PubLic Health Briefs a report to the US Congress on childhood lead poisoning. Environ Res 1989; 50:1136. 9. Pirkle JIL, Schwartz J, Landis JR, Harlan WR: The relationship between blood lead levels and blood-pressure and its cardiovascular risk implications. Am J Epidemiol 1985; 121:246-258. 10. Sharp DS, Smith AH, Holman BL, Fisher JM, Osterloh J, Becker CE: Elevated blood pressure in treated hypertensives with lowlevel lead accumulation. Arch Environ Health 1989; 44:18-22. 11. Meranger JC, Cunningham HM, Giraoux A: Extraction of heavy metals from plastic
12.
13. 14. 15.
food containers: An x-ray fluorescence and atomic absorption study. Can J Public Health 1974; 65:292-295. Alam MS, Srivastava SP, Seth PK Factors influencing the leaching of heavy metals from plastic materials used in the packaging of food and biomedical devices. Indian J Environ Health 1988; 30:131-141. Mimeault VJ: Colorants for plastics. Additives for Plastics, Vol. 2. New York: Academic Press, 1978. Reilly C: Metal Contamination of Food. London: Applied Science Publishers, 1980. Preda N, Popa L, Ariesan M: The possibility of food contamination with cadmium
by means of coloured plastics. J Appl Toxicol 1983; 3(3):139-142. 16. US Congress, Office of Technology Assessment: Facing America's Trash: What Next for Municipal Solid Waste? Washington, DC: OTA-424, 1989. 17. US Environmental Protection Agency: Air Quality Criteria for Lead Vol. II. EPA 600/ 8-83/028 BF. Washington, DC: EPA, June 1986. 18. American Academy of Pediatrics, Committee on Environmental Hazards, Committee on Accident and Poison Prevention: Statement on childhood lead poisoning. Pediatrics 1987; 79:457-465.
Non-Hodgkin's Lymphoma in a Cohort of Vietnam Veterans a cot~~~~~~ixt of it~~~~~~~~~$i3 Umte~~~~~~~.......at
Thomas R O'Brien MD, MPH, Pierre Decoufle, ScD, and Coleen A. Boyle, PhD
Introdudion Results of studies of occupational groups exposed to phenoxy herbicides have raised concems that Vietnam veterans may have an increased risk of developing non-Hodgkin's lymphoma (NHL) because of possible exposure to the phenoxy herbicide Agent Orange, used in South Vietnam between 1966 and 1970.1-3 These concerns have been heightened by reports of an increased risk of NHL among Vietnam veterans.4,5 In the Centers for Disease Control Vietnam Experience Study (VES), the health ofUS Army Vietnam veterans was compared with that of Vietnam-era Army veterans who had not served in Vietnam. Although the VES was not designed to assess the risk of rare cancers among Vietnam veterans, the high level of concern about NHL led us to investigate and report the findings for NHL. ---
Methds ......o
The study population consisted of 18,313 randomly selected, male US Army veterans (9,324 Vietnam veterans and 8,989 non-Vietnam veterans) who entered military service between January 1965 and December 1971. The VES included both mortality and health interview components, and the methods have been described in detail elsewhere.6,7 In this analysis, we combined mortality and interview data to determine the
number of veterans with NHL in the cohort. Two hundred forty-six Vietnam veterans and 200 non-Vietnam veterans had died between separation from active duty and December31, 1983, the closing date of the mortality component. A panel of physicians examined medical records of these veterans to determine the causes of death for each veteran. In the interview component of the VES, we attempted to locate and contact all veterans not identified as deceased. Altogether, we interviewed 15,288 veterans (87.3 percent of eligible Vietnam veterans and 83.8 percent of non-Vietnam veterans) by telephone during 1985-86. If the veteran reported that he had been diagnosed with cancer, we asked him to describe the type of cancer that he had. To verify three self-reported cases of NHL and to identify other cases, we sought medical records for 47 veterans, including men who reported a malignant neoplasm of the lymphatic or hematopoietic tissues, men who reported a diagnosis of cancer of a site that could be NHL (e.g. lung, neck, stomach, lymph nodes), and men who reported a diagnosis of cancer but could not name a specific tpe or site. We could not From the Center for Environmental Health and Injuiy Control, Centers for Disease Control. Address reprint requests to Thomas R. O'Brien, MD, MPH, CDC, 1600 Clifton Road (E45), Atlanta, GA 30333. This paper, submitted to the Journal May 25, 1990, was revised and accepted for publication January 23, 1991.
June 1991, Vol. 81, No. 6
Pubik Health Briefs
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obtain medical records for six of the 47 veterans; none of the six had reported a lymphatic or hematopoietic cancer during the interviews. We made final diagnoses on the basis ofpathology reports found in the medical records or, when no pathology report was available, the preponderance of evidence from the medical records. Pathology records were available in 31 of 41 (75.6 percent) of these medical records. For analytic purposes, we divided the number of veterans with NHL (ascertained through either the mortality component or the interview) in each cohort by the sum of the number of veterans who had died and the number of veterans who had been interviewed (8,170 Vietnam veterans and 7,564 non-Vietnam veterans).
Results We confirmed that all three veterans who had reported a history of NHL during the interview had been so diagnosed. A fourth veteran who, in the interview, had not specified the type of cancer had also been diagnosed with NHL. All four of these men were Vietnam veterans (Table 1). In the mortality study, three Vietnam veterans and one non-Vietnam veteran were found to have NHL. In total, seven Vietnam veterans and one non-Vietnam veteran were diagnosed with some type of NHL (p = 0.07, Fisher exact test (twotailed)). On the basis of published agespecific cancer incidence data,8 about 3.9
June 1991, Vol. 81, No. 6
cases of NHL would have been expected among Vietnam veterans (p = 0.10, Poisson) and about 3.5 cases would have been expected among non-Vietnam veterans (p = 0.14, Poisson). All of the Vietnam veterans with NHL had begun their tour in Vietnam from 1966 to 1968. The men had served in a variety of military occupations, and no specific occupation predominated. Regarding pathology, two Vietnam veterans were diagnosed as having Burkitt's lymphoma. On further pathologic review, one case was reported as possibly Burkitt's lymphoma, and the second was reported as acute lymphoblastic leukemia (Table 1). The "latency period" was short for two Vietnam veterans (Table 1). One veteran first developed NHL eight months after arriving in Vietnam and a second Vietnam veteran had a "latency period" of 47 months.
Discussion Although these results suggest an increased risk of NHL among Vietnam veterans, our findings should be interpreted with caution. The number of cases is small and, on review, one of the Vietnam veterans may have had lymphocytic leukemia rather than NHL. (These diseases are, however, closely related.9) The time period between the beginning ofthe veteran's tour of duty in Vietnam and the diagnosis of NHL should also be considered when in-
terpreting these data, as the "latent period" for some of the cases presented here is much shorter than the usual period for environmentally caused cancers.Y0 The collective evidence for an unusual risk of NHL among Vietnam veterans is inconsistent. Two other studies have shown that Vietnamveterans may be at increased risk of NHL. Increased mortality from NHL was seen in a large study of US Marine Corps Vietnam veterans (proportionate mortality ratio (PMR) = 2.10; 95% confidence interval = 1.173.79), although the same investigators found a deficit of deaths from NHL in US Army veterans (PMR = 0.81; 95% CI = 0.63-1.04).4 An elevated risk of NHL in Vietnam veterans was also reported in a large population-based case-control study (Odds ratio = 1.47; 95% CI = 1.09-1.97).5 In contrast, a case-control study using subjects from Veterans Administration hospitals found a modest negative association between Vietnam service and NHL (OR = 0.72; 95% CI = 0.560.92).11 We could only indirectly assess possible exposure of these veterans to Agent Orange while in Vietnam. Although most of the men served in Vietnam during the time (1967-69) and area (III Corps) of heaviest spraying,' three of seven had non-combat militaryjob titles that suggest they were unlikely to have been in contact with herbicides. Although the three men with combat-related job titles may have been exposed to Agent Orange, previous
American Journal of Public Health 759
Public Health Briefs
work suggests that, with the exception of men whose military occupation entailed handling herbicides, most US Army combat troops who served in Vietnam were not heavily exposed to dioxin.12 Since no other factor in the Vietnam experience has been linked to the increased NHL risk, reasons for the excess found in this study and two other studies remain unclear. O
2.
3.
4.
Acklowledgments
sions. Washington, DC: National Academy of Sciences, 1974; 111-117. Hardell L, Ericksson M, Lenner P, et aL Malignant lymphoma and exposure to chemicals, especially organic solvents, chlorophenols and phenoxy acids: A casecontrol study. Br J Cancer 1981; 43:169176. Hoar SK, Blair A, Holmes FF, et ak Agricultural herbicide use and risk of lymphoma and soft-tissue sarcoma. JAMA 1986; 256:1141-1146. Breslin P, Kang K, Lee Y, Burt V, Shepard BM: Proportionate mortality study of US Army and US Marine Corps veterans of the Vietnam war. JOM 1988; 30:412419. Selected Cancers Cooperative Study Group. The association of selected cancers with service in the US military in Vietnam. I. Non-Hodgkin's Lymphoma. Arch Intern
Linda Moyer, RN, obtained and abstracted medical records that were reviewed in this study. Dr. Elaine S. Jaffe reviewed microscopic tissue specimens. Sandra Tully and Sheila Allgood assisted with manuscript preparation. Data for this study were gathered under an interagency agreement with the Veterans Administration.
5.
References
6. Centers for Disease Control Vietnam Experience Study. Postservice mortality among Vietnam veterans. JAMA 1987;
1. Committee on the Effects of Herbicides in Vietnam: The effects ofherbicides in South Vietnam. Part A-Summary and conclu-
Med 1990; 150:2473-2483.
257:790-795. 7. Centers for Disease Control Vietnam
Experience Study: Health status of Vietnam veterans. I. Psychosocial characteristics. JAMA 1988; 259:2701-2707. 8. National Cancer Institute: Surveillance, epidemiology, and end results: Incidence and mortality data, 1973-77. National Cancer Institute Monograph 57. NIH Pub. No. 81-2330. Washington, DC: Govt Printing Office, 1981. 9. Heath CW Jr: The leukemias. In: Schottenfeld D, Fraumeni JF Jr (eds): Cancer Epidemiology and Prevention. Philadelphia: WB Saunders, 1982; 728-738. 10. Decoufle P: Occupation. Ix Schottenfeld D, Fraumeni JF Jr (eds): Cancer Epidemiology and Prevention. Philadelphia: WB Saunders, 1982; 318-335. 11. Dalager N, Kang H, Burt V: NonHodgkin's lymphoma among Vietnam-era veterans (abstract). Am J Epidemiol 1989; 130:815. 12. Centers for Disease Control Veterans Health Studies: Serum 2,3,7,8-tetrachlorodibenzo-p-dioxin levels in US Army Vietnam-era veterans. JAMA 1988; 260:1249-1254.
Endemic Giardiasis and Municipal Water Supply G. Graham Fraser, MB, ChB, MSc, and Kenneth R. Cooke, MB, ChB, PhD ...........
o
ar
N~~~~~w Z~~~~uw J~~~~~................emu33(9O%~~~~~~~~~~~~~........
Introdution
Methods
Epidemics of waterbome giardiasis originating from water supplies have been clearly associated with surface catchments, treatment systems that do not eliminate Giardia cysts, and downstream contamination of the reticulation system.1-5 In contrast, there have been few tests of the hypothesis that surface catchment waters contribute to endemic giardiasis where treatment systems cannot eliminate cysts.16,7 Giardia cysts have only recently been isolated from water supplies in New Zealand. No substantive epidemics attributable to giardiasis have yet been documented. Many municipal supplies use surface waters and simple treatment methods that would not reliably filter or deactivate giardia cysts.3,8 The present study took advantage of a natural experiment-the divided water supply of the city of Dunedin, New Zealand-to test the hypothesis that endemic giardiasis might be transmitted by unfiltered municipal water supplies.
Dunedin (population 89,000) is supplied almost entirely by water from surface catchments. Most water is filtered by mechanical microstrainers (screen size 23 jLm). Part of the city water is treated at a modem station (Mount Grand) using coagulation/flocculation and direct dual media filtration (anthracite and silica sand) that would normally be expected to remove any Giardia cysts present.3'8 All water supplies are chlorinated and fluoridated. Records of all laboratory-proven cases of giardiasis from persons residing within the Dunedin municipal water supAddress reprint requests to G. Graham Fraser, MB, Manager, Public Health and Primary Care Programs, Otago Area Health Board, Dunedin, New Zealand. He is also Clinical Lecturer, and Dr. Cooke is Senior Lecturer in Epidemiology, in the Department of Preventive and Social Medicine, University of Otago Medical School. This paper, submitted to the Journal June 1, 1990, was revised and accepted for publication January 24, 1991.
June 1991, Vol. 81, No. 6
12.
13. 14. 15.
food containers: An x-ray fluorescence and atomic absorption study. Can J Public Health 1974; 65:292-295. Alam MS, Srivastava SP, Seth PK Factors influencing the leaching of heavy metals from plastic materials used in the packaging of food and biomedical devices. Indian J Environ Health 1988; 30:131-141. Mimeault VJ: Colorants for plastics. Additives for Plastics, Vol. 2. New York: Academic Press, 1978. Reilly C: Metal Contamination of Food. London: Applied Science Publishers, 1980. Preda N, Popa L, Ariesan M: The possibility of food contamination with cadmium
by means of coloured plastics. J Appl Toxicol 1983; 3(3):139-142. 16. US Congress, Office of Technology Assessment: Facing America's Trash: What Next for Municipal Solid Waste? Washington, DC: OTA-424, 1989. 17. US Environmental Protection Agency: Air Quality Criteria for Lead Vol. II. EPA 600/ 8-83/028 BF. Washington, DC: EPA, June 1986. 18. American Academy of Pediatrics, Committee on Environmental Hazards, Committee on Accident and Poison Prevention: Statement on childhood lead poisoning. Pediatrics 1987; 79:457-465.
Non-Hodgkin's Lymphoma in a Cohort of Vietnam Veterans a cot~~~~~~ixt of it~~~~~~~~~$i3 Umte~~~~~~~.......at
Thomas R O'Brien MD, MPH, Pierre Decoufle, ScD, and Coleen A. Boyle, PhD
Introdudion Results of studies of occupational groups exposed to phenoxy herbicides have raised concems that Vietnam veterans may have an increased risk of developing non-Hodgkin's lymphoma (NHL) because of possible exposure to the phenoxy herbicide Agent Orange, used in South Vietnam between 1966 and 1970.1-3 These concerns have been heightened by reports of an increased risk of NHL among Vietnam veterans.4,5 In the Centers for Disease Control Vietnam Experience Study (VES), the health ofUS Army Vietnam veterans was compared with that of Vietnam-era Army veterans who had not served in Vietnam. Although the VES was not designed to assess the risk of rare cancers among Vietnam veterans, the high level of concern about NHL led us to investigate and report the findings for NHL. ---
Methds ......o
The study population consisted of 18,313 randomly selected, male US Army veterans (9,324 Vietnam veterans and 8,989 non-Vietnam veterans) who entered military service between January 1965 and December 1971. The VES included both mortality and health interview components, and the methods have been described in detail elsewhere.6,7 In this analysis, we combined mortality and interview data to determine the
number of veterans with NHL in the cohort. Two hundred forty-six Vietnam veterans and 200 non-Vietnam veterans had died between separation from active duty and December31, 1983, the closing date of the mortality component. A panel of physicians examined medical records of these veterans to determine the causes of death for each veteran. In the interview component of the VES, we attempted to locate and contact all veterans not identified as deceased. Altogether, we interviewed 15,288 veterans (87.3 percent of eligible Vietnam veterans and 83.8 percent of non-Vietnam veterans) by telephone during 1985-86. If the veteran reported that he had been diagnosed with cancer, we asked him to describe the type of cancer that he had. To verify three self-reported cases of NHL and to identify other cases, we sought medical records for 47 veterans, including men who reported a malignant neoplasm of the lymphatic or hematopoietic tissues, men who reported a diagnosis of cancer of a site that could be NHL (e.g. lung, neck, stomach, lymph nodes), and men who reported a diagnosis of cancer but could not name a specific tpe or site. We could not From the Center for Environmental Health and Injuiy Control, Centers for Disease Control. Address reprint requests to Thomas R. O'Brien, MD, MPH, CDC, 1600 Clifton Road (E45), Atlanta, GA 30333. This paper, submitted to the Journal May 25, 1990, was revised and accepted for publication January 23, 1991.
June 1991, Vol. 81, No. 6
Pubik Health Briefs
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............
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Xe
....
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X
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x ..................... .......... ............
WI .............%_.-.-...:... .......................................
obtain medical records for six of the 47 veterans; none of the six had reported a lymphatic or hematopoietic cancer during the interviews. We made final diagnoses on the basis ofpathology reports found in the medical records or, when no pathology report was available, the preponderance of evidence from the medical records. Pathology records were available in 31 of 41 (75.6 percent) of these medical records. For analytic purposes, we divided the number of veterans with NHL (ascertained through either the mortality component or the interview) in each cohort by the sum of the number of veterans who had died and the number of veterans who had been interviewed (8,170 Vietnam veterans and 7,564 non-Vietnam veterans).
Results We confirmed that all three veterans who had reported a history of NHL during the interview had been so diagnosed. A fourth veteran who, in the interview, had not specified the type of cancer had also been diagnosed with NHL. All four of these men were Vietnam veterans (Table 1). In the mortality study, three Vietnam veterans and one non-Vietnam veteran were found to have NHL. In total, seven Vietnam veterans and one non-Vietnam veteran were diagnosed with some type of NHL (p = 0.07, Fisher exact test (twotailed)). On the basis of published agespecific cancer incidence data,8 about 3.9
June 1991, Vol. 81, No. 6
cases of NHL would have been expected among Vietnam veterans (p = 0.10, Poisson) and about 3.5 cases would have been expected among non-Vietnam veterans (p = 0.14, Poisson). All of the Vietnam veterans with NHL had begun their tour in Vietnam from 1966 to 1968. The men had served in a variety of military occupations, and no specific occupation predominated. Regarding pathology, two Vietnam veterans were diagnosed as having Burkitt's lymphoma. On further pathologic review, one case was reported as possibly Burkitt's lymphoma, and the second was reported as acute lymphoblastic leukemia (Table 1). The "latency period" was short for two Vietnam veterans (Table 1). One veteran first developed NHL eight months after arriving in Vietnam and a second Vietnam veteran had a "latency period" of 47 months.
Discussion Although these results suggest an increased risk of NHL among Vietnam veterans, our findings should be interpreted with caution. The number of cases is small and, on review, one of the Vietnam veterans may have had lymphocytic leukemia rather than NHL. (These diseases are, however, closely related.9) The time period between the beginning ofthe veteran's tour of duty in Vietnam and the diagnosis of NHL should also be considered when in-
terpreting these data, as the "latent period" for some of the cases presented here is much shorter than the usual period for environmentally caused cancers.Y0 The collective evidence for an unusual risk of NHL among Vietnam veterans is inconsistent. Two other studies have shown that Vietnamveterans may be at increased risk of NHL. Increased mortality from NHL was seen in a large study of US Marine Corps Vietnam veterans (proportionate mortality ratio (PMR) = 2.10; 95% confidence interval = 1.173.79), although the same investigators found a deficit of deaths from NHL in US Army veterans (PMR = 0.81; 95% CI = 0.63-1.04).4 An elevated risk of NHL in Vietnam veterans was also reported in a large population-based case-control study (Odds ratio = 1.47; 95% CI = 1.09-1.97).5 In contrast, a case-control study using subjects from Veterans Administration hospitals found a modest negative association between Vietnam service and NHL (OR = 0.72; 95% CI = 0.560.92).11 We could only indirectly assess possible exposure of these veterans to Agent Orange while in Vietnam. Although most of the men served in Vietnam during the time (1967-69) and area (III Corps) of heaviest spraying,' three of seven had non-combat militaryjob titles that suggest they were unlikely to have been in contact with herbicides. Although the three men with combat-related job titles may have been exposed to Agent Orange, previous
American Journal of Public Health 759
Public Health Briefs
work suggests that, with the exception of men whose military occupation entailed handling herbicides, most US Army combat troops who served in Vietnam were not heavily exposed to dioxin.12 Since no other factor in the Vietnam experience has been linked to the increased NHL risk, reasons for the excess found in this study and two other studies remain unclear. O
2.
3.
4.
Acklowledgments
sions. Washington, DC: National Academy of Sciences, 1974; 111-117. Hardell L, Ericksson M, Lenner P, et aL Malignant lymphoma and exposure to chemicals, especially organic solvents, chlorophenols and phenoxy acids: A casecontrol study. Br J Cancer 1981; 43:169176. Hoar SK, Blair A, Holmes FF, et ak Agricultural herbicide use and risk of lymphoma and soft-tissue sarcoma. JAMA 1986; 256:1141-1146. Breslin P, Kang K, Lee Y, Burt V, Shepard BM: Proportionate mortality study of US Army and US Marine Corps veterans of the Vietnam war. JOM 1988; 30:412419. Selected Cancers Cooperative Study Group. The association of selected cancers with service in the US military in Vietnam. I. Non-Hodgkin's Lymphoma. Arch Intern
Linda Moyer, RN, obtained and abstracted medical records that were reviewed in this study. Dr. Elaine S. Jaffe reviewed microscopic tissue specimens. Sandra Tully and Sheila Allgood assisted with manuscript preparation. Data for this study were gathered under an interagency agreement with the Veterans Administration.
5.
References
6. Centers for Disease Control Vietnam Experience Study. Postservice mortality among Vietnam veterans. JAMA 1987;
1. Committee on the Effects of Herbicides in Vietnam: The effects ofherbicides in South Vietnam. Part A-Summary and conclu-
Med 1990; 150:2473-2483.
257:790-795. 7. Centers for Disease Control Vietnam
Experience Study: Health status of Vietnam veterans. I. Psychosocial characteristics. JAMA 1988; 259:2701-2707. 8. National Cancer Institute: Surveillance, epidemiology, and end results: Incidence and mortality data, 1973-77. National Cancer Institute Monograph 57. NIH Pub. No. 81-2330. Washington, DC: Govt Printing Office, 1981. 9. Heath CW Jr: The leukemias. In: Schottenfeld D, Fraumeni JF Jr (eds): Cancer Epidemiology and Prevention. Philadelphia: WB Saunders, 1982; 728-738. 10. Decoufle P: Occupation. Ix Schottenfeld D, Fraumeni JF Jr (eds): Cancer Epidemiology and Prevention. Philadelphia: WB Saunders, 1982; 318-335. 11. Dalager N, Kang H, Burt V: NonHodgkin's lymphoma among Vietnam-era veterans (abstract). Am J Epidemiol 1989; 130:815. 12. Centers for Disease Control Veterans Health Studies: Serum 2,3,7,8-tetrachlorodibenzo-p-dioxin levels in US Army Vietnam-era veterans. JAMA 1988; 260:1249-1254.
Endemic Giardiasis and Municipal Water Supply G. Graham Fraser, MB, ChB, MSc, and Kenneth R. Cooke, MB, ChB, PhD ...........
o
ar
N~~~~~w Z~~~~uw J~~~~~................emu33(9O%~~~~~~~~~~~~~........
Introdution
Methods
Epidemics of waterbome giardiasis originating from water supplies have been clearly associated with surface catchments, treatment systems that do not eliminate Giardia cysts, and downstream contamination of the reticulation system.1-5 In contrast, there have been few tests of the hypothesis that surface catchment waters contribute to endemic giardiasis where treatment systems cannot eliminate cysts.16,7 Giardia cysts have only recently been isolated from water supplies in New Zealand. No substantive epidemics attributable to giardiasis have yet been documented. Many municipal supplies use surface waters and simple treatment methods that would not reliably filter or deactivate giardia cysts.3,8 The present study took advantage of a natural experiment-the divided water supply of the city of Dunedin, New Zealand-to test the hypothesis that endemic giardiasis might be transmitted by unfiltered municipal water supplies.
Dunedin (population 89,000) is supplied almost entirely by water from surface catchments. Most water is filtered by mechanical microstrainers (screen size 23 jLm). Part of the city water is treated at a modem station (Mount Grand) using coagulation/flocculation and direct dual media filtration (anthracite and silica sand) that would normally be expected to remove any Giardia cysts present.3'8 All water supplies are chlorinated and fluoridated. Records of all laboratory-proven cases of giardiasis from persons residing within the Dunedin municipal water supAddress reprint requests to G. Graham Fraser, MB, Manager, Public Health and Primary Care Programs, Otago Area Health Board, Dunedin, New Zealand. He is also Clinical Lecturer, and Dr. Cooke is Senior Lecturer in Epidemiology, in the Department of Preventive and Social Medicine, University of Otago Medical School. This paper, submitted to the Journal June 1, 1990, was revised and accepted for publication January 24, 1991.
June 1991, Vol. 81, No. 6
