1 POLICY PAPER HAIR ANALYSIS Dr Malclm Brwn Occupatinal and Envirnmental Physician 185 Cper Street Epping 3076 Hnrary Lecturer Dept Epidemilgy & Preventive Medicine Mnash University Olaf H. Drummer Head (Frensic & Scientific Services) Victrian Institute f Frensic Medicine Adjunct Prfessr Department f Frensic Medicine - Mnash University MELBOURNE Assciate Prfessr Jhn Edwards Department f Envirnmental Health Schl f Medicine Flinders University GPO Bx 2100 ADELAIDE Dr Mary Wyatt Occupatinal and Envirnmental Physician Suite C Level St Kilda Rd Melburne 3004 Hnrary Lecturer Dept Epidemilgy & Preventive Medicine Mnash University 1. Backgrund Occupatinal Medicine Occupatinal medicine invlves dealing with hazards at wrk - bth preventin and dealing with and adverse health effects. Hazards may be physical, chemical, psychlgical, ergnmic r bilgical. Assessing expsure t chemical hazards includes mnitring f wrkplace air, histry and physical examinatin,
2 as well as bilgical mnitring in certain situatins. Bilgical mnitring includes sampling and analysis f bld and urine, analysis f exhaled breath, and in sme cases, hair analysis. Occupatinal physicians are invlved in giving advice t individuals and emplyers regarding apprpriate mnitring techniques at wrk, and in interpreting results f tests rdered by themselves r thers. They may be required t give expert pinins t envirnmental wrkers cmpensatin authrities in a legal cntext, r appear in curt as an expert witness. Sme chemicals such as heavy metals have been used in manufacturing and ther industry fr hundreds f years. Fr example cases f lead pisning have been dcumented thrughut mst f recrded histry. As many heavy metals have been used widely fr industrial purpses and are persistent in the envirnment, ver-expsure in the ccupatinal and general scietal settings has been the subject f extensive study fr many years. Bilgical mnitring and measurements Occupatinal and general envirnmental expsure t chemicals may be assessed using measurements f levels present in the envirnment (air and sil) and present in the human bdy (knwn as bilgical mnitring). Measurement in air r sil gives an indicatin f envirnmental levels, but bilgical mnitring gives a mre precise measure f the ttal amunt f substance which has been absrbed via different rutes such as inhalatin, ingestin, r skin absrptin. It als takes accunt f excretin thrugh exhalatin, urine and faeces. Althugh bilgical mnitring is ften mre accurate in assessing bdy burden f chemical substances, there may be advantages and disadvantages assciated with the specific matrices that are cllected and analysed: Urine cllectin is nn-invasive but usually indicates the cncentratins f water-sluble metablites and represents recent expsure. Bld samples are invasive, requiring clinical expertise fr sampling and are nt well tlerated, particularly by children. Exhaled air may be useful fr vlatile materials, but requires specialised sampling, strage and transprt prcedures.
3 Hair, nails and deciduus teeth are tissues in which chemicals may be depsited ver the medium t lngerterm, s culd represent a mre integrated measure f expsure ver such perids. Children s deciduus teeth may be cllected and analysed as they naturally fall ut in childhd t be replaced by permanent adult teeth, althugh sampling is pprtunistic and there may be disadvantages in the time delay while waiting fr the teeth t shed. Individuals wh believe they have suffered ver-expsure and adverse health effects frm chemical substances smetimes feel the tests carried ut by their medical practitiners may nt be sufficiently cmprehensive. Despite extensive bld tests and ther investigatins, they may nt accept a cnclusin that their symptms d nt arise frm chemical expsure. Sme peple lk fr further infrmatin, different analytical methds and different methds f bilgical mnitring. In respnse t this, envirnmental txiclgical analysis and diagnsis services have been established t prvide alternative analytical appraches. In these cases, hair and nails may be viewed as preferred tissues fr analysis, since they are rbust and cnvenient t cllect, usually withut particular technical expertise r ther cnsideratins. They may be dispatched by mail r ther rutes withut need fr specialist handling r strage.
4 Aims and bjectives f this paper Hair analysis can be used in research and in limited clinical applicatins. It is a useful tl in limited circumstances. Hwever it is als being used by a limited number f practitiners, diagnsing individuals with chemical related diseases, ften fr peple with nn specific symptms. Rigur in the applicatin f the test results is ften missing, and the negative impact n peple s lives when an inapprpriate diagnsis is given can be substantial. The aim f this paper is t prvide useful and practical advice, based n the science f the tpic. The bjectives are T assist practitiners understandings f the ptential pitfalls f hair analysis T assist practitiners understandings f the issues that need t be addressed if hair analysis is ging t be used T highlight the fallacies in using the prcedure in many clinical situatins. 2. Applicatins Bilgical mnitring fr chemical expsure using hair samples has been reprted in bth ccupatinal and envirnmental settings fr decades (Clarksn et al 1988). It has been applied t a wide range f putative chemical expsures ranging frm drugs, inrganic cmpunds (metals, fluride) t rganic pllutants (pesticides, PCBs). Metals Occupatinal expsure t metals is the greatest reprted applicatin f hair analysis. Examples have included vertly txic metals such as lead, mercury, chrmium, cadmium and thers as well as essential metals including selenium, cpper, zinc, and irn. These investigatins are predminantly hygiene-based, using the levels f metals detected in hair as an index f relative expsure rather than an index f txicity and may demnstrate crrelatins between hair cncentratins f selected metals and bld cncentratins (e.g. Lee and White 1980). Envirnmental applicatins f hair analysis t metals expsure have been well reprted fr lead, mercury (and
5 methylmercury) and arsenic frm seafd, grundwater and ther surces (Barbsa et al 2005; Weihe et al 2005; Hughes 2006). Pesticides Pesticide levels in hair, particularly the rganchlrines, rganphsphates and pyrethrids, have been reviewed by Tsatsakis and Tudaki (2004). This review als examined the use f hair fr ther persistent pllutants such as dixins (PCDD), dibenzfurans (PCDF) and biphenyls (PCBs). Maternal hair has als been examined during pregnancy t determine expsure t a wide range f pesticides (Ostrea et al 2006). In each case the authrs were generally supprtive f the use f these indicatrs as expsure markers, and demnstrated crrelatins between hair and bld pesticide cncentratins, but did nt establish any ppulatin nrms r reference ranges. Pharmaceuticals Measurement f therapeutic drugs in hair may be a useful adjunct t mre traditinal bld and urine analysis techniques (Lalup et al 2005; Kaddumi et al 2004) but has als been used t test patient treatment cmpliance with antipsychtic drugs (Shen et al 2002) and in frensic assessments (Maurer 2000). Nictine Recent papers have examined the use f hair as a matrix fr envirnmental expsure t tbacc smke, especially in children and in service industry wrkers (Chetiyanukrnkul et al 2004; Grner et al 2005; Dimich-Ward et al 2005). Illicit drugs Envirnmental expsure t illicit drugs, either thrugh their manufacture, use r as incidentally-expsed bystanders (especially children) (Wlff et al 1999; De Girgi et al 2004; Pichini et al 2006) have been explred. These studies have generally nt used reference ranges as sample cmparatrs, but have established cut-ff values t indicate a psitive r negative test utcme. See als the fllwing papers fr applicatins f hair testing t determine expsure t drugs and prblems assciated with such testing (Kintz 2007 Bianalytical prcedures fr detectin f chemical agents in hair in the case f drug-
6 facilitated crimes, Anal Bianal Chem 2007 March 6 e-pub and Pragst and Balikva State f the art in hair analysis fr detectin f drug and alchl abuse Clin Chim Acta. 2006; 370:17-49). 3. Principles f Use There has been a significant grwth in the number f labratries ffering cmmercial tests f hair fr metals, trace elements and txins. Seidel et al i reprted ver 225,000 such tests by nine US labratries in a single year, at an estimated cst f $9.6 millin. The US Agency fr Txic Substances and Disease Registry established an expert panel t discuss the methdlgical and analytical issues surrunding the use fr hair analysis (ATSDR 2001 ii ). Apprpriate versus current use f hair analysis Analytical appraches t assist diagnsis f disease are best used frm an a priri basis. That is, medical screening based upn a reprt f symptms, leading t a hypthesized cnditin, which may have a suspected cause. Analytical chemistry may permit samples f tissues t be examined fr the presence r cncentratin f chemicals f interest. The cnfirmed presence r the measured cncentratin f a txic quantity f suspect chemicals wuld enable practitiners t determine causal relatinships and initiate apprpriate interventins. In the case f cmmercial hair analysis, the main surce f clients appears t be individuals with vague symptms f unwellness, r with cncerns abut envirnmental chemical expsure. These then have a brad spectrum f ptential cntaminants determined in hair samples. These are cmpared pst hc with in-huse nrms, reference ranges r standards t deduce txic verexpsure t selected cntaminants. This expeditinary apprach is nt well based in the scientific methd, nr is it txiclgically sund. Figure 1 demnstrates an example f a hair analysis reprt. This de-identified reprt is frm a prvider that takes referrals directly frm the public, and frwards the reprt t the persn r their medical practitiner.
7 Figure 1 Example f hair analysis reprt available directly t the public This reprt wuld leave many peple with a high level f cncern, withut gd reasn.
8 Limitatins t interpretatin Limitatins in interpreting the hair analysis findings include: Thse based n the interpretatin f data cllected The methd f analysis used. Mst cmmercial hair analysis prviders examined by the US review f hair analysis prvided n txiclgical basis fr their analytical cnclusins. In particular, the establishment f dse-respnse relatinships was missing there was n basis t frm the view abut expected adverse utcmes at high analyte cncentratins. Seidel et al i described the results f a rund-rbin submissin f split hair samples, cllected frm the scalp f a single dnr, t six cmmercial hair analysis labratries in the USA. They fund the fllwing significant prblems in their cmparisn f labratry analyses: 1. Significant variatins, fr sme analytes exceeding 10- fld, were bserved in the reprted cncentratins f metals between different labratries 2. Five f the labratries reprted at least ne element exceeding the reference range, but different labratries did nt reprt the same element in each case 3. Reference ranges, sample handling and methdlgical cnditins were different amngst labratries 4. Diagnstic interpretatins between labratries were in pr agreement, in sme cases suggesting verexpsure even in cases where elements were determined t be within their nrmal range 5. Tw thirds f labratries recmmended prprietary interventins in the frm f supplements r diet mdificatin. The IARC (2001) Errr! Bkmark nt defined. als cncluded that; Fr mst substances, insufficient data currently exist that wuld allw the predictin f a health effect frm the cncentratin f the substance in hair. The presence f a substance in hair may indicate expsure (bth internal and external) but des nt necessarily indicate the surce f expsure.
9 Prfessinal advice and assistance A variety f prfessinal bdies are able t prvide expert advice n the use and practical applicatin f analytical methds fr detecting and quantitating chemical expsure. 1. Fr assistance with the medical aspects f the case, Australasian Faculty f Occupatinal and Envirnmental Medicine. AFOEM members can prvide specific expertise in medical aspects f ccupatinal and envirnmental chemical expsure 2. Fr assistance with the technical aspects f the case, such as use f accredited labratries, standards f testing. Australian Institute f Occupatinal Hygienists Chemical expsures in ccupatinal and envirnmental settings may be determined by ccupatinal hygienists and envirnmental health prfessinals respectively. These grups have expertise in evaluating surces f chemical cntaminants and may be able t prvide technical methds fr measuring chemicals in specific envirnments. Australasian Cllege f Txiclgy and Risk Assessment. (ACTRA) N website available Txiclgists (wh may be registered r certified as prfessinal practitiners, fr example in Eurpe and the UK, USA and elsewhere) can prvide specific advice n the chemical, physilgical and txiclgical basis fr determining whether an adverse effect may be assciated with particular chemical expsures. Txiclgical risk assessment is a specialized branch f txiclgy practice, and the Australian Cllege f Txiclgy and Risk Assessment may prvide technical supprt in this area. 3. Fr interpretatin f results All f the abve grups can assist with interpretatin f the results. Making sense f the results is a difficult area, with a number f labratries reprting significantly different reference ranges.
10 Gvernment departments, such as: Australian Gvernment Department Health and Aging The state wrkplace based safety authrities may als be able t assist. 4. Analytical Issues Hair may be useful t establish pre-expsure t substances including heavy metals frm ccupatinal settings many weeks t mnths prir t cllectin. Entry f substance int hair Substance entry int hair is cmplicated and invlves a number f prcesses. Incrpratin by entrapment frm the bld bathing the grwing fllicle is a majr mechanism, althugh incrpratin thrugh direct cntact f mature hair with sweat and/r sebaceus secretins may als be a significant surce f entry. Because f the ability f hair t directly absrb freign substances, cntaminatin f hair by direct envirnmental expsure shuld als be reasnably excluded, if hair results are t be used. There is a wide range f uptake int hair even fr the same substance and fr the same expsure. Large variatins ccur between substances. Retentin f the substance int hair There are a number f factrs that affect retentin f substances int hair. These include Hair clur Hair structure The chemical prperties f freign substance Bleaching and excessive use f shamp and cnditiners can reduce the cncentratin f substance in hair Technical issues t be addressed External cntaminatin can ccur, making the interpretatin f hair data difficult. Labratries can reduce this artefact by incrprating washing techniques.
11 Metal cncentratins by themselves in hair will rarely prvide sufficient prf f excessive expsure unless cmpared t and crrelated with the histry and the medical details f any expsure. Segmental analysis f 1-2 cm sectins can prvide sme picture f changing expsure ver a lnger perid f time. This may assist in determining if expsure has ccurred and a pssible time frame f expsure. Whilst the majrity f hair is in the grwing phase, a substantial prtin f hair may n lnger be grwing. Cnsequently, segmental analysis rarely prvides a sharp histry f expsure if mre than ne hair is taken fr analysis. Cllectin f hair shuld fllw standard prcedures t avid cntaminatin f hair by the cllectr and t ensure cllectin frm the nape f the head which shws the mst cnsistent grwth f hair. Labratries cnducting testing will usually have cllectin kits and prtcls available. Analysis methds vary widely but generally invlve spectrscpic methds. These are very specific techniques and can detect several elements in ne test. Hwever, given the large number f elements targeted search fr presumed expsed substances is warranted rather than examining hair fr any substance. Fr sme metals, e.g. arsenic and mercury rganic frms derived frm fd are fat less txic than inrganic frms. Cnsequently, the hair test will need t differentiate the chemical frm f substance. 5. Recmmendatins Because this area is cmplex, and has the ptential t be misunderstd with significant negative cnsequences if nt dealt with apprpriately, it is strngly recmmended that expert advice and input is sught. There are early reprts that ther testing methds, such as tenail analysis, may be useful in sme circumstances. The Seidal i review indicates cnfusin with setting f nrmal ranges, and the interpretatin f results needs t be undertaken with cautin. We recmmend advice frm accredited prviders, accredited medical practitiners, and analytical services accredited by Natinal Assciatin f Testing Authrities (NATA).
12 6. Case Studies Case Study 1 prductive use f hair analysis A yung wman was attending a nightclub with friends. Sme alchl was cnsumed. Hurs later the wman wke up and fund herself n the flr in a rm adjacent t the club. She felt dizzy and had difficulty walking. Her clthing was in disarray suggesting a pssible sexual assault. Several hurs later she reprted the event t the plice which resulted in an examinatin by a frensic medical fficer. Subsequent tests revealed a likely sexual assault with suspicin f surreptitius administratin f a drug, pssibly frm a drink given t her by a man at the club. Analysis f her urine cnfirmed the presence f the benzdiazepine temazepam. Hair analysis was activated t nt nly cnfirm the presence f this benzdiazepine in anther tissue but als establish the pssible time frame f expsure and eliminate persnal use f this drug. Hair was taken 2 weeks later t ensure externalizatin f the embrynic hair expsed t drug and her 10-cm lng hair was cut int 1-cm segments and analysed fr benzdiazepines. Temazepam was nly fund in the first segment f hair (clsest t scalp). These results supprted the claim f surreptitius administratin f temazepam at abut the time f the assault and shw n prir recent use f the drug. While these results d nt f themselves prve a drug facilitates sexual assault hair analysis they prvide useful infrmatin t supprt a prsecutin. Case Study 2 - prductive use f hair analysis Hair analysis can prvide a histry f drug expsure by the analysis f segments f hair. Fr example, in a case f a drug dependent persn seeking treatment it is hped that the treatment (pharmactherapy, cunselling etc) at least reduces (illicit) drug use. In the case f 30-year male wh had been drug-dependent (herin, amphetamines and benzdiazepines) fr 12 years the entry int a drug treatment prgram prvides an pprtunity t mnitr drug use and hpefully t successfully treat his addictin. In additin t clinical and psychlgical signs f imprvement the use f a hair test at the 6-mnth pint can prvide an bjective measure f declining drug use.
13 In this case, segmental analysis f his 8-cm lng hair will prvide a histry f abut 8-mnths f drug use (hair grws at abut 1-cm per mnth). Results frm the labratry shwed that the cncentratins f the herin metablites (6- acetylmrphine & mrphine) and methamphetamine were steadily decreasing frm the time befre treatment t the mst recent grwth and indeed at this pint the cncentratins f drugs were quite small suggesting little use f these drugs. The benzdiazepine (alprazlam) was present at similar cncentratins thrughut treatment, but this was expected since this drug was being prescribed t treat his anxiety and insmnia. A further hair test at 12-mnths wuld be useful t further mnitr his drug use. Case study 3 cunterprductive use f hair analysis A 58 year ld wman cmplaining f headaches and neurlgical disturbances had sent a hair sample t a cmmercial labratry t determine if she had been expsed t envirnmental chemicals. The analysis cnfirmed very high hair cncentratins f mercury, and indicated that she shuld begin chelatin therapy t be detxified. She was als advised t cease cnsumptin f ptential mercury surces in diet, especially fish (tuna and shark). Fllwing n frm this advice the individual apprached the lcal health department t help her identify the surce f her expsure. During the curse f the discussin, she revealed that sme years ag she had been prvided with a ltin t treat a scalp cnditin. She had discvered a bttle f ltin in her cabinet in the previus mnths and recmmenced treatment. The ltin was a mixture f salicylic acid and mercurus chlride. Althugh her symptms were cnsistent with mercury expsure, the assessment f hair in this case yielded a very high mercury cncentratin as a result f the direct applicatin f ltin t the hair. Hence the analysis revealed mercury depsited during the hair grwth as well as frm direct surface applicatin, verestimating the extent f her expsure. Withut a detailed histry, the analytical reprt als gave pr advice regarding the surce f her expsure. Case study 4 unprductive use f hair analysis
14 A 49 year ld wman cmplaining f nn-specific symptms (headache, malaise) sught specific advice frm her lcal GP suspecting sme frm f envirnmental chemical expsure may have been respnsible. Althugh n specific agent was identified, she sent a hair sample t a cmmercial labratry. Results were reprted t her that she had elevated mercury and needed t detxify and exclude mercury-cntaminated fds, especially fish. The subject suffered frm fd intlerance and culd nt cnsume meat, but culd nly eat fish prtein. She was cncerned that she wuld nt be able t include fish in her diet in future. In spite f bld analysis and urinalysis fr mercury yielding unremarkable results, and extensive analysis f fish fillets (including tuna) frm her suppliers demnstrating n significant mercury cntaminatin, her symptms have persisted. The cause is still unknwn. 7. References i Seidel S et al, Assessment f cmmercial labratries perfrming hair mineral analysis. JAMA 2001; 285: ii ATSDR Hair analysis panel discussin: explring the state f the science. Atlanta. GA: Agency fr Txic Substances and Disease Registry. Available frm Accessed 20 March Drasch G, Rider G, Assessment f hair mineral analysis cmmercially ffered in Germany. J Trace Elem Med Bil. 2002; 16(1):27-31 Barrett S, Cmmercial hair analysis. Science r scam? JAMA. 1985; 254: Website details fr relevant Agencies Australasian Faculty f Occupatinal and Envirnmental Medicine
15 Natinal Assciatin f Testing Authrities Frensic & Medical Sexual Assault Clinicians Australia Inc Department f Health and Aging The Internatinal Assciatin f Frensic Txiclgists (TIAFT) Sciety fr Hair Testing (SOHT)
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The fllwing tpics were discussed in the March 24, 2016 meeting with law firms representing VCF claimants. Grup A Payment Issues: We cntinue t fcus n paying Grup A claims in full and are meeting the schedule
Hw t Finance yur Investment Acquiring a Lan - Key Steps Using the bank's mney t finance the purchase f a business rather than using yur wn capital will give yu significant tax advantages, s speak t yur
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