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· - - - ~· Al
Medical Follow-up Agency
INSTITUTE OF MEDICINE
by
Susan Thrum, William F. Page, Harriet Crawford, and
Heather O'Maonaigh
with oversight from the
Committee to Study the Mortality of Military Personnel
Present at Atmospheric Tests of Nuclear Weapons
NATIONAL ACADEMY PRESS
Washington, D.C.
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NOTICE: The project that is the subject of this report was approved by the Governing
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tute of Medicine. The members of the advisory committee for the report were chosen for
their special competences and with regard for appropriate balance.
Support for this project was provided by the Defense Threat Reduction Agency,
formerly the Defense Nuclear Agency (DNA), under Contract No. DNA001-92-C-0042.
The views, opinions, and/or findings contained in this report are those of the authors and
should not be construed as an official Defense Threat Reduction Agency position, policy,
or decision unless so designated by other documentation.
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. . .
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AUTHORS, INSTITUTE OF MEDICINE
SUSAN THAUL (Study Director), Epidemiologist
WILLIAM F. PAGE, Statistician
HARRIET CRAWFORD, Operations Director
HEATHER O'MAONAIGH, Research Associate
ADVISORY COMMITTEE TO STUDY THE MORTALITY OF
MILITARY PERSONNEL PRESENT AT ATMOSPHERIC TESTS OF
NUCLEAR WEAPONS
Current Advisory Committee
HARVEY CHECKOWAY (Chair), Professor, Departments of Environmental
Health and Epidemiology, University of Washington, Seattle
RICHARD J. M. FRY, Consultant, Biology Division, Oak Ridge National
Laboratory, Oak Ridge, Tennessee
SAMUEL HELLMAN, A.N. Pritzker Distinguished Service Professor,
Department of Radiation and Cellular Oncology, The University of Chicago
ELAINE RON, Chief, Radiation Epidemiology Branch, National Cancer
Institute, National Institutes of Health, Bethesda, Maryland
WILLIAM G. SEIBERT, Senior Archivist, National Personnel Records
Center, St. Louis, Missouri
JOHN E. TILL, President, Risk Assessment Corporation, Neeses, South
Carolina
CLARICE R. WEINBERG, Chief, Biostatistics Branch, National Institute of
Environmental Health Sciences, National Institutes of Health, Research
Triangle Park, North Carolina
Former Members of Advisory Committee
CLARK W. HEATH, JR. (until 2/lS/99)
DAVID HOEL (until 12/l/94)
JOHN LITTLE (until 319194)
RODNEY WITHERS (until 819194)
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WORKING GROUP ON DOSIMETRY
JOHN E. TILL (Chair), committee member
F. OWEN HOFFMAN, SENES of Oak Ridge, Inc.
KEITH J. SCHIAGER, Department of Radiological Health, University of
Utah, Salt Lake City
JOHN TASCHNER, Los Alamos National Laboratory, New Mexico
CLARICE R. WEINBERG, committee member
MEDICAL FOLLOW-UP AGENCY
RICHARD N. MILLER, Director
PAMELA RAMEY-McCRAY, Administrative Assistant
Not a member of the advisory committee.
V1
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REVIEWERS
This report has been reviewed in draft form by individuals chosen for their
diverse perspectives and technical expertise, in accordance with procedures ap-
proved by the National Research Council's Report Review Committee. The pur-
pose of this independent review is to provide candid and critical comments that
will assist the Institute of Medicine in making the published report as sound as
possible and to ensure that the report meets institutional standards for objectiv-
ity, evidence, and responsiveness to the study charge. The review comments and
draft manuscript remain confidential to protect the integrity of the deliberative
process. The committee wishes to thank the following individuals for their par-
ticipation in the review of this report:
JOHN D. BOICE, JR., International Epidemiology Institute, Rockville,
Maryland
DAVID BRENNER, Center for Radiological Research, Columbia University
School of Public Health, New York
ETHEL S. GILBERT, Radiation Epidemiology Branch, National Cancer
Institute, National Institutes of Health, Bethesda, Maryland
MAUREEN M. HENDERSON, Department of Epidemiology, University of
Washington, Seattle
MATTHEW PUGLISI, The American Legion, Washington, D.C.
JONATHAN M. SAMET, Department of Epidemiology, Johns Hopkins
University School of Hygiene and Public Health, Baltimore, Maryland
RICHARD B. SETLOW, Brookhaven National Laboratory, Upton, New York
Although the individuals listed above have provided constructive comments
and suggestions, it must be emphasized that responsibility for the final content
of this report rests entirely with the authors and the Institute of Medicine.
;
V11
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Preface
For more than half a century, veterans, scientists, and the public have de-
bated and searched for answers about whether military personnel involved in
nuclear tests experienced adverse health effects because of their participation.
The study we report here is the latest attempt to quantify and understand the
aftermath of those tests.
Throughout the Five Series Study, the Medical Follow-up Agency staff has
relied on the guidance of the Institute of Medicine advisory committee created to
oversee the study. Members included leading experts in radiation and cancer
epidemiology, biostatistics, radiation biology and medicine, radiation physics
and dosimetry, and national archival sources. The committee provided informa-
tion, leads, insight, and technical assistance and the report is better for that inter-
action, but responsibility for the final product rests with the staff.
This report presents the information that we could derive from this study.
How scientists, the government, veterans, and the general public interpret and use
that information is now open for discussion but not within the scope of this study.
Susan Thaul, Ph.D.
William F. Page, Ph.D.
Harriet Crawford, B.S.
Heather O'Maonaigh, M.A.
1X
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Acknowledgments
The study of the five series participants has been underway in some form or
another since 1982. The list of people who deserve recognition for their contri-
butions is enormous. The initial study team that began the current Five Series
Study was led by Dennis Robinette, a radiation biologist who died shortly before
the contract to do this study was signed. His earlier report, coauthored with
Seymour Jablon and Thomas Preston, set the stage for this study.
Members of the data operations staff who worked through almost the entire
life of the study were Chiquita "Squeaky" Benson, Mary Juman, and Sylvia
McGinnis, joined in recent years by Jihad Daghmash. Others who worked on the
data collection and management for this project include Phillip Bailey, Noah
Dropkin, Nicholas Findlay, Faye Lucas, Jean Philemond, Elaine Pickens, Alex
Saenger, and Denise Tyner-Parker. Erin Bell, Christopher Howson, Philip Ren-
zullo, and Youn Shim each worked on the epidemiology of this study. Christo-
pher Johnson, to whom this report is dedicated, was the project director and
source of radiation and health physics and military radiation safety operations
information for the most of the study period.
The data collection efforts for the Five Series Study involved a cast of hun-
dreds. We appreciate the efforts of Robert Bilgrad and staff at the National
Death Index; Clifford Amsler, Barbara Bauman, and staff at the National Per-
sonnel Records Center in St. Louis, Missouri; and staff at many federal archives
centers and VA regional offices across the country, especially the VA regional
office in the District of Columbia.
We relied on a few consultants external to the staff for some technical work
critical to the conduct of the study: Charles Alcorn, Gary Marsh, Jeanette Peter-
son, Florence Poillon, Karl Wise, and Ada Youk. Jeremy Yu assisted during a
summer internship.
X1
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xx
ABBREVIATIONS, ACRONYMS, AND GLOSSARY
NPRC. National Personnel Records Center, St. Louis, Missouri.
NRC. National Research Council; a component of the National Academies.
NRPB. National Radiological Protection Board, U.K.
NTPR. See Nuclear Test Personnel Review Program.
NTS. See Nevada Test Site.
nuclear device. Any device in which the explosion results from the energy
released by reaction involving atomic nuclei (Bruce-Henderson, 1982~.
Nuclear Regulatory Commission. Independent regulatory agency established
by the U.S. Congress to ensure adequate protection of the public health and
safety, the common defense and security, and the environment in the use of
nuclear materials in the United States.
Nuclear Test Personnel Review (NTPRJ Program. Maintained by the Defense
Threat Reduction Agency, DoD.
nuclear weapon. See nuclear device (Bruce-Henderson, 19824.
01-010. Commissioned officer paygrades.
observed to expected. Comparison of number of observed events (e.g., deaths)
in one group with expected values based on a standard or specifically cho-
sen comparison population.
OCMAP; OCMAP-PLUS. Occupational Cohort Mortality Analysis Program.
Computer program developed by Gary Marsh and others at the University
of Pittsburgh Department of Biostatistics.
Office of Technology Assessment (OTAJ. Former nonpartisan research unit
within the U.S. Congress that provided congressional committees analyses
of emerging, difficult, and often highly technical issues and helped to iden-
tify policy options.
OTA. See Office of Technology Assessment.
outcome measures. Measures of the possible results that may stem from an
exposure to a causal factor (Last, 1995~.
Oversight committee. A National Research Council volunteer committee of
experts that provides guidance, but does not author a report.
p. Probability (epidemiology/statistics, e.g., p = .05~. See Appendix C.
Pacific Proving Ground ('PPG). Site of most U.S. oceanic nuclear weapons
tests. Consisted primarily of the Enewetak and Bikini Atolls in the north-
western Marshall Islands of the Pacific Ocean (Gladeck and Johnson,
1996~.
participating unit. Military unit designations by which individuals are associ-
ated with an atmospheric nuclear test. These are the units that members
participated with during the test (JAYCOR, 19954.
paygrade. Referred to in military records as a payrate, it is uniform across the
branches of service; examples are E3 (third grade enlisted personnel 3) and
O 1 (lowest grade officer).
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ABBREVIATIONS, ACRONYMS, AND GLOSSARY
XXI
permanent unit. Military units that participants were permanently assigned to
during the operation. It was common for a veteran's permanent unit and
participating unit to be the same (JAYCOR, 1995~.
personal dosimeters. Devices (usually film badges3 for measuring radiation
dose to an individual.
personnel roster. Air Force, Army, and Marine Corps documents that list the
name, military service number, and grade or rank or rate of each person in a
unit on a given date.
PHREG. Proportional hazards regression program, SAS.
PLUMBBOB. Military code name of atmospheric test of nuclear weapons,
1957, Nevada Test Site.
potential radiation exposure. Radiation exposures of uncertain occurrence.
PPG. See Pacific Proving Ground.
radiation. Energy propagated through space or matter as waves (gamma rays,
ultraviolet light) or as particles (alpha or beta rays). External radiation is
from a source outside the body, whereas internal radiation is from a source
inside the body (e.g., radionuclides deposited in tissues).
Radiation Effects Research Foundation (RERFJ. A cooperative Japan-United
States research organization.
radiogenic. Causally linked to radiation.
RADSAFE. Military units or personnel that provide radiation safety monitoring
functions.
rank. Personnel grades sometimes referred to as ratings; examples include
Admiral, General, Private, and Seaman (JAYCOR, 1995~; these are not
consistent across branches of service.
ratio. The value obtained by dividing one quantity by another (Last, 1995~.
REDWING. Military code name of atmospheric test of nuclear weapons, 1956,
Bikini and Enewetak Atolls, Marshall Islands.
referent. Member of a comparison group or the comparison group itself.
referent population. The standard against which a population being studied can
be compared.
regression. Statistical analysis that seeks to determine the "best" mathematical
function to describe a series of data points.
relative risk (RR9. The ratio of the incidence of a condition in the exposed
population divided by the incidence in the nonexposed population. If there
is no difference as a result of exposure, the RR is 1.0.
rem. A unit of radiation dose equivalent; replaced by the sievert; 1 rem is
equivalent to 0.01 Sv.
RERF. See Radiation Effects Research Foundation.
risk. The probability that an event will occur.
RR. See relative risk.
SAS. Originally "Statistical Analysis System," proprietary software package.
sea series. Oceanic nuclear weapons test series. In this report, Operations
GREENHOUSE, CASTLE, AND REDWING.
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. .
XX11
ABBREVIATIONS, ACRONYMS, AND GLOSSARY
selection series. For this study, the first (or only) of the five studied series in
which a member of the participant cohort was present; the selection series for
a member of the referent cohort is the series corresponding to the time period
and set of unit matching criteria that was used to select the participant cohort.
series. An official grouping of nuclear weapons tests.
shield (shielding. A body of material used to physically reduce the intensity of
radiation.
shot. The detonation of a nuclear device; used synonymously with test in dis
cussion of the atmospheric nuclear weapons testing program.
SI. International System of Units (as instituted in 1960~.
sievert (Sib. A unit of effective or equivalent dose. Equivalent dose incorpo
rates an adjustment for the fact that different types of radiation (alpha, beta,
gamma, neutron) differ in their ability to do biologic damage. Effective
dose also incorporates adjustments for the relative sensitivity of different
organ systems. The sievert is the SI unit that replaced the rem. 1 Sv is
equivalent to 100 rem.
SMR. Standardized mortality ratio. See Chapter 9.
SSN. Social Security number.
statistical adjustment. The use of statistical methods to control for potentially
biasing factors in an analysis.
statistical significance. See Appendix C.
stratification. The process of or result of separating a sample into several sub
samples according to specified criteria (e.g., age, sex) (Last, 1995~.
survival time. The period of study time that an individual is observed until the
occurrence of the outcome of interest or the end of the study.
Sv. See sievert.
systematic differences.
Differences that are not randomly distributed.
tests. The detonation of a nuclear weapon (device); also called a shot.
thermonuclear device. Fusion-based nuclear weapons.
time-dependent. Not constant over time.
timescale. Units selected for the measurement of time, for example, calendar
time or age.
tumor. An abnormal mass of tissue that forms when cells in a specific area
reproduce at an increased rate. Also known as a neoplasm. May be benign
or malignant (AMA, 1989~.
underlying cause of death. The disease or injury that initiated the train of
events leading to death or the circumstances of the accident of violence that
produced the fatal injury (Last, 1995~.
unit diary. The document that recorded the daily duty status changes of per-
sonnel assigned to Marine Corps company-level units (JAYCOR, 19954.
United Nations Scientific Committee on the Effects of Atomic Radiation (UN-
SCEARJ. A committee of the U.N. General Assembly.
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ABBREVIATIONS, ACRONYMS, AND GLOSSARY
. . .
XX111
UNSCEAR. See United Nations Scientific Committee on the Effects of Atomic
Radiation.
UPSHOT-KNOTHOLE. Military code name of atmospheri
weapons, 1953, Nevada Test Site.
US. United States.
USS. United States Ship, Navy.
c
VA. Department of Veterans Affairs.
validation. Exercise to assess acceptability of data ascertainment.
test of nuclear
VAMI. See Veterans Administration Master Index.
VARO. Veterans Affairs regional office.
verification. Efforts to verify that information obtained is accurate.
Veterans Administration Master Index (VA MI). Index cards for each VA benefi-
ciary; system superseded by BIRLS in 1972.
vital status. Determination as to whether an individual is alive or deceased.
W1-W4. Warrant officer paygrades.
yield. The total effective energy released in a nuclear detonation (Gladeck and
Johnson, 1996~.
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Contents
ABBREVIATIONS, ACRONYMS, AND GLOSSARYxiii
SUMMARY1
1 STUDY RATIONALE AND OVERVIEW
Rationale, 5
Background, 5
Overview, 7
2 OTHER STUDIES OF RADIATION EXPOSURE OF
MILITARY PERSONNEL..........................................................................
Introduction, 8
Military Populations, 9
3 AN OVERVIEW OF THE U.S. NUCLEAR WEAPONS
TESTING PROGRAM..............................................................................
GREENHOUSE, 14
UPSHOT-KNOTHOLE, 15
CASTLE, 15
REDWING, 16
PLUMBBOB, 16
Estimates of External Doses, 17
4 DATA SOURCES...................................................
Cohort Identification, 20
Nuclear Test Personnel Review Program, 20
National Archives and Military Collections, 21
xxv
.8
13
19
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XXVI
CONTENTS
Characteristics of Cohort Members, Including Date of Birth and
Vital Status, 21
Beneficiary Identification and Records Locator Subsystem, 21
VA Master Index, 24
Military Personnel Folder, 24
Cause of Death, 24
Veteran's Claim Folder, 24
National Death Index, 25
Population Mortality Rates for Comparison, 25
THE PARTICIPANT COHORT 26
Relationship of Participant Rosters Used in the 1985 Publication and
This Report, 29
Participation in Series Other than the Selection Series, 30
~arms D ~ ¢¢ ~ ~ 1~T'r ~ ^~1] T
V l~= NINNY ~ ~l . J~
7 EXPOSURE DEFINITION AND MEASUREMENT
DNA-Provided Dose Estimates, 37
Individual Doses, 37
Alternative Uses of Dose Data, 38
Potential Surrogate Measures of Dose, 39
Decisions for the Analyses in This Report, 40
Future Options for Use of Dosimetry, 41
8 MORTALITY ASCERTAINMENT
Fact-of-Death Ascertainment, 42
Fact-of-Death Validation, 43
Date of Death, 46
Cause-of-Death Acquisition, 48
Cause-of-Death Validation, 48
9 ANALYSIS STRUCTURE
Overview, 50
Available Data, 50
Analysis, 52
Variables, 52
Type of Analysis, 52
Diagnosis Groups, 54
.36
.42
.50
10 DESCRIPTION OF COHORT CHARACTERISTICS 56
11 FINDINGS 61
Tests of Predetermined Principal Endpoints, 61
Descriptive Analyses of Predetermined Additional Mortality Endpoints, 62
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CONTENTS
Investigating Leukemia Risk by Land and Sea Series Participation, 69
Investigating Leukemia Risk by Time Since First Participation and
Age at First Participation, 70
12 DTSCUSSION...........................
Limitations, 73
xxv
Fact-of-Death and Cause-of-Death Ascertainment, 73
Statistical Power, 75
Other Possible Confounding Factors, 75
Inadequate Dosimetry, 76
Discussion, 77
Leukemia, 77
Thyroid Cancer, 78
Lung Cancer, 79
Nasal Cancer, 79
Prostate Cancer, 80
Concluding Comments, 80
REFERENCES 83
APPENDIXES
A A Review of the Dosimetry Data Available in the Nuclear Test
Personnel Review Program, 89
B National Association of Atomic Veterans Medical Survey, 153
C Epidemiology Primer, 159
D Verification of Completeness and Accuracy of the Participant Roster, 168
E Additional Analyses, 183
F Biographical Summaries, 198
TABLES
TABLE 2-1. Selected Findings from Studies of Military Participants at
- Atomic Tests, 10
TABLE 3-1. Nuclear Test Personnel Review Program-Provided Summary of
External Doses (in rem) for Atmospheric Nuclear Test Participants as of
30 September 1993, in Percentage of Series Participants, 18
TABLE 4-1. Sources of Data Items, 22
TABLE 5-1. Official Operational and Postoperational Periods for the
Five Series, 28
TABLE 5-2. Estimates and Determined Extent of Participant Misclassification
in the 1985 Dataset, 29
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. . .
XXV111
TABLES-3. Total Number of Series in which Members of Each Selection
Series Participated, 31
CONTENTS
TABLE 6-1. Closeness of Frequency Matching in the Selection of Referent
Cohort Members, 35
TABLE 8-1. Vital Status as of December 31, 1996, 43
TABLE 8-2. Vital Status Data as of December 31, 1996: Process and
Availability, 44
TABLE 8-3. Date-of-Death Data: Process and Availability Deaths Only, 47
TABLE 8-4. Cause-of-Death Availability-Deaths Only, 49
TABLE 8-5. Cause-of-Death Source Deaths Only, 49
TABLE9-1. Variables Considered for Analysis and Their Utility, 51
TABLE9-2. Broad Categories of Noncancer Causes of Death as Grouped by
ICD-9 Codes, 54
TABLE 9-3. Cause-of-Death Categories Within Broad Category of Malignant
Neoplasms, 55
TABLE10-1. Cohort Member Characteristics: Branch of Military Service, 57
TABLE10-2. Cohort Member Characteristics: Selection Series, 57
TABLE 10-3. Cohort Member Characteristics: Age at Start of Follow-Up, 57
TABLE 10-4. Cohort Member Characteristics: Source of Date of Birth, 58
TABLE 10-5. Cohort Member Characteristics: Paygrade, 59
TABLE 10-6. Distribution of Participant and Referent Cohort Members by
Branch of Service and Selection Series, 60
TABLEll-l. Number of Observed Deaths and Standardized Mortality Ratio
(SMR), by Cohort, and Hazard Ratio for Participants Relative to
Referents for Planned Analysis Causes of Death, 63
TABLE11-2. Number of Observed Deaths and Standardized Mortality Ratio
(SMR), by Cohort, and Hazard Ratio for Participants Relative to
Referents for Broad Cause-of-Death Categories, 64
TABLE11-3. Number of Observed Deaths and Standardized Mortality Ratio
(SMR), by Cohort, and Hazard Ratio for Participants Relative to
Referents for Causes of Death Within the Broad Category of Malignant
Neoplasms, 66
TABLE11-4. Number of Observed Deaths and Standardized Mortality Ratio
(STIR), by Cohort, and Hazard Ratio for Participants Relative to
Referents for the ICD-9-Defined Subtypes of Leukemia, 68
TABLE11-5. Number of Participants Who Participated in Any Land Series
and in Any Sea Series, by Selection Series, 69
TABLE 11-6. Observed Deaths and Hazard Ratio of Participants Relative to
Referents, for Land Series and Sea Series Participation, 71
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CONTENTS
TABLE 11-7. Hazard Ratios for Leukemia, Excluding Chronic Lymphoid
Leukemia, by Time After First Exposure, 72
TABLE 11-8. Hazard Ratios for Leukemia, Excluding Chronic Lymphoid
Leukemia, by Age at First Participation, 72
XXIX
TABLED-1. Instructions to Staff-Common Errors, 170
TABLE D-2. Instructions to Staff Examples, 170
TABLE D-3. Instructions to Staff Availability and Consistency of
Identification Data, 171
TABLED-4. Matching of Participant Names on the 1985 and 1999 Study
Rosters by Types of Matching Methods Used, 172
TABLED-5. Comparison of Current (1999) Five Series Participant Dataset and
1985 Dataset, 174
TABLED-6. Summary of Completeness of the Nuclear Test Personnel Review
Participant List as Indicated by Data Collected by the National Association
of Atomic Veterans (NAAV) Health Survey, 177
TABLED-7. Completeness of the Nuclear Test Personnel Review Participant
List as Indicated by Veteran Responses to Solicitations in Veterans'
Publications, 179
TABLE D-8. Completeness of the Nuclear Test Personnel Review Participant
List as Indicated by Veteran Responses to Public Meeting Inquiries, 180
TABLED-9. Estimated Errors of Inclusion and Omission in the 1999 Dataset,
181
TABLE D-10. Nuclear Test Personnel Review (NTPR) Compared to Other
Sources, 182
TABLE E-1. Cohort Member Characteristics: Paygrade, 184
TABLE K-2. Cohort Member Characteristics: Type of Military Unit, 186
TABLE K-3. Age at Selection Series, 188
TABLE K-4. Paygrade Groups at Selection Series, 190
TABLE K-5. Standardized Mortality Ratios (SMRs) and Hazard Ratios, by
Series and Participant Status, for Selected Causes of Death, 192
TABLE K-6. Standardized Mortality Ratios (SMRs) and Hazard Ratios, by
Branch and Participant Status, for Selected Causes of Death, 193
TABLE K-7. Standardized Mortality Ratios (SMRs) and Hazard Ratios, by
Paygrade and Participant Status, for Selected Causes of Death, 195
TABLE E-8. Number of Participants and Percentage by Assigned Series and
Type of Participation, 196
TABLE K-9. elative Hazards (and 95% confidence interval ICI]) for Leukemia
Mortality, by Series: All Participants Versus Single Series Participants, 197
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DEDICATION
We dedicate this report to
J. Christopher Johnson
(1 949 ~ 999)
