Cohort study among workers exposed to benzene in China: II. Exposure assessment

The Distribution and Concentration Monitoring of Benzene Industries - Six PLADs, China, 2020

WHAT IS ALREADY KNOWN ABOUT THIS TOPIC?

Benzene is classified as a Class I human carcinogen by the International Agency for Research on Cancer. Long-term exposure to benzene increases the risk of chronic benzene poisoning and leukemia. However, benzene is still widely used in the manufacturing industry.

WHAT IS ADDED BY THIS REPORT?

The scale of enterprises most exposed to benzene was small enterprises, and joint-equity enterprises had the highest number that exceeded the permissible concentration-time weighted average.

WHAT ARE THE IMPLICATIONS FOR PUBLIC HEALTH PRACTICE?

It is still necessary to strengthen the monitoring of benzene concentrations in the manufacturing industry, especially in small enterprises. The occupational exposure limit of benzene should be appropriately reduced.

Shanghai Health Study (2001-2009): What was learned about benzene health effects?

The Shanghai Health Study (SHS) was a large epidemiology study conducted as a joint effort between the University of Colorado and Fudan University in Shanghai, China. The study was funded by members of the American Petroleum Institute between 2001 and 2009 and was designed to evaluate the human health effects associated with benzene exposure. Two arms of the SHS included: an occupational-based molecular epidemiology study and several hospital-based case control studies. Consistent with historical literature, following sufficient exposure to relatively high airborne concentrations and years of exposure, the SHS concluded that exposure to benzene resulted in an increased risk of various blood and bone marrow abnormalities such as benzene poisoning, aplastic anemia (AA), myelodysplastic syndrome (MDS), and acute myeloid leukemia (AML). Non-Hodgkin lymphoma (NHL) was not significantly increased for the exposures examined in this study. Perhaps the most important contribution of the SHS was furthering our understanding of the mechanism of benzene-induced bone marrow toxicity and the importance of identifying the proper subset of MDS relevant to benzene. Investigators found that benzene-exposed workers exhibited bone marrow morphology consistent with an immune-mediated inflammatory response. Contrary to historic reports, no consistent pattern of cytogenetic abnormalities was identified in these workers. Taken together, findings from SHS provided evidence that the mechanism for benzene-induced bone marrow damage was not initiated by chromosome abnormalities. Instead, chronic inflammation, followed by an immune-mediated response, is likely to play a more significant role in benzene-induced disease initiation and progression than previously thought.

Evaluating Exposure-Response Associations for Non-Hodgkin Lymphoma with Varying Methods of Assigning Cumulative Benzene Exposure in the Shanghai Women's Health Study

Objectives

To provide insight into the contributions of exposure measurements to job exposure matrices (JEMs), we examined the robustness of an association between occupational benzene exposure and non-Hodgkin lymphoma (NHL) to varying exposure assessment methods.

Methods

NHL risk was examined in a prospective population-based cohort of 73087 women in Shanghai. A mixed-effects model that combined a benzene JEM with >60000 short-term, area benzene inspection measurements was used to derive two sets of measurement-based benzene estimates: 'job/industry-specific' estimates (our presumed best approach) were derived from the model's fixed effects (year, JEM intensity rating) and random effects (occupation, industry); 'calibrated JEM' estimates were derived using only the fixed effects. 'Uncalibrated JEM' (using the ordinal JEM ratings) and exposure duration estimates were also calculated. Cumulative exposure for each subject was calculated for each approach based on varying exposure definitions defined using the JEM's probability ratings. We examined the agreement between the cumulative metrics and evaluated changes in the benzene-NHL associations.

Results

For our primary exposure definition, the job/industry-specific estimates were moderately to highly correlated with all other approaches (Pearson correlation 0.61-0.89; Spearman correlation > 0.99). All these metrics resulted in statistically significant exposure-response associations for NHL, with negligible gain in model fit from using measurement-based estimates. Using more sensitive or specific exposure definitions resulted in elevated but non-significant associations.

Conclusions

The robust associations observed here with varying benzene assessment methods provide support for a benzene-NHL association. While incorporating exposure measurements did not improve model fit, the measurements allowed us to derive quantitative exposure-response curves.

Retrospective benzene exposure assessment for a multi-center case-cohort study of benzene-exposed workers in China

Quality of exposure assessment has been shown to be related to the ability to detect risk of lymphohematopoietic disorders in epidemiological investigations of benzene, especially at low levels of exposure. We set out to build a statistical model for reconstructing exposure levels for 2898 subjects from 501 factories that were part of a nested case-cohort study within the NCI-CAPM cohort of more than 110,000 workers. We used a hierarchical model to allow for clustering of measurements by factory, workshop, job, and date. To calibrate the model we used historical routine monitoring data. Measurements below the limit of detection were accommodated by constructing a censored data likelihood. Potential non-linear and industry-specific time-trends and predictor effects were incorporated using regression splines and random effects. A partial validation of predicted exposures in 2004/2005 was performed through comparison with full-shift measurements from an exposure survey in facilities that were still open. Median cumulative exposure to benzene at age 50 for subjects that ever held an exposed job (n=1175) was 509 mg/m(3) years. Direct comparison of model estimates with measured full-shift personal exposure in the 2004/2005 survey showed moderate correlation and a potential downward bias at low (<1 mg/m(3)) exposure estimates. The modeling framework enabled us to deal with the data complexities generally found in studies using historical exposure data in a comprehensive way and we therefore expect to be able to investigate effects at relatively low exposure levels.

A retrospective cohort study of cause-specific mortality and incidence of hematopoietic malignancies in Chinese benzene-exposed workers

Benzene exposure has been causally linked with acute myeloid leukemia (AML), but inconsistently associated with other hematopoietic, lymphoproliferative and related disorders (HLD) or solid tumors in humans. Many neoplasms have been described in experimental animals exposed to benzene. We used Poisson regression to estimate adjusted relative risks (RR) and the likelihood ratio statistic to derive confidence intervals for cause-specific mortality and HLD incidence in 73,789 benzene-exposed compared with 34,504 unexposed workers in a retrospective cohort study in 12 cities in China. Follow-up and outcome assessment was based on factory, medical and other records. Benzene-exposed workers experienced increased risks for all-cause mortality (RR = 1.1, 95% CI = 1.1, 1.2) due to excesses of all neoplasms (RR = 1.3, 95% CI = 1.2, 1.4), respiratory diseases (RR = 1.7, 95% CI = 1.2, 2.3) and diseases of blood forming organs (RR = ∞, 95% CI = 3.4, ∞). Lung cancer mortality was significantly elevated (RR = 1.5, 95% CI = 1.2, 1.9) with similar RRs for males and females, based on three-fold more cases than in our previous follow-up. Significantly elevated incidence of all myeloid disorders reflected excesses of myelodysplastic syndrome/acute myeloid leukemia (RR = 2.7, 95% CI = 1.2, 6.6) and chronic myeloid leukemia (RR = 2.5, 95% CI = 0.8, 11), and increases of all lymphoid disorders included excesses of non-Hodgkin lymphoma (RR = 3.9, 95%CI = 1.5, 13) and all lymphoid leukemia (RR = 5.4, 95%CI = 1.0, 99). The 28-year follow-up of Chinese benzene-exposed workers demonstrated increased risks of a broad range of myeloid and lymphoid neoplasms, lung cancer, and respiratory diseases and suggested possible associations with other malignant and non-malignant disorders.

Changes in poly(ADP-ribosyl)ation patterns in workers exposed to BTX

Occupational exposure to (benzene, toluene and xylene, BTX is common in the Chinese workplace. Chronic occupational exposure to benzene is associated with an increased risk of hematological malignancies such as acute myeloid leukemia (AML), but the underlying mechanisms are still unclear. This study investigates changes in poly(ADP-ribosyl)ation and DNA methylation in subjects occupationally exposed to a BTX. Blood DNA samples and exposure data were obtained from subjects with different levels of exposure, including 132 decorators, 129 painters, and 130 unexposed referents in a container-manufacturing factory in Shenzhen, China. Occupational exposure assessment included personal monitoring of airborne benzene, toluene and xylene. Hematological parameters were measured and the cytokinesis-block micronucleus (CBMN) assay was used to detect DNA damage in peripheral lymphocytes. Quantitative real-time PCR was used to detect the mRNA expression of poly(ADP-ribose) polymerase 1 (PARP1) and poly(ADP-ribose) glycohydrolase (PARG), DNA methyltransferases (DNMTs) including DNMT1, DNMT3a and DNMT3b, methyl-CpG-binding domain protein 2(MBD2). PARP1 assay was used to measure PARP activity. Airborne levels of benzene, toluene and xylene in the two exposed groups were significantly higher than those of controls (P<0.001). The two exposed groups (decorators, painters) showed decreased PARP1, DNMTs and MBD2 expression relative to controls (P<0.05), and PARP activity was also decreased (P<0.05). Decreased PARP1, DNMT1, DNMT3a, DNMT3b and MBD2 mRNA expression was correlated with increased airborne BTX (Pearson's r: -0.587, -0.314, -0.636, -0.567 and -0.592 respectively, P<0.001). No significant differences in hematological parameters and CBMN were found among the three groups. Together, these results suggest that decreased DNMTs, MBD2 and PARP1 might be involved in the global hypomethylation associated with BTX exposure, and the imbalance of PARP/PARG might participate in the down-regulation of DNMTs. This is the first human study to link altered poly(ADP-ribosyl)ation patterns, which reproduce the aberrant epigenetic patterns found in benzene-treated cells, to chronic occupational exposure to BTX.

Microsomal epoxide hydrolase (EPHX1) polymorphisms are associated with aberrant promoter methylation of ERCC3 and hematotoxicity in benzene-exposed workers

Benzene is an important industrial chemical and widespread environmental pollutant known to induce leukemia and other blood disorders. To be carcinogenic, benzene must be metabolized to produce toxic metabolites. To investigate whether single nucleotide polymorphisms (SNPs) in the metabolic enzyme genes are associated with benzene-induced alterations in DNA methylation and hematotoxicity, we genotyped four commonly studied SNPs in three metabolic enzymes genes CYP1A1, EPHX1 and NQO1; and analyzed promoter DNA methylation status in 11 genes which have been reported to be associated with benzene-induced hematotoxicity (BLM, CYP1A1, EPHX1, ERCC3, NQO1, NUDT1, p15, p16, RAD51, TP53 and WRAP53) in 77 benzene-exposed workers and 25 unexposed controls in China. ERCC3, a DNA repair gene, showed a small but statistically significant increase of promoter DNA methylation in the exposed group compared with the unexposed group (mean ± SD: 4.73 ± 3.46% vs. 3.63 ± 1.96%, P = 0.048). We also observed that an increased number of C allele for rs1051740 in EPHX1 was associated with decreased ERCC3 methylation levels in benzene-exposed workers (P(trend)  = 0.001), but not in unexposed controls (P(trend)  = 0.379). Interestingly, another EPHX1 SNP (rs2234922) was associated with lower white blood cell (WBC) counts (P(trend)  = 0.044) in benzene-exposed workers. These associations remained the same when ERCC3 promoter methylation and WBCs were dichotomized according to the 90th percentile (≥6%) of methylation levels in controls and a leucopenia cutoff (<4 × 10(9) /L), respectively. Our findings suggest that benzene exposure may be associated with hypermethylation in ERCC3, and that genetic variants in EPHX1 may play an important role in epigenetic changes and hematotoxicity among benzene-exposed workers.

Combining a job-exposure matrix with exposure measurements to assess occupational exposure to benzene in a population cohort in shanghai, china

BACKGROUND

Generic job-exposure matrices (JEMs) are often used in population-based epidemiologic studies to assess occupational risk factors when only the job and industry information of each subject is available. JEM ratings are often based on professional judgment, are usually ordinal or semi-quantitative, and often do not account for changes in exposure over time. We present an empirical Bayesian framework that combines ordinal subjective JEM ratings with benzene measurements. Our aim was to better discriminate between job, industry, and time differences in exposure levels compared to using a JEM alone.

METHODS

We combined 63 221 short-term area air measurements of benzene exposure (1954-2000) collected during routine health and safety inspections in Shanghai, China, with independently developed JEM intensity ratings for each job and industry using a mixed-effects model. The fixed-effects terms included the JEM intensity ratings for job and industry (both ordinal, 0-3) and a time trend that we incorporated as a b-spline. The random-effects terms included job (n = 33) and industry nested within job (n = 399). We predicted the benzene concentration in two ways: (i) a calibrated JEM estimate was calculated using the fixed-effects model parameters for calendar year and JEM intensity ratings; (ii) a job-/industry-specific estimate was calculated using the fixed-effects model parameters and the best linear unbiased predictors from the random effects for job and industry using an empirical Bayes estimation procedure. Finally, we applied the predicted benzene exposures to a prospective population-based cohort of women in Shanghai, China (n = 74 942).

RESULTS

Exposure levels were 13 times higher in 1965 than in 2000 and declined at a rate that varied from 4 to 15% per year from 1965 to 1985, followed by a small peak in the mid-1990s. The job-/industry-specific estimates had greater differences between exposure levels than the calibrated JEM estimates (97.5th percentile/2.5th percentile exposure level, (B)(G)R(95)(B): 20.4 versus 3.0, respectively). The calibrated JEM and job-/industry-specific estimates were moderately correlated in any given year (Pearson correlation, r(p) = 0.58). We classified only those jobs and industries with a job or industry JEM exposure probability rating of 3 (>50% of workers exposed) as exposed. As a result, 14.8% of the subjects and 8.7% of the employed person-years in the study population were classified as benzene exposed. The cumulative exposure metrics based on the calibrated JEM and job-/industry-specific estimates were highly correlated (r(p) = 0.88).

CONCLUSIONS

We provide a useful framework for combining quantitative exposure data with expert-based exposure ratings in population-based studies that maximized the information from both sources. Our framework calibrated the ratings to a concentration scale between ratings and across time and provided a mechanism to estimate exposure when a job/industry group reported by a subject was not represented in the exposure database. It also allowed the job/industry groups' exposure levels to deviate from the pooled average for their respective JEM intensity ratings.

Retrospective occupational exposure assessment for case-control and case-series epidemiology studies based in Shanghai China

To provide exposure information for epidemiology studies conducted in Shanghai from 2001 to 2008, we completed retrospective exposure assessments (EA) of benzene and other hazards. Interviewers administered questionnaires to subjects from Shanghai area hospitals. An initial exposure screening by EA staff members, blinded as to case-control status, stratified jobs into exposed, unexposed, or uncertain categories prior to review by a separate expert panel (EP). Resources for the EA included job/industry-specific questionnaire responses by subjects, short-term benzene area concentration measurements from a Shanghai regulatory agency database, Chinese literature for qualitative and short-term quantitative measurements, on-site investigations, summaries of technology changes, and selected task simulations with concurrent benzene concentration measurements. An EP in Shanghai completed semi-quantitative benzene exposure assignments, with categories of 0 to 4 corresponding to intensity ranges of none, <1, 1 to 10, >10 to 100, and >100 mg/m(3). For other hazards, sources included the EP's knowledge of the industries and Chinese and Western literature. For benzene, 20% of the EAs selected by a stratified random process were evaluated by two alternate methods. The study database of potential cases and controls included 18,857 jobs from the subjects' work histories. From 818 individuals initially screened as probably benzene exposed, 964 jobs underwent further review. From subjects with final diagnoses, 755 jobs qualified for inclusion in the final database for any study. For other exposures, the EA considered 17,893 jobs from 7654 subjects for possible exposures and were in the final study database. Of these, 2565 individuals had exposures of study interest from their 4909 exposed jobs. The prevalent exposures included agricultural chemicals, petroleum products, and metals. The EA involved extensive information assembly and exposure assignment by an EP and periodic reviews. The methods described went beyond those typically applied in past general population studies and may have provided improved information for the epidemiologic analyses. However, sufficient, reliable measured historical data are lacking to evaluate this conclusion.

Effects of co-exposure of benzene, toluene and xylene to Drosophila melanogaster: alteration in hsp70, hsp60, hsp83, hsp26, ROS generation and oxidative stress markers

Benzene, toluene and xylene are monocyclic aromatic hydrocarbon compounds, used both as individual compound and as mixtures, in industry as well as household. Previous studies involving exposures to these compounds, individually, have shown that benzene was more toxic compared to toluene or xylene. Here, we tested a working hypothesis that toluene and/or xylene in a mixture containing benzene affect benzene induced toxicity in a non-target organism, Drosophila melanogaster. We exposed D. melanogaster larvae transgenic for hsp70, hsp83 or hsp26 and wild type (Oregon R strain) larvae to 25.0-100.0mM benzene, 25.0-100.0mM toluene and 25.0-100mM xylene, individually or in mixtures. Subsequently, we examined the expression of stress genes (encoding heat shock proteins, hsps), generation of reactive oxygen species (ROS), induction of anti-oxidant stress markers and emergence of flies under treatment as well as control conditions. We observed that all these endpoints were significantly altered in all the treatment groups compared to their respective controls. However, the magnitude of toxicity of a benzene-toluene (BT) or benzene-xylene (BX) or benzene-toluene-xylene (BTX) mixture was significantly lower in the organism than that of individual chemical. Our results also show the modulation of toluene toxicity by xylene. Present study suggests antagonistic effect of xylene and toluene on benzene toxicity and additive/synergistic effect of xylene on toluene induced toxicity. Thus, expression of stress genes may be used as an assay for detection of early cellular toxicity. Further, our study supports the use of Drosophila as an alternative animal model for first tier screening of adverse effects of chemical mixtures.

Incidence and risk factors of aplastic anemia in Latin American countries: the LATIN case-control study

Background Associations between aplastic anemia and numerous drugs, pesticides and chemicals have been reported. However, at least 50% of the etiology of aplastic anemia remains unexplained.

DESIGN AND METHODS

This was a case-control, multicenter, multinational study, designed to identify risk factors for agranulocytosis and aplastic anemia. The cases were patients with diagnosis of aplastic anemia confirmed through biopsy or bone marrow aspiration, selected through an active search of clinical laboratories, hematology clinics and medical records. The controls did not have either aplastic anemia or chronic diseases. A total of 224 patients with aplastic anemia were included in the study, each case was paired with four controls, according to sex, age group, and hospital where the case was first seen. Information was collected on demographic data, medical history, laboratory tests, medications, and other potential risk factors prior to diagnosis.

RESULTS

The incidence of aplastic anemia was 1.6 cases per million per year. Higher rates of benzene exposure (>/=30 exposures per year) were associated with a greater risk of aplastic anemia (odds ratio, OR: 4.2; 95% confidence interval, CI: 1.82-9.82). Individuals exposed to chloramphenicol in the previous year had an adjusted OR for aplastic anemia of 8.7 (CI: 0.87-87.93) and those exposed to azithromycin had an adjusted OR of 11.02 (CI 1.14-108.02). Conclusions The incidence of aplastic anemia in Latin America countries is low. Although the research study centers had a high coverage of health services, the underreporting of cases of aplastic anemia in selected regions can be discussed. Frequent exposure to benzene-based products increases the risk for aplastic anemia. Few associations with specific drugs were found, and it is likely that some of these were due to chance alone.

Benzene exposure in industries using or manufacturing paint in China--a literature review, 1956-2005

A systematic review of the Chinese literature was conducted from 1956 to 2005. The survey included both online and manual searching, as well as expert discussions aimed at providing insight into factors affecting benzene exposure levels in paint/coatings industries. Data extracted from 204 papers included: (1) year of occurrence, (2) type of paint/coatings products, (3) type of industries where the products were used or produced, (4) job titles and work activities, (5) type of literature searched, (6) working conditions whenever data were available, and (7) exposure levels. Most benzene measurements were short-term samples for comparison with the Chinese maximum allowable concentration standard. The accuracy and precision of the sampling and analytical methods were not reported. The distribution of benzene concentrations was tested and found to fit neither normal nor lognormal distributions. Analysis of variance (comparison for more than two groups) and t-test (comparison for two groups) were conducted on Blom-transformed benzene concentration data. The overall median benzene exposure levels were 215, 82, 31, and 6 mg/m(3) during the periods 1956-1978, 1979-1989, 1990-2001, and 2002-2005, respectively. Mean benzene exposure was significantly lower for paint manufacturing than paint spraying. No significant difference was found among paint types and benzene exposure for paint application. Benzene exposure was significantly higher in workplaces judged to have poor ventilation. No significant differences were found in benzene exposure as a function of industry type. Even though substantially lower when compared with levels in the past, recent benzene exposure measurements suggested that many facilities in the paint/coatings industries in China still have benzene concentrations that are above the current China occupational exposure limit for benzene (6 mg/m(3) as a time-weighted average). Benzene concentrations from the present exercise, while not directly supporting quantitative retrospective exposure estimating, provide insight on relative benzene exposure for painting tasks in the reported industries over time.

Multiple synchronous primary malignancies induced by benzene exposure: a case report

Background

Chronic exposure to high concentrations of benzene is usually associated with the development of haematological diseases. However, solid tumors induced by benzene exposure are less frequent.

Case presentation

We present an unusual case of triple synchronous primary malignancies most likely induced by occupational benzene exposure in a male patient. This spray painter was diagnosed as chronic aplastic anemia in his 21 years old after exposing to high concentration of benzene for three years. Then he was treated with glucocorticoid for four years. 40 years later, this patient developed three synchronous primary neoplasms with three different histologies including a basaloid squamous cell carcinoma of the esophagus, primary hepatocellular carcinoma, and well-differentiated squamous cell carcinoma of the gum.

Conclusion

This case reminds us that the occurrence of solid tumors should be monitored in workers with occupational history linked with a high concentration exposure to benzene, though it's rarely happened.

ATSDR evaluation of health effects of benzene and relevance to public health

As part of its mandate, the Agency for Toxic Substances and Disease Registry (ATSDR) prepares toxicological profiles on hazardous chemicals found at Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA) National Priorities List (NPL) sites that have the greatest public health impact. These profiles comprehensively summarize toxicological and environmental information. This article constitutes the release of portions of the Toxicological Profile for Benzene. The primary purpose of this article is to provide public health officials, physicians, toxicologists, and other interested individuals and groups with an overall perspective on the toxicology of benzene. It contains descriptions and evaluations of toxicological studies and epidemiological investigations and provides conclusions, where possible, on the relevance of toxicity and toxicokinetic data to public health.

Guidelines to evaluate human observational studies for quantitative risk assessment

BACKGROUND

Careful evaluation of the quality of human observational studies (HOS) is required to assess the suitability of HOS for quantitative risk assessment (QRA). In particular, the quality of quantitative exposure assessment is a crucial aspect of HOS to be considered for QRA.

OBJECTIVE

We aimed to develop guidelines for the evaluation of HOS for QRA and to apply these guidelines to case-control and cohort studies on the relation between exposure to benzene and acute myeloid leukemia (AML).

METHODS

We developed a three-tiered framework specific for the evaluation of HOS for QRA and used it to evaluate HOS on the relation between exposure to benzene and AML.

RESULTS

The developed framework consists of 20 evaluation criteria. A specific focus of the framework was on the quality of exposure assessment applied in HOS. Seven HOS on the relation of benzene and AML were eligible for evaluation. Of these studies, five were suitable for QRA and were ranked based on the quality of the study design, conduct, and reporting on the study.

CONCLUSION

The developed guidelines facilitate a structured evaluation that is transparent in its application and harmonizes the evaluation of HOS for QRA. With the application of the guidelines, it was possible to identify studies suitable for QRA of benzene and AML and rank these studies based on their quality. Application of the guidelines in QRA will be a valuable addition to the assessment of the weight of evidence of HOS for QRA.

Chemical process based reconstruction of exposures for an epidemiological study

As part of an historical cohort study to investigate the mortality experience of industrial workers exposed to chloroprene (beta-CD) and other substances, all available industrial hygiene exposure monitoring data were collected and summarized. From discussions with on-site industrial hygiene personnel, it was apparent that these data were not collected for epidemiological purposes and, therefore, their use in characterization of exposures was problematic as the data mostly pertained to samples collected to investigate the performance of specific tasks. These data were, however, informative for validating the exposure modeling process used to estimate historical exposures. The data summarized below clearly indicate that exposures to beta-CD were lowered across the time period of this study. Typically, the exposures recorded were less than the occupational exposure limits of the periods in which the exposures were recorded. Additionally, exposure measurements recorded in the recent past do not represent the exposure actually experienced by the worker as a strict personal protective equipment use program has been in place for the facilities studied since the mid-1980s.

Progress of Epidemiological and Molecular Epidemiological Studies on Benzene in China

Benzene is an organic solvent that has been used in industry for about 100 years throughout the world. Since 1973, a series of toxicological and molecular epidemiological studies on benzene were conducted by researchers at the Chinese Academy of Preventive Medicine (CAPM) (1973-1986) and subsequently by a collaboration between the CAPM and the National Cancer Institute (NCI) in the United States that began in 1986, which was joined by investigators from the University of California at Berkeley, the University of North Carolina at Chapel Hill, and New York University. The findings demonstrated that the risk of leukemia and lymphoma among benzene-exposed workers was significantly increased, with elevated risks for leukemia present not only at higher exposure but also among workers exposed to under 10 ppm. Therefore, the benzene permissible level was decreased to 1.8 ppm (6 mg/m(3)) and benzene-induced leukemia is treated as an occupational cancer in China. The benzene permissible level is 1.0 in the United States and in several other developed countries and it has been suggested to be decreased to 0.5 ppm (ACGIH). A number of potential biomarkers are related to benzene exposure and poisoning. Some of these are benzene oxide-protein adducts, chromosome aberration of lymphocytes, and GPA mutations in erythrocytes, a decrease in B cell and CD4(-)T cell counts in peripheral blood, and altered expression of CXCL16, ZNF331, JUN, and PF4 in lymphocytes. Variation in multiple benzene metabolizing genes may be associated with risk of benzene hematotoxicity, including CYP2E1, MPO, NQO1, and GSTT1.

Opportunities for cancer epidemiology in developing countries

Most cancer epidemiology studies involve people living in North America and Europe, which represent only a fraction of the global population. The wide variety of dietary, lifestyle and environmental exposures, as well as the genetic variation among people in developing countries can provide valuable new information on factors that contribute to cancer or that protect against it. What are the challenges and advantages to performing large epidemiological studies in developing nations?

Agreement of job-exposure matrix (JEM) assessed exposure and self-reported exposure among adult leukemia patients and controls in Shanghai

BACKGROUND

Estimating a person's history of occupational exposure in case-control studies is difficult.

METHODS

Percent agreement between selected self-reported occupational exposures and job-exposure matrix (JEM) exposure assessment for all participants and various subgroups of a population-based case-control interview study of 486 leukemia subjects and 502 healthy controls in Shanghai was evaluated.

RESULTS

With JEM as the "gold standard," the sensitivities for self-reported exposures ranged from 0.75 to 0.98. However, that for pesticide exposure was 0.44 in subjects >51 years old. Self-reported exposures specificities ranged from 0.87 to 0.99. Agreement between self-reported exposures and JEM assessment was good (kappa coefficients [kappa]: 0.48-0.84). Variations in agreement for benzene exposure between males and females as well as between the direct interview and surrogate interview subgroups were observed.

CONCLUSIONS

The levels of agreement between self-report and JEM in this study suggest that self-reported exposures are a suitable method for assessing occupational exposures in this population.

Leukemia in relation to occupational exposures to benzene and other agents: a case-control study nested in a cohort of gas and electric utility workers

BACKGROUND

Many occupational and environmental exposures have been implicated in the etiology of leukemia, but only a few, such as benzene, are well-established leukemogens. The risk of leukemia in a large cohort of gas and electricity utility workers with exposures to several suspected or confirmed carcinogens was investigated.

METHODS

A case-control study nested within the cohort was conducted, with 72 leukemia cases identified among male workers, and 285 controls matched to the cases by year of birth. Only cases, and their matched controls, active in the company at the date of diagnosis were included. Exposure assessment was based on a job-exposure matrix (JEM) developed from expert judgment using a standardized procedure.

RESULTS

The risk of leukemia was increased in workers with an estimated cumulative exposure to benzene > or = 16.8 ppm-years (OR = 3.6; 95% CI 1.1-11.7), and there was an indication of a dose-response relation (OR = 1.2; 95% CI 1.0-1.5 per 10 ppm-years increase in exposure). The link with benzene was more pronounced for acute leukemia than for chronic leukemia, but no association with a particular leukemia cell type was apparent. The risk of leukemia remained elevated for latency periods of 2, 5, or 10 years.

CONCLUSIONS

From our evaluation, it could be estimated that the median TWA exposure to benzene among exposed workers was 0.16 ppm, i.e., within concentration ranges where an increased leukemia risk was usually not apparent in previous epidemiological studies. Although an increased leukemia risk may be real, it may also be related to other occupational factors not totally controlled for in the analysis, or to benzene exposures actually higher than expected.

Benzene and lymphohematopoietic malignancies in humans

BACKGROUND

Quantitative evaluations of benzene-associated risk for cancer have relied primarily on findings from a cohort study of highly exposed U.S. rubber workers. An epidemiologic investigation in China (NCI/CAPM study) extended quantitative evaluations of cancer risk to a broader range of benzene exposures, particularly at lower levels.

METHODS

We review the evidence implicating benzene in the etiology of hematopoietic disorders, clarify methodologic aspects of the NCI/CAPM study, and examine the study in the context of the broader literature on health effects associated with occupational benzene exposure.

RESULTS

Quantitative relationships for cancer risk from China and the U.S. show a relatively smooth increase in risk for acute myeloid leukemia and related conditions over a broad dose range of benzene exposure (below 200 ppm-years mostly from the China study and above 200 ppm-years mostly from the U.S. study).

CONCLUSIONS

Risks of acute myeloid leukemia and other malignant and nonmalignant hematopoietic disorders associated with benzene exposure in China are consistent with other information about benzene exposure, hematotoxicity, and cancer risk, extending evidence for hematopoietic cancer risks to levels substantially lower than had previously been established. Published 2001 Wiley-Liss, Inc.

Non-Hodgkin's lymphoma and exposure to benzene in a multinational cohort of more than 308,000 petroleum workers, 1937 to 1996

Petroleum workers are exposed to benzene or benzene-containing petroleum products. As such, studies of these workers provide an opportunity for investigating the relationship between benzene and non-Hodgkin's lymphoma (NHL). However, few cohort studies of petroleum workers report results of NHL separately. One reason is that NHL is usually grouped with other lymphopoietic cancers in the analysis. Another reason is the relatively small number of NHL cases in some studies. To determine the risk of NHL in petroleum workers, we identified 26 cohorts of petroleum workers in the United States, the United Kingdom, Canada, Australia, Italy, and Finland. Authors of the original studies were contacted, and data on the number of observed deaths and person-years of observation were requested. Data from these studies were reviewed individually as well as combined in a pooled analysis (meta-analysis). In particular, results for individual cohorts, most of which had never been reported before, were presented. The combined multinational cohort consisted of more than 308,000 petroleum workers (6.6 million person-years), and the observation period covered an interval of 60 years from 1937 to 1996. A total of 506 NHL deaths were observed, compared with 561.68 expected. The standardized mortality ratio was 0.90 and the 95% confidence interval was 0.82 to 0.98. Analyses were performed by type of facility and industrial process. Stratum-specific standardized mortality ratios (95% confidence intervals) were 0.96 (0.86 to 1.07) for US refinery workers, 1.12 (0.90 to 1.37) for non-US refinery workers, 0.64 (0.50 to 0.82) for product (gasoline) distribution workers, and 0.68 (0.47 to 0.95) for crude oil workers. When individual cohorts were stratified by length of observation, no pattern was detected. In general, exposure levels before 1950 were much higher than thereafter. However, analysis of workers by hire date (< 1950, > or = 1950) revealed no difference in NHL mortality. Furthermore, none of the individual studies showed significant exposure-response relations. In summary, results from individual studies, as well as from the pooled analysis, indicated that petroleum workers were not at an increased risk of NHL as a result of their exposure to benzene or other benzene-containing petroleum products in their work environment. This conclusion was supported by cohort studies of workers in other industries who were exposed to benzene as well as by population-based case-control studies of NHL and occupational exposures.

China's "market economics in command": footwear workers' health in jeopardy

This study of occupational safety and health (OSH) problems in the footwear industry in China, the world's largest shoemaker, is based on four years of research in China supplemented by research in Taiwan, Australia, and the United States. With the advent of the economic reforms of the early 1980s, the Chinese state is being driven by an economic imperative under which the profit motive overrides other concerns, causing a deterioration in OSH conditions. Footwear workers are being exposed to high levels of benzene, toluene, and other toxic solvents contained in the adhesives used in the shoe-making process. Many workers have been afflicted with aplastic anemia, leukemia, and other health problems. Most of China's current permissible exposure limits to toxins are either outdated or underenforced. As a result, the Chinese state's protection of footwear workers' health is inadequate. The article aims to draw the attention of the international OSH community to the importance of setting specific exposure standards for the footwear industry worldwide.

A critique of the exposure assessment in the epidemiologic study of benzene-exposed workers in China conducted by the Chinese Academy of Preventive Medicine and the US National Cancer Institute

As reviewed in some detail in the present paper, workers employed in a wide variety of industries were included in the Chinese benzene study, and were exposed to not only benzene but also a wide range of other industrial chemicals. To attribute any or all health effects observed in the exposed cohort to benzene without examining other concomitant exposures is not appropriate. Although it was stated that one of the major objectives of the expanded study was to examine the effects of other risk factors, no such examination was made in any of the analyses in the expanded CAPM-NCI study. The CAPM-NCI study suffered from a number of limitations. One of the most serious limitations of the study involved the exposure estimates developed by the US NCI team. Comparing the assumptions used in the development of estimates and the exposure estimates themselves to actual data reported previously by the Chinese investigators revealed numerous inconsistencies and, in many cases, large discrepancies. It appeared that the exposure estimates were consistently lower than the actual exposure data. The so-called indirect validation conducted by the NCI team served no useful purpose, since by definition it could not validate the absolute values of the estimates. NCI was fully aware of some of the inadequacies of its exposure estimates. Although in a 1994 paper, the NCI team recognized that little confidence could be attached to the estimated (e.g., only 2% of the estimates for the time interval 1949-1959 and only 6% of the estimates prior to 1975 were rated in the high confidence category), the inadequacy of the estimates was never mentioned or discussed in any subsequent analyses or in the latest report (Hayes et al., 1998). Instead, the exposure of the workers was hailed as "well characterized" (Hayes et al., 1998). In conclusion both CAPM and NCI have made substantial efforts in studying the relationship between benzene exposure and various malignancies. Unfortunately, there were many inherent problems in the data as well as serious limitations in the exposure estimates. Because of these unresolved problems and limitations, many of the results in the CAPM-NCI study are unreliable. Therefore, the conclusions of the study, particularly those involving exposure estimates, are not justified.

An evaluation of modeled benzene exposure and dose estimates published in the Chinese-National Cancer Institute collaborative epidemiology studies

Risk estimates and cause and effect determinations are directly dependent on exposure and dose-response relationships. Recently, relative risks and excess cancer mortality attributed to occupational benzene exposure have been published in collaborative studies conducted by Chinese investigators and scientists from the National Cancer Institute. The results of these studies suggest increased risk of acute nonlymphocytic leukemia at relatively low benzene concentrations and associations with cancers not previously associated with benzene exposure. These studies are potentially important due to their size and potential to more thoroughly investigate the link between benzene exposure and cancer. However, there are questions concerning the validity of exposure and dose estimates supporting relative risk characterizations in these studies. Apparent discrepancies between modeled exposure and dose estimates and sources of actual measured exposure information and clinical markers of benzene toxicity raise serious concerns questioning the reliability of relative risk and cancer associations stated in these studies.

Occupational cancer among women: research status and methodologic considerations

Occupational causes of cancer have not been well-evaluated among women. An increase in the number of women in the work force in jobs with potentially hazardous exposures during the past few decades raises the question as to whether there is a need to enhance our efforts in this area. The inability to evaluate occupational causes of female gynecologic tumors in studies of men, plus the potential for variation in outcome responses between men and women because of gender-based exposure and susceptibility differences, underscore the need for investigations specifically focused on women. Investigations of occupational exposures and cancer risk among women may require design considerations that differ somewhat from studies of men. Issues to consider include the impact of studying outcomes with high survival (e.g., breast cancer), gender-specific exposure patterns and toxicokinetic processing of some chemicals, special limitations in the use of the general population as the referent, and the need to control for established risk factors for gynecologic tumors.

Non-Hodgkin's lymphoma risk derived from exposure to organic solvents: a review of epidemiologic studies

The rate of non-Hodgkin's lymphomas (NHL) has increased around the world during the last decades. Apart from the role of the human immunodeficiency virus (HIV) infection in the development of NHL, exposure to chemical agents like phenoxyacetic pesticides, hair dyes, metal fumes and organic solvents are suspected to be involved. The present review evaluates the results of studies that directly or indirectly searched for an association between solvent exposure and NHL. The selected studies comprised those published from 1979 to 1997, designed to investigate risk factors for NHL, whether specifically looking for solvent exposure or for general risks in which solvent exposure could be included. In 25 of the 45 reviewed studies (55.5%), fifty-four statistically significant associations between NHL and solvent exposure related occupations or industries were reported. Statistical significance was more frequently shown in studies where solvent exposure was more accurately defined. In eighteen of such studies, 13 (72.2%) defined or suggested organic solvents as possible risk factors for NHL.

Comprehensive evaluation of long-term trends in occupational exposure: Part 1. Description of the database

OBJECTIVES

To conduct a comprehensive evaluation of long term changes in occupational exposure among a broad cross section of industries worldwide.

METHODS

A review of the scientific literature identified studies that reported historical changes in exposure. About 700 sets of data from 119 published and several unpublished sources were compiled. Data were published over a 30 year period in 25 journals that spanned a range of disciplines. For each data set, the average exposure level was compiled for each period and details on the contaminant, the industry and location, changes in the threshold limit value (TLV), as well as the type of sampling method were recorded. Spearman rank correlation coefficients were used to identify monotonic changes in exposure over time and simple linear regression analyses were used to characterise trends in exposure.

RESULTS

About 78% of the natural log transformed data showed linear trends towards lower exposure levels whereas 22% indicated increasing trends. (The Spearman rank correlation analyses produced a similar breakdown between exposures monotonically increasing or decreasing over time.) Although the rates of reduction for the data showing downward trends ranged from -1% to -62% per year, most exposures declined at rates between -4% and -14% per year (the interquartile range), with a median value of -8% per year. Exposures seemed to increase at rates that were slightly lower than those of exposures which have declined over time. Data sets that showed downward (versus upward) trends were influenced by several factors including type and carcinogenicity of the contaminant, type of monitoring, historical changes in the threshold limit values (TLVs), and period of sampling.

CONCLUSIONS

This review supports the notion that occupational exposures are generally lower today than they were years or decades ago. However, such trends seem to have been affected by factors related to the contaminant, as well as to the period and type of sampling.

Validation of benzene exposure assessment

We conducted a methodologic study to validate a quantitative retrospective exposure assessment method used in a follow-up study of workers exposed to benzene. Assessment of exposure to benzene was carried out in 672 factories in 12 cities in China. Historical exposure data were collected for 3179 unique job titles. The basic unit for exposure assessment was a factory/work-unit/job-title combination over seven periods between 1949 and 1987. A total of 18,435 exposure estimates was developed, using all available historical information, including 8477 monitoring data. Overall, 38% of the estimates were based on benzene monitoring data. The highest time-weighted average exposures occurred in the rubber industry (30.7 ppm), particularly for rubber glue applicators (52.6 ppm). Because of its recognized link with benzene exposure, the association between a clinical diagnosis of benzene poisoning (hematotoxicity) and benzene exposure was evaluated (412 cases and 614,509 person-years) to validate the exposure-assessment method. Relative risks of benzene hematotoxicity increased very sharply with increasing estimated intensity of benzene exposure. Odds ratios were 2.2 (95% CI: 1.7-2.9), 4.7 (95% CI: 3.4-6.5), and 7.2 (95% CI: 5.3-9.8) for the intensity levels of less than 5 ppm, 5-19 ppm, 20-39 ppm, and 40 and more ppm, respectively. This sharp trend between benzene hematotoxicity and estimated exposure to benzene indicated that the exposure-estimation method used in this cancer epidemiology study is reliable.

Hematopoietic and lymphatic malignancies in vehicle mechanics

Although it is generally acknowledged that benzene causes leukemia, especially acute myeloid leukemia, considerable divergences persist in the assessment of the leukemia risk due to occupational low-level benzene exposure. Specifically, the risk for vehicle mechanics is considered by some authors as being nondetectable with epidemiologic methods, whereas others calculated that the incidence rate of leukemia (all types) in vehicle mechanics is increased more than 60 times. The purpose of this review is to examine the publications on this topic in light of criteria for causal inference and to discuss the possible role of bias, confounding factors, and chance. The results of this analysis reveal that there are surprisingly few epidemiologic observations supporting an increased incidence of leukemia in vehicle mechanics. Apparently, publications suggesting a leukemogenic effect of low-level benzene exposure in garage mechanics are more often quoted than their negative counterparts, although they are not better designed.

Benzene and the dose-related incidence of hematologic neoplasms in China. Chinese Academy of Preventive Medicine--National Cancer Institute Benzene Study Group

BACKGROUND

Benzene is a widely distributed environmental contaminant known to cause leukemia, particularly acute nonlymphocytic leukemia, and perhaps other hematologic neoplasms and disorders. Few epidemiologic studies, however, have been able to address relationships between the extent of benzene exposure and the level of risk.

PURPOSE

A large cohort study was carried out in China to evaluate the risks of developing specific hematologic neoplasms and selected related disorders in relationship to quantitative estimates of occupational benzene exposure.

METHODS

A cohort of 74828 benzene-exposed and 35805 unexposed workers employed from 1972 through 1987 in 12 cities in China was identified and followed to determine the incidence of hematologic neoplasms and related disorders. Estimates of benzene exposure were derived from work histories and available historic benzene measurements. Existing pathologic material and supporting medical records were reviewed to establish diagnoses of disease. Relative risks (RRs) (i.e., ratios of incidence rates for specific hematologic neoplasms and related disorders in the benzene-exposed group to incidence rates in the unexposed group) were determined by use of Poisson regression analysis, with stratification by age and sex.

RESULTS

For workers historically exposed to benzene at average levels of less than 10 parts per million (ppm), the RR for all hematologic neoplasm combined was 2.2 (95% confidence interval [CI] = 1.1-4.2), and, for the combination of acute nonlymphocytic leukemia and related myelodysplastic syndromes, the RR was 3.2 (95% CI = 1.0-10.1). For individuals who were occupationally exposed to benzene at constant levels of 25 ppm or more, the RR for the combination of acute nonlymphocytic leukemia and related myelodysplastic syndromes was 7.1 (95% CI = 2.1-23.7). Workers with 10 or more years of benzene exposure had an RR of developing non-Hodgkin's lymphoma of 4.2 (95% CI = 1.1-15.9), and the development of this neoplasm was linked most strongly to exposure that had occurred at least 10 years before diagnosis (i.e., distant exposure) (P for trend = .005, two-sided). In contrast, the risk for the combination of acute nonlymphocytic leukemia and related myelodysplastic syndromes was significantly increased among those with more recent benzene exposure (P for trend = .003, two-sided), but it was not linked to distant exposure (P for trend = .51, two-sided).

CONCLUSIONS

The results of this study suggest that benzene exposure is associated with a spectrum of hematologic neoplasms and related disorders in humans. Risks for these conditions are elevated at average benzene-exposure levels of less than 10 ppm and show a tendency, although not a strong one, to rise with increasing levels of exposure. The temporal pattern of benzene exposure appears to be important in determining the risk of developing specific diseases.

Cancer risks among iron and steel workers in Anshan, China, Part II: Case-control studies of lung and stomach cancer

Nested case-control interview studies of lung cancer (610 incident cases), stomach cancer (292 incident cases), and 959 controls were conducted to follow up leads from a proportional mortality analysis of deaths among male workers in a large integrated iron-steel complex in Anshan, China. For lung cancer, after adjusting for the significant non-occupational risk factors (smoking, other pulmonary disease, family history of lung cancer, and low consumption of fruit or tea), risks were significantly elevated for those employed for 15 or more years in smelting and rolling (OR = 1.5, CI = 1.1-2.2), in the fire-resistant brick factory (OR = 2.9, CI = 1.4-5.9), in general loading (OR = 2.5, CI = 1.0-6.1), and as coke oven workers (OR = 3.4; CI = 1.4-8.5). For stomach cancer, after adjusting for consumption of pickled vegetables, prior gastric diseases, family history of stomach cancer, low intake of fruits and vegetables, and education, risks were significantly elevated for those employed for 15 or more years in ore sintering and transportation (OR = 2.1, CI = 1.0-4.4), in the fire-resistant brick factory (OR = 2.5, CI = 1.1-5.8), in general loading (OR = 3.2, CI = 1.2-8.9), as boilerworkers and cooks (OR = 2.6, CI = 1.2-5.6), and as coke oven workers (OR = 5.4, CI = 1.8-16.0). For both lung and stomach cancers, significant dose-response gradients were observed for exposure to total dust and benzo(a)pyrene, but not for specific chemical components of dust. Overall, long-term steel workers with exposure to workplace pollutants had a 40% increased risk of both lung and stomach cancers. These case-control studies confirm many of the occupational findings reported in the proportionate mortality analysis, and suggest avenues for further work to evaluate the carcinogenicity of individual components of dust.

Benzene induces gene-duplicating but not gene-inactivating mutations at the glycophorin A locus in exposed humans

Occupational exposure to benzene is known to cause leukemia, but the mechanism remains unclear. Unlike most other carcinogens, benzene and its metabolites are weakly or nonmutagenic in most simple gene mutation assays. Benzene and its metabolites do, however, produce chromosomal damage in a variety of systems. Here, we have used the glycophorin A (GPA) gene loss mutation assay to evaluate the nature of DNA damage produced by benzene in 24 workers heavily exposed to benzene and 23 matched control individuals in Shanghai, China. The GPA assay identifies stem cell or precursor erythroid cell mutations expressed in peripheral erythrocytes of MN-heterozygous subjects, distinguishing the NN and N phi mutant variants. A significant increase in the NN GPA variant cell frequency (Vf) was found in benzene-exposed workers as compared with unexposed control individuals (mean +/- SEM, 13.9 +/- 1.7 per million cells vs. 7.4 +/- 1.1 per million cells in control individuals; P = 0.0002). In contrast, no significant difference existed between the two groups for the N phi Vf (9.1 +/- 0.9 vs. 8.8 +/- 1.8 per million cells; P = 0.21). Further, lifetime cumulative occupational exposure to benzene was associated with the NN Vf (P = 0.005) but not with the N phi Vf (P = 0.31), suggesting that NN mutations occur in longer-lived bone marrow stem cells. NN variants result from loss of the GPA M allele and duplication of the N allele, presumably through recombination mechanisms, whereas NO variants arise from gene inactivation, presumably due to point mutations and deletions. Thus, these results suggest that benzene produces gene-duplicating mutations but does not produce gene-inactivating mutations at the GPA locus in bone marrow cells of humans exposed to high benzene levels. This finding is consistent with data on the genetic toxicology of benzene and its metabolites and adds further weight to the hypothesis that chromosome damage and mitotic recombination are important in benzene-induced leukemia.

Cohort study among workers exposed to benzene in China: I. General methods and resources

Benzene is recognized internationally as a leukemogen, but the available data to clarify dose-response relationships and examine risks of malignancies other than leukemia are sparse. A collaborative study was therefore carried out to expand on a previous retrospective cohort mortality study of Chinese benzene-exposed workers. Methods and resources used in the 16-year follow-up of 74,828 benzene-exposed and 35,805 unexposed workers employed for any length of time during 1972-1987 in 712 factories in 12 cities in China are described. Details are provided of the study organization, assessment of benzene exposures since 1949, characterization of factories and workers by exposure status, city, and sex, identification and confirmation of cancers and other deaths, and quality control procedures. The distinguishing features of the study are discussed in relation to earlier cohort studies, and study limitations as well as strengths are presented.