Exposure measurement errors, risk estimate and statistical power in case-control studies using dichotomous analysis of a continuous exposure variable.

BACKGROUND: Non-differential errors in exposure measurements have been shown to lead to differential misclassification of exposure. As a consequence, the common tenet that, in absence of bias, imprecise exposure assessment can only bias the risk estimates conservatively does not necessarily hold. We investigate the effects of exposure measurement errors on the risk estimate and on statistical power. METHODS: We used a computer model that simulates a case-control study. We used both hypothetical data and data modelled on empirical measurements of environmental magnetic fields exposure. RESULTS: Measurement errors are found to have a lesser impact on risk estimates and statistical power than would have been the case had misclassification been truly non-differential. However, for a given cutpoint, a bias away from the null cannot be excluded. The predominant direction of the errors is found to have important consequences on both the study power and the risk estimates. CONCLUSION: When sufficient empirical data are available, computer modelling may give a more accurate estimate of the effects of measurement errors than algebraic corrections.

Imprecise exposure assessment and the sample size requirements of case-control studies of residential magnetic field exposure and cancer in adults.

A computer program simulating case-control studies is described. It is used to estimate the minimum sample size required and to assess how this is affected by imprecise exposure assessment. In particular, the consequences of neglecting measurements of nonresidential exposure in case-control studies of residentially exposed adults are investigated. According to this model, while the consequent loss of power is not as large as was predicted by algebraic methods, it would be unwise to neglect it when planning a study.

Epidemiological studies of work with video display terminals and adverse pregnancy outcomes (1984-1992).

Many epidemiological studies have investigated the claim that work with video display terminals (VDT) is a risk factor during pregnancy. Results have been inconsistent, although in the majority of cases the hypothesis was not supported. Exposure assessment has been very poor and the statistical power of the studies generally low. Overall, the studies indicate that VDT operators are not at greater risk than the general population, because very low frequency (VLF) magnetic fields do not appear to be a risk factor and extremely low frequency (ELF) magnetic field exposure is not significantly greater than that experienced in other occupational and residential environments. However, since some studies lend support to the hypothesis that ELF magnetic fields may be a risk factor for pregnancy outcome, studies of subjects exposed to higher than average ELF fields are justified.

Development and evaluation of a location-specific wire code.

The development of a wire code protocol based on a study of electrical installations in Melbourne, Australia, is described. Because of very significant differences between the Melbourne power distribution system and that used in Denver, Colorado, an approach different from that used by Wertheimer and Leeper was required. A combined practical and theoretical approach was used to determine a continuous exposure index, defined as a measure of the potential for exposure due to external electrical installations. The protocol was tested on a convenient sample of 41 homes in which the field was monitored over a 12 hour overnight period. A correlation of 0.85 (95% CI 0.74-0.92, P < .0001) was obtained between the measured time-weighted average and the wire coding exposure index. To assess the efficacy of the wiring configuration index, a computer simulation of a case-control study was then performed. It was concluded that, using the same basic reasoning of the Wertheimer and Leeper code, it is possible to develop a location-specific code that provides a good correlation with the residential time-weighted average and an acceptable degree of exposure misclassification.

Misclassification of ELF occupational exposure resulting from spatial variation of the magnetic field.

The adequacy of a single hip- or chest-worn magnetic field dosimeter to reliably classify subjects with respect to their occupational ELF magnetic field exposure is investigated. Hip-worn dosimeters consistently underestimate both whole-body average exposure and head exposure, tentatively regarded here as two possible definitions of the "true" exposure measurement. The approximate resulting bias in the relative risk estimate in hypothetical case-control studies is evaluated. A chest-worn dosimeter is found to be generally superior to a hip-worn one in assessing exposure during the occupational tasks considered here.

An apparently incongruous exposure-response relationship resulting from the use of job description to assess magnetic field exposure.

Empirical data are presented to support the observation that nondifferential misclassification of subjects classified according to an ordinal scale can result in an artifactual nonmonotonic exposure-response curve. This phenomenon can be interpreted erroneously as an indication that an observed relationship is not causal. The occupational exposure of 40 subjects to extremely low-frequency magnetic fields was estimated on the basis of their job description while their "true" exposure was determined by direct dosimetry. A "true" risk was assumed to exist, and estimates of risk that could be obtained through hypothetical case-referent or cohort studies were calculated.

Relative-risk-estimate bias and loss of power in the Mantel test for trend resulting from the use of magnetic-field point-in-time ("spot") measurements in epidemiological studies based on an ordinal exposure scale.

We assessed the merits of various point-in-time ("spot") measurement protocols in case-control studies based on an ordinal exposure scale. After classifying a number of houses on the basis of prolonged monitoring of the ambient, extremely low frequency (ELF) magnetic field, we determined the probability of misclassification for each "spot" measurement protocol. We calculated the effect of this misclassification on the relative risk estimates and on the Mantel test for trend. We found that classification based on a small group of point-in-time measurements allows an adequate estimate of the relative risk, although the statistical significance of the dose-response gradient may be seriously underestimated. However, the use of automated ambient-field monitors, which results in loss of information on spatial variability, can lead to similar consequences. Therefore, manually collected point-in-time measurements remain a viable option for exposure assessment.

An analysis of associations between social class and ambient magnetic fields in metropolitan Melbourne.

In the course of a study on residential magnetic-field exposure, some incidental data were obtained that bear on the issue of confounding of magnetic field exposure by social class. We have explored the possibility that the magnetic flux density of 50 Hz fields measured in Melbourne streets is correlated with a number of variables that index the socio-economic status of the neighborhood. We have examined also for a correlation between field-intensity levels and sums of some or all of the indicators, which were weighted to provide an overall score on socio-economic status. Although some of the indexes were weakly, but significantly, correlated with environmental levels of magnetic fields, the combined indices were not. These results indicate that socio-economic status is not likely to be a confounder in epidemiological studies of residential exposure to ELF magnetic fields in Melbourne.

The use of 'spot' measurements in epidemiological studies of the health effects of magnetic field exposure.

In several countries, epidemiological studies are being planned, or are in progress, to test the hypothesis that a causal relation exists between exposure to extremely low frequency magnetic fields and cancer incidence. One of the major difficulties in these studies is the development of valid and efficient protocols to assess magnetic field exposure. In studies focusing on residential magnetic fields, many researchers are turning to recently developed stationary automated magnetic field monitors to characterize exposure. We argue that a relatively small number of manually collected 'spot' measurements may be an adequate alternative which has several advantages. We compared a dichotomous exposure classification based on continuous magnetic field monitoring of 40 houses with that obtained through 'spot' measurements randomly sampled from the continuous records. We found that a single spot measurement had at least an 80% chance of classifying houses correctly and that this probability did not increase significantly as the number of readings was increased. We also calculated the sensitivity and specificity of various simulated measurement protocols and, from these, the effect of misclassification on estimates of relative risk. Since relatively large spatial variations in background magnetic field exist in many homes, we suggest that a small number of readings collected manually at several points within a residence may characterize the magnetic field better than continuous monitoring at one fixed location.

A model to assess personal exposure to ELF magnetic fields from common household sources.

Emission data are inadequate to characterize the contribution of a source to the total personal extremely-low-frequency (ELF) magnetic field exposure. In this paper, a simple model is proposed that takes into consideration the position of the subject with respect to the source and the duration of exposure. The magnetic field is spatially averaged over the whole body of the exposed subject and integrated over time. Exposure is regarded as significant if it approaches or exceeds 400 microT-h/year. By use of this method, the ELF magnetic fields generated by several household sources were compared with the levels of residential external sources, to assess their relative significance. Some common domestic electrical appliances are found to be responsible for an exposure comparable to that from power lines. When the model is used to assess exposure to electric blankets, apparently conflicting findings may be reconciled.

An evaluation of the existing evidence on the carcinogenic potential of extremely low frequency magnetic fields.

The existing evidence suggesting a link between exposure to Extremely Low Frequency (ELF) magnetic fields and an increased incidence of cancer is reviewed and evaluated.

On the safe use of microwave and shortwave diathermy units.

Diathermy is a common treatment modality used to relieve pain through localized heating. This paper briefly discusses the mechanisms through which heat is generated in tissue and the absorption characteristics of the applied electromagnetic radiation. The adverse effects of this radiation are reviewed with particular emphasis on the current exposure limits for operators and non-patients in the vicinity of diathermy devices. The newly introduced codes of practice for the 'Safe Use of Shortwave (Radiofrequency) and Microwave Diathermy' are also discussed.