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PAPERS: Paul Altmann, John Cunningham, Usha Dhanesha, Margaret Ballard, James Thompson, and Frank Marsh Disturbance of cerebral function in people exposed to drinking water contaminated with aluminium sulphate: retrospective study of the Camelford water incident BMJ 1999; 319: 807-811 [Abstract] [Full text]

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ALUMINIUM POISONING

Neil D Burman   (6 October 1999)

Cerebral Dysfunction, in Camelford: inappropriate study, inapprop riate conclusions

Murray Virginia   (28 October 1999)

Study has several methodological shortcomings

Theodore I Lidsky   (13 December 1999)

ALUMINIUM POISONING 6 October 1999
Neil D Burman Send response to journal: Re: ALUMINIUM POISONING	DEAR SIR, The valuable Camelford Aluminium report (Altmann P et al BMJ 99:319:807-811) raises more questions than it answers. What was the outcome of the damages claims? Your Commentary “This Week” notes that two Inquiries dismissed complaints. Yet by 1980, after UK-led enthusiasm for Aluminium Hydroxide therapy in dialysis patients a decade before, we were painfully aware of water, dialysate and oral aluminium causing neuro- and bone toxicity, worldwide clinical disasters in dialysis units including ours in cape Town leading us to abandon aludrox in favour of (Vital) dolomite (calcium-magnesium carbonate vitamin D) as the ideal oral phosphate binder, antacid, anti-cramp, anxiolytic and supplement for needed calcium, magnesium and carbonate. People do not take medicines (unlike nutritional supplements) unless ill. Mineral (alum) salts including sulfacrate are taken for symptoms – ie dyspepsia, gastritis, diarrhoea etc. It is axiomatic from time immemorial that chronic dyspepsia means hyperacidity or inflammation of the upper gastrointestinal tract, and that while absorption of micronutrients eg B12 may be thereby impaired, the absorption of metals is increased. So the duplicity of the medicinal Aluminium industry (in still claiming that their products are safe) is like that of the cigarette industry - they both know they market dangerous patented poisons. Like unprocessed foods, long-used naturals including linseed, dolomite, valerian, st john's wort and perhaps even marijhuana are safe and cheap in moderate longterm use, which is why they are not promoted for prescription like the patented statins, margarines, aluminium and H2 antagonist! Non-medicinal aluminium intake may arguably now be minimal in first-world communities, but not if oral aluminium medicines (in antacids, antidiarrhoeals, aspirin, douches & pastes) are still marketted. Dreisbach RH & Robertson WO, (Handbook of Poisons, 12th Ed, Lange, Connecticut ) noted p 430-1 that alum salts have an exposure limit of 2mg/cubic metre, toxicity including encephalopathy, weakness and osteomalacia.. Casdorf H & Walker M, (Toxic Metal Syndrome, Avery, NewYork 1994) notes p 126 that “toxicity of alum is aggravated by insufficiency of zinc, and excess of arsenic, cadmium, iron, lead, manganese mercury” etc; that “coffee is the chief source of dietary cadmium, that hyperacidity promotes aluminium absorption; and that the director of the early FDA Dr WH Wiley in 1929 wrote that aluminium was universally condemned as a poison in foods”! So, apart from the controversy over “aluminium in cow's milk, in tea, in cooking utensils" ( perhaps harmless) , "aluminosis from air pollution, and water purification by alum , and Alzheimer' disease”, oral Aluminium medicines should have been banned as unnecessary years ago, but for the tenacity of unscrupulous marketeers. Just as the USA Secretary for Health 40 years ago was dismissed after he produced the latest FDA report showing that (unlike the biggest killers of all, smoking and alcohol), marijhuana never kills anyone, and should be released on prescription, so cigarettes and aluminium medicines are still heavily marketted, while marijhuana is proscribed except in a few states of America.. In the light of the decades of knowledge about (dietary and water) aluminium poisoning by 1988, the Camelford Commissions, and the various Authorities that allowed, ignored, and dismissed the poisoning, were surely prosecuted for negligence and damages? Neil D Burman MRCP(UK) retired renal physician, Cape Town, PO Box 44285, Claremont, 7735 RSA.
Cerebral Dysfunction, in Camelford: inappropriate study, inapprop riate conclusions 28 October 1999
Murray Virginia Send response to journal: Re: Cerebral Dysfunction, in Camelford: inappropriate study, inapprop riate conclusions	Could a chemical incident resulting in water contamination such as Camelford happen again? We believe that the conclusions of Altmann et al (1) about cerebral dysfunction are limited by design and experimental technique. In addition their study does not report on the subsequent developments to respond to or prevent a similar incident happening again. In 1988, the domestic water supply of 20 000 people in the Lowermoor area was contaminated with aluminium sulphate. However much of the information on the adverse health effects arising from the exposure were obtained from self-reported questionnaires that may not have been completed by a representative sample of the local population (2). In Altman’s study the 55 cases were also a self-selected group. Differences in psychomotor tests and visually evoked potentials (VEP) were found when they were compared to unmatched controls and the cases’ siblings but VEP were only measured in half the cases. Amongst other issues already raised, differences in VEP have also been observed in major depression (3) and there was no formal psychological evaluation of the study group. A timely response to assess the impact of any chemical incident on a population is essential. Since 1996 health authorities have been required to have contracts with chemical incident service provider units. The Chemical Incident Response Service is one of the five UK providers and has contracts with all health authorities in six of the eight English Regions. Incident identification and management has pointed to the need for early response with appropriate collection of biological and environmental samples, usually within hours of exposure. These issues are discussed by public health physicians attending training courses and supported by relevant guidance material, including a recent handbook (4). With continuing surveillance to monitor response effectiveness methods are now in place to prevent the delays in investigation identified in the Camelford incident. All water utilities have also responded to the lessons learnt from Camelford. Following the Camelford incident a report was written by an independent non-executive director of the South West Water Authority which made recommendations to prevent a similar incident occurring again in the future. These recommendations were largely concerned with the control of access to water treatment plant and control of chemical deliveries (5). The Government sent copies of the report to the Chief Executives of all water authorities, who were then obliged to inform Government of the management and operating procedures they had put in place to implement the recommendations. In addition, water utilities are now required to inform health authorities immediately about any customer health concerns or operational incidents. Dr Virginia Murray, Director, Chemical Incident Response Service Faith Goodfellow, Research Engineer – Water, Chemical Incident Response Service Ivan House, Medical Toxicology Unit Laboratory Dr Richard Bogle, Specialist Registrar, Chemical Incident Response Service Medical Toxicology Unit, Guy’s and St Thomas’ Hospital Trust, Avonley Road, London SE14 5ER References: 1. Altmann, P, Cunningham, J, Dhanesha U, Ballard M, Thompson, J, Marsh F. BMJ 1999; 319:807-11. 2. Lowermore Incident Health Advisory Group. Water pollution at Lowermore, North Cornwall. London: HMSO, 1989. 3. Sloan E, Fenton G. Serial visual evoked potential recordings in geriatric psychiatry. Electroenceph Clin Neurophys. 1992; 84:325-331 4. Irwin DJ, Cromie DT, Murray V. Chemical incident management for public health physicians. The Stationery Office, 1999 5. Lawrence, J. The Report of an Inquiry into the Lowermore Incident, 6 July 1988. Produced by South West Water Authority for the Department of the Environment. 12/8/88.
Study has several methodological shortcomings 13 December 1999
Theodore I Lidsky Send response to journal: Re: Study has several methodological shortcomings	EDITOR- Altman et al1 described sequelae of the Camelford water incident that suggest the possibility that ingestion of aluminum- containing water causes brain damage. However, consideration of a variety of methodological and interpretational issues raises serious questions about the validity of their findings. Subjects were volunteers with unverified exposure to aluminum sulfate. Since this study was commissioned by attorneys who were acting on the behalf of plaintiff's in a lawsuit, the potential monetary gain to be derived from claiming such exposure must be considered as a potential influence on self classification. Moreover, the base rates of cognitive symptoms in the general population are not insignificant. Testing such self-selected subjects increased the probability of a disproportionately high representation of cognitively-impaired people in the exposure group. The cognitive assessment suffered from several weaknesses including the omission of an assessment of depression, and tests of symptom validity. Depression can lead to psychomotor slowing as well as impairment of memory, attention and executive functioning2. This is particularly important since an earlier study of persons claiming aluminum exposure at Camelford indicated increasing incidence of depression over time3. In view of the monetary incentive to appear impaired, some efforts should have been made to detect malingering. Although there are shortcomings in such tests, they are usually effective in discriminating the more obvious examples of symptom exaggeration4. An additional problem was the use of the Bexley Maudsley Automated Psychological Screening (BMAPS) as the method for evaluating cognitive functioning. BMAPS is a screening device in which an abnormal score is taken as the indication of the need for neuropsychological testing. However BMAPS does not substitute for such testing3 and, as a screening device, should not be used to diagnose impairment. The primary distinguishing feature of the exposure group was inferior performance on the digit- symbol test. However such abnormal results are not specific to the effects of brain injury. Impairments on this test can be caused by a variety of factors including, but not limited to, depression, untreated hypertension and lack of aerobic exercise5. The authors recorded visual evoked potentials suggesting that these "...measurements, carefully administered, are extremely objective and not subject to the individual's wish to underperform." Unfortunately, visual evoked potentials are no more immune from the effects of intentional under -performance than are neuropsychological tests and can also be affected by emotional state and a variety of commonly used medications3. In summary, the Altman et al1 study has several methodological shortcomings that, considered individually, raise serious concerns. Taken together, these weaknesses are sufficiently significant to preclude meaningful interpretation of this study's conclusions. Theodore I. Lidsky head, laboratory of electrophysiology Department of Psychobiology, New York State Institute for Basic Research in Developmental Disabilities, 1050 Forest Hill Road, Staten Island, New York, 10314 USA 1. Altman P, Cunningham J, Dhanesha U, Ballard M, Thompson J, Marsh F.Disturbance of cerebral function in people exposed to aluminium sulfate: retrospective study of the Camelford water incident. BMJ 1999:319:807-11. (29 September). 2. Alexander M, Benson F, Delis DC, LaRue A, Meador K, Ponton MO, et al. Assessment: neuropsychological testing of adults. Considerations for neurologists. Neurol 1996:47:592-9. 3. David AS., Wessely S.C. The legend of Camelford: medical consequences of a water pollution accident. J Psychosom Res 1995:39:1-9. 4. Hinnant D, Tollison CD. Impairment and disability associated with mild head injury: medical and legal aspects. Sem in Neurol 1994:14:84-9. 5. Lezak MD. Neuropsychological Assessment. Third Edition. New York, Oxford University Press, 1995.