668
Bulletin o the World Health Organization
|
September 2007, 85 (9)
Objective
Arsenic concentrations in 25% o tube wells in Bangladesh exceed 50μg/L, a level known to be hazardous. Levels inindividual wells vary widely. We gathered data on arsenic exposure levels and skin lesion prevalence to address the lack o knowledgeabout risks where the average arsenic concentrations was lower.
Methods
The nongovernmental organization Gonoshasthaya Kendra did three related studies o keratotic skin lesions since 2004:(1) an ecological prevalence survey among 13 705 women aged
>
18 in a random sample o 53 villages; (2) a case-control study o176 cases and age- and village-matched reerents; and (3) a prevalence survey o the entire population o 11 670 in two additionalvillages. We calculated prevalence as a unction o average arsenic concentrations as reported in the National Hydrochemical Survey,and measured arsenic concentrations in wells used by subjects in the case-control study.
Findings
The prevalence o skin lesions was 0.37% in people exposed to arsenic concentrations below 5μg/L, 0.63% at 6–50μg/L,and 6.84% at 81μg/L. In the case-control analysis, relative risk o skin lesions increased threeold at concentrations above 50μg/L(
P
< 0.05).
Conclusion
Little serious skin disease is likely to occur i the arsenic concentration in drinking water is kept below 50μg/L, butensuring this water quality will require systematic surveillance and reliable testing o all wells, which may be impractical. Moreresearch is needed on easible prevention o toxic eects rom arsenic exposure in Bangladesh.
Bulletin o the World Health Organization 2007;85:668–673.
Une traduction en rançais de ce résumé fgure à la fn de l’article. Al fnal del artículo se acilita una traducción al español.
Risk of arsenic-related skin lesions in Bangladeshi villages atrelatively low exposure: a report from Gonoshasthaya Kendra
Corbett McDonald,
a
Rezaul Hoque,
b
Nazmul Huda
c
& Nicola Cherry
d
.ةلقا هذل مكلا لا ةين ف ةصخلا هذل ةبرعلا ةجتلا
a
Department o Occupational and Environmental Medicine, National Heart and Lung Institute, Imperial College, London, UK. Correspondence to Corbett McDonald(e-mail: c.mcdonald@imperial.ac.uk).
b
Gonoshasthaya Kendra, Nayarhat, Savar, Dhaka, Bangladesh.
c
Institute o Child and Mother Health, Matuail, Dhaka, Bangladesh.
d
Community and Occupational Medicine Program, University o Alberta, Edmonton, Canada.doi: 10.2471/BLT.
06.036764
(
Submitted: 19 September 2006 – Final revised version received: 9 February 2007 – Accepted: 13 February 2007
)
Introduction
Arsenic is a human carcinogen and skinpathogen; the evidence has been docu-mented by the International Agency or Research on Cancer on several oc-casions.
1
A potentially serious threat topublic health that has become evidentduring the last 30–40 years is naturalarsenic contamination o drinking water,notably in South America and Asia andmore recently in Bangladesh and WestBengal (India). oxic maniestationshave been primarily keratotic skin le-sions; more threatening, however, areinternal cancers, or which there is lesscertain evidence.
2
A major national di-saster was evidenced by the publicationin 2001 o a systematic survey o nearly 4000 wells
3
showing that hal Bangla-desh’s administrative districts had aver-age arsenic concentrations above – oten well above – 50
m
g/L, a level known tobe hazardous. Tese averages may be apoor reection o the problem, as levelsvaried enormously within and betweenvillages by several orders o magnitude.Tus it is virtually impossible to estimate what proportion o Bangladesh’s ruralpopulation is at risk even at the nationalstandard o 50
m
g/L, let alone abovethe WHO recommended guideline o 10
m
g/L. Given this extremely variedpattern o exposure, there is need orepidemiological data over a wide rangeo concentrations.Tere have been ve recent preva-lence studies: one in West Bengal,
4
laterused in a case-control analysis,
5
and ourin Bangladesh,
6–9
where exposures esti-mated individually were related to risk o skin lesions. wo studies
6–7
reportedvery low risks below 50
m
g/L, rising toprevalences o 20–30% at higher con-centrations. Te two remaining studiesby Ahsan et al.
8
and Rahman et al.
9
published in 2006 were both large androm circumscribed areas south-east o Dhaka, where arsenic contaminationsare high. Te ormer study, in Araihazar,reported a systematic increase in preva-lence odds ratios (OR) compared tothose in drinking water containing<8.1
m
g/L, o 1.91 at 8.1–40
m
g/L, ris-ing to 5.39 at > 175.1
m
g/L. Rahman etal. did not present comparable data onexposure-response in Matlab, but theoverall prevalence in adults was only 4/1000 ater an average o some 20 years’tube-well use, and a mean exposure o 167
m
g/L. Te apparent dierence be-tween the ndings in these two studiesand others is addressed below.
Research objectives
Uncertainties over levels o risk at rela-tively low arsenic concentrations seri-ously concern Gonoshashthaya Kendra(GK), a large NGO long known interna-tionally or innovations in health care.
10
GK provides comprehensive services orthe entire population o over a millionin some 600 villages spread across mucho the country, excepting the divisions
669
Bulletin o the World Health Organization
|
September 2007, 85 (9)
Research
Risk of arsenic-related skin lesions in Bangladeshi villagesCorbett McDonald et al.
o Khulna in the south and Sylhet in thenorth-east. Only 3% o GK’s villages arein districts with average concentrationsabove 50
m
g/L, and hal in districts below 11
m
g/L. GK is thus well-placed to study the eects o relatively low average expo-sures, although such studies are compli-cated by the wide variations within andbetween villages. GK is also concernedthat the risk is not conned to skin le-sions, and in particular about possibleeects in pregnancy and internal cancers,both o which it has begun to investigate.First, however, it was thought importantto assess the risk o skin lesions at levelsprevailing in the villages or which itis responsible and which are typical o much o Bangladesh.
Methods
Selection o villages, together withtraining and supervision o paramedics, was described in a preliminary report.
11
Cases were dened as women with oneor more nodules or characteristic skinthickening on palms or soles, recordedand graded by specially trained villageparamedics. No account was taken o ulceration or lesions elsewhere, andquestions o diagnosis or causation weredeliberately avoided. Prevalence rates by age were calculated against average con-centrations reported by the NationalHydrochemical Survey (NHS)
3
basedon 129 wells tested in the upazillas (sub-districts) where the study villages werelocated.o assess relative risk within vil-lages, each o the 176 women with skinlesions identied in the initial survey was matched on age (+/– 5 years) withone unaected reerent (randomly cho-sen within age strata) in the same village. At a visit by one o this paper’s authorsin 2005–6 to the 27 villages with oneor more case-control pairs, tube wellscurrently used by subjects were identi-ed and a record made o how longeach woman had used this water source.Photographs were taken o the lesionsin all reported cases or later evaluation,and three water samples rom each well were tested using the Arsenator equip-ment used in the NHS, which provideda digital readout o arsenic concentra-tion. In the NHS, a comparison wasmade between the Arsenator and BritishGeological Survey (BGS) laboratory re-sults based on some 250 samples in theManduri village survey.
3
No evidence was ound o any systematic dierencebetween the two sets, details o whichare presented in the NHS.Te same survey procedure was ol-lowed in the study o two large Rajshahivillages, A and B. As these villages werenew to GK, a census o all residents wasthe rst step. O the total populationlisted (
n
= 11 670), 11 021 (94%) wereexamined by a paramedic, includingchildren under ve i the mothers hadnoticed any skin abnormalities. Tissurvey sought to assess prevalence inmales and emales over the ull agerange. Several young children were seen,but none showed signicant signs. A comprehensive study o arsenic levelsin some 1400 tube wells in these twovillages is in progress, with sites o each well and house addresses o each case, asdetermined by the Global PositioningSystem. Tese ndings will be reportedseparately.
Statistical procedures
Prevalence (%) was calculated by age andupazilla or the 53 villages in the initialsurvey, and by age and sex in the study o the two special villages;
c
² statistics with tests or trend were calculated toinvestigate dierences in prevalence by upazilla grouped by arsenic concentra-tion. Conditional logistic regression was used to determine the relation withexposure (highest o three concentra-tions recorded) in the case-control study.Prevalence odds ratios associated withage, sex and village were calculated by logistic regression in the report on thespecial villages.
Results
Tese three surveys’ essential ndingsare summarized in ables 1–3. able 1shows the prevalence o skin lesions waslow (0.37%) among 6448 women livingin upazillas A-E (25 villages) with anaverage arsenic concentration o 5
m
g/Lor less. It was 0.63% among 5547 women in upazillas F-K (21 villages),average concentration 16–50
m
g/L, butvery much higher (6.84%) among 1710 women in upazilla L (7 villages) with anaverage concentration o 81
m
g/L. Whilethe range o average concentrations inthe rst group was narrow (0–9
m
g/L),that in the three higher groups (F-L) was very wide indeed (0–166
m
g/L).Recorded data rom 33 wells in the sameunion helped to narrow the range (seeable 1); however, only the values romall wells measured in each upazilla areused in the present paper.Te case-control study, potentially based on 176 pairs (352 women), wasnally reduced to 155 pairs by the losso 21 cases: 14 women had movedelsewhere, and seven were unwilling toparticipate or not available. Te resultsin able 2 correlate well with those onprevalence in able 1, showing a three-old increase at over 50
m
g/L (
P
< 0.05),and some indication o an increase above10
m
g/L. As cases and controls werematched or village and age, the relativerisks show only the eect o dieringexposure within and not between vil-lages, and not in duration to the extentthat age is a reliable surrogate. A urtheranalysis o pairs aged over and under40 years (not shown) suggests that therelative risks were similar in older andyounger women.able 3, based on the two largevillages, shows that the overall preva-lence was over twice as high in VillageB (3.2%) as in Village A (1.3%); it wasairly similar in men and women inVillage B, but less so in Village A. Preva-lence in both villages rose sharply withage, with rates somewhat higher in menthan in women. Cases in children werevery rare. A logistic regression, excludingthose aged 5 years or less (and those withunknown age) conrmed (
P
< 0.001)the higher risk in village B (OR = 2.44,95% CI: 1.74–3.41) and the increas-ing risk with age (OR = 1.034, 95%CI: 1.027–1.042): the observed slightincrease in prevalence in men was notsignicant in this model (OR = 1.19,95% CI: 0.87–1.62). In women over30, in Village B, the average prevalence(5.2%) approximated that in upazilla L(able 1). O the 10 wells recorded inthe upazilla in which these two villages A and B were located, only one showed aconcentration above 1.1
m
g/L (57.8
m
g/Lin Village A). In our ongoing survey,however, many wells in both villages hadconcentrations above 100
m
g/L.
Discussion
Te main epidemiological problems inassessing the arsenic hazard in Bangla-desh are in exposure estimation at theindividual or household level, and inidentiying potentially related disease.Te commonly observed gradient withage in prevalence studies suggests thatexcept perhaps in pregnancy, risk is de-termined by both arsenic concentrationin drinking water and duration o con-sumption over at least 20 years. o as-semble such data reliably or a large study
670
Bulletin o the World Health Organization
|
September 2007, 85 (9)
Research
Risk of arsenic-related skin lesions in Bangladeshi villagesCorbett McDonald et al.
Table 1.
Skin lesion prevalence (%) in 12 upazillas by average arsenic concentration (μg/L)UpazillaVillages
n
Wellstested
n
Averageμg/LRangeμg/LWells in same union
a
Women
n
Cases
n
Prevalence(%)
n
mean
A811
< 1
0–22024319B38
< 1
0–1207514C47
1
0–5215701D18
1
0–9524070E98
5
0–7––228910
A–E254210–9 (0%)
b
1116448240.37
F310
16
0–633175517G412
16
0–1154312366H39
19
0–6444611786I18
21
0–10725990
F–I1139190–115 (13%)
b
13193064190.62
J714
39
2–118346195613K38
50
10–811315273
J–K1022432–118 (41%)
b
4422483160.64L710812–166 (70%)
b
25017101176.84Total53113210–166301813 7051761.28
a
Included in upazilla average.
b
Proportion o wells above 50μg/L.
Table 2.
Risk of skin lesions by arsenic concentration in drinking water(conditional logistic regression)Arsenic
a
concentration (µg/L)CasesControlsOddsratio95% CI
n
%
N
%
0–108554.89762.61 –11–505334.24931.61.330.77–2.2851+1711.095.82.961.02–8.59All155100.0155100.0 – –
CI
,
confdence interval.
a
Highest measured concentration.
population would be extremely difcultand, as mentioned earlier, was attemptedby Haque et al.
5
in West Bengal, wherethe mean arsenic concentration was185
m
g/L (range 0–3400
m
g/L). A nestedcase control study limited to 21 villagesin which the primary drinking-watersources contained < 500
m
g/L had only limited success in estimating past expo-sure, but the odds ratio in relation topeak concentration o < 50
m
g/L was 2.4at 50–99
m
g/L, a result close both to ourown rom a similar nested study (2.96)and to that reported by Ahsan
8
(3.03) orexposures in the range 40–91
m
g/L.Because the assessment o indi-vidual exposures is so difcult, we optedinitially or an ecological approach orassessing prevalence, using data romthe National Hydrochemical Survey.
3
Tis survey o almost 4000 wells useda systematic grid resulting in one welltested each 37km², but amounted toonly about 60 wells per district and 8per upazilla or the calculation o aver-ages. Although the geographical patterno arsenic concentrations ater statisticalsmoothing appeared clear, this obscuredenormous local variations. For example,in three special survey areas concentra-tions ranged rom < 3 to 2542
m
g/L.Even in the upazilla where Villages A and B are located, despite an averageo 6
m
g/L, the only well tested in Village A had a level o 57.8
m
g/L. Tus theecological approach, though useul, haslimitations. A urther difculty lies in the as-certainment o skin lesions. Whereas werelied on paramedics to describe objec-tively the results o simple inspection,other studies
4–8
have used physiciansexercising their varying levels o judge-ment, and in one
9
(Matlab, Bangladesh)expert panels o physicians and derma-tologists were used to reach consensuson the diagnosis o arsenical keratosis.Tis resulted in rejection o 70% o cases reported by the eld workers. Tisalone may largely explain the dierencesbetween their rates and others, includ-ing ours, though it is worth notingthat the average exposure in Matlab was 167
m
g/L, and only our upazilla L(able 1) had values approaching thatlevel, though with a wide range in valuesor the 10 wells tested (2–166
m
g/L). Also relevant is the act that the averageduration o tube-well use in Matlab wasabout 20 years, whereas most o the wells in upazilla L were reported to daterom 1953, up to 50 years earlier thanour survey. An important purpose o the 53-village prevalence study was to evalu-ate the published ecological data
3
andadequacy o the national standard o 50
m
g/L in assuring saety. able 1 sug-gests that the number o cases in groups A-E was probably negligible, and ingroup L, in clear excess. Te interpreta-tion o groups F-I and J-K is more di-cult. Te prevalence rates are almostdouble the lowest group (
P
= 0.04),but the average concentrations in both
Search History:
Result 00 of 00
00 results for result for
p.
27143166
61
Reads
0
Readcasts
0
Embed Views
Get Scribd Mobile
To get Scribd mobile enter your number and we'll send you a link to the Scribd app for iPhone & Android.We've sent a link to the Scribd app. If you didn't receive it, try again.
We'll never share your phone number.
More From This User
Notes
Load more
