246 N, HIGH STREETPOST o"ice BOX tieCOLUMBUS, OHIO 432184)118

RICHAHD F.CEL2STC

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FOR IMMEDIATE RELEASEJune 30, 1588

ODH Releases Results of Ashtabula Waste Sit* Study

The Ohio Department of Health released the results of the follow-up study of brain cancer cases found near the Fields BrookHazardous Waste Site in Ashtabula County. Researchers did notidentify environmental factors that caused or contributed to thedisease*

In the previous study, total cancer incidence and mortality didno t d i f f e r s i g n i f i c a n t l y f r o m U.S. and Ohio popula t ions .However> brain and other centra l nervous system cancers werefound to be higher.

•Action was in i t i a ted in June / 1987 to ascer ta in what riskfactors may have accounted for the increased brain cancerincidence," said Dr* Ronald Pletcher, director, Ohio Depar tmentof Health.

Only about 1.5 deaths and less than l inc idence of brain cancerwere expected. Yet, the initial surveillance ef for ts revealednine brain cancer cases, of which eight were deceased. Of those,only f i v e had p r i m a r y site cancer** m e a n i n g the diseaseoriginated in the 'brain.

A l t h o u g h the study did not f i n d a cause for the cancer, itconcluded that the excess of brain cancer cases may be due to amisclassification of primary disease/ environmenta l factors/ orchance alone* "Intense survei l lance does not always lead toident i f ica t ion of a causal element because there are so manyfactors involved," Pletcher said. "The total environment is notonly d e f i n e d in terms of smoke stacks and was te sites, but alsoinclude* personal behavioral habits*"

Surve i l lance of adverse r e p r o d u c t i v e ou tcomes* such ascongenital abnormalities, low birth weights and fetal deaths inthe study population did not reveal any significant differenceswhen compared to Ohio or Ashtabula County.

"It was not surprising to f i n d some type of cancer elevatedbecause this is w h a t we often f i n d in cancer survei l lancestudies," Fletcher said. "One out of three persons in the UnitedStates will develop cancer in their l ifet ime,"

Contact: Richard L. Wittenberg, 614/644-6562

* a i HOamd/OMIAN3/aiON3 ' WOMJ bt =81 BE-QC-AON

CANCER SURVEILLANCE IN THS POPULATION IN CLOSE PROXIMITYTO THE FIELDS BROOK HAZARDOUS WASTE SITE

ASHTABULA COUNTY, OHIO

ADDENDUM: BRAIN CANCSR FOLLOW-UP ANDADVERSE REPRODUCTIVE OUTCOME SURVEILLANCE

Bobert W. Indian* M.S.Ravishankar A. Kao, H.F.H.

Special Studies BranchDivision of Bpidwnioloyy

The Ohio'Dapartnent of1989

Case Report Ho. 850301

Copy and fucthor infornation r«qu«*ts to Special Studies Branch, Division ofBpldtffliolo^y, Ohio Department of Health, P.O. Box US/ CoUalms, Ohio, 43266-0lie/telephone < 6 H > 466-0291.

s i =

Division of Epidemiology* Ohio Department of HealthAddendum - Cancer Surveillance* field Brook Site

Case Log Ho. 950601; Cunt/ 1968

I, IHTRODOCTIOH

A, Overview

In a follov-up of brain cancer cases found during wurveillance of cancer inthe population in clove proximity to the Fields Brook Hazardous Waste Sitewe could not identify factors that caused or contributed to the disease.The apparent brain cancer excess may bo duo to a misclassification ofprimary disease/ environmental factors* or to chance. Surveillance ofadverse reproductive outcomes* i.e.* congenital anonalies* low birthweight/and fetal deaths in the Study Population did not differ significantly <p <0,05) fron Ohio or Ashtabula County experience. *

B. Initiation of Action

This action was initiated in June- 1987 by tbe recomwndations of our FinalReport concerning cancer surveillance in the population in close proximitytfl tfe* FUldl Brook B*»*rdou* Santo Sit* in Aehtabul* County, Ohio (IndianIW, Ruaftiey V, 1U?). OUT fturveUlanftfl fl$ W«ic.fcr incidence and mortality inthe study population revealed that total cancer incidence and nortality didnot differ significantly <p < 0.05) from the United States and Ohioexperience. However* brain and other central nervous system cancerincidence <n • 3) and nortality <n « 3) was found to be significantly higher<p < 0.05) when compared to the 0.8. and Ohio. It was drained prudent that afollow-up study of these cancer cases bo conducted tc further define theproblem and ascertain what ris3c factors oay have played a role in theincreased burden. We recommended that this action include; a) A detailedmedical record review of the cases to verify the diagnoses* to identify thespecific type of brain or other central nervous sytem cancer; as well as toascertain tbe physicians impressions of what factors may have played a rolein the disease process; and b> Conduct coorprenenE ive interviews with theoases and/or their families to ascertain possible risk factors for thedisease, including familial history of disease; viral* chemical andradiation exposures;' occupational and residential histories, etc.

The Cancer Surveillance Report also noted that exposure to various toxicagents can increase the risk of adverse reproductive outcomes* e.g. fetaldeath, low birtfcwaight* and birth defects <Mattison, 1983>. Furthermore*the latency period between exposure and reproductive damage is potentiallyshort* so that surveillance of adverse reproductive outcomes may provideearlier evidence of toxic effects than can chronic diseases* such as cancer.In view of tbe identified potential pathways of exposure to toxic ayentsfrom the site CO. S. Environmental Protection Agency* 1985; U.S.Environmental Protection Agency/ 1986)* and the apparent high rate of brainand other central nervous system cancer* it was thought prudent to conductat least a preliminary analysis of fetal deaths, low birthweight* and birthdefects in the study population using tbe existing vital record system atthe Ohio Department of Health.

Sl ! 8I 9B-80-r ,3M

The purpose of this Addendum Report is to present the result* of thesefollow-up actions* We would like to take this opportunity to think andgratefully acknowledge the efforts of Richard S. Hopkins* M.D»* M.S.F.H.,Physician Consultant to the Ohio Department of Health and James V. Writer,M,?*H. for their work in the follow-up of the brain and other centralnervous system cancer cases. Dr. Hopkins is a professor of Epidemiology inthe Department of Preventive medicine at the Ohio State University. Mr.Writer is a former Bpidemiology Investigator in the Special Studies Branchin the Division of Bpidemiology at the Ohio Department of Health and iscurrently at the New York State University at Stony Brook. We are also ingratitude to the extensive assistance of Hark Herberts H,D. Dr. Herbertserved a Preventive Medicine Residency with the Special Studies Branch andworked on the adverse reproductive outcome surveillance* Dr. Herbert iscurrently with the Mount Carvel Hospital Medical Center in Columbus,

II. BRAIN CAHCBR FOLLOW-UP

The household cancer incidence survey described in the Cancer SurveillanceReport revealed three reported brain cancers during the period January 1* 1977 -June 30* 1936 when only 0.29 would be expected based upon National CancerInstitute data <National Cancer Institute/ 1964), Tot Standardizeft IncidenceRatio <SIK> was 10.34 with a 95% Confidence Interval <CI> of 2.13-30.23 whichwas significantly higher than expected at p < 0*05. Two of these reported caseswere reported deceased. The review of Ohio certificates of death for the studyarea for the year* 1980-1985 revealed eight brain cancer deaths/ two of whichwere the reported decedents found in the household cancer incidence survey.Only 1*5 brain cancer deaths would be expected based on Ohio data Division ofEpidemiology/ Ohio Department of Health/ 1966) and only 1,4 deaths based onHational Cancer Institute data (Rational Cancer Institute* 1964)* The SMRs were5.16 <95% CI 2*22-10.15) and 5.63 (95% CI 2.43-11.00) respectively which aresignificantly elevated at p < 0.05. Thus, these were a total of nine braincancer casts/ revealed by the initial surveillance effort.

The follow-up of the three cases reported during the cancer incidence householdsurvey included interviews with surviving family members* medical record reviewand interviews with the treating and/or diagnosing physicians. One'of the cases(deceased) was found to have brain cancer as a metastatic lesion/ primary siteunknown. The other two cases were found to be true primary site brain tumors.This new information makes it mandatory to recalculate the SIR. Two oasesremain with 0.29 expected. The SIR is 6.90 <95% CI 0.84-24.91) which is notstatistically significant, i.e.* distribution of the case* co-old have happenedby chance alone more than five times of a hundred.

The mortality phase of the study revealed eight brain cancer deaths in tHe studyarea/ two of which were the primary brain cancer "incidence" cases describedabove. Of the remaining six deaths* medical record review and interviewsrevealed that three were not primary brain malignancies* i.e./ were metasticlesions. The other three were classified as probable primary malignancies.

Attempts were made to contact informants for the five cases of probable braincancer. The purpose of the contact was to readiest participation in a follow-upstudy to identify possible risk factors for brain cancer. For the five c*se«*two had informants that agreed to participate; two had potential informants thatrefttted to participate* and for one no informants could be found. Interviewswith the informants for the two cases revealed the following:

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Case 1

Case one was a white male and 55 years of age at the time of death. Hereportedly bad 12 jobs since 1945* but the usual employment appear* to have beenas a lab technician for companies in Aehtabula and Cleveland. His residencereportedly changed frequently with most of his tine in Conneaut, Cleveland/ andJtehtabula. Ho had no known exposure to the Fields Brook but he did keep a boatin the Jtehtabula River, He had no known history of serious head trauma, x-raytreatment for tinea capitis or epilepsy. There was no known family history ofepilepsy or brain cancer. The informant reported that the case had a eub-mandibular resection in 1961 and may have received numerous x-rays to the headand neck.

Case 2

Case two was a white female and 65 years of age at the tine of death. Her twolifetime residences reportedly were within yards of each other in Ashtabula.She reportedly was employed for about 10 years outside the home in the late1940'E and early 195Q's, There were two reported employers during.this time - alocal retail store and a manufacturing firm. Otherwise she appears to have beena housewife. There was no known history of exposure to the Fields Brook orAshtabula River* head trauma/ or x-ray treatment for tinea capitis, There wasno Xnown personal history of epilepsy or family history of brain cancer.

This review revealed that only five of the reported eight decedents found duringthe mortality phase were true primary site brain cancer cases. However* arecalculation of the SHR would be inappropriate. The source of mortality datafor both the study area and for all Ohio was computerized information from OhioCertificates of Death. Supplemental data gathered by interviews for both thestudy area and all reported brain cancer deaths in Ohio would be needed for avalid recalculatign gf the SHR,

In conclusion*' in the follow-up of these brain cancer cases one could notIdentify factors that caused or contributed to the disease* In fact/ theapparent brain cancer may be due to a aisclaBBif ication of primary disease,tuldeternined environmental factors, or to chance alone*

III. A0VBRSS REPRODUCTIVE OUTCOHS SURVEILLANCE!

A. Hethods

The Study Area and study population for this surveillance was the same asthat presented in the Cancer Surveillance Report, i.e., the area andhouseholds within a one mile radius of the approximate geographic center 'ofthe cite. Thus, the Study Area was defined as that area of the City ofAshtabula and Jfcshtabula Township bounded on the north by Lake Brie and LakeShore Park; en the east by an area approximately midway between State Roadand Cook Road; on the sooth by O.S. Route 20 and Schenley Avenue; and on thewest by the AshtainUa River/ an area of about three square miles asindicated on the attached Hap. This area has about 1,596 households withabout 839 households in Aahtalmla City and about 757 households in AshtabulaTownship <Polk Ashtabula City Directory, 19S6>.

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Consultation with epidemiology and nodical staff resulted in a decision todefine an eight year surveillance period, 1979-1986. These years were•elected as they would present the most recent* relevant informationconcerning the adverse reproductive outcome burden* i.e.* cogenitalanonaHes* low-weight births «2*500 grams)* and fatal death.

1. Congenital anomalies

Surveillance of congenital anomalies present at birth and using OhioCertificates; of Birth was Initiated to estimate if the Study Populationhas experienced a statistically significant greater number of congenitalanomalies than would be expected based on two conparison groups. Thefirst comparison group was the White population in Ohio* and the secondconparison group was the reminder of the White population in AshtabulaCounty,

Congenital anomalies noted at birth were identified by generating birthcertificate numbers from the computerized birth records of the OhioDepartment of Health for the years 1979-1986 for all births in febtabulaCounty. These Ohio Certificates of Birth were then examined in theArchives at the Ohio Department of Health and any congenital anomaly <ifpresent> and the exact geographic residence of the mother at the tiae ofbirth recorded. Births were classified as either "congenital anomalyreported" or "congenital anomaly not reported**. Congenital anomalieswere classified by the International Classification of Diseases <ICD)codes 740-799 EWorld Health Organization? 1973)t Births were classifiedby residence of mother ae within the Study Area or within the conparisonarea.

Expected values for congenital anomalies prevalence in the studypopulation litre generated by computation of Standardized IncidenceRatios <SIB*)/ based on the age-specific congenital anomalies experienceof the mothers in the two comparison populations using eight age groups:<15 years/ 15-19 years/ 20-24 years/ 25-39 years/ 30-34 years/ 35-39years* 40-44 years/ 45+ years.

The SIR is given by (Mausner S* Bahn AK, 1974).

total obseryej casesSIR = total expected cases

If this incidence ratio is greater than one, it indicates that morecases are observed in the study population than would be expected basedon the rate of incidence in the comparison population. SIB* werecomputed from the White populations in Ohio and the remainder ofJtehtabula Count;. The ratio of the observed to the expected numberswere tested for statistical significance at the probability 0.05 in themanner described by Bailar and Sderer (Bailar JC* Sderer F, 1964).

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2. Low- weight births

A retrospective low-weight birth survey was aleo conducted to deter nineif the Study Population has experienced a statistically significantgreater number of low ?eight births thin would be expected based on theexperience of the two previously described comparison groups. Low birthweight was defined as birth weight lew than or equal to 2*500 grams.The exact birth weight was abstracted from each of the previouslydescribed birth certificates for the years 1979*1986. Birth weight wasclassified as either "low-weight birth" or "non-low weight birth". Theexact geographic residence of the mother was classified 35 previouslydescribed. A comparison of the low-weight birth experience of the studypopulation with the two comparison populations w«s facll itated bycomputing SIRs as previously described. The computed SIBS were testedfor statistical significance at the 0.05 level* again in the manner of

«nd Bderer <Bailar JC, Sderer F, 1964).

3* Fetal Deaths

A retrospective fetal death survey was also conducted to determine itthe study population has experienced statistically significant greaternumber of fetal deaths than would be expected based on the experience ofthe two comparison groups. Fetal death was defined as "death prior tocouplets expulsion cr extraction from its mother of a product ofconception of at least 20 weeks gestation, which offer such expulsion orextraction does not breathe or show any evidence of life, such asbeating of the heart, pulsation cf the umbilical cord or definitemovement of voluntary muscle* < Public Health Council/ 1980).

Fetal death certificate numbers were generated iron the computerizeddeath records of the Ohio Department of Health for 1979-1986 forAshtabxila County residents. These fetal death certificates were thenexamined in the Archives at the Ohio Department of Health and the exactgeographic residence of the mother at the tine of the fetal death wasrecorded. Fetal deaths by residence of mother were classified aspreviously described.

A comparison of the fetal death experience of the study population withthe experience of the two comparison populations was facilitated bycomputing SMR's as previously described. The computed SMBs were testedfor statistical significance at 0.05 level in the manner of Bailar andBderer (Bailar JC, Sderer F, 1964).

B. Results

1* Live Births

There were 12*010 live births in the population of Ashtabula County forthe years 1979-1986. Of these, 11/396 were classified as White < about95%) while 614 were classified as Black or other <about five %>. Duringthie time period there were 1,302,338 births in Ohio, of which about 85%were White and about 15% were Black and other. Individual checking ofthe Ashtabula County births for the exact geographic residence of themother at the time of birth revealed that 378 were in the Study Area.

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17. DISCUSSION

Several methodological considerations need to be addressed in this analysis ofadverse reproductive outcomes. This analysis used birth certificates and fetaldeath certificates. Fetal death certificates are subject to the cameHaltat ions as discussed in the Cancer Surveillance Report as well as others.Birth certificates are often used as sources of infernation in epidemiologicresearch. Their efficiency in terns of providing record* of large numbers ofcases at relatively low cost has been amply demonstrated* however theirreliability in terns of completeness and accuracy of recorded nedical and healthinformation is somewhat uncertain, The completeness of reporting congenitalmalformation* on bilth certificates compared with hospital records has beanfound tc vary between 14 and 79 percent <Hay S/ Lunde A* Haokeprang M* 1970;Hilhan S, 1963; Mlienfeld AM* Farkhurst B* Fatten R> et al., 1951). Hoi*v«r, astudy in Iowa <Haokerpang M* Hay S* Lunde AS* 1972) comparing birth certificatesand Bed leal records found over 75 percent accuracy for major anomalies such ascleft palate and spina bifada, To our knowledge/ only limited studiesconcerning such accuracy have been conducted in Ohio. These have involvedstudies of Downs Syndrome which indicate that about 33 percent of Down'sSyndrome cases nay be accurately ascertained fron birth certificates alone<Huether CA* Summere GR* Rook 5* et al.* 1961; Bnether CA* Ouumere ER* 1982).

It is important to note that the Birth Defects Monitoring Program <BD«P)established by the Centers for Disease Control in metropolitan Atlanta., Georgia,Nebraska and Florida follows infants up to one year of age to ascertainincidence (Edmunds LD* Layde FH* Flyxit, J9* 1981), whereas birth certificatesgenerally reflect only anomalies readily ascertainabl* at birth. It is obviousthen that the anomalies ascertained in this analysis probably do not reflect thetrue burden of congenital anomalies in the; study or comparison populations.However since a local comparison group was utilized* it would be reasonable tcassume that this poss ible under ascertainment of cases would be evenl ydistributed between the two groups.

The ascertainment of low birthweight and fetal deaths also have limitations.The definition of low birthweight as less than 2500 grams has universalapplication »c a reliable indicator of fetal maturity (Albernan B, 1984).However, it oust be recognized that there are several problems inherent in itsmeasurement and definition. Among these are the length of time after birth ofthe weighing of the infant* errors introduced by inaccurate scales* inaccuratereading of the scales* and the round ing up or down of the reading/ and theabsence of a lower limit of birthweight. It is Important to note that it isleft to the individual attendant at the birth to decide whether a neonatepresents any signs of life, but at the low end of the birthweight range it mayvery well be difficult to ascertain whether a neonate presenting such signs thatsubsequently dies should be counted as a live birth or as a fetal death.

The incidence of adverse reproductive outcomes is influenced by multipleenvironmental and host factors. Among these are genetics (Cohen BH* LllienfeldAH, Huang PC, 1978; Rartindale B, Yale S* 1983; McKusic 7A, 1975) / exposures totertogenic agents including alcohol., tobacco* certain viruses* certain chemicalsand ionizing radiation <Shepard TH/ 1980; Staplre/ 1976; Vaughan Tl», Darling J>Starzyk H, 1984)* and parental ag« <Lilienfeld AS/ 1969; El wood JH, SI wood JH,I960). Although we could ascertain parental age in this analysis* we could notdetermine exposure to environmental variables.

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Geographic differences in the incidence of certain anonalies such ** aneitcephalyhave been observed <Elwood JH, SI wood JH, 1980; El wood JM* SI wood JH> 1982).Thus* a local comparison group was used in this analysis in *n attempt tocontrol for possible regional differences. Although the study and localcomparison populations were snail* they did allow for possible mitigatingdifferences in other regional environmental exposures and quality of medicalcare. Based on this comparison and the comparison to Ohio data there IE noevidence of a significantly higher (p < 0.05) incidence of adverse reproductiveoutcomes in the Field* Brook Study Area for tn* years 1979-1986.

COHCLOSIONS

A. In the follow-up of brain cancer cases found during surveillance of cancerin the population in clo*e proximity to the Fields Brook Hazardous Se*teSite we could not identify factors that caused or contributed to thedisease. In fact' the apparent brain cancer excess may be due to aroi*cla**ification of primary disease, environmental factor** or to chancealone.

B. Adverse reproductive outcones* i.e.* congenital anomalies/ low birthweight*and fetal deaths in the population in close pcoxinity to the Field* BrookHazardous Watte Site do not differ significantly (p < 0.05) from the Ohio orJtehtabula County experience.

The Final Report of the study and this Addendumwithin th* cowBtmity for resident* to review.

be made available

Respectfully rulmittvd*

Robert 9. Indian/ M.S./ ChiefSpecial Studies BranchDivision of EpidemiologyOhio Department of HealthP.O. Box 116Coluabuc, Ohio 43266-0118<o!4) 466-0261

Ravishankar A. Rao, H.P. H.Bp.ideniology Investigator IIISpecial Studies BranchDivision of EpidemiologyOhio Department of Health9.0. Box 113ColflObus* Ohio 43266-0118<814> 466-0287

B. Kin Borrenten. Ph.D.ChiefDivision of SpidemioloyyOhio Departnent of HealthC614) 4W-0277

Thomas J. HaJChiefBureau of Preventive MedicineOhio Bepartoent of Health<614> 466-0302

6

El/ l I 6 1 ' 8 1 9B-80-ACN

1. Aberman 5 <Bditor>, 1984, Perinatal Epidemiology, pp 86-95* OxfordPress.

2. tohtabula* Ohio City Director* 1986* PL Polk and Company Publisher*; lay lot.Michigan.

3. Bailar JC* Sderer F* 1964. Significance factor* for the ratio of * poismonvariable to its expectation. Biometrics 20:633-643.

4. Cohen BH/ Lilienfeld AM* Huang PC (Editors), 1978/ Genetic Issues in PublicHealth and Medicine/ Charles C, Thomas Publishers* Springfield/ Illinois.

5. Division of Epidemiology/ Ohio Department of Health/ 1986, Cancer Mortality inOhio. 1979-1984, Unpublished data.

6. Bdmonds* LD* Layde PH/ Flynt JW* et al. * 1981* Congenital MalformationsSurveillance; Two finerlean Systems* International Journal of EpidemiologyNX 5>:247-252.

7. Blvood * SI wood JH/ I960. Spideaioloo/y of an encephalus and spina bifada*Oxford Oniverslty Press/ New York^ Hen York,

8. El wood JH* El wood JH, 1982 / International variation in the prevalence at birthof an encephalus in relation to maternal factors. International Journal ofEpidemiology 11:132-137.

9. Hay Sr Lurid* JL HacXeprang H. 1970. Background and methodology of a study ofcongenital naiformations. Public Health fieportor 85:913-917.

10- Huether CA, dGunnere SR/ Nook KB/ et al./ 1981, Down1* Syndrone: Ptrcentagereporting on birth certificates and • Ingle year maternal age risk rates forOhio* 1970-1979; Comparison with Cpatatt Hew 7ork data, Alter lean Journal ofPublic Health 71< 12>: 13^7-1372.

11. Huether CJL Ouaoere OR/ 1982. Influence on demographic factors on annual Down'sSyndrome births in Ohio, 1970-1979, and the United States* 1920-1979, AmericanJournal of Epidemiology* 115<6):846-860.

12* Indian 59* Hundley, 1988. Cancer Surveillance in the Population in CloseProximity to the Fields Brook Hazardous Waste Site* tehtabula County, Ohio!Final fiepott. Division of Sploemiology* Ohio Department of Health.

13. Lilianfeld £M* P*tfchurst E* Patton R/ Scblesinger SR, 1951. Accuracy ofsupplemental medical information on birth certificates. Public Health Reporter*«6:191-198.

14. LHienfeia AH* 1969. Epidemiology of Hongolisn. The Johns Hopkins UniversityPress/ Baltimore* Maryland.

15. Maokerpang H/ Hay S, Lunde AS* 1972. Completeness and accuracy of reporting ofmalformations on birth certificates. H8HHA Health Reports* 67:43-49.

E l / Z t 3Otfd B3Olf r f r3CEE 'QI HOMnd/OMIAN3/aON3 ' WOJIJ 61 '81 96-e0-AON

References (continued)

16. Martindals B/ Yale 8./ 1983. HuntingtojTs Chorea; neglected opportunities forpreventive medicine* Lancet 1:634-636.

17. MattiBon DR <Bditor>/ 1963. Reproductive Toxicology/ Alan R. Mas* Inc., NewYork.

IS. Nauszter J3/ B»hn AK < Editors)• 1974. Epidemiology. pp 126-159, VB SaundercCompany* Philadelphia.

19. HcKusic VA, 1975. Herdelian Inheritance in Han. The Johns Hopkins UniversityPress/ Baltinore, Maryland.

20. Milnan S, 1963. Underreporting of incidence of cleft lip and palate. AmericanJournal of Diseases in Children/ 106:185-168-

21. National Cancer Institute* 1984. Surveillance, Epidemiology and Bnd Results:Cancer Incidence and Hortality in the United States, 1973-1981. KIH Publication^ jHo. 83-1837. ^*

22* Public Health Council, 1980. Rules of the Public Health Council "Definitions",Sule No, 3701-5-01/ pp 593,

23. Shepard TB/ 1980. Catalog of Teratogenic £genta. The Johns Hopkins UniversityPress/ Baltimore, Maryland.

24. Staples B5/ 1976. PredictSveness and limitations of test methods in teratology.Bnvironental Health Perspectives 18:95-96.

25. United States Environmental Protection Agency/ 1986. Public Cement FeasibilityStudy: Fields Brook Site. Ahstabula* Ohio Sediaent Operable Qnlt/ July 3/ 1986*

26. Vavghan/ 7t/ Darling Jfi/ Starcy KPH/ 1984. Fetal death and maternal occupation.Journal of Occupational Medicine 26:676-676.

SM'27. World Health Organization* 1975* Manual of the International StatisticalClassification of Diseases, Injuries* and Causes of Death* Ninth Revision*Geneva/ Switzerland.

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