed after restriction of consideration to the “larger studies” (those with a sample population of about 10,000 or more or with more than 10 cases). Only the study by Nuccetelli et al. (2005) achieved a statistically significant finding, showing a significant increase in the risk of Hodgkin lymphoma. Most of the smaller studies show nonsignificantly decreased risk of incidence or death. Non-Hodgkin Lymphoma and Other Lymphatic Cancers Table 8-5 presents the results of 24 published studies of a possible relation- ship between exposure to natural or depleted uranium and NHL. Most of them showed that exposed subjects experienced a risk of NHL equal to or lower than that in unexposed subjects. The same is true if one considers only the larger studies. One study indicated a significant increase in risk: the study by Archer et al. (1973), which had a sample size of only 662, including four cases of lymphatic cancer. The committee concludes that there is inadequate/insufficient evidence to determine whether an association between exposure to uranium and lymphomas exists. This conclusion applies to both Hodgkin lymphoma and non-Hodgkin lymphoma. On the basis of the available evidence, the committee concludes that there is a lack of strong and consistent evidence of an association between uranium exposure and lymphatic cancers. The finding is unchanged when one considers evidence from the studies with larger samples and stronger designs: there is no consistent evidence of effect. The pattern among studies is highly varied, as one would expect if there truly were no effect in the population. Although the avail- able evidence does not justify further consideration of a possible association

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18 UPDateD literatUre review oF DePleteD UraniUm between depleted uranium and lymphatic cancers, the committee concludes that further study of this type of cancer may be warranted on biologic grounds, given that uranium is known to accumulate in the lymph nodes. Bone Cancer Twelve studies of uranium-processing workers, one study of a deployed population, and two residential studies assessed bone-cancer outcomes. In most of the studies, the risk of bone cancer was the same or decreased after exposure to natural or depleted uranium (see Table 8-6). Only one study had a significant find- ing: a statistically significant increase in bone-cancer incidence—four cases— in a Danish military population deployed to the Balkans (SIR, 600; 95% CI, 160-1,530) (Storm et al., 2006). However, because three of the four cases occurred within the first year after deployment, it is unlikely that deployment-related expo- sure was a factor, given the latency of cancer. After lagging 1 year after deploy- ment, bone-cancer incidence dropped to one case, with a nonsignificant SIR of 170 (95% CI, 0-1,010). The committee concludes that there is inadequate/insufficient evidence to determine whether an association between exposure to uranium and bone cancer exists. Overall, the available studies do not provide clear and consistent evidence of an association between natural or depleted uranium and bone cancer. The estimated effects vary greatly from study to study, showing decreased risk, the same risk, or higher risk after exposure. Given that bone cancer is a relatively uncommon malignancy, relatively large study populations are generally needed to demonstrate any significant moderate effects. The studies reviewed by the com- mittee generally did not have adequate sample size. On the basis of the available evidence, the committee would assign a low priority to additional study of an association between exposure to depleted uranium and bone cancer. Renal Cancer The committee considered 20 studies of an association between natural or depleted uranium and renal cancer. None of the published results demonstrated a significant increase in risk after uranium exposure (see Table 8-7). The reported SMRs, SIRs, and RRs varied above and below unity except for one residential study (Boice et al., 2003c), which indicated a statistically significant decrease in renal-cancer mortality associated with uranium exposure (RR, 0.58; p < 0.05). That study did not include exposure assessment or information on other risk fac- tors. In a more detailed analysis, Dupree-Ellis and colleagues (2000) examined a possible dose-response relationship and found an increasing trend, driven primar-

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1 ConClUsions ily by four renal-cancer deaths in the highest-dose group (excess risk, 10.5/mSV; 90% CI, 0.6-57.4). That result was not statistically significant. The committee concludes that there is inadequate/insufficient evidence to determine whether an association between exposure to uranium and renal cancer exists. None of the 20 studies considered by the committee demonstrated a signifi- cant increase in risk of renal cancer after exposure to uranium. When attention was restricted to the studies with the largest samples, there was no positive evi- dence of an effect at the low exposures observed in the studies. On the basis of the available evidence, the committee would assign a low priority to further study of an association between exposure to depleted uranium and renal cancer. Bladder Cancer The committee evaluated 20 published studies of a potential association between exposure to natural or depleted uranium and bladder cancer: 14 uranium- processing studies, two studies of military populations, and four residential studies (see Table 8-8). Most of the studies reported the same or reduced bladder-cancer mortality or incidence in exposed subjects. Only one finding achieved statistical significance: a UK processing study found a significant reduction in bladder- cancer incidence (SIR, 76; p < 0.05) but roughly equal mortality (SMR, 92; nonsignificant) (McGeoghegan and Binks, 2000b). That study is limited by a lack of data on internal radiation exposure and other risk factors. Two studies of veterans deployed to the Balkans reported increased but nonsignificant SIRs for bladder cancer, but both studies were based on very small numbers of observed cases (Gustavsson et al., 2004; Storm et al., 2006). The committee concludes that there is inadequate/insufficient evidence to determine whether an association between exposure to uranium and bladder cancer exists. Overall, the committee finds little evidence that exposure to natural or depleted uranium increases the risk of bladder cancer. Most of the studies, whether small or large, show the same or reduced risk of bladder cancer in people exposed to uranium. Although the two studies of deployed populations showed nonsignificant increases in risk, the estimates were based on small numbers of cases—two and seven. A small number of cases renders findings less robust in that changes in exposure or outcome status in only one or two people could have altered the findings substantially, so confidence in the findings is reduced. The committee would assign a low priority to further study of an association between exposure to depleted uranium and bladder cancer.

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200 UPDateD literatUre review oF DePleteD UraniUm Brain and Other Central Nervous System Cancers Findings of 20 published studies of an association between uranium exposure and brain and other central nervous system cancers are described in Table 8-9. Almost all failed to demonstrate statistically significant associations between uranium exposure and brain and other central nervous system cancers, but they are roughly evenly split between those showing increases in and those showing the same or decreases in mortality or incidence. That overall pattern is unchanged if one restricts attention to the larger or better designed studies. Only two studies had significant results: significant decreases in risk after uranium exposure. The study by Cragle et al. (1988) reported a statistically significant decrease in mortal- ity after exposure in hourly workers at a nuclear-fuels production facility (SMR, 23; p < 0.05). However, the SMRs for salaried workers and for combined hourly and salaried workers were not statistically significant. In addition to a possible healthy-worker effect, the study may be limited by a lack of detailed exposure assessment and the use of “hourly” vs “salaried” as a proxy for socioeconomic status. Beral et al. (1988) also reported a significant deficit in mortality from brain and other nervous system cancers in processing workers (SMR, 32; p < 0.05). The committee concludes that there is inadequate/insufficient evidence to determine whether an association between exposure to uranium and cancers of the central nervous system, including brain cancer, exists. The published studies show inconsistent results that do not lead to a conclu- sion of an association between natural or depleted uranium and cancers of the central nervous system. Studies of some other cancers (for example, bladder can- cer) showed an equal or reduced risk after exposure, but the distribution of studies of brain and other central nervous system cancers is more balanced: results are roughly equally divided between studies that show increased risk and studies that show the same or decreased risk. Because of that pattern, the committee believes that further study of an association between depleted uranium and central nervous system cancers may be warranted but should not be assigned a high priority. Stomach Cancer The committee considered 21 published studies of a possible association between natural or depleted uranium and stomach cancer, including 16 process- ing studies, one study of military populations, and four residential studies (see Table 8-10). All but three had statistically nonsignificant results, and most dem- onstrated the same or decreased mortality or incidence. The pattern is unchanged if one restricts consideration to the larger or better designed studies. The three studies that had statistically significant results all showed a decrease in mortality or incidence (Beral et al., 1988; Dupree-Ellis et al., 2000; McGeoghegan and

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201 ConClUsions Binks, 2000b). McGeoghegan and colleagues found a significantly decreased risk of stomach cancer (SIR, 76; p < 0.05) but an approximately equal risk of stomach-cancer death (SMR, 92; nonsignificant) in workers at the Springfields uranium-production facility (McGeoghegan and Binks, 2000b); however, the study is limited by inadequate data on exposure, particularly internal exposure. The committee concludes that there is inadequate/insufficient evidence to determine whether an association between exposure to uranium and stomach cancer exists. Overall, the committee finds little evidence to suggest that exposure to natural or depleted uranium increases the risk of stomach cancer. Most of the studies showed similar or reduced risk of stomach-cancer death and incidence in people exposed to uranium. Although four uranium-processing studies showed nonsignificant increase in SMRs, the findings were based on 15 or fewer cases. Similarly, the study of Danish deployed populations that showed a nonsignificant increase in risk was based on two cases. Therefore, confidence in the findings is low. In the view of the committee, further study of an association between depleted uranium and stomach cancer would have a low priority. Male Genital Cancers Prostatic cancer is the most frequently diagnosed cancer in men in the United States, and any increase in risk could result in a large increase in the number of cases or deaths. Testicular cancer, the most common cancer among young men, is of special interest to Gulf War veterans, and some studies of veterans suggested a higher but nonsignificantly increased risk (IOM, 2006). Prostatic Cancer The committee evaluated 19 published studies of a potential association between exposure to natural or depleted uranium and prostatic cancer, including 14 processing studies, two studies of deployed populations, and three residential studies (see Table 8-11). Only one reported a statistically significant finding: McGeoghegan and Binks (2000b) found a significant reduction in prostatic- cancer incidence (SIR, 77; p < 0.05) but not mortality (SMR, 89; nonsignificant) in workers at the Springfields uranium-processing plant. The study is limited by the lack of data on internal radiation exposure. Three other studies of processing workers reported increased prostatic-cancer mortality, but none of the SMRs was statistically different from the null value indicating no effect (Beral et al., 1988; Loomis and Wolf, 1996; Ritz, 1999). The larger studies (those with samples of about 10,000 or more or with more than 10 affected cases) had more findings of decreased risk than of increased

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202 UPDateD literatUre review oF DePleteD UraniUm risk in those exposed to uranium. No study showed a statistically significant increase in risk. The only statistically significant finding was a decrease in cancer incidence (SIR, 77; p < 0.05). Overall, there is little evidence of an association between uranium exposure and prostatic cancer. The committee concludes that there is inadequate/insufficient evidence to determine whether an association between exposure to uranium and prostatic cancer exists. Of the 19 studies considered, none demonstrated a significantly increased risk of prostatic cancer after exposure to uranium, and one showed a significant decrease in cancer incidence but not mortality. If only the studies with the largest samples are considered, the committee finds that there is no affirmative evidence of effect. On the basis of the available evidence, the committee would assign a low priority to further study of an association between exposure to depleted uranium and prostatic cancer. Testicular Cancer Table 8-12 summarizes the findings of 15 published studies considered by the committee for a possible relationship between exposure to natural or depleted uranium and testicular cancer, including 11 studies of uranium-processing work- ers, three studies of military populations, and one study of residents living near a nuclear facility in Pennsylvania. None of the results achieved statistical signifi- cance. All studies of processing workers showed reduced testicular-cancer mor- tality in people exposed to uranium but did not reach the 5% level of statistical significance. All three studies of deployed veterans found increased incidence rate ratios or SIRs, but they also did not reach statistical significance (Macfarlane et al., 2003; Gustavsson et al., 2004; Storm et al., 2006). The committee concludes that there is inadequate/insufficient evidence to determine whether an association between exposure to uranium and testicular cancer exists. The committee finds no consistent evidence that uranium exposure increases the risk of testicular cancer. All occupational cohorts had lower mortality. Tes- ticular cancer, although very rare in the general population, is common in young adults and therefore prevalent in deployed veterans. The nonsignificant excess in incidence observed in the studies of military populations could be due in part to routine medical surveillance of the deployed veterans. Despite the inconsistent evidence, testicular cancer is of special interest to Gulf War veterans. The com- mittee believes that further study of an association between depleted uranium and testicular cancer may be warranted but should not be assigned a high priority.

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20 ConClUsions Other Cancers A study of health outcomes in 53,462 Gulf War veterans reported only all- cancer incidence, not site-specific incidence (Macfarlane et al., 2005). It did not find a statistically significant increase in cancer incidence (mortality rate ratio, 1.01; 95% CI, 0.79-1.30). However, the 13-year followup period may be too short for most cancers to have developed. Early studies by Archer et al. (1973), Wagoner et al. (1964), and Waxweiler et al. (1983) combined hematopoietic and lymphopoietic cancers, but only one (that by Archer et al.) found a significant increase (SMR, 392; p < 0.05). Beral et al. (1988) also found a significantly lower RR of all lymphopoietic and hemato- poietic cancers (RR, 0.46; 95% CI, 0.23-0.94) in workers with radiation-exposure records than in those without exposure records. NONCANCER OuTCOMES The following subsections present the strength of the evidence of associa- tions between exposure to natural or depleted uranium and specific nonmalignant health outcomes. They draw on the information from the many studies that were described in Chapter 7 and volume 1. The committee has highlighted the relevant findings on nonmalignant outcomes from the literature, with a focus on outcomes related to the organs and organ systems likely to be affected by natural or depleted uranium, such as the kidneys and the respiratory, central nervous, and reproduc- tive systems. The findings show both positive and negative associations between uranium and nonmalignant health outcomes. Nonmalignant Renal Disease Mortality Fourteen studies assessed the association between occupational exposure and renal-disease mortality. Four reported an excess in mortality that was not statisti- cally significant (see Table 8-13). Two of those followed the mortality experi- ence of uranium millers in the Colorado Plateau region. In 1983, Waxweiler and colleagues reported an excess in deaths from chronic nephritis (SMR, 167; 95% CI, 60-353). However, all deaths in the group occurred in short-term workers, and this lessened the likelihood that the deaths were related to uranium exposure (IOM, 2000). In a followup study of the Colorado group, Pinkerton and col- leagues also observed an increase in mortality due to chronic renal disease (SMR, 135; 95% CI, 58-267) (Pinkerton et al., 2004) that was not statistically significant. Similarly, Dupree-Ellis and colleagues (2000) found an excess in mortality from chronic nephritis (SMR, 188; 95% CI, 75-381) in workers at the Mallinckrodt Chemical works plant that was not statistically significant. The authors noted that

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22 TABLE 8-15 Mortality from Nonmalignant Respiratory Disease No. No. Observed Expected SMR Study Cohort/Study Site Population Deaths Deaths (95% CI) Disease Classification Waxweiler et al., 1983 Uranium mills, 2,002 55 33.7 163 (123-212) ICD-7 470-527 Colorado Plateau Pinkerton et al., 2004 Uranium mills, 1,484 100 70.16 143 (116-173) ICD-9 460-519 Colorado Plateau State rates 94 79.32 1.9 (0.96-1.45) Ritz, 1999 Uranium-processing plant, OH 4,014 53 79.78 66 (50-87) ICDA-8 460-519 Checkoway et al., 1988 Y-12 uranium-materials 6,781 37 48.9 76 (53-104) ICD-8 460-519 fabrication plant, Oak Ridge, TN Frome et al., 1990 Y-12, K-25 uranium-enrichment 28,008 792 634.11 125 (117-133)a ICDA-8 460-519 facilities, research laboratory, Oak Ridge, TN Polednak and Frome, Y-12 uranium-processing plant, 18,869 340 310.11 122 (110-136)b Diseases of respiratory 1981 Oak Ridge, TN system Frome et al., 1997 Four uranium-processing plants, 27,982 1,568 1,400c 112 (NS) ICDA-8 460-519 Oak Ridge, TN

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Ritz et al., 2000 Rocketdyne/Atomics International 2,297 30 40.26 75 (50-106) ICD-8 460-519 Boice et al., 2006 Rocketdyne/Atomics International 5,801 68 NR 67 (52-84) ICD-9 460-479, 488-519 Dupree-Ellis et al., 2000 Mallinckrodt Chemical works 2,514 64 80 80 (62-101) ICD-8 460-519 plant, St. Louis, MO McGeoghegan and Binks, British Nuclear Fuels plant, 2,628 22 45.43 48 (p < 0.01)d Diseases of respiratory 2001 Chapelcross site system McGeoghegan and Binks, British Nuclear Fuels plant, 19,454 379 481.09 79 (p = 0.02) Diseases of respiratory 2000b Springfields site system McGeoghegan and Binks, British Nuclear Fuels plant, 12,543 53 75.62 70 (p = 0.008) Diseases of respiratory 2000a Capenhurst system Cragle et al., 1988 Nuclear-fuels production facility, 9,860 17 41.02 41 (24-66)e ICDA-8 460-519 Savannah River Plant, SC NOTE: CI = confidence interval, ICD = International Classification of Diseases, ICDA = International Classification of Diseases, Adapted, NR = not reported, NS = not significant, SMR = standardized mortality ratio. aConfidence interval calculated by Committee on Health Effects Associated with Exposure During the Gulf War; not stated in study (IOM, 2000). bCorrected for incomplete ascertainment of deaths and for deaths of unknown cause. cNumber of expected deaths calculated by committee; not stated in study. dSMR based on population rates for England and Wales. eListed SMR for hourly workers only. 2

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2 TABLE 8-16 Nonmalignant Respiratory Disease—Morbidity Risk Study Population Exposure Outcomes Results Adjustments Comments Boiano et al., 146 (70%) of 208 Self-reported exposure Lung function, Smoking Limitations Ratio of FEV1 to 1989 eligible long-term incidents, job history, symptoms FVC associated with in exposure employees at FFMPC assessed urinary- job-history–derived partly based on Cross-sectional after releases of uranium data uranium-exposure recall; crude, uranium oxide from index; other imprecise dust collectors in spirometry results not exposure November-December associated; shortness categories (low, 1984 of breath significantly medium, high) associated with self- reported uranium- exposure incidents Pinney et al., 8,464 people in Residential proximity Self-reported Asthma: Age, sex Study 2003 FMMP; comparison (less than 2 miles) to symptoms of chronic SPR, 85 (99% CI, questionnaires rates NHIS (and FFMPC in direction bronchitis, asthma, 73-98) not directly Cohort NHANES, not listed) of groundwater runoff emphysema Chronic bronchitis: comparable; or possible well or SPR, 19 (99% CI, FMMP cistern contamination 14-24) self-selected in January 1952- Emphysema: volunteer December 1984 SPR, 61 (99% CI, group 41-86) NOTE: CI = confidence interval, FEV1 = forced expiratory volume in 1 second, FFMPC = Fernald Feed Materials Production Center, FMMP = Fernald Medical Monitoring Program, FVC = forced vital capacity, NHANES = National Health and Nutrition Examination Survey, NHIS = National Health Interview Study, SPR = standardized prevalence ratio.

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TABLE 8-17 Mortality from Neurologic Disease No. No. Observed Expected Study Cohort/Study Site Population Deaths Deaths SMR (95% CI) Disease Classification Frome et al., 1990 Y-12, K-25 uranium-enrichment 28,008 76 81.76 93 (71-115)a ICDA-8 320-389 facilities, research laboratory, Oak Ridge, TN Polednak and Frome, Y-12 uranium-processing plant, Oak 18,869 38 49.3 77 (49-105)a Diseases of nervous 1981 Ridge, TN system Dupree-Ellis et al., 2000 Mallinckrodt Chemical works plant, St. 2,514 11 13.41 82 (43-141) ICD-8 320-389 Louis, MO Frome et al., 1997 Four uranium-processing plants, Oak 27,982 148 211.43b 70 (NS) ICDA-8 320-329 Ridge, TN Boice et al., 2006 Rocketdyne/Atomics International 5,801 30 NR 96 (65-137) ICD-9 320-389 McGeoghegan and Binks, British Nuclear Fuels plant, 19,454 40 58.25 69 (p < 0.05) Diseases of nervous, 2000b Springfields site sense organs McGeoghegan and Binks, British Nuclear Fuels plant, 12,543 10 10.25 98 (NS) Diseases of nervous, 2000a Capenhurst sense organs McGeoghegan and Binks, British Nuclear Fuels plant, Chapelcross 2,628 5 7.06 71 (NS) Diseases of nervous, 2001 site sense organs Cragle et al., 1988 Nuclear-fuels production facility, 9,860 8 9.92 81 (NS)c ICDA-8 320-389 Savannah River plant, SC NOTE: CI = confidence interval, ICD = International Classification of Diseases, ICDA = International Classification of Diseases, Adapted, NR = not reported, NS = not significant, SMR = standardized mortality ratio. aConfidence interval calculated by Committee on Health Effects Associated with Exposure During the Gulf War; not stated in study (IOM, 2000). bNumber of expected deaths calculated by committee; not stated in study. cListed SMR for hourly workers only. 2

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TABLE 8-18 Reproductive and Developmental Effects 26 Outcomes or Study Population Exposure Outcome Measures Results Adjustments McDiarmid et al., 29 exposed Gulf War Exposure to DU by Neuroendocrine Prolactin, 2.1-17.7 Stratification at median 2000 veterans exposed to friendly fire, may measures: FSH, LH, µg/g of creatinine; low into low-, high-result DU during friendly-fire have inhaled, ingested prolactin, testosterone; urinary uranium, 1.66; groups Case series incidents in February airborne DU particles, semen characteristics high urinary uranium, 1991, 38 unexposed experienced wound 12.47; p = 0.04 veterans, examined in contamination by March-June 1997 DU; assessed urinary and seminal uranium concentration McDiarmid et al., 50 exposed Gulf War Exposure to DU by Neuroendocrine No statistically Prescription 2001 veterans divided into friendly fire, may measures: FSH, LH, significant differences psychotropic-, low-uranium and have inhaled, ingested TSH, free thyroxine, in FSH, LH, prolactin, antidepressant-drug use Case series high-uranium groups, airborne DU particles, prolactin, testosterone; testosterone, thyroid examined in March- experienced wound semen characteristics measures between July 1999 contamination by low- and high-urinary- DU; assessed urinary uranium groups uranium concentration Semen characteristics: Total sperm count [≥40 million] Low urinary uranium, 286.6 ± 44.8 million; high urinary uranium, 583.5 ± 106.1 million; p = 0.02

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Total progressive sperm (WHO Class A and B) [≥20 million] Low urinary uranium, 108.2 ± 19.2 million; high urinary uranium, 220.9 ± 44.0 million; p = 0.03 Total rapid progressive sperm (WHO Class A) [≥10 million] Low urinary uranium, 81.3 ± 15.4 million; high urinary uranium, 155.5 ± 31.1 million; p = 0.04 McDiarmid et al., 39 Gulf War veterans Same exposure as in Neuroendocrine No statistically 2004 exposed to DU during McDiarmid et al., 2001 measures: FSH, LH, significant differences friendly-fire incidents prolactin, TSH, free in reproductive-health Case series in February 1991, thyroxine, testosterone; measures examined in April-July semen characteristics 2001, followup 1994- 2001 McDiarmid et al., 32 Gulf War veterans Same exposure as in Neuroendocrine No statistically 2006 exposed to DU during McDiarmid et al., 2001 measures: FSH, LH, significant differences friendly-fire incidents, prolactin, TSH, free in reproductive-health Case series examined in April-July thyroxine, testosterone; measures 2003 semen characteristics Continued 2

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TABLE 8-18 Continued 28 Outcomes or Study Population Exposure Outcome Measures Results Adjustments McDiarmid et al., 34 Gulf War veterans Exposure to DU by Neuroendocrine No statistically 2007 exposed to DU during friendly fire, may measures, semen significant differences friendly-fire incidents, have inhaled, ingested characteristics in reproductive-health Case series examined in April-June airborne DU particles, measures 2005 experienced wound contamination by DU; assessed urinary uranium concentration; both current and cumulative exposure measures reported Sumanovic- All liveborn, stillborn Living in western Major congenital 1995 cohort: Glamuzina et al., neonates in Maternity Herzegovina after malformations Major malformations 2003 Ward of Mostar military activities in 40 of 1,853 neonates University Hospital of (2.16%; 95% CI, 1.49- Pre-post western Herzegovina, 2.82%) comparison part of Bosnia and Herzegovina 2000 cohort: immediately (1995) Major malformations and 5 years after (2000) in 33 of 1,463 neonates 1991-1995 military (2.26%; 95% CI, 1.50- activities 3.01%) NOTE: BDI = Beck Depression Inventory, CI = confidence interval, DU = depleted uranium, FSH = follicle-stimulating hormone, LH = luteinizing hormone, TSH = thyroid-stimulating hormone, WHO = World Health Organization.

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2 ConClUsions REFERENCES Archer, V. E., J. K. Wagoner, and F. E. Lundin, Jr. 1973. Cancer mortality among uranium mill work- ers. Journal of occupational medicine 15(1):11-14. ATSDR (Agency for Toxic Substances and Disease Registry). 1999. toxicological profile for uranium. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service. Auvinen, A., P. Kurttio, J. Pekkanen, E. Pukkala, T. Ilus, and L. Salonen. 2002. Uranium and other natural radionuclides in drinking water and risk of leukemia: A case-cohort study in Finland. Cancer Causes Control 13(9):825-829. Auvinen, A., L. Salonen, J. Pekkanen, E. Pukkala, T. Ilus, and P. Kurttio. 2005. Radon and other natu- ral radionuclides in drinking water and risk of stomach cancer: A case-cohort study in Finland. international Journal of Cancer 114(1):109-113. Beral, V., P. Fraser, L. Carpenter, M. Booth, A. Brown, and G. Rose. 1988. Mortality of employees of the atomic weapons establishment, 1951-82. British medical Journal 297(6651):757-770. Boiano, J. M., C. E. Moss, and G. A. Burr. 1989. Health hazard evaluation report Heta 8-1-2001, feed materials production center. Fernald, OH: Westinghouse Materials Company of Ohio. Boice, J. D., Jr., W. L. Bigbee, M. T. Mumma, and W. J. Blot. 2003a. Cancer incidence in munici- palities near two former nuclear materials processing facilities in Pennsylvania. Health Physics 85(6):678-690. ———. 2003b. Cancer mortality in counties near two former nuclear materials processing facilities in Pennsylvania, 1950-1995. Health Physics 85(6):691-700. Boice, J. D., Jr., M. Mumma, S. Schweitzer, and W. J. Blot. 2003c. Cancer mortality in a Texas county with prior uranium mining and milling activities, 1950-2001. Journal of radiological Protection 23(3):247-262. Boice, J. D., S. S. Cohen, M. T. Mumma, E. Dupree Ellis, K. F. Eckerman, R. W. Leggett, B. B. Boecker, A. B. Brill, and B. E. Henderson. 2006. Mortality among radiation workers at Rocket- dyne (Atomics International), 1948-1999. radiation research 166(1 Pt 1):98-115. Brown, D. P., and T. Bloom. 1987. mortality among uranium enrichment workers. Cincinnati, OH: NIOSH. Checkoway, H., N. Pearce, D. J. Crawford-Brown, and D. L. Cragle. 1988. Radiation doses and cause- specific mortality among workers at a nuclear materials fabrication plant. american Journal of epidemiology 127(2):255-266. Cragle, D. L., R. W. Mclain, J. R. Qualters, G. S. Wilikinson, W. G. Tankersley, and C. C. Lushbaugh. 1988. Mortality among workers at a nuclear fuels production facility. american Journal of industrial medicine 14:379-401. Cross, F. T., R. F. Palmer, R. H. Busch, R. E. Filipy, and B. O. Stuart. 1981. Development of lesions in Syrian golden hamsters following exposure to radon daughters and uranium ore dust. Health Physics 41(1):135-153. Dupree, E. A., D. L. Cragle, R. W. McLain, D. J. Crawford-Brown, and M. J. Teta. 1987. Mortality among workers at a uranium processing facility, the Linde air products company ceramics plant, 1943-1949. scandinavian Journal of work, environment, and Health 13(2):100-107. Dupree, E. A., J. P. Watkins, J. N. Ingle, P. W. Wallace, C. M. West, and W. G. Tankersley. 1995. Uranium dust exposure and lung cancer risk in four uranium processing operations. epidemiol- ogy 6(4):370-375. Dupree-Ellis, E., J. Watkins, J. N. Ingle, and J. Phillips. 2000. External radiation exposure and mortality in a cohort of uranium processing workers. american Journal of epidemiology 152(1):91-95. Filippova, L. G., A. P. Nifatov, and E. R. Liubchanskii. 1978. Some of the long-term sequelae of giving rats enriched uranium. radiobiologiia 18(3):400-405. Frome, E. L., D. L. Cragle, and R. W. McLain. 1990. Poisson regression analysis of the mortality among a cohort of World War II nuclear industry workers. radiation research 123(2):138-152.

OCR for page 193
260 UPDateD literatUre review oF DePleteD UraniUm Frome, E. L., D. L. Cragle, J. P. Watkins, S. Wing, C. M. Shy, W. G. Tankersley, and C. M. West. 1997. A mortality study of employees of the nuclear industry in Oak Ridge, Tennessee. radia- tion research 148(1):64-80. Gustavsson, P., M. Talback, A. Lundin, B. Lagercrantz, P. E. Gyllestad, and L. Fornell. 2004. Inci- dence of cancer among Swedish military and civil personnel involved in UN missions in the Balkans 1989-99. occupational and environmental medicine 61(2):171-173. Hadjimichael, O. C., A. M. Ostfeld, D. A. D’Atri, and R. E. Brubaker. 1983. Mortality and cancer incidence experience of employees in a nuclear fuels fabrication plant. Journal of occupational medicine 25(1):48-61. Hahn, F. F., R. A. Guilmette, and M. D. Hoover. 2002. Implanted depleted uranium fragments cause soft tissue sarcomas in the muscles of rats. environmental Health Perspectives 110(1):51-59. IOM (Institute of Medicine). 2000. Gulf war and health, volume 1: Depleted uranium, pyridostigmine bromide, sarin, vaccines. Washington, DC: National Academy Press. ———. 2006. Gulf war and health, volume : Health effects of serving in the Gulf war. Washington, DC: The National Academies Press. Kathren, R. L., J. F. McInroy, R. H. Moore, and S. E. Dietert. 1989. Uranium in the tissues of an occupationally exposed individual. Health Physics 57(1):17-21. Kurttio, P., A. Auvinen, L. Salonen, H. Saha, J. Pekkanen, I. Makelainen, S. B. Vaisanen, I. M. Penttila, and H. Komulainen. 2002. Renal effects of uranium in drinking water. environmental Health Perspectives 110(4):337-342. Kurttio, P., H. Komulainen, A. Leino, L. Salonen, A. Auvinen, and H. Saha. 2005. Bone as a pos- sible target of chemical toxicity of natural uranium in drinking water. environmental Health Perspectives 113(1):68-72. Kurttio, P., A. Harmoinen, H. Saha, L. Salonen, Z. Karpas, H. Komulainen, and A. Auvinen. 2006a. Kidney toxicity of ingested uranium from drinking water. american Journal of Kidney Disease 47(6):972-982. Kurttio, P., L. Salonen, T. Ilus, J. Pekkanen, E. Pukkala, and A. Auvinen. 2006b. Well water radioac- tivity and risk of cancers of the urinary organs. environmental research 102(3):333-338. Leach, L. J., C. L. Yuile, H. C. Hodge, G. E. Sylvester, and H. B. Wilson. 1973. A five-year inhalation study with natural uranium dioxide (UO2) dust. II. Postexposure retention and biologic effects in the monkey, dog and rat. Health Physics 25(3):239-258. Loomis, D. P., and S. H. Wolf. 1996. Mortality of workers at a nuclear materials production plant at Oak Ridge, Tennessee, 1947-1990. american Journal of industrial medicine 29(2): 131-141. Macfarlane, G. J., A. M. Biggs, N. Maconochie, M. Hotopf, P. Doyle, and M. Lunt. 2003. Incidence of cancer among UK Gulf War veterans: Cohort study. British medical Journal 327(7428):1373. Macfarlane, G. J., M. Hotopf, N. Maconochie, N. Blatchley, A. Richards, and M. Lunt. 2005. Long-term mortality amongst Gulf War veterans: Is there a relationship with experiences during deployment and subsequent morbidity? international Journal of epidemiology 34(6):1403-1408. Maynard, E. A., and H. C. Hodge. 1949. Studies of the toxicity of various uranium compounds when fed to experimental animals. In Pharmacology and toxicology of uranium compounds, edited by C. Voegtlin and H. C. Hodge. Pp. 309-376. McDiarmid, M. A., J. P. Keogh, F. J. Hooper, K. McPhaul, K. Squibb, R. Kane, R. DiPino, M. Kabat, B. Kaup, L. Anderson, D. Hoover, L. Brown, M. Hamilton, D. Jacobson-Kram, B. Burrows, and M. Walsh. 2000. Health effects of depleted uranium on exposed Gulf War veterans. envi- ronmental research 82(2):168-180. McDiarmid, M. A., K. Squibb, S. Engelhardt, M. Oliver, P. Gucer, P. D. Wilson, R. Kane, M. Kabat, B. Kaup, L. Anderson, D. Hoover, L. Brown, and D. Jacobson-Kram. 2001. Surveillance of depleted uranium exposed Gulf War veterans: Health effects observed in an enlarged “friendly fire” cohort. Journal of occupational and environmental medicine 43(12):991-1000.

OCR for page 193
261 ConClUsions McDiarmid, M. A., F. J. Hooper, K. Squibb, K. McPhaul, S. M. Engelhardt, R. Kane, R. DiPino, and M. Kabat. 2002. Health effects and biological monitoring results of Gulf War veterans exposed to depleted uranium. military medicine 167(2 Suppl):123-124. McDiarmid, M. A., S. Engelhardt, M. Oliver, P. Gucer, P. D. Wilson, R. Kane, M. Kabat, B. Kaup, L. Anderson, D. Hoover, L. Brown, B. Handwerger, R. J. Albertini, D. Jacobson-Kram, C. D. Thorne, and K. S. Squibb. 2004. Health effects of depleted uranium on exposed Gulf War veter- ans: A 10-year follow-up. Journal of toxicology and environmental Health a 67(4):277-296. McDiarmid, M. A., S. M. Engelhardt, M. Oliver, P. Gucer, P. D. Wilson, R. Kane, M. Kabat, B. Kaup, L. Anderson, D. Hoover, L. Brown, R. J. Albertini, R. Gudi, D. Jacobson-Kram, C. D. Thorne, and K. S. Squibb. 2006. Biological monitoring and surveillance results of Gulf War I veterans exposed to depleted uranium. international archives of occupational and environmental Health 79(1):11-21. McDiarmid, M. A., S. M. Engelhardt, M. Oliver, P. Gucer, P. D. Wilson, R. Kane, A. Cernich, B. Kaup, L. Anderson, D. Hoover, L. Brown, R. Albertini, R. Gudi, D. Jacobson-Kram, and K. S. Squibb. 2007. Health surveillance of Gulf War I veterans exposed to depleted uranium: Updat- ing the cohort. Health Physics 93(1):60-73. McGeoghegan, D., and K. Binks. 2000a. The mortality and cancer morbidity experience of workers at the Capenhurst uranium enrichment facility 1946-95. Journal of radiological Protection 20(4):381-401. ———. 2000b. The mortality and cancer morbidity experience of workers at the Springfields uranium production facility, 1946-95. Journal of radiological Protection 20(2):111-137. ———. 2001. The mortality and cancer morbidity experience of employees at the Chapelcross plant of British Nuclear Fuels PLC, 1955-95. Journal of radiological Protection 21(3):221-250. Miller, A. C., C. Bonait-Pellie, R. F. Merlot, J. Michel, M. Stewart, and P. D. Lison. 2005. Leukemic transformation of hematopoietic cells in mice internally exposed to depleted uranium. molecular and Cellular Biochemistry 279(1-2):97-104. Mitchel, R. E. J., J. S. Jackson, and B. Heinmiller. 1999. Inhaled uranium ore dust and lung cancer risk in rats. Health Physics 76(2):145-155. NRC (National Research Council). 2008. review of toxicologic and radiologic risks to military personnel from exposure to depleted uranium during and after combat. Washington, DC: The National Academies Press. Nuccetelli, C., M. Grandolfo, and S. Risica. 2005. Depleted uranium: Possible health effects and experimental issues. microchemical Journal 79(1-2):331-335. Pinkerton, L. E., T. F. Bloom, M. J. Hein, and E. M. Ward. 2004. Mortality among a cohort of uranium mill workers: An update. occupational and environmental medicine 61(1):57-64. Pinney, S. M., R. W. Freyberg, G. E. Levine, D. E. Brannen, L. S. Mark, J. M. Nasuta, C. D. Tebbe, J. M. Buckholz, and R. Wones. 2003. Health effects in community residents near a uranium plant at Fernald, Ohio, USA. international Journal of occupational medicine and environmental Health 16(2):139-153. Polednak, A. P., and E. L. Frome. 1981. Mortality among men employed between 1943 and 1947 at a uranium-processing plant. Journal of occupational medicine 23(3):169-178. Richardson, D. B., and S. Wing. 2006. Lung cancer mortality among workers at a nuclear materials fabrication plant. american Journal of industrial medicine 49(2):102-111. Ritz, B. 1999. Radiation exposure and cancer mortality in uranium processing workers. epidemiol- ogy 10(5):531-538. Ritz, B., H. Morgenstern, D. Crawford-Brown, and B. Young. 2000. The effects of internal radiation exposure on cancer mortality in nuclear workers at Rocketdyne/Atomics International. environ- mental Health Perspectives 108(8):743-751. Shawky, S., H. A. Amer, M. I. Hussein, Z. el-Mahdy, and M. Mustafa. 2002. Uranium bioassay and radioactive dust measurements at some uranium processing sites in Egypt—health effects. Journal of environmental monitoring 4(4):588-591.

OCR for page 193
262 UPDateD literatUre review oF DePleteD UraniUm Stayner, L. T., T. Meinhardt, R. Lemen, D. Bayliss, R. Herrick, G. R. Reeve, A. B. Smith, and W. Halperin. 1985. A retrospective cohort mortality study of a phosphate fertilizer production facil- ity. archives of environmental Health 40(13):133-138. Storm, H. H., H. O. Jorgensen, A. M. Kejs, and G. Engholm. 2006. Depleted uranium and cancer in Danish Balkan veterans deployed 1992-2001. european Journal of Cancer 42(14):2355-2358. Sumanovic-Glamuzina, D., V. Saraga-Karacic, Z. Roncevic, A. Milanov, T. Bozic, and M. Boranic. 2003. Incidence of major congenital malformations in a region of Bosnia and Herzegovina al- legedly polluted with depleted uranium. Croatian medical Journal 44(5):579-584. USACHPPM (U.S. Army Center for Health Promotion and Preventive Medicine). 2004. Capstone report: Depleted uranium aerosol doses and risks: summary of U.s. assessments. Fort Belvoir, VA: U.S. Army Heavy Metals Office, Chemical and Biological Defense Information Analysis Center. Wagoner, J. K., V. E. Archer, B. E. Carroll, D. A. Holaday, and P. A. Lawrence. 1964. Cancer mortality patterns among U.S. uranium miners and millers, 1950 through 1962. Journal of the national Cancer institute 32(4):787-801. Waxweiler, R. J., V. E. Archer, R. J. Roscoe, A. Watanabe, and M. J. Thun. 1983. Mortality patterns among a retrospective cohort of uranium mill workers. In Epidemiology Applied to Health Physics, Proceedings of the Sixteenth Midyear Topical Meeting of the Health Physics Society, Albuquerque, New Mexico, January 9-13:428-435.