Arsenic contamination of drinking water and foodstuffs causing endemic chronic poisoning

A mass-balance approach to evaluate arsenic intake and excretion in different populations

Unless a toxicant builds up in a deep compartment, intake by the human body must on average balance the amount that is lost. We apply this idea to assess arsenic (As) exposure misclassification in three previously studied populations in rural Bangladesh (n = 11,224), Navajo Nation in the Southwestern United States (n = 619), and northern Chile (n = 630), under varying assumptions about As sources. Relationships between As intake and excretion were simulated by taking into account additional sources, as well as variability in urine dilution inferred from urinary creatinine. The simulations bring As intake closer to As excretion but also indicate that some exposure misclassification remains. In rural Bangladesh, accounting for intake from more than one well and rice improved the alignment of intake and excretion, especially at low exposure. In Navajo Nation, comparing intake and excretion revealed home dust as an important source. Finally, in northern Chile, while food-frequency questionnaires and urinary As speciation indicate fish and shellfish sources, persistent imbalance of intake and excretion suggests imprecise measures of drinking water arsenic as a major cause of exposure misclassification. The mass-balance approach could prove to be useful for evaluating sources of exposure to toxicants in other settings.

Pollution and Risk Assessment of Heavy Metals in the Sediments and Soils around Tiegelongnan Copper Deposit, Northern Tibet, China

The surface sediments of the Rongna River and the surface soils around the Tiegelongnan copper deposit were collected, and the heavy metals Cu, Zn, Pb, Cr, Cd, As, Hg, and Ni were measured for their concentrations and health risk assessment. When the Rongna River passed through the Cu deposit area, the concentrations of Cu, Zn, As, Cd, Ni, and Hg in the surface sediments increased significantly, and the concentrations of Cu, Zn, and As exceeded the corresponding Grade II environmental quality standard. The heavy metals in the soil of the mining area were greater than the background value of the soil in Tibet. The geoaccumulation index indicated that the sediments of the river entering the mining area were very highly polluted by Cu and moderately polluted by Cd and Zn, and the soils in the mining area were moderately polluted by Cu. The potential ecological risk (PER) indices revealed that the sediments of the river entering the mining area had significantly high ecological risks, while the PER of the sediments away from the river section of the mining area was low, and the PER of the soils around the Cu deposit was moderate. The results of the health risk assessment indicated that the noncarcinogenic risks of heavy metals in sediments and soil of the mining area were within the acceptable range for adults and children. However, the carcinogenic risk of As and Cd in the sediment and As in the soil exceeds the relevant national standards, which may pose a certain risk to human health.

Electrochemical removal of amphoteric ions

Several harmful or valuable ionic species present in seawater, brackish water, and wastewater are amphoteric, weak acids or weak bases, and, thus, their properties depend on local water pH. Effective removal of these species can be challenging for conventional membrane technologies, necessitating chemical dosing of the feedwater to adjust pH. A prominent example is boron, which is considered toxic in high concentrations and often requires additional membrane passes to remove during seawater desalination. Capacitive deionization (CDI) is an emerging membraneless technique for water treatment and desalination, based on electrosorption of salt ions into charging microporous electrodes. CDI cells show strong internally generated pH variations during operation, and, thus, CDI can potentially remove pH-dependent species without chemical dosing. However, development of this technique is inhibited by the complexities inherent to the coupling of pH dynamics and ion properties in a charging CDI cell. Here, we present a theoretical framework predicting the electrosorption of pH-dependent species in flow-through electrode CDI cells. We demonstrate that such a model enables insight into factors affecting species electrosorption and conclude that important design rules for such systems are highly counterintuitive. For example, we show both theoretically and experimentally that for boron removal, the anode should be placed upstream and the cathode downstream, an electrode order that runs counter to the accepted wisdom in the CDI field. Overall, we show that to achieve target separations relying on coupled, complex phenomena, such as in the removal of amphoteric species, a theoretical CDI model is essential.

Fluoride and arsenic contamination in drinking water due to mining activities and its impact on local area population

Contamination of arsenic and fluoride in drinking water reservoirs is a serious health issue in the Sibi district, Balochistan, Pakistan. The contamination has already been affecting a large population of the district. Dental fluorosis and dermatitis are the most common reported illnesses in the area. This study focused on the evaluation of the root causes and pathway by which it reached to the body. Questioner analysis, simple examination, and pictorial representation were used to study the prevalence of diseases caused by As and F. People of the Sibi district were found to consume both surface and groundwater, which were highly contaminated with arsenic and fluoride. The saturation index, ranging from 1 to 7, showed high enrichment of contaminants in both types of water. Geochemical calculations and the sodium absorption ratio were evaluated. High values of the saturation index of different salts showed high saturation of salts in water. The principal component analysis grouped the data into three clusters, showing that the surface water has no resemblance with the control water. High degree of contamination was observed for most of the samples, whereas, some samples of ground water were closed to the control group; a group of samples within WHO limits. The correlation studies and other calculations also revealed that the F and As reached lethal limits in the drinking water and thus caused severe health damage to the local area population. The diseases found in the area are fluorosis, keratosis, dermatitis, and melanosis.

Cardiomyopathy in Children: Classification and Diagnosis: A Scientific Statement From the American Heart Association

In this scientific statement from the American Heart Association, experts in the field of cardiomyopathy (heart muscle disease) in children address 2 issues: the most current understanding of the causes of cardiomyopathy in children and the optimal approaches to diagnosis cardiomyopathy in children. Cardiomyopathies result in some of the worst pediatric cardiology outcomes; nearly 40% of children who present with symptomatic cardiomyopathy undergo a heart transplantation or die within the first 2 years after diagnosis. The percentage of children with cardiomyopathy who underwent a heart transplantation has not declined over the past 10 years, and cardiomyopathy remains the leading cause of transplantation for children >1 year of age. Studies from the National Heart, Lung, and Blood Institute-funded Pediatric Cardiomyopathy Registry have shown that causes are established in very few children with cardiomyopathy, yet genetic causes are likely to be present in most. The incidence of pediatric cardiomyopathy is ≈1 per 100 000 children. This is comparable to the incidence of such childhood cancers as lymphoma, Wilms tumor, and neuroblastoma. However, the published research and scientific conferences focused on pediatric cardiomyopathy are sparcer than for those cancers. The aim of the statement is to focus on the diagnosis and classification of cardiomyopathy. We anticipate that this report will help shape the future research priorities in this set of diseases to achieve earlier diagnosis, improved clinical outcomes, and better quality of life for these children and their families.

Arsenic, selenium, boron, lead, cadmium, copper, and zinc in naturally contaminated rocks: A review of their sources, modes of enrichment, mechanisms of release, and mitigation strategies

Massive and ambitious underground space development projects are being undertaken by many countries around the world to decongest megacities, improve the urban landscapes, upgrade outdated transportation networks, and expand modern railway and road systems. A number of these projects, however, reported that substantial portions of the excavated debris are oftentimes naturally contaminated with hazardous elements, which are readily released in substantial amounts once exposed to the environment. These contaminated excavation debris/spoils/mucks, loosely referred to as "naturally contaminated rocks", contain various hazardous and toxic inorganic elements like arsenic (As), selenium (Se), boron (B), and heavy metals like lead (Pb), cadmium (Cd), copper (Cu), and zinc (Zn). If left untreated, these naturally contaminated rocks could pose very serious problems not only to the surrounding ecosystem but also to people living around the construction and disposal sites. Several incidents of soil and ground/surface water contamination, for example, have been documented due to the false assumption that excavated materials are non-hazardous because they only contain background levels of environmentally regulated elements. Naturally contaminated rocks are hazardous wastes, but they still remain largely unregulated. In fact, standard leaching tests for their evaluation and classification are not yet established. In this review, we summarized all available studies in the literature about the factors and processes crucial in the enrichment, release, and migration of the most commonly encountered hazardous and toxic elements in naturally contaminated geological materials. Although our focus is on naturally contaminated rocks, analogue systems like contaminated soils, sediments, and other hazardous wastes that have been more widely studied will also be discussed. Classification schemes and leaching tests to properly identify and regulate excavated rocks that may potentially pose environmental problems will be examined. Finally, management and mitigation strategies to limit the negative effects of these hazardous wastes are introduced.

High risks of lung disease associated with early-life and moderate lifetime arsenic exposure in northern Chile

BACKGROUND

Arsenic in drinking water has been associated with increases in lung disease, but information on the long-term impacts of early-life exposure or moderate exposure levels are limited.

METHODS

We investigated pulmonary disease and lung function in 795 subjects from three socio-demographically similar areas in northern Chile: Antofagasta, which had a well-described period of high arsenic water concentrations (860μg/L) from 1958 to 1970; Iquique, which had long-term arsenic water concentrations near 60μg/L; and Arica, with long-term water concentrations ≤10μg/L.

RESULTS

Compared to adults never exposed >10μg/L, adults born in Antofagasta during the high exposure period had elevated odds ratios (OR) of respiratory symptoms (e.g., OR for shortness of breath=5.56, 90% confidence interval (CI): 2.68-11.5), and decreases in pulmonary function (e.g., 224mL decrease in forced vital capacity in nonsmokers, 90% CI: 97-351mL). Subjects with long-term exposure to arsenic water concentrations near 60μg/L also had increases in some pulmonary symptoms and reduced lung function.

CONCLUSIONS

Overall, these findings provide new evidence that in utero or childhood arsenic exposure is associated with non-malignant pulmonary disease in adults. They also provide preliminary new evidence that long-term exposures to moderate levels of arsenic may be associated with lung toxicity, although the magnitude of these latter findings were greater than expected and should be confirmed.

A review on exposure and effects of arsenic in passerine birds

Arsenic (As) is a metalloid of high concern because of its toxic effects for plants and animals. However, it is hard to find information on this metalloid in passerines. This review presents a comprehensive overview of As exposure and effects in birds, and more particularly in passerines, as a result of an extensive search of the literature available. Internal tissues are the most frequently analyzed matrices for As determination in passerines (37.5% of the reviewed studies used internal tissues), followed by feathers and eggs (32.5% each), feces (27.5%), and finally blood (15%). A clear tendency is found in recent years to the use of non-destructive samples. Most studies on As concentrations in passerines have been done in great tit (Parus major; 50%), followed by pied flycatcher (Ficedula hypoleuca; 22.5%). Some factors such as diet and migratory status are crucial on the interspecific differences in As exposure. More studies are needed to elucidate if intraspecific factors like age or gender affect As concentrations in different tissues. The literature review shows that studies on As concentrations in passerines have been done mainly in the United States (30%), followed by Belgium (22.5%), and Finland (20%), making evident the scarce or even lack of information in some countries, so we recommend further research in order to overcome the data gap, particularly in the southern hemisphere. Studies on humans, laboratory animals and birds have found a wide range of effects on different organ systems when they are exposed to different forms of As. This review shows that few field studies on As exposure and effects in passerines have been done, and all of them are correlative so far. Arsenic manipulation experiments on passerines are recommended to explore the adverse effects of As in free-living populations at similar levels to those occurring in the environment.

CAPSULE

This review summarizes the most interesting published studies on As exposure and effects in passerines.

Drinking Water Arsenic Contamination, Skin Lesions, and Malignancies: A Systematic Review of the Global Evidence

Skin lesions and cancer are known manifestations of chronic exposure to arsenic contaminated drinking water. Epidemiologic data primarily comes from regions with exposures 1-2 orders of magnitude above the current World Health Organization (WHO) guidelines of 10 μg/L. Emerging evidence indicates that more common exposures may also be related to both noncancerous and cancerous changes to the skin. In this review, we focus on the body of epidemiologic literature that encompasses exposures within the WHO guidelines, excluding studies that lacked individual exposure estimates and case reports. For skin lesions and skin cancers, 15 and 10 studies were identified that met our criteria, respectively. For skin lesions, a consistent dose-response relationship with water arsenic has been observed, with increased risk evident at low- to moderate-dose exposure. Of the larger studies of specific histologic types of skin cancers, although with differing exposure definitions, there was evidence of dose-related relationships with both basal cell carcinomas and squamous cell carcinomas. The effect of arsenic exposure on skin lesion risk is likely modified by genetic variants that influence arsenic metabolism. Accumulating evidence suggests that arsenic may increase risk of skin lesions and skin cancers at levels not previously considered harmful, and that genetic factors may influence risk.

Elevated lung cancer in younger adults and low concentrations of arsenic in water

Arsenic concentrations greater than 100 µg/L in drinking water are a known cause of cancer, but the risks associated with lower concentrations are less well understood. The unusual geology and good information on past exposure found in northern Chile are key advantages for investigating the potential long-term effects of arsenic. We performed a case-control study of lung cancer from 2007 to 2010 in areas of northern Chile that had a wide range of arsenic concentrations in drinking water. Previously, we reported evidence of elevated cancer risks at arsenic concentrations greater than 100 µg/L. In the present study, we restricted analyses to the 92 cases and 288 population-based controls who were exposed to concentrations less than 100 µg/L. After adjustment for age, sex, and smoking behavior, these exposures from 40 or more years ago resulted in odds ratios for lung cancer of 1.00, 1.43 (90% confidence interval: 0.82, 2.52), and 2.01 (90% confidence interval: 1.14, 3.52) for increasing tertiles of arsenic exposure, respectively (P for trend = 0.02). Mean arsenic water concentrations in these tertiles were 6.5, 23.0, and 58.6 µg/L. For subjects younger than 65 years of age, the corresponding odds ratios were 1.00, 1.62 (90% confidence interval: 0.67, 3.90), and 3.41 (90% confidence interval: 1.51, 7.70). Adjustments for occupation, fruit and vegetable intake, and socioeconomic status had little impact on the results. These findings provide new evidence that arsenic water concentrations less than 100 µg/L are associated with higher risks of lung cancer.

Increased lung and bladder cancer incidence in adults after in utero and early-life arsenic exposure

BACKGROUND

From 1958 to 1970, >100,000 people in northern Chile were exposed to a well-documented, distinct period of high drinking water arsenic concentrations. We previously reported ecological evidence suggesting that early-life exposure in this population resulted in increased mortality in adults from several outcomes, including lung and bladder cancer.

METHODS

We have now completed the first study ever assessing incident cancer cases after early-life arsenic exposure, and the first study on this topic with individual participant exposure and confounding factor data. Subjects included 221 lung and 160 bladder cancer cases diagnosed in northern Chile from 2007 to 2010, and 508 age and gender-matched controls.

RESULTS

ORs adjusted for age, sex, and smoking in those only exposed in early life to arsenic water concentrations of ≤110, 110 to 800, and >800 μg/L were 1.00, 1.88 [95% confidence interval (CI), 0.96-3.71], and 5.24 (3.05-9.00; P(trend) < 0.001) for lung cancer, and 1.00, 2.94 (1.29-6.70), and 8.11 (4.31-15.25; P(trend) < 0.001) for bladder cancer. ORs were lower in those not exposed until adulthood. The highest category (>800 μg/L) involved exposures that started 49 to 52 years before, and ended 37 to 40 years before the cancer cases were diagnosed.

CONCLUSION

Lung and bladder cancer incidence in adults was markedly increased following exposure to arsenic in early life, even up to 40 years after high exposures ceased. Such findings have not been identified before for any environmental exposure, and suggest that humans are extraordinarily susceptible to early-life arsenic exposure.

IMPACT

Policies aimed at reducing early-life exposure may help reduce the long-term risks of arsenic-related disease.

Arsenic exposure decreases rhythmic contractions of vascular tone through sodium transporters and K+ channels

Arsenic-contaminated drinking water is a public health problem in countries such as Taiwan, Bangladesh, United States, Mexico, Argentina, and Chile. The chronic ingestion of arsenic-contaminated drinking water increases the risk for ischemic heart disease, cerebrovascular disease, and prevalence of hypertension. Although toxic arsenic effects are controversial, there is evidence that a high concentration of arsenic may induce hypertension through increase in vascular tone and resistance. Vascular tone is regulated by the rhythmic contractions of the blood vessels, generated by calcium oscillations in the cytosol of vascular smooth muscle cells. To regulate the cytosolic calcium oscillations, the membrane oscillator model involves the participation of Ca²⁺ channels, calcium-activated K⁺ channels, Na⁺/Ca²⁺ exchange, plasma membrane Ca²⁺-ATPase, and the Na⁺/K⁺-ATPase. However, little is known about the role of K⁺ uptake by sodium transporters [Na⁺/K⁺-ATPase or Na⁺-K⁺-2Cl^- (NKCC1)] on the rhythmic contractions. Vascular rhythmic contractions, or vasomotion are a local mechanism to regulate vascular resistance and blood flow. Since vascular rhythmic contractions of blood vessels are involved in modulating the vascular resistance, the blood flow, and the systemic pressure, we suggest a model explaining the participation of the sodium pump and NKCC1 co-transporter in low dose arsenic exposure effects on vasomotion and vascular dysfunction.

Non-healing Scalp Ulcer Accompanying Chronic Arsenicosis: A Case Report

Arsenic, an environmental toxin, significantly contributes to the development of several health problems. Epidemiological studies done across the globe have reported that a prolonged arsenic exposure has been associated with characteristic skin lesions, neuropathy and an increased risk of skin, lung, liver (angiosarcoma), bladder, kidney and colon cancers. In present study, we are reporting a case of a 60-year-old male, who presented with a large (5cm x 4cm) painless ulcer in fronto-parietal area of scalp, with occasional oozing of blood. X-ray of skull (AP and lateral view) revealed granular well-outlined osteolytic lesions in right fronto-parietal skull vault, which raised a suspicion of malignancy. An incisional biopsy was taken and histopathology revealed no evidence of malignancy. A benign, non-healing skin ulcer is rarely seen in a setting of chronic arsenicosis. His skin examination showed characteristic fine freckles of spotted pigmentary changes i.e. classic rain-drop pigmentations which were present all over the body, particularly on trunk, palms and soles. Arsenic levels seen in hair and nail of the patient were 1.23 micrograms/gram and 3.26 micrograms/gram respectively, which were in accordance with WHO suggested diagnostic criteria of chronic arsenicosis.

Arsenic, tobacco smoke, and occupation: associations of multiple agents with lung and bladder cancer

BACKGROUND

Millions of people worldwide are exposed to arsenic in drinking water, and many are likely coexposed to other agents that could substantially increase their risks of arsenic-related cancer.

METHODS

We performed a case-control study of multiple chemical exposures in 538 lung and bladder cancer cases and 640 controls in northern Chile, an area with formerly high drinking water arsenic concentrations. Detailed information was collected on lifetime arsenic exposure, smoking, secondhand smoke, and other known or suspected carcinogens, including asbestos, silica, and wood dust.

RESULTS

Very high lung and bladder cancer odds ratios (ORs), and evidence of greater than additive effects, were seen in people exposed to arsenic concentrations >335 µg/L and who were tobacco smokers (OR = 16, 95% confidence interval = 6.5-40 for lung cancer; and OR = 23 [8.2-66] for bladder cancer; Rothman Synergy Indices = 4.0 [1.7-9.4] and 2.0 [0.92-4.5], respectively). Evidence of greater than additive effects were also seen in people coexposed to arsenic and secondhand tobacco smoke and several other known or suspected carcinogens, including asbestos, silica, and wood dust.

CONCLUSIONS

These findings suggest that people coexposed to arsenic and other known or suspected carcinogens have very high risks of lung or bladder cancer.

Arsenic levels in drinking water and mortality of liver cancer in Taiwan

The carcinogenic effect of arsenic is well documented, but epidemiologic data on liver cancer were limited. To evaluate the dose-response relationship between arsenic in drinking water and mortality of liver cancer, we conducted a study in 138 villages in the southwest coast area of Taiwan. We assessed arsenic levels in drinking water using data from a survey conducted by the government and reviewed death certificates from 1971 to 1990 to identify liver cancer cases. Using village as the unit, we conducted multi-variate regression analyses and then performed post hoc analyses to validate the findings. During the 20-year period, 802 male and 301 female mortality cases of liver cancer were identified. After adjusting for age, arsenic levels above 0.64 mg/L were associated with an increase in the liver cancer mortality in both genders, but no significant effect was observed for lower exposure categories. Post hoc analyses and a review of literature supported these findings. We concluded that exposures to high arsenic levels in drinking water are associated with the occurrence of liver cancer, but such an effect is not prominent at exposure levels lower than 0.64 mg/L.

Chronic respiratory symptoms in children following in utero and early life exposure to arsenic in drinking water in Bangladesh

BACKGROUND

Arsenic exposure via drinking water increases the risk of chronic respiratory disease in adults. However, information on pulmonary health effects in children after early life exposure is limited.

METHODS

This population-based cohort study set in rural Matlab, Bangladesh, assessed lung function and respiratory symptoms of 650 children aged 7-17 years. Children with in utero and early life arsenic exposure were compared with children exposed to less than 10 µg/l in utero and throughout childhood. Because most children drank the same water as their mother had drunk during pregnancy, we could not assess only in utero or only childhood exposure.

RESULTS

Children exposed in utero to more than 500 µg/l of arsenic were more than eight times more likely to report wheezing when not having a cold [odds ratio (OR) = 8.41, 95% confidence interval (CI): 1.66-42.6, P < 0.01] and more than three times more likely to report shortness of breath when walking on level ground (OR = 3.86, 95% CI: 1.09-13.7, P = 0.02) and when walking fast or climbing (OR = 3.19, 95% CI: 1.22-8.32, P < 0.01]. However, there was little evidence of reduced lung function in either exposure category.

CONCLUSIONS

Children with high in utero and early life arsenic exposure had marked increases in several chronic respiratory symptoms, which could be due to in utero exposure or to early life exposure, or to both. Our findings suggest that arsenic in water has early pulmonary effects and that respiratory symptoms are a better marker of early life arsenic toxicity than changes in lung function measured by spirometry.

Drinking water arsenic in northern chile: high cancer risks 40 years after exposure cessation

BACKGROUND

Millions of people worldwide are exposed to arsenic-contaminated water. In the largest city in northern Chile (Antofagasta), more than 250,000 people were exposed to high arsenic drinking water concentrations from 1958 until 1970 when a water treatment plant was installed. Because of its unique geology, limited water sources, and good historical records, lifetime exposure and long-term latency patterns can be assessed in this area with better accuracy than in other arsenic-exposed areas worldwide.

METHODS

We conducted a population-based case-control study in northern Chile from October 2007 to December 2010 involving 232 bladder and 306 lung cancer cases and 640 age- and gender-matched controls, with detailed information on past exposure and potential confounders, including smoking and occupation.

RESULTS

Bladder cancer ORs for quartiles of average arsenic concentrations in water before 1971 (<11, 11-90, 91-335, and >335 μg/L) were 1.00, 1.36 [95% confidence interval (CI), 0.78-2.37], 3.87 (2.25-6.64), and 6.50 (3.69-11.43), respectively. Corresponding lung cancer ORs were 1.00, 1.27 (0.81-1.98), 2.00 (1.24-3.24), and 4.32 (2.60-7.17). Bladder and lung cancer ORs in those highly exposed in Antofagasta during 1958 to 1970 but not thereafter were 6.88 (3.84-12.32) and 4.35 (2.57-7.36), respectively.

CONCLUSIONS

The lung and bladder cancer risks that we found up to 40 years after high exposures have ended are very high.

IMPACT

Our findings suggest that prevention, treatment, and other mortality reduction efforts in arsenic-exposed countries will be needed for decades after exposure cessation.

Bladder cancer and arsenic through drinking water: a systematic review of epidemiologic evidence

Exposure to inorganic arsenic (As) through drinking water is a major international public health issue. We carried out a systematic review of the existing literature examining the association between the risk of bladder cancer in humans and exposure to arsenic through drinking water. We searched electronic databases for studies published from January 2000 up to April 2013. Eight ecological studies, six case-control studies, four cohort studies and two meta-analyses were identified. The vast majority of the studies were carried out in areas with high arsenic concentrations in drinking water such as southwestern and northeastern Taiwan, Pakistan, Bangladesh, Argentina (Cordoba Province), USA (southeastern Michigan, Florida, Idaho) and Chile. Most of the studies reported higher risks of bladder cancer incidence or mortality in areas with high arsenic concentrations in drinking water compared to the general population or a low arsenic exposed control group. The quality assessment showed that among the studies identified, arsenic exposure was assessed at the individual level only in half of them and only three assessed exposure using a biomarker. Further, five out of eight ecological studies presented results with adjustment for potential confounders except for age; all cohort and case-control studies presented results with adjustment for cigarette smoking status in the analysis. The majority of the studies with varying study designs carried out in different areas provided evidence of statistically siginificant increases in bladder cancer risk at high concentrations of arsenic (>50 μg L(-1)). Assessing bladder cancer risk at lower exposure concentrations requires further investigation.

Nutritional deficiency and arsenical manifestations: a perspective study in an arsenic-endemic region of West Bengal, India

Objective

To assess whether nutritional deficiency increases susceptibility to arsenic-related health effects.

Design

Assessment of nutrition was based on a 24 h recall method of all dietary constituents.

Setting

Epidemiological cross-sectional study was conducted in an arsenic-endemic area of West Bengal with groundwater arsenic contamination.

Subjects

The study was composed of two groups – Group 1 (cases,n108) exhibiting skin lesions and Group 2 (exposed controls,n100) not exhibiting skin lesions – age- and sex-matched and having similar arsenic exposure through drinking water and arsenic levels in urine and hair.

Results

Both groups belonged to low socio-economic strata (Group 1 significantly poorer,P< 0·01) and had low BMI (prevalence of BMI < 18·5 kg/m2: in 38 % in Group 1 and 27 % in Group 2). Energy intake was below the Recommended Daily Allowance (set by the Indian Council of Medical Research) in males and females in both groups. Increased risk of arsenical skin lesions was found for those in the lowest quintile of protein intake (v. highest quintile: OR = 4·60, 95 % CI 1·36, 15·50 in males; OR = 5·62, 95 % CI 1·19, 34·57 in females). Significantly lower intakes of energy, protein, thiamin, niacin, Mg, Zn and choline were observed in both males and females of Group 1 compared with Group 2. Significantly lower intakes of carbohydrate, riboflavin, niacin and Cu were also observed in female cases with skin lesions compared with non-cases.

Conclusions

Deficiencies of Zn, Mg and Cu, in addition to protein, B vitamins and choline, are found to be associated with arsenical skin lesions in West Bengal.

Chronic arsenic toxicity: studies in West Bengal, India

Chronic arsenic toxicity (arsenicosis) as a result of drinking arsenic-contaminated groundwater is a major environmental health hazard throughout the world, including India. A lot of research on health effects, including genotoxic effect of chronic arsenic toxicity in humans, have been carried out in West Bengal during the last 2 decades. A review of literature including information available from West Bengal has been made to characterize the problem. Scientific journals, monographs, and proceedings of conferences with regard to human health effects, including genotoxicity, of chronic arsenic toxicity have been reviewed. Pigmentation and keratosis are the specific skin diseases characteristic of chronic arsenic toxicity. However, in West Bengal, it was found to produce various systemic manifestations, such as chronic lung disease, characterized by chronic bronchitis, chronic obstructive and/or restrictive pulmonary disease, and bronchiectasis; liver diseases, such as non cirrhotic portal fibrosis; polyneuropathy; peripheral vascular disease; hypertension; nonpitting edema of feet/hands; conjunctival congestion; weakness; and anemia. High concentrations of arsenic, greater than or equal to 200 μg/L, during pregnancy were found to be associated with a sixfold increased risk for stillbirth. Cancers of skin, lung, and urinary bladder are the important cancers associated with this toxicity. Of the various genotoxic effects of arsenic in humans, chromosomal aberration and increased frequency of micronuclei in different cell types have been found to be significant. Various probable mechanisms have been incriminated to cause DNA damage because of chronic arsenic toxicity. The results of the study in West Bengal suggest that deficiency in DNA repair capacity, perturbation of methylation of promoter region of p53 and p16 genes, and genomic methylation alteration may be involved in arsenic-induced disease manifestation in humans. P53 polymorphism has been found to be associated with increased occurrence of arsenic-induced keratosis. Of the various genes involved in the regulation of arsenic metabolism, single-nucleotide polymorphisms of purine nucleoside phosphorylase, in one study, showed increased occurrence of arsenicosis.

Simon Bolivar's medical labyrinth: an infectious diseases conundrum

According to history books, tuberculosis was responsible for the death of Simon Bolivar at the age of 47 years in 1830. The results of an autopsy performed by Alexandre Prospère Révérend, the French physician who cared for him during the terminal phase of his illness, have long been regarded as proof of the diagnosis. On careful reanalysis of Bolivar's medical history and post mortem examination, we reach a different conclusion. On the basis of several critical clinical, epidemiological, and pathological features of his fatal disorder, we conclude that either paracoccidioidomycosis or bacterial bronchiectasis complicating chronic arsenic intoxication was more likely responsible for his death than was tuberculous "consumption."

Evaluation of toxic elements in scalp hair samples of myocardial infarction patients at different stages as related to controls

In the present study, the association of arsenic, cadmium, lead, and nickel between scalp hair samples and mortality from myocardial infarction (MI) patients at first, second, and third heart attack was studied. The biological samples of 130 MI patients (77 male and 53 female) age ranged (45-60 years), were collected and 61 healthy persons of same age group (33 male and 28 female) was selected as control subjects. The toxic elements (TEs) in biological samples were assessed by the electrothermal atomic absorption spectrophotometry prior to microwave-assisted acid digestion. The validity of methodology was checked by the certified human hair reference material (BCR 397). It was observed during the study that 78% of 32 patients of the third MI, age >50 years were expired. In these subjects, the level of As, Cd, Ni, and Pb were increased by 10.6%, 19.5%, 15.7%, and 9.8% in the scalp hair as compared to those who tolerated third MI attack (p = 0.12). The high level of toxic metals may play a role in the development of heart disease in the subjects of this study.

Murshidabad—One of the Nine Groundwater Arsenic-Affected Districts of West Bengal, India. Part II: Dermatological, Neurological, and Obstetric Findings

INTRODUCTION

To understand the severity of related health effects of chronic arsenic exposure in West Bengal, a detailed 3-year study was carried out in Murshidabad, one of the nine arsenic-affected districts in West Bengal.

METHODS

We screened 25,274 people from 139 arsenic-affected villages in Murshidabad to identify patients suffering from chronic arsenic toxicity for evidence of multisystemic features and collected biological samples such as head hair, nail, and spot urine from the patients along with the tubewell water they were consuming.

RESULTS

Out of 25,274 people screened, 4813 (19%) were registered with arsenical skin lesions. A case series involving arsenical skin lesions resulting in cancer and gangrene were noted during this study. Representative histopathological pictures of skin biopsy of different types of lesions were also presented. Out of 2595 children we examined for arsenical skin lesions, 122 (4%) were registered with arsenical skin lesions, melanosis with or without keratosis. Different clinical and electrophysiological neurological features were noticed among the arsenic-affected villagers. Both the arsenic content in the drinking water and duration of exposure may be responsible in increasing the susceptibility of pregnant women to spontaneous abortions, stillbirths, preterm births, low birth weights, and neonatal deaths. Some additional multisystemic features such as weakness and lethargy, chronic respiratory problems, gastrointestinal symptoms, and anemia were also recorded in the affected population.

DISCUSSION

The findings from this survey on different health effects of arsenic exposure were compared to those from previous studies carried out on arsenic-affected populations in India and Bangladesh as well as other affected countries.

CONCLUSION

Multisystemic disorders, including dermal effects, neurological complications, and adverse obstetric outcomes, were observed to be associated with chronic arsenic exposure in the study population in Murshidabad, West Bengal. The magnitude of severity was related to the concentration of arsenic in water as well as duration of the exposure.

Evaluation of biochemical changes in chronic arsenic poisoning among Bangladeshi patients

An estimated 40 million people in Bangladesh have been suffering from arsenic toxicity-related diseases because of drinking water contamination with high levels of naturally occurring arsenic. To evaluate the biochemical changes in chronic arsenic exposure, a total of 115 exposed subjects diagnosed as arsenicosis patients were examined and interviewed, and 120 unexposed volunteers were enrolled in this study. Drinking water, urine and peripheral blood samples were collected from all participants and analyzed. The average levels of arsenic in the drinking water and spot urine samples of the arsenicosis patients were 218.1 microg/L and 234.6 microg/L, respectively, and duration of exposure was 7.6 +/- 5.2 yrs that ranged from 1-25 yrs. Prevalence of diabetes mellitus among chronic arsenic-exposed subjects was about 2.8 times higher than the unexposed subjects. The activities of alkaline phosphatase were significantly elevated in the patients, 197 U/L compared to 149 U/L in the controls, but alanine transaminase and aspartate transaminase were mostly normal. The patients had significantly lower levels of serum creatinine, 0.97 mg/dL compared to 1.15 mg/dL in the controls; but had significantly elevated levels of total protein, 84 g/L and 77 g/L respectively. The mean level of inorganic phosphate in the serum of arsenicosis patients was 6.4 mg/dL compared to 4.6 mg/dL in the unexposed subjects and the level was significantly higher, indicating substitution of the pentavalent arsenate for the phosphate ion causing underutilization of the latter. Evaluation of the lipid profiles showed while the levels of triacylglycerol were not much different, the patients had significantly lower levels of cholesterol, HDL-cholesterol and LDL-cholesterol compared to the unexposed subjects. These findings suggest significant changes in biochemical parameters in human arsenic toxicity.

Adsorption of arsenate on untreated dolomite powder

Raw dolomite powder was evaluated for its efficiency in adsorbing As(V) from water. An experimental setup comprised of a fluidized dolomite powder bed was used to assess the impact of various test variables on the efficiency of removal of As(V). Test influents including distilled water (DW), synthetic groundwater (SGW) and filtered sewage effluent (FSE) were employed to assess the effect of influent parameters on the adsorption process and the quality of the effluent generated. Dolomite exhibited good As(V) removal levels for distilled water (>92%) and synthetic ground water (>84%) influents at all initial As(V) concentrations tested (0.055-0.600 ppm). Breakthrough of dolomite bed occurred after 45 bed volumes for DW and 20 bed volumes for SGW influents with complete breakthrough taking place at more than 300 bed volumes. As(V) removal from FSE influents was relatively unsuccessful as compared to the DW and SGW influents. Partial removal in the order of 32% from filtered sewage effluent at initial concentration of 0.6 mg/L started at 75 bed volumes and gradually stopped at 165 bed volumes. Varying degrees of As(V) adsorption capacities were observed by the different test influents employed, which indicate that the adsorption of As(V) is adversely affected by competing species, mainly sulfates and phosphates present in the influent. The adsorptive behavior of dolomite was described by fitting data generated from the study into the Langmuir and Freundlich isotherm models. Both models described well the adsorption of dolomite. The average isotherm adsorptive capacity was determined at 5.02 mug/g. Regeneration of the dolomite bed can be achieved with the use of caustic soda solution at a pH of 10.5.

Polymorphisms in nucleotide excision repair genes, arsenic exposure, and non-melanoma skin cancer in New Hampshire

BACKGROUND

Arsenic exposure may alter the efficiency of DNA repair. UV damage is specifically repaired by nucleotide excision repair (NER), and common genetic variants in NER may increase risk for non-melanoma skin cancer (NMSC).

OBJECTIVE

We tested whether polymorphisms in the NER genes XPA (A23G) and XPD (Asp312Asn and Lys751Gln) modify the association between arsenic and NMSC.

METHODS

Incident cases of basal and squamous cell carcinoma (BCC and SCC, respectively) were identified through a network of dermatologists and pathology laboratories across New Hampshire. Population-based controls were frequency matched to cases on age and sex. Arsenic exposure was assessed in toenail clippings. The analysis included 880 cases of BCC, 666 cases of SCC, and 780 controls.

RESULTS

There was an increased BCC risk associated with high arsenic exposure among those homozygous variant for XPA [odds ratio (OR) = 1.8; 95% confidence interval (CI), 0.9-3.7]. For XPD, having variation at both loci (312Asn and 751Gln) occurred less frequently among BCC and SCC cases compared with controls (OR = 0.8; 95% CI, 0.6-1.0) for both case groups. In the stratum of subjects who have variant for both XPD polymorphisms, there was a 2-fold increased risk of SCC associated with elevated arsenic (OR = 2.2; 95% CI, 1.0-5.0). The test for interaction between XPD and arsenic in SCC was of borderline significance (p < 0.07, 3 degrees of freedom).

CONCLUSIONS

Our findings indicate a reduced NMSC risk in relation to XPD Asp312Asn and Lys751Gln variants. Further, these data support the hypothesis that NER polymorphisms may modify the association between NMSC and arsenic.

Increased mortality from lung cancer and bronchiectasis in young adults after exposure to arsenic in utero and in early childhood

Arsenic in drinking water is an established cause of lung cancer, and preliminary evidence suggests that ingested arsenic may also cause nonmalignant lung disease. Antofagasta is the second largest city in Chile and had a distinct period of very high arsenic exposure that began in 1958 and lasted until 1971, when an arsenic removal plant was installed. This unique exposure scenario provides a rare opportunity to investigate the long-term mortality impact of early-life arsenic exposure. In this study, we compared mortality rates in Antofagasta in the period 1989-2000 with those of the rest of Chile, focusing on subjects who were born during or just before the peak exposure period and who were 30-49 years of age at the time of death. For the birth cohort born just before the high-exposure period (1950-1957) and exposed in early childhood, the standardized mortality ratio (SMR) for lung cancer was 7.0 [95% confidence interval (CI), 5.4-8.9; p<0.001] and the SMR for bronchiectasis was 12.4 (95% CI, 3.3-31.7; p<0.001). For those born during the high-exposure period (1958-1970) with probable exposure in utero and early childhood, the corresponding SMRs were 6.1 (95% CI, 3.5-9.9; p<0.001) for lung cancer and 46.2 (95% CI, 21.1-87.7; p<0.001) for bronchiectasis. These findings suggest that exposure to arsenic in drinking water during early childhood or in utero has pronounced pulmonary effects, greatly increasing subsequent mortality in young adults from both malignant and nonmalignant lung disease.

Arsenic carcinogenesis in the skin

Chronic arsenic poisoning is a world public health issue. Long-term exposure to inorganic arsenic (As) from drinking water has been documented to induce cancers in lung, urinary bladder, kidney, liver and skin in a dose-response relationship. Oxidative stress, chromosomal abnormality and altered growth factors are possible modes of action in arsenic carcinogenesis. Arsenic tends to accumulate in the skin. Skin hyperpigmentation and hyperkeratosis have long been known to be the hallmark signs of chronic As exposure. There are significant associations between these dermatological lesions and risk of skin cancer. The most common arsenic-induced skin cancers are Bowen's disease (carcinoma in situ), basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Arsenic-induced Bowen's disease (As-BD) is able to transform into invasive BCC and SCC. Individuals with As-BD are considered for more aggressive cancer screening in the lung and urinary bladder. As-BD provides an excellent model for studying the early stages of chemical carcinogenesis in human beings. Arsenic exposure is associated with G2/M cell cycle arrest and DNA aneuploidy in both cultured keratinocytes and As-BD lesions. These cellular abnormalities relate to the p53 dysfunction induced by arsenic. The characteristic clinical figures of arsenic-induced skin cancer are: (i) occurrence on sun-protected areas of the body; (ii) multiple and recrudescent lesions. Both As and UVB are able to induce skin cancer. Arsenic treatment enhances the cytotoxicity, mutagenicity and clastogenicity of UV in mammalian cells. Both As and UVB induce apoptosis in keratinocytes by caspase-9 and caspase-8 signaling, respectively. Combined UVB and As treatments resulted in the antiproliferative and proapoptotic effects by stimulating both caspase pathways in the keratinocytes. UVB irradiation inhibited mutant p53 and ki-67 expression, as well as increased in the number of apoptotic cells in As-BD lesions which resulted in an inhibitory effect on proliferation. As-UVB interaction provides a reasonable explanation for the rare occurrences of arsenical cancer in the sun-exposed skin. The multiple and recurrent skin lesions are associated with cellular immune dysfunction in chronic arsenism. A decrease in peripheral CD4+ cells was noticed in the inhabitants of arsenic exposure areas. There was a decrease in the number of Langerhans cells in As-BD lesion which results in an impaired immune function on the lesional sites. Since CD4+ cells are the target cell affected by As, the interaction between CD4+ cells and epidermal keratinocytes under As affection might be closely linked to the pathogenesis of multiple occurrence of arsenic-induced skin cancer. In this review, we provide and discuss the pathomechanisms of arsenic skin cancer and the relationship to its characteristic figures. Such information is critical for understanding the molecular mechanism for arsenic carcinogenesis in other internal organs.

Assessing the measurement precision of various arsenic forms and arsenic exposure in the National Human Exposure Assessment Survey (NHEXAS)

Archived samples collected from 1995 to 1997 in the National Human Exposure Assessment Survey (NHEXAS) in U.S. Environmental Protection Agency Region 5 (R5) and the Children's Study (CS) in Minnesota were analyzed for total arsenic, arsenate [As(V)], arsenite, dimethyl arsenic acid (DMA), monomethyl arsenic acid (MMA), arsenobetaine (AsB), and arsenocholine. Samples for the CS included drinking water, urine, hair, and dust; both studies included food (duplicate plate, composited 4-day food samples from participants). Except for AsB and As(V), the levels for As species measured in the food and drinking water samples were very low or nonexistent. The analytical methods used for measuring As species were sensitive to < 1 ppb. During the analysis of food and drinking water samples, chromatographic peaks appeared that contained As, but they did not correspond to those being quantified. Thus, in some samples, the sum of the individual As species levels was less than the total As level measured because the unknown forms of As were not quantified. On the other hand, total As was detectable in almost all samples (> 90%) except for hair (47%), indicating that the analytical method was sufficiently sensitive. Population distributions of As concentrations measured in drinking water, food (duplicate plate), dust, urine, and hair were estimated. Exposures to total As in food for children in the CS were about twice as high as in the general R5 population (medians of 17.5 ppb and 7.72 ppb, respectively). In addition, AsB was the most frequently detected form of As in food eaten by the participants, while As(V) was only rarely detected. Thus, the predominant dietary exposure was from an organic form of As. The major form of As in drinking water was As(V). Spearman (rank) correlations and Pearson (log-concentration scale) correlations between the biomarkers (urine, hair) and the other measures (food, drinking water, dust) and urine versus hair were performed. In the NHEXAS CS, total As and AsB in the food eaten were significantly correlated with their levels in urine. Also, levels of As(V) in drinking water correlated with DMA and MMA in urine. Arsenic levels in dust did not show a relationship with urine or hair levels, and no relationship was observed for food, drinking water, and dust with hair. Urine samples were collected on days 3, 5, and 7 of participants' monitoring periods. Total As levels in urine were significantly associated across the three pairwise combinations--i.e., day 3 versus day 5, day 3 versus day 7, and day 5 versus day 7. Because the half-life of As in the body is approximately 3 days, this suggests that some exposure occurred continually from day to day. This trend was also observed for AsB, suggesting that food is primarily responsible for the continual exposure. DMA and MMA in urine were also significantly correlated but not in all combinations.

Arsenic exposure and cardiovascular disease: a systematic review of the epidemiologic evidence

Arsenic exposure is a likely cause of blackfoot disease and a potential risk factor for atherosclerosis. The authors performed a systematic review of the epidemiologic evidence on the association between arsenic and cardiovascular outcomes. The search period was January 1966 through April 2005. Thirteen studies conducted in general populations (eight in high-arsenic areas in Taiwan, five in other countries) and 16 studies conducted in occupational populations were identified. Exposure was assessed ecologically in most studies. In Taiwan, relative risks comparing the highest arsenic exposure category with the lowest ranged from 1.59 to 4.90 for coronary disease, from 1.19 to 2.69 for stroke, and from 1.66 to 4.28 for peripheral arterial disease. In other general populations, relative risks ranged from 0.84 to 1.54 for coronary disease, from 0.69 to 1.53 for stroke, and from 0.61 to 1.58 for peripheral arterial disease. In occupational populations, relative risks ranged from 0.40 to 2.14 for coronary disease mortality and from 0.30 to 1.33 for stroke mortality. Methodologic limitations, however, limited interpretation of the moderate-to-strong associations between high arsenic exposure and cardiovascular outcomes in Taiwan. In other populations or in occupational settings, the evidence was inconclusive. Because of the high prevalence of arsenic exposure, carefully performed studies of arsenic and cardiovascular outcomes should be a research priority.

Health effect levels for risk assessment of childhood exposure to arsenic

Health risks to children from chemicals in soil and consumer products have become a regulatory focus in the U.S. This study reviews short-term health effect levels for arsenic exposure in young children (i.e., 0-6 years old). Acute health effects are described mostly in adults in case reports of arsenic poisoning from water or food and in studies of medicinal arsenic treatment. Several epidemiological studies report health effects from subchronic arsenic exposure in children primarily from drinking water in developing countries. Acute health effects typically include gastrointestinal, neurological, and skin effects, and in a few cases facial edema and cardiac arrhythmia. Dermatoses are most consistently reported in both adults and children with subchronic exposure. With low exposure, the prevalence and severity of disease generally increases with age (i.e., length of exposure) and arsenic dose. The available data collectively indicate a lowest-observed-adverse-effect level around 0.05mg/kg-day for both acute and subchronic exposure. At low doses, children do not appear to be more sensitive than adults on a dose-per-body-weight basis, although data for acute exposures are limited and uncertainties exist for quantifying potential neurological or vascular effects at low-level subchronic exposures. Based on these data, possible reference levels for acute and subchronic exposure in young children are 0.015 and 0.005mg/kg-day, respectively.

Arsenic in drinking water and skin lesions: dose-response data from West Bengal, India

BACKGROUND

Over 6 million people live in areas of West Bengal, India, where groundwater sources are contaminated with naturally occurring arsenic. The key objective of this nested case-control study was to characterize the dose-response relation between low arsenic concentrations in drinking water and arsenic-induced skin keratoses and hyperpigmentation.

METHODS

We selected cases (persons with arsenic-induced skin lesions) and age- and sex-matched controls from participants in a 1995-1996 cross-sectional survey in West Bengal. We used a detailed assessment of arsenic exposure that covered at least 20 years. Participants were reexamined between 1998 and 2000. Consensus agreement by four physicians reviewing the skin lesion photographs confirmed the diagnosis in 87% of cases clinically diagnosed in the field.

RESULTS

The average peak arsenic concentration in drinking water was 325 microg/liter for cases and 180 microg/liter for controls. The average latency for skin lesions was 23 years from first exposure. We found strong dose-response gradients with both peak and average arsenic water concentrations.

CONCLUSIONS

The lowest peak arsenic ingested by a confirmed case was 115 microg/liter. Confirmation of case diagnosis and intensive longitudinal exposure assessment provide the basis for a detailed dose-response evaluation of arsenic-caused skin lesions.

Peripheral vascular diseases resulting from chronic arsenical poisoning

Drinking water contaminated by arsenic remains a major public health problem. Long-term arsenic exposure has been found to be associated with peripheral vascular diseases in a variety of studies. Reports of vascular effects of arsenic in drinking water, which span almost 100 years, have been published in Taiwan, Chile, Mexico, and China. This paper reviewed the association of peripheral vascular diseases resulting from arsenic exposure to drinking water from the clinical and pathological points of view. An endemic peripheral vascular disorder called "blackfoot disease" has been noticed in a limited area in Taiwan. This disease results in gangrene in the extremities. It has been associated with the ingestion of high concentrations of arsenic-tainted artesian well water. Epidemiological studies confirmed a dose-response relationship between long-term arsenic exposure and the occurrence of blackfoot disease. Whereas arsenic has induced various clinical manifestations of vascular effects in Chile, Mexico and China, they do not compare in magnitude or severity to the blackfoot disease found in Taiwan. The pathogenesis of vascular effects induced by arsenic is still controversial. The possible mechanisms include endothelial cell destruction, arsenic-associated atherogenesis, carotene and zinc deficiency, and/or some immunological mechanism. Microcirculatory assessments revealed that deficits of capillary blood flow and permeability exist in clinically normal skin of patients with chronic arsenical poisoning. The vascular effects of chronic arsenic poisoning may involve cardiovascular and cerebrovascular systems as well. In view of the increasing public health problems caused by arsenic exposure, vascular effects should be included in the future study of health effects of arsenic.

Assessment of cancer risk and environmental levels of arsenic in New Hampshire

The Agency for Toxic Substances and Disease Registry (ATSDR) and the United States (US) Environmental Protection Agency (EPA) Office of Solid Waste and Emergency Response (OSWER) list arsenic as a major concern for Superfund sites and the environment at large. Arsenic is clearly linked to skin, bladder, and lung cancer occurrence in populations highly exposed to arsenic occupationally, medicinally, or through contaminated drinking water (Agency for Toxic Substances and Disease Registry, 1999; IARC, 1987). While these studies have identified important adverse health effects, they cannot provide risk information at lower levels of exposure such as those commonly found in the US. Additionally, precise measurement of exposure is critical to assessing risk in populations consuming relatively trace amounts of arsenic. In New Hampshire, domestic wells serve roughly 40% of the population, and about 10% of these contain arsenic concentrations in the controversial range of 10 to 50 micrograms/l. New Hampshire, along with other states in New England, has among the highest bladder cancer mortality rates in the country. Therefore, we are conducting a population-based epidemiologic study in New Hampshire (1) to assess the risk of skin and bladder cancer associated with arsenic exposure in a US population, (2) to evaluate methods of quantifying individual exposure to arsenic at low to moderate levels, and (3) to explore alternative models of determining the dose-response relationship at the lower end of exposure. Our findings to date indicate that toenail arsenic concentrations are a reliable, long-term biomarker of total arsenic exposure and reflect arsenic intake by drinking water containing 1 microgram/l or more. We found that urinary arsenic cannot be detected consistently in a population for which drinking water arsenic is primarily below 50 micrograms/l. Lastly, our data suggest that use of a biologic marker along with alternative statistical approaches may aid detection of the levels at which arsenic may affect cancer occurrence in the US.

Appropriate use of animal models in the assessment of risk during prenatal development: an illustration using inorganic arsenic

BACKGROUND

Assessing risks to human development from chemical exposure typically requires integrating findings from laboratory animal and human studies.

METHODS

Using a case study approach, we present a program designed to assess the risk of the occurrence of malformations from inorganic arsenic exposure. We discuss how epidemiological data should be evaluated for quality and criteria for determining whether an association is causal. In this case study, adequate epidemiological data were not available for evaluating the potential effect of arsenic on development. Consequently, results from appropriately designed, conducted, and interpreted developmental toxicity studies, which have been shown to be predictive of human risk under numerous scenarios, were used. In our case study, the existing animal data were not designed appropriately to assess risk from environmental exposures, although such studies may be useful for hazard identification. Because the human and animal databases were deficient, a research program comprising modern guideline toxicological studies was designed and conducted.

RESULTS

The results of those studies in rats, mice, and rabbits indicate that oral and inhalational exposures to inorganic arsenic do not cause structural malformations, and inhalational exposures produced no developmental effects at all. The new study results are discussed in conjunction with considerations of metabolism, toxicokinetics, and maternal toxicity.

CONCLUSIONS

Based on the available experimental data, and absent contrary findings from adequately conducted epidemiological studies, we conclude that exposure to inorganic arsenic by environmentally relevant routes poses no risk of the occurrence of malformations and little risk of other prenatal developmental toxicity in developing humans without concomitant and near-lethal toxicological effects in mothers.

Confounding variables in the environmental toxicology of arsenic

Arsenic is one of the most important global environmental toxicants. For example, in regions of West Bengal and Inner Mongolia, more than 100000 persons are chronically exposed to well water often strongly contaminated with As. Unfortunately, a toxicologically safe risk assessment and standard setting, especially for long-term and low-dose exposures to arsenic, is not possible. One reason is that the key mechanism of arsenic's tumorigenicity still is not elucidated. Experimental data indicate that either DNA repair inhibition or DNA methylation status alteration may be causal explanations. Moreover, when comparing epidemiological data, it cannot be ruled out that the susceptibility to arsenic's carcinogenicity may be different between Mexican and Taiwanese people. Some other studies indicate that some Andean populations do not develop skin cancer after long-term exposure to As. It is not known yet how this resistance could be mediated. Finally, the situation is even more complicated when taking into consideration that there are several compounds suspected to modulate the chronic environmental toxicity of arsenic, variables that may either enhance or suppress the in vivo genotoxicity and carcinogenicity of the metalloid. Among them are nutritional factors like selenium and zinc as well as drinking water co-contaminants like antimony. Further, yet unidentified factors influencing the body burden and/or the excretion of arsenic are possibly prevailing: preliminary data from own human biomonitoring studies showed a peaking of As in urine samples of non-exposed people which was not caused by elevated exposure to As through seafood consumption. The relevance of these putative confounding variables cannot be finally evaluated yet. Further experimental as well as epidemiological studies are needed to answer these questions. This would help to conduct a toxicologically improved risk assessment, especially for low-dose and long-term exposures to arsenic.

Relations between exposure to arsenic, skin lesions, and glucosuria

OBJECTIVES

Exposure to arsenic causes keratosis, hyperpigmentation, and hypopigmentation and seemingly also diabetes mellitus, at least in subjects with skin lesions. Here we evaluate the relations of arsenical skin lesions and glucosuria as a proxy for diabetes mellitus.

METHODS

Through existing measurements of arsenic in drinking water in Bangladesh, wells with and without arsenic contamination were identified. Based on a questionnaire, 1595 subjects > or = 30 years of age were interviewed; 1481 had a history of drinking water contaminated with arsenic whereas 114 had not. Time weighted mean arsenic concentrations and mg-years/l of exposure to arsenic were estimated based on the history of consumption of well water and current arsenic concentrations. Urine samples from the study subjects were tested by means of a glucometric strip. People with positive tests were considered to be cases of glucosuria.

RESULTS

A total of 430 (29%) of the exposed people were found to have skin lesions. Corresponding to drinking water with < 0.5, 0.5-1.0, and > 1.0 mg/l of arsenic, and with the 114 unexposed subjects as the reference, the prevalence ratios for glucosuria, as adjusted for age and sex, were 0.8, 1.4, and 1.4 for those without skin lesions, and 1.1, 2.2, and 2.6 for those with skin lesions. Taking exposure as < 1.0, 1.0-5.0, > 5.0-10.0 and > 10.0 mg-years/l of exposure to arsenic the prevalence ratios, similarly adjusted, were 0.4, 0.9, 1.2, and 1.7 for those without and 0.8, 1.7, 2.1, and 2.9 for those with skin lesions. All series of risk estimates were significant for trend, (p < 0.01).

CONCLUSIONS

The results suggest that skin lesions and diabetes mellitus, as here indicated by glucosuria, are largely independent effects of exposure to arsenic although glucosuria had some tendency to be associated with skin lesions. Importantly, however, glucosuria (diabetes mellitus) may occur independently of skin lesions.

Using ecological data to estimate a regression model for individual data: the association between arsenic in drinking water and incidence of skin cancer

In ecologic studies, participants are studied by groups, and the exposure status of each group is usually represented by a single indicator, mostly the mean exposure. In this paper, we propose using multiple variables derived from dummy variables at the individual level to describe the exposure. An analysis of the association between arsenic in drinking water and skin cancer was used as an example. Well water arsenic levels and skin cancer incidence from 1980 to 1987 were assessed for 243 townships in Taiwan. We first analyzed the data using the mean arsenic concentration in each township as the only exposure variable. The second analysis used multiple variables to describe arsenic exposure; each variable denoted the percentage of wells with arsenic levels within a specific range in each township. Although the first approach did not identify associations between arsenic levels and skin cancer, the multiple-variable approach identifies a positive association at the highest arsenic exposure category (>0.64 mg/L) in both men and women. Therefore, using multiple variables to describe an exposure in ecologic studies may facilitate a better description of the exposure status and thereby lead to more accurate risk assessment, especially when the dose-response relationship is not linear.

An assessment of the developmental toxicity of inorganic arsenic

A critical analysis of the literature base regarding the reproductive and developmental toxicity of arsenic compounds, with emphasis on inorganic arsenicals, was conducted. The analysis was stimulated by the great number of papers that have purported to have shown an association between exposure of pregnant laboratory animals to arsenic compounds and the occurrence of offspring with cranial neural tube defects, particularly exencephaly. For the most part, the literature reports of arsenic developmental toxicity in experimental animals are inadequate for human risk assessment purposes. Despite the shortcomings of the experimental database, several conclusions are readily apparent when the animal studies are viewed collectively. First, cranial neural tube defects are induced in rodents only when arsenic exposure has occurred early in gestation (on Days 7 [hamster, mouse], 8 [mouse], or 9 [rat]). Second, arsenic exposures that cause cranial neural tube defects are single doses that are so high as to be lethal (or nearly so) to the pregnant animal. Third, the effective routes of exposure are by injection directly into the venous system or the peritoneal cavity; even massive oral exposures do not cause increases in the incidence of total gross malformations. Fourth, repetition of similar study designs employing exaggerated parenteral doses is the source of the large number of papers reporting neural tube defects associated with prenatal arsenic exposure. Fifth, in five repeated dose studies carried out following EPA Guidelines for assessing developmental toxicity, arsenic was not teratogenic in rats (AsIII, 101 micromol/kg/d, oral gavage; 101 micromol/m3, inhalation), mice (AsV, 338 micromol/kg/d, oral gavage; est. 402 micromol/kg/d, diet), or rabbits (AsV, 21 micromol/kg/d, oral gavage). Data regarding arsenic exposure and adverse outcomes of pregnancy in humans are limited to several ecologic epidemiology studies of drinking water, airborne dusts, and smelter environs. These studies failed to (1) obtain accurate measurements of maternal exposure during the critical period of organogenesis and (2) control for recognized confounders. The lone study that examined maternal arsenic exposure during pregnancy and the presence of neural tube defects in progeny failed to confirm a relationship between the two. It is concluded that under environmentally relevant exposure scenarios (e.g., 100 ppm in soil), inorganic arsenic is unlikely to pose a risk to pregnant women and their offspring.

Sister chromatid exchanges in Vicia faba induced by arsenic-contaminated drinking water from Zimapan, Hidalgo, Mexico

Sister chromatid exchanges (SCE) in Vicia faba root tips were used to examine well water containing high levels of arsenic. The increased amount of arsenic was contained in well water from different towns of Zimapan, Hidalgo, Mexico. Treatments of 3 h were applied followed by the differential staining technique of Tempelaar et al. (Mutation Res. 103 (1982) 321-326). Concentrations of arsenic from 0.267 up to 1.070 mg/l were determined by colorimetry in the polluted samples used for this study. These values were above the permissible limit of 0.05 mg/l in drinking water. In all cases, except one in which the As concentration was 0.021, the arsenic-contaminated water produced significant increases of SCE compared with the control (p < 0.001) and a concentration-response relationship was observed. The SCE potency factor of 33 per mg/l of arsenic was calculated as the slope of a common regression line, pooling data previously obtained in the Comarca Lagunera and the results observed in Zimapan.

Trace element concentration and arsenic speciation in the well water of a Taiwan area with endemic blackfoot disease

Blackfoot disease is a peripheral vascular disease resulting in gangrene of the lower extremities. Although extensive epidemiological study has implicated high arsenic content in artesian well water in the endemic area, there is more to learn about the etiology of the disease. In this study, effort is paid on multielement determination and arsenic speciation in order to find out whether the trace element concentration pattern in well water in the Blackfoot disease endemic area is different from those of two control areas. Experimental results indicate that the concentrations of Fe, P, Na, and Ba in well water in the Blackfoot disease endemic area are found to be significantly higher than those of the controls, but they are still below the drinking water standard. The total arsenic in well water in the endemic area (671 +/- 149 ppb) is much higher than that of one normal control area of Hsin-Chu (< 0.7 ppb), but is a similar level as that of other control areas of I-Lan (653 +/- 71 ppb) where no Blackfoot disease has ever been found. It was also found that the insoluble arsenic in the endemic area (21.9 ppb) is much higher than that in two control areas (< or = 1.8 ppb), and the concentration ratio between As(III) and As(V) species in the endemic area (2.6) is much lower than that in one of the control areas, where the total arsenic is also high (14.7). The possible connection of Blackfoot disease with trace elements, arsenic species, and possibly other as yet undefined environmental factors in the artesian well water, is discussed.

Increased Prevalence of Hypertension and Long-term Arsenic Exposure

Abstract To examine the association between long-term exposure to inorganic arsenic and the prevalence of hypertension, we studied a total of 382 men and 516 women residing in villages where arseniasis was hyperendemic. Hypertension was defined as a systolic blood pressure of 160 mm Hg or greater, a diastolic blood pressure of 95 mm Hg or greater, or a history of hypertension treated regularly with antihypertensive drugs. The long-term arsenic exposure was calculated from the history of artesian well water consumption obtained through standardized interviews based on a structured questionnaire and the measured arsenic concentration in well water. Residents in villages where long-term arseniasis was hyperendemic had a 1.5-fold increase in age- and sex-adjusted prevalence of hypertension compared with residents in nonendemic areas. Duration of artesian well water consumption, average arsenic concentration in drinking water, and cumulative arsenic exposure were all significantly associated with hypertension prevalence. The higher the cumulative arsenic exposure, the higher the prevalence of hypertension. This dose-response relation remained significant after adjustment for age, sex, diabetes mellitus, proteinuria, body mass index, and serum triglyceride level. The results suggest that long-term arsenic exposure may induce hypertension in humans.

Arsenic in drinking water and mortality from vascular disease: an ecologic analysis in 30 counties in the United States

Chronic arsenic consumption can cause vascular diseases. Adverse vascular effects of arsenic in drinking water in the United States have not been studied. This study investigated the ecological relationship between the population-weighted mean arsenic concentration in public drinking water supplies and mortality from circulatory diseases in 30 U.S. counties from 1968 to 1984. Mean arsenic levels ranged from 5.4 to 91.5 micrograms/l. Standardized mortality ratios (SMRs) for diseases of arteries, arterioles, and capillaries (DAAC) (ICD 8th/9th revision, 440-448) for counties exceeding 20 micrograms/l were 1.9 (90% confidence interval [CI] = 1.7-2.1) for females and 1.6 (90% CI = 1.5-1.8) for males. The SMRs for the three subgroups of DAAC--arteriosclerosis, aortic aneurysm, and all other DAAC--tended to be elevated. With respect to the same arsenic group, the SMRs for congenital anomalies of the heart (ICD-8/9, 746/745-746) and circulatory system (ICD-8/9, 747) also tended to be elevated. Two competing interpretations emerge as possibilities: either there are spurious associations resulting from invalid outcome data or causal associations.

Non-carcinogenic effects of inorganic arsenic

This review will focus primarily on ohe effects of the inorganic arsenicals (arsenate and arsenite forms) that are present in drinking water. They are acutely toxic to both humans and animals, an effect that may be related to their bioavailibility. In humans, arsenicals have been reported to cause dermatitis and mucous membrane irritation upon exposure. They have also been reported to cause skin lesions and peripheral neurotoxicity in smelter workers and in patients treated with Fowler's Solution. When humans are exposed to arsenic in drinking water, effects such as hyperkeratosis, electromyographic abnormalities and vascular effects have been reported. In experimental animals, arsenic has been demonstrated to affect the liver and kidneys. In mice, arsenic has also been reported to decrease the animal's resistance to certain viral infections. The arsenite (+3) and arsenate (+5) forms have different modes of action. Arsenite binds to sulphhydryl groups and has been reported to inhibit over 100 different enzymes, while the arsenate can substitute for phosphate in various high energy intermediates, resulting in arsenolysis. In addition, when arsenate is reduced to arsenite in the body, it can also cause toxicity as that species.

Squamous cell carcinoma of the skin (excluding lip and oral mucosa)

The striking impression obtained from reviewing the cancer literature is how difficult it is to analyze the data for answers to many important biologic, behavioral, prognostic, and therapeutic questions about squamous cell carcinoma of the skin. This article addresses current concepts, controversies, and management of cutaneous squamous cell carcinoma (excluding the lip and oral mucosa).