Leukemia FAQ’s

Frequently Asked Questions about Churchill County Leukemia Cases

The City of Fallon prepared this document as a public service. The City is not considered an expert on the subject of leukemia. Sources of information include the State Health Division, National Cancer Institute, Leukemia & Lymphoma Society and American Cancer Society. In addition, information was taken from newspaper articles, Web sites and reports prepared by the City’s own environmental consultants. This information is not provided as medical advice or as an official report of scientific research, but as public information.

  • Chronology of the State’s Leukemia Investigation

What agencies are involved in the cluster investigation?
Nevada State Health Division
University of Nevada School of Medicine—State Health Laboratory
University of Nevada, Reno—Cooperative Extension
Nevada Division of Environmental Protection (NDEP)
Nevada Department of Agriculture
Nevada Division of Emergency Management

Federal Agencies
The Centers for Disease Control and Prevention (CDC)
National Center for Environmental Health (NCEH)
Agency for Toxic Substances and Disease Registry (ATSDR)
Environmental Protection Agency (EPA)
United States Geological Survey (USGS)

Has there been a recent update on the investigation?
In September the Centers for Disease Control and Prevention (CDC), established a Field Testing Office in Fallon to begin biological and environmental testing. The CDC randomly selected Churchill County families to participate as control subjects in a cross-sectional exposure assessment. Approximately 56 families with a child similar in age and sex to case families affected with childhood leukemia were asked to participate in an interview and provide blood, urine, and cheek cell swabs. The collection of these biological samples was completed at the end of October.When you use the laser light pen before need read the guidebook.

The investigation is now moving to the analytical phase. The samples will be sent to CDC headquarters in Atlanta for careful and extensive analysis. Results may be expected in approximately one year. CDC will test for a large number of potential environmental contaminants. In this way, case families can be compared with other families in the Churchill County Community not affected with leukemia. High levels of one substance found among case families, but not control families, may provide important clues in identifying potential causal factors. 

What is the status of the environmental testing?
According to the CDC the Fallon probe will include the highest level of environmental testing ever done by the agency. Investigators will look for carcinogens such as benzene, petrochemicals, heavy metals, pesticides, radioactive materials, chromium, nickel and other toxins.

The Nevada Division of Environmental Protection (NDEP), in cooperation with the Agency for Toxic Substances and Disease Registry (ATSDR), is conducting the environmental portion of the cross-sectional exposure assessment. Their goal is to determine if environmental contaminants may be associated with the cluster. Samples of soil, dust, and air have been collected from case and control family homes. USGS will also test tap water at each home.

ATSDR has a team of scientists working on various parts of a pathway assessment in Churchill County. The agency has identified many sources of data to use in this pathway evaluation. These data include the types of industries in the area as well as information on chemical releases in the area.

A pathway assessment evaluates the five parts of an exposure pathway: 1-what is the source of a chemical? 2-where is the chemical in the environment? 3-where do people come into contact with the chemical? 4-how can the chemical get into the body? 5-who can be exposed based on where or when the chemical is present? There is a completed exposure pathway when all five parts of the pathway exist.

The United States Geological Survey (USGS) has finished sampling 100 wells. This new survey will test for 266 possible contaminants, including pesticides, metals, uranium, volatile organic compounds and consumer chemicals, such as caffeine. Part of the survey will evaluate the water used by the patient families.

Investigation history:
A preliminary investigation began last summer by the Nevada State Health Division to ensure that public health officials were aware of all cases of childhood leukemia in the area and to identify any common characteristics among the case families. Case families have been asked about their residential history, sources of water for drinking and cooking, medical history, family history, and potential sources of chemical and radiation exposure.

An expert panel from outside the state, consisting of representatives from the Centers for Disease Control and academic institutions, reviewed the initial findings of the Health Division. In March, that group released its report. The investigation is ongoing and will now focus on environmental testing. The expert panel’s report states that there are three distinct possibilities of a cause: (1) an environmental cancer-causing contaminant, (2) a viral or bacterial infectious agent brought to the community by “population mixing,” or (3) random chance.

The State has tested some of the patient families’ private wells and tests show no jet fuel or other volatile organic chemicals. The well water did show the expected high levels of arsenic and some tested positive for naturally occurring uranium.

Background and demographic information about case families The State Health Division is investigating 15 cases related to the cluster. Ten were diagnosed while living in Churchill County and four while living elsewhere, but they had previously lived in the area. Nine still live in Fallon or Churchill County.

Of the 15 cases, 12 families’ questionnaires have been analyzed. The State has recently interviewed the remaining two families. Information from the 12 interviews includes:

  • Six patients are male and six are female.
  • Six of the children’s ages range from three to five years old, the peak time of incidence for acute lymphocytic leukemia.
  • Seven of the patient mothers resided in Churchill County for part or all of their pregnancy. Five resided elsewhere during pregnancy.
  • Churchill County was the place of residence at the time of birth for six of the patients.
  • Seven families lived in Churchill County for less than two years before time of diagnosis. Five lived in the County for two years or more.
  • Nine patients resided in Churchill County at the time of diagnosis. Three resided elsewhere.

All of the patients have acute lymphocytic leukemia (ALL), except one who has acute myelogenuous leukemia (AML). AML involves a different class of white blood cells and is a less commonly diagnosed leukemia in children. Patients’ ages at time of diagnosis range from 0 to 19 years old.. Two of the patients, Adam Jernee and Stephanie Sands, have died.When will this cluster be over?
No one knows if additional children will be diagnosed. In other communities where childhood leukemia cases have clustered, cases have sometimes been diagnosed over a period of several years. Health officials will know the cluster has subsided when the rate of newly diagnosed childhood leukemia cases in Churchill County become similar to the rate for the state and other communities. Since December 2001, there have been no additional cases reported.

Is there a common characteristic among the families?
Based on an initial analysis, there does not appear to be a common characteristic among the case families other than their residency. The families reported no consistent exposures to any particular environmental hazard. It is, however, important to note that people may not always be aware of their exposure to an environmental hazard.

The families had various sources of drinking water (some drank tap water from the municipal system, some drank tap water from domestic wells, and some drank bottled water). Half of the families’ residences were part of the municipal water system and half used private wells. The municipal system and nine of the private wells have been tested and show no presence of any volatile organic compounds, including those related to jet fuel. Tests are ongoing.

How was the “cluster” defined?
The State Health Division determined that the case definition is as follows: Medically confirmed diagnosis of leukemia, in an individual age 0-19 at the time of diagnosis, having resided in the Fallon area prior to the diagnosis.

Some earlier cases of leukemia (those occurring before 1997) have not been included in the State’s cluster investigation because they are outside the scope of the cluster and most likely related to expected rates for the disease.

What can I do to help the families?
The Fallon Families First committee, comprised of Churchill County community leaders, has been established to focus on patient and family services and public education. Money that will directly benefit the families can be donated to the City of Fallon Mayor’s Youth Fund. Goods and Services can be donated to FRIENDS Family Resource Center. For more information about making donations, call Fallon’s City Clerk at 775-423-5104.

What potential environmental triggers are being investigated?
Is there a link between the arsenic and leukemia?
There is currently no evidence that arsenic causes childhood leukemia. The families had various sources of drinking water (some drank tap water from the municipal system, some drank tap water from domestic wells, and some drank bottled water). Dr. Randall Todd, the state epidemiologist, says it’s unlikely the longstanding occurrence of arsenic caused a sudden spike in the area’s leukemia rate. The water has been tapped from the same source for 58 years with no reported clusters of any type in the past. Dr. Alan Smith from Berkeley confirmed Dr. Todd’s position – that arsenic is not likely the cause – at legislative hearings and meetings with the affected families.

Is Uranium in drinking water the cause?
The families of the children with leukemia had lived in nearly two dozen different residences in Churchill County. Of these about half were served by public water systems. The public water systems in Fallon draw their water from a deep aquifer that has not been shown to contain elevated levels of uranium. The other residences were served by domestic wells, which draw their water from more shallow aquifers. Although the United States Geological Survey (USGS) has found evidence of uranium in some shallow and intermediate depth wells around the Fallon area, the testing of the case family wells to date has found only one residence with an amount of natural uranium exceeding Safe Drinking Water Act standards. Therefore, it seems unlikely that uranium is responsible for the observed cluster of childhood leukemia cases.

Is there a link to pesticides?
Pesticides have not been found in the municipal water supply and water tests from patient families with private wells do not show the presence pesticides. Modern pesticides are created to target a single organism and are strictly regulated by the EPA and Nevada Department of Agriculture. Those who use pesticides are typically well trained about how to use them. Fortunately, 80 percent of Churchill County’s agriculture is dedicated to raising alfalfa, a crop that does not require heavy doses of pesticides.

Could Navy jet fuel be the cause?
The base has 100 monitoring wells and no fuel contamination has been recorded off Navy property. The fuel pipeline that runs between Sparks and the Fallon Naval Air Station is continuously monitored and evidence of a leak has never been found.

No jet fuel has contaminated the municipal water supply and water tests from patient families with private wells do not show the presence of any components of jet fuel.

The pipeline that carries fuel to NAS Fallon is regulated by several state and federal agencies, including the Department of Transportation and the Office of Pipeline Safety. Senator Reid has requested information from the Navy, the Secretary of Transportation and Kinder Morgan, operators of the pipeline, about the transportation, storage, use and disposal of jet fuel in Fallon.

Nevada Division of Environmental Protection officials have flown and walked the route of the pipeline in Fallon to look for potential problems–none were found.

Is there a link between atomic tests and leukemia?
Fallon is 28 miles from the site of a 1963 nuclear bomb test. Department of Energy officials say that radiation from the test site has not migrated to Fallon. The test wells have been monitored since 1963 and the EPA checks the wells annually. Scientists from the energy department, EPA and Desert Research Institute use eight on-site wells and a dozen off-site wells to search for radioneuclides like tritium. The ground water below the test site does not connect with the basalt aquifer, Fallon’s source of drinking water.

Is there a link with PCBs in our community?
There are no traces of PCB, a cancer-causing agent, in the City water supply or the patient families’ wells that have been tested. Containment issues at the Fallon Freight Yard were addressed in 2000 and the Nevada Division of Environmental Protection reported that there was no public health hazard. The Bureau of Reclamation is conducting a Phase I environmental assessment of the Freight Yard property to ensure that no contaminants are present.

Why has the investigation focused on these particular children and time period?
The unusually high number of cases includes those diagnosed after 1997, with the majority being diagnosed in 1999 and 2000. All the children lived in Churchill County for some period of time. This residency and time of diagnosis is what has determined their inclusion in the cluster.

What is leukemia?
Leukemia is a form of cancer. ALL, known as acute lymphocytic Leukemia or acute lymphoblastic leukemia, is a rapidly progressive cancer that starts by the malignant transformation of a marrow lymphocyte. ALL is the most common form of childhood leukemia. The transformed, now malignant, cell multiplies and accumulates in the marrow as leukemic lymphoblasts. The lymphoblasts block normal blood cell-formation in the marrow, resulting in insufficient production of red cells, white cells and platelets. The specific chromosome and genic changes in the affected cells can be used to classify ALL. These findings can be used to determine the expected response of that type of ALL to treatment. The risk category of the ALL determined from the genic changes can affect the treatment applied.

Acute Myelogenous Leukemia (AML) is a progressive cancer that starts by the malignant transformation of an immature cell in the bone marrow. This affected cell usually is a primitive multipotential cell, meaning that its normal counterpart can give to a variety of blood cells. The transformed cell multiplies and accumulates in the marrow as leukemic myeloblasts. AML can occur at any age but increases exponentially in incidence after age 45 years. This leukemia can have a myriad of genetic alterations and the appearance of the leukemic cells can be represented by many different subtypes. Although several genetic changes, especially translocations of chromosomes, are relatively common, a large proportion of patients has uncommon or rare genetic changes. Other terms that are synonyms for AML include acute non-lymphocytic leukemia, acute myeloid leukemia, and acute myelocytic leukemia.

What is a cancer cluster?
A disease cluster of any kind is the occurrence of a greater than expected number of cases of a particular disease within a group of people, geographic area, or a period of time. Cancer clusters may be suspected when people report that several family members, friends, neighbors or coworkers have been diagnosed with cancer.

Various statistical methods are used to determine whether the reported number of cancer cases is really a larger number than would normally be expected to occur. True clusters are difficult to define and, if they turn out to be real, the causes are often obscure. Most non-occupational cancer clusters turn out to be the result of the random nature of the disease.

How are cancer clusters investigated?
Epidemiologists, scientists who study the frequency and distribution of diseases in populations, may investigate reported disease clusters, including suspected cancer clusters. Investigations of suspected cancer clusters can be limited by the current status of scientific knowledge and tools related to genetics; effects of environmental factors on humans; the availability of statistics on cancer and other diseases by local area; and resources.

What are possible causes of leukemia?
Anyone can get leukemia. Leukemia strikes all ages and both sexes. The cause of leukemia is not known. Chronic exposure to benzene, usually in the workplace, has been established as a cause of AML. Federal and State regulations have led to a reduction in such exposures. Extraordinary doses or irradiation can increase the incidence of AML, CML or ALL but not relationship has been established with lower doses such as those present with diagnostic imaging procedures. The use of certain types of chemotherapy for the treatment of other cancers may increase the risk of later developing AML. Source: Leukemia & Lymphoma Society

What are the risk factors for childhood leukemia?
For the most part, lifestyle risk factors such as diet and exercise, while important in adult cancers, are not linked to childhood cancers.

What are the symptoms of leukemia?
Early signs of childhood leukemia may be similar to those of the flu or other common diseases. General symptoms can include feeling tired or weak all the time, weight loss, fever and loss of appetite. Most symptoms of acute leukemia are caused by a shortage of normal blood cells. Anemia is a result of a shortage of red blood cells. Anemia causes shortness of breath, fatigue and a pale skin color. Not having enough platelets can lead to bruising, bleeding, frequent or severe nosebleeds and bleeding from the gums.

What should I do if I think my child may have leukemia?
Immediately consult your physician or healthcare provider for assistance, evaluation, and early intervention. Your physician will complete tests he or she determines to be needed to make an accurate diagnosis and begin treatment, if necessary. A bone marrow test is required to diagnose leukemia. Local physicians are monitoring all cases and will report any new diagnosis to the State Health Division.

How is leukemia treated?
Treatment decisions for each child are based on a number of individual factors. It is generally treated with chemotherapy. Chemotherapy refers to the use of anticancer drugs that enter the bloodstream and spread throughout the body to kill cancer cells.

Bone marrow transplants are also used in the early stages of some types of leukemia.

Can children who have leukemia be cured?
The five-year survival rate for patients with leukemia has tripled in the last 40 years. Today, the overall survival rate for patients with acute and chronic leukemia is 44 percent. The five-year survival rate for children with ALL is 81 percent; AML is 43 percent. The aim of treatment is to bring about a complete remission. Complete remission means that there is no evidence of the disease and the patient returns to good health with normal blood and marrow cells. Relapse indicates a return of the cancer cells and return of other signs and symptoms of the disease. For leukemia, a complete remission that lasts five years after treatment often indicates cure. Treatment centers are reporting increasing numbers of patients with leukemia in complete remission at least five years after diagnosis of their disease.

Where are the children from Fallon being treated?
The State Health Division and local medical authorities work to keep the identities of the children private. Some receive medical care in Fallon, while others travel out of state for specialized care from time to time. Others no longer reside in Churchill County.

Where can I get more information about leukemia?
State Health Division officials have set up a toll-free Community hotline, open weekdays between 8am and 6pm for inquiries: 1-888-608-4623.

State Health Division Web site, Health2k.state.nv.us
Leukemia and Lymphoma Society of America, www.leukemia.org or 1-800-955-4572
Childhood Leukemia Center, www.patientcenters.com
National Cancer Institute, www.nci.nih.gov or 1-800-4-CANCER
American Cancer Society, www.cancer.org or 1-800-ACS-2345
Department of Health and Human Services, www.os.dhhs.gov/
Centers for Disease Control, www.atsdr.cdc.gov/

Is there an elevated rate of other types of cancer in Fallon?
The State’s Cancer Registry has been analyzed, and Churchill County does not have an increased rate of any other type of cancer. This analysis is ongoing.

How long will it take to determine the cause?
Out of more than 700 state and federal cancer cluster investigations in the last three decades, almost all were inconclusive in identifying a source for the disease. Some high-profile cancer/leukemia cluster cases include: Tom’s River, NJ; Hinkley, CA; Woburn, MA; La Hague, France; and Seascale, Britain. The CDC and State Health Division have said that it would not be responding at this level if the agency didn’t believe there’s a possibility of finding a cause. The expert panel’s findings indicate three distinct possibilities that will be examined: environmental contaminants, infectious agents, and random chance. The mixing of Fallon’s more isolated population with other groups is being studied.

Where does the City of Fallon’s water come from and why is arsenic in the water?
The city’s water source has been an underground basalt aquifer for the past 58 years. Water is withdrawn from the aquifer through four deep wells. Arsenic is a naturally occurring mineral. The amount of arsenic in Fallon’s drinking water is 100 parts per billion (ppb), which exceeds the EPA standards. The arsenic levels are constant and have remained so for at least the 60 years that the municipal water system has operated.

The City of Fallon Municipal Water System routinely monitors for constituents according to Federal and State laws. The City monitored for 49 synthetic organic compounds and 56 volatile organic compounds and there were no detected quantities of any of these contaminants.

What is the City doing to take the arsenic out of the water?
The City is on target to meet the EPA deadline for arsenic removal by September 15, 2003. In 1990, The City of Fallon entered into a Compliance Schedule Agreement to remove arsenic from its public water supply once a standard was set. A permanent federal standard of 10ppb was not set until November 1, 2001.

Since last year, the City has been distributing quarterly notices to customers that advise using alternative sources for drinking water, including bottled water, filtered water available for purchase at grocery stores or water filtered at home through a reverse osmosis system.

The City performs regular tests on its water supply, and expanded those tests once the leukemia cluster was discovered. To date, only arsenic has been identified in the water. Tests for known carcinogens and contaminants have been extensive.

In April 2000, the City retained a nationally recognized environmental and engineering consulting firm, Shepherd Miller, to conduct chemistry testing of the city’s water. The City has exceeded required testing requirements, in both the frequency of testing and the types of contaminants. Additional tests have been completed for contaminants that are linked, or suspected to be linked, to leukemia. None were found. Water tests also show no contamination from fuel, radiation, pesticides or herbicides.

The City has been working with Shepherd Miller to determine which arsenic treatment technologies are best suited to Fallon’s water chemistry and will be installing a treatment system to meet all Federal requirements. Pilot testing was completed May 30, 2001. The results indicate that enhanced coagulation with pressure media filtration will be a cost effective method for arsenic removal to a level below 5 ppb.

The design of a treatment facility is scheduled for completion by June 30, 2002, and start-up testing will begin June 15, 2003.

Should I have my private well for drinking water tested?
If you don’t know what’s in your well, you should have it tested. You should know the arsenic levels, bacteria levels, and other contaminants present. You should contact the Health Division hotline at 1-888-608-4623 or Bureau of Health Protection Services in the Nevada State Health Division, 775-687-4750 extension 237.

The Cooperative Extension field office in Fallon and Churchill Community Hospital have teamed up to provide water testing information and instructions, sample bottles and courier service to the state laboratory on the UNR campus. The public transportation system serving Churchill County will even transport samples to the hospital if needed. For more information call Nevada Cooperative Extension at 775-428-0202.