Public Health Evaluation of Health Concerns Related to Madison Kipp Corporation

Prepared by John S Hausbeck, Environmental Epidemiologist, Madison Dept of Public Health, June 20, 2001

Abstract

In order to assess reports of illness related to Madison Kipp Corporation, Madison Department of Public Health developed a surveillance procedure to collect health data in the neighboring community. Data on environmental concerns and self-reported symptoms were collected between June 1997 and December 1999. During this time, 31 individuals contacted the Department 112 times to report environmental or health concerns. Analysis of the symptoms reported during this time found little similarity in the symptoms reported by individuals and a lack of consistency in the symptoms reported by individuals over time. The most frequently reported symptoms were relatively common or non-descriptive symptoms that may result from many illnesses or chemical exposures. Data collected during the surveillance period do not support the performance of a health study in the community surrounding Madison Kipp.

Introduction

Madison Kipp Corporation has been a focus of concern in the neighborhood since the early 1990's when production increased and processes were changed to include chlorine demagging. In the first several years, concerns reported to Madison Department of Public Health (MDPH) focused on noise generated and emissions released from the facility. Prior to 1994, MDPH received few calls regarding illness associated with Madison Kipp. However, copies of letters to and reports from Wisconsin Department of Natural Resources (WI DNR) during this time indicated that there was some level of concern in the neighborhood about the health impact of Madison Kipp's emissions.

In May 1994, MDPH received a copy of the Clean Air Petition signed by neighbors of the Madison Kipp facility. This petition listed symptoms of eyes/nose/throat irritation, metallic taste in mouth, bronchial and asthma symptoms, headaches, nausea, and stomach aches. In response to this petition, MDPH distributed a health questionnaire to all persons signing the petition to gather specific information about their health concerns. Of 38 surveys mailed, 26% were returned. Analysis of the returned surveys did not identify a community-wide health concern related to Madison Kipp.

Madison Department of Public Health and the WI DNR continued to receive many complaints since 1994 concerning Madison Kipp. Ongoing complaints included noise, nuisance odor, concerns about the health impact of Madison Kipp emissions, and self-reported Madison Kipp-related illness. From May 1994 through December 1996, MDPH has received calls from 5 individuals with self-reported illness that coincided with MKC activities. Symptoms included cough, pounding heartbeat, sore throat, nose irritation, and chest pain.

At a public meeting in June 1997, several community residents reported that they were concerned about a potential cluster of illness resulting from Madison Kipp. In order to assess this concern, MDPH developed a process for increased surveillance of health concerns in the neighborhood surrounding Madison Kipp. The purpose of this surveillance was to gather health data that would allow the Department to determine if there is sufficient evidence of illness related to Madison Kipp emissions to support a health study.

Methods

Reports of illness related to Madison Kipp were evaluated using the US Centers for Disease Control and Prevention (CDC) guidelines for investigating clusters of health events (1). According to this framework, identification of any cluster must identify an excess of illness and a causal link to an exposure causing the illness.

During the public meeting in June 1997, MDPH initiated a passive surveillance system in order to collect more complete information about illness that neighbors related to Madison Kipp emissions. With more than 100 people in attendance, those present were asked to contact MDPH if they had health concerns related to Madison Kipp. Attendees of this meeting were also asked to inform their friends and neighbors in the community to contact MDPH with health concerns. Wisconsin Department of Natural Resources staff and Madison Kipp officials also agreed to participate by forwarding and referring all calls received from the community that pertained to adverse health effects related to Madison Kipp. Subsequent communication with members of the community included reminders about calling MDPH with health concerns. MDPH did not actively solicit health information from the community due to concerns that it could heighten anxiety in the community and further bias the data collected. When requested by the caller, follow-up calls were made to other individuals with similar symptoms or exposures.

Madison Department of Public Health designed a call intake form to standardize the information collected from persons calling with concerns about Madison Kipp. The intake form asked for the following information:

• Contact information from the caller.
• Exposure information (type of environmental problem experienced, date and time of problem, where the problem occurred, and how long the problem lasted)
• Illness information (list of symptoms common to previous calls, date and time when symptoms started, and how long it took for the symptoms to go away).
• Comments for any other information the caller wished to provide.

Prior to WI DNR's permit hearing for Madison Kipp in December 1999, call intake data was reviewed and summarized for discussion at the permit hearing. Data analysis was performed to determine if this data identified unusual clusters of illness. This analysis looked for repeating patterns of symptoms among calls and grouping of symptoms or illness over time and geographic area. Reported symptoms also were evaluated according to their potential to result from exposure to Madison Kipp emissions or other conditions that may also cause the symptom or illness.

Data Collected

Symptom patterns

From June 1997 through December 1999, MDPH received 112 calls from 31 individuals directly or through referrals from WI DNR or Madison Kipp. Of these contacts, 55 calls from 13 individuals included a report of one or more symptoms that the caller related to Madison Kipp. The raw symptom data from these calls is presented in Appendix 1. A wide variety of symptoms were reported. To simplify symptom comparisons, symptoms were grouped into 25 symptom or illness groups. Some symptom groups contained several different symptoms. Self-reported symptoms were not verified with clinical testing or medical data. Figure 1 identifies the percentage of calls that included each symptom group. However, the number of calls made by each individual may have biased the observed frequency of the symptoms reported. To adjust for this effect, Figure 2 presents the number of individuals that reported the symptom group at least once during the surveillance period.

Determination of a case definition, a symptom or multi-symptom group that best described the illness resulting from exposure to Madison Kipp emissions, was not possible due to the large variation in symptoms reported among calls. Non-statistical comparison of symptoms reported for each caller did not identify obvious similarities in symptom patterns (combinations of individual symptoms reported) among callers or even among multiple calls from individuals (Appendix 1). Also, most callers reported self-identified symptoms rather than diagnosed conditions. Considering the symptoms reported, it is expected that most callers did not seek medical attention.

Callers reporting health concerns during the surveillance period were not asked if they had been diagnosed with asthma or had asthmatic episodes. However, asthma data specific to this community was collected on two separate occasions. In December 1999, WI DNR held a public hearing concerning Madison Kipp's air permit application. 201 residents were in attendance or represented at the meeting. Of these residents, nine (4.5%) reported developing or worsening asthma and an additional 6 (3%) reported other respiratory or allergic conditions. The following spring, Clean Air Madison (CAM) received responses to flyers distributed in the community. In response to these fliers, 13 of 226 persons reported either general or specific health impacts that they attributed to Madison Kipp's emissions. Eight (3.5%) of those returning a flier identified development or worsening of asthma as one of their concerns.

Grouping of symptoms over time and geography

During two and a half years of data collection, very few calls reporting health concerns related to Madison Kipp were received during similar time periods. The largest number of callers reporting health effects on any given day was 2. This occurred 4 times between June 97 and Dec 99. For two of the 4 times that multiple calls were received on the same day, none of the reported symptoms matched. On the two other days, only one symptom matched. During any given month, the largest number of callers reporting health effects was 4. The most common symptoms shared by these callers were nausea and sore throat. Evaluation of this data by time is limited by the small number of calls received on any given day or month.

Little geographic or spatial clustering was observed among the callers reporting symptoms during the surveillance period. The largest geographic group of callers was composed of 3 individuals residing east of Madison Kipp. While these individuals contacted MDPH within one month of each other, the symptom patterns were not similar for these individuals. Three other groups of two individuals each were identified southeast and southwest of the facility. Individuals in each of these small groups reported dissimilar symptoms at different times during the surveillance period.

Discussion

Lack of agreement and consistency in symptom groups, symptom timing, and geographic location of callers suggests that a variety of illnesses, conditions, or exposures may be causing the symptoms reported. While individuals will vary in their response to environmental exposures, some pattern in symptoms is expected when a group is exposed to a specific chemical or point source of emissions. Because a case definition of a multi-symptom pattern is not apparent in this data, the symptoms reported are discussed individually.

The most common symptoms reported by callers were nonspecific and may result from many different exposures, illnesses, or conditions. The two most commonly reported symptoms were nausea and sore throat. Nausea is common to many illnesses (2). Sore throat is usually associated with infection; however, may result from trauma or injury by chemicals or radiation among other causes (3). Although these symptoms were reported frequently, these reports came from a small number of callers. During the surveillance period, nausea and sore throat were reported by 4 (13%) and 5 (16%) individuals respectively. Because these symptoms are commonly associated with many illnesses, the expected occurrence of these symptoms in the community is expected to be high. Due to the small number of persons reporting these symptoms and the fact that these symptoms did not occur at similar times, it is difficult to conclude that these episodes of illness resulted from similar exposures.

The third most common symptom reported was difficulty breathing (9% of all calls). This symptom group included general, non-descriptive reports of trouble breathing and a few reports specific to shortness of breath. This symptom was reported by 3 (10%) of those contacting MDPH during the surveillance period. One difficulty in interpreting these reports is that very little information was gathered on the caller's history of respiratory or cardiovascular illness. Difficulty breathing is known to be associated with these illnesses as well as with anxiety (4). One of the three callers reporting this symptom also reported having asthma. It is unknown if the other two individuals reporting this symptom were also asthmatic or suffered from other pre-existing respiratory conditions. Data on the prevalence or incidence of this symptom in the general population was not available. However, it is not possible to conclude that an excess of this symptom exists in this community based on the reports of three individuals.

Headache and nose and throat irritation were also reported in more than 5% of the calls received. Headache is considered to be a common experience in many populations and can be associated with many exposures, illnesses and conditions (5). It is reported that severe headaches occur at least annually in 40% of persons worldwide. Nose and throat irritation generally involves an irritation or inflammation of the mucous membranes in these parts of the respiratory tract. This irritation is known to result after exposure to specific chemicals or air contaminants but may also be a part of allergic or infectious conditions in the respiratory system. Six callers, 19% of all callers contacting MDPH, reported headache over the 2.5-year surveillance period. Three callers reported nose and throat irritation over this period. As with nausea, sore throat, and difficulty breathing, the small number of callers reporting these symptoms over a fairly long period of time is not suggestive of an excess level of illness in this community.

While asthma is a growing public health concern, the community specific asthma prevalence (3.5% to 4.5%) is lower than the 1998 estimated prevalence for Wisconsin of 6.7% (6). Beth Fiore, epidemiologist for the Department of Health and Family Services, verified that current asthma rates in Wisconsin are estimated to be 7% for adults and 9% for children. Clearly, the data collected at the public hearing and during CAM's flyer distribution was not collected scientifically and is potentially biased. However, data collected to date does not suggest that asthma levels in this neighborhood are excessive.

After sufficient exposure, the chemicals emitted by Madison Kipp may cause one or more of the symptoms reported above. However, environmental data collected and compiled by WI DNR suggest that ambient levels of chemicals emitted by Madison Kipp meet air quality standards and are not expected to cause these symptoms.

The data presented in this report is limited by the small number of individuals that contacted MDPH over the surveillance period. It was suggested by several callers that other residents of this neighborhood were ill but did not contact MDPH for various reasons. Clearly, this limits the ability to draw conclusions about the community in general from the data collected. However, it is still possible to evaluate the data with respect to the 31 persons that contacted MDPH.

Conclusions

In order to conclude that an epidemiological health study is appropriate, the assessment of a reported illness cluster should identify an actual excess in illness and a potential exposure that may cause this illness (1). This report presents the findings of a surveillance system operated by MDPH from June 1997 through December 1999. Due to the lack of consistency in the symptoms reported and the small number of callers with similar symptoms that group over time or space, there is insufficient evidence of an excess of illness in this community at this time. While the community has made clear its concern about respiratory illness related to Madison Kipp, available asthma data, although incomplete, does not indicate that asthma is more prevalent in this community than it is statewide. Also, the symptoms that best characterize the illnesses reported to MDPH are relatively common and non-descriptive, which are extremely difficult to observe and objectively evaluate using currently available epidemiological methods. For these reasons, a health study is not indicated at this time.

Bibliography

1. Guidelines for Investigating Clusters of Health Events. 1990. MMDW, Centers for Disease Control and Prevention. Vol. 39 / No. RR-11.

2. Friedman, L.S. and K.J. Isselbacher. Anorexia, Nausea, Vomiting, and Indegestion. 1994. Harrison's Principals of Internal Medicine, 13th ed. McGraw-Hill, Inc. pp. 208-213.

3. Lebovics, R. and A.S. Baker. 1994. Infectious diseases of the Upper Respiratory Tract. Harrison's Principals of Internal Medicine, 13th ed. McGraw-Hill, Inc. pp. 515-520.

4. McFadden, E.R. Jr. Asthma. 1994. Harrison's Principals of Internal Medicine, 13th ed. McGraw-Hill, Inc. pp. 1167-1172.

5. Raskin, NH. Headache. 1994. Harrison's Principals of Internal Medicine, 13th ed. McGraw-Hill, Inc. pp. 65-71.

6. Forecasted State-Specific Estimates of Self-Reported Asthma Prevalence - United States, 1998. MMDW Weekly, Centers for Disease Control and Prevention. 47(47):1022-1025

See Appendix 1