1. Venice, december 17th, 2007.ISPESL & ICEMS Foundations of bioelectromagnetics: Anna Zucchero MD towards a new rationale for risk assessment and management Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital.

2. ELECTROSENSITIVITY (ES) (Perception of electromagnetic field - emf) ELECTROHYPERSENSITIVITY (EHS) (Reaction to emf : imply an established casual trigger or decisive relationship between symptoms and emf. WHO, 2006) Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

3. Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital The perception threshold of the most sensible person is 8 fold (men) and 15 fold (women) lower than the related mean values; The perception threshold of the most sensible person is 8 fold (men) and 15 fold (women) lower than the related mean values; Considerably more women are classified as very sensible (4.2%) compared with men (1.7%); Considerably more women are classified as very sensible (4.2%) compared with men (1.7%); Electrosensitivity in very sensible people have more variability in different days as regards the normal people. Electrosensitivity in very sensible people have more variability in different days as regards the normal people. 2% of very sensible people dont have subjective EHS symptoms. 2% of very sensible people dont have subjective EHS symptoms. THE AUTHORS MAKE A HYPOTHESIS THAT THESE DIFFERENCES DEPEND OF DIFFERENT STATUS OF THE AUTONOMOUS NERVOUS SYSTEM (LYSKOV ET AL. 2001) Leitgeb et al. 2003 - Austria

4. ES: the distribution of men population according to the perception level of low frequency emf (50 Hz) (Leitgeb et al. 2002) Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

5. Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital EHSGENERALPOPULATIONT-test Electrosensitive56%~18%P<0,001 Very electrosensitive 11% 2 % P<0,001 Schröttner J. et al - 2007 - Austria Electric current perception: the distribution of population according to the perception level of low frequency emf (50 Hz) in general population and EHS population. Comment: In this study it sees that the EHS have the perception threshold lower than the general population but 33% not differ from general population.

6. Electric current perception ability of elderly people dont differ from adult general population; Electric current perception ability of elderly people dont differ from adult general population; Question of the authors: Question of the authors: ES is precondition to develop health problem or ES is a consequence of imprecise health problem of EHS people? ES is precondition to develop health problem or ES is a consequence of imprecise health problem of EHS people? Nervous system status dysbalance could be important rather than a causal EMF interaction? Nervous system status dysbalance could be important rather than a causal EMF interaction? (Lyskov et al. 2001) Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital Schröttner J. et al - 2007 - Austria

7. THE MAGNETIC ELECTROHYPERSENSITIVITY THE MAGNETIC ELECTROHYPERSENSITIVITY Definition: symptoms that are experienced in proximity to or during the use of electrical equipment and that result in varying degree of disconfort or ill health and that an individual attributes to activation of electrical equipment Definition: symptoms that are experienced in proximity to or during the use of electrical equipment and that result in varying degree of disconfort or ill health and that an individual attributes to activation of electrical equipment (Hillert L. 2004, Sweden in Proceeding International Workshop on EMF Hypersensitivity. Prague, 2004. Publication of WHO, 2006); The symptoms appear at the EMF level more lower than those considerate dangerous for the health due to the thermal effects. Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

8. WHO SUMMARY WORKSHOP PRAGUE 2004 Publication 2006 The symptoms are real and can vary widely in their severity. For some individuals the symptoms can change their life style The symptoms are real and can vary widely in their severity. For some individuals the symptoms can change their life style Like other Idyopathic Environmental Intolerance (IEI) it is: Like other Idyopathic Environmental Intolerance (IEI) it is: An acquired disorder with multiple recurrent symptoms; An acquired disorder with multiple recurrent symptoms; Associated with diverse environmental factor tolerated by the majority of people Associated with diverse environmental factor tolerated by the majority of people Not explained by any known medical psychiatric or psychological disorder or organic diseases Not explained by any known medical psychiatric or psychological disorder or organic diseases Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

9. ETIOPATOGENESIS EXISTS EXISTS Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital EMF – EHS CAUSAL RELATIONSHIP DONT EXISTS DONT EXISTS There are two scientific positions

10. ETIOPATOGENESIS EXISTS EXISTS There is a causal relationship EMF-EHS or trigger or decisive. Many studies found a temporary-spatial relationship between EMF sources and persons with EHS symptoms; other studies founded biological mechanism explaining EHS. Experimental study: Johansson O. Sweden: Evidence for effect on the immune system Bioinitiative report 2007 Lai H. USA : Evidence for effect on neurology and behavior. Bioinitiative report 2007 Goldsworthy A. UK: The biological effects of weak electromagnetic field: Ca++ theory. Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital EMF – EHS CAUSAL RELATIONSHIP

11. EXISTS EXISTS OBSERVATIONAL STUDY: RESIDENTIAL EXPOSURE : Santini R. 2002 France Navarro E. 2003 Spain Oberfeld G. 2004 Spain Preece A.W. 2005 Ciprus Hutter E.R. 2006 Austria Abdel Rassoul. 2006 Egypt OCCUPATIONAL EXPOSURE Hansson Mild K. et al Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital EMF – EHS CAUSAL RELATIONSHIP ETIOPATOGENESIS

12. EXISTS EXISTS CLINICAL STUDY: Huss A. 2006 Switzerland. General Practitioners observed in clinical work problems in patient to use mobile phone or to live near base-station APPEALS (Bamberg, Friburg, Ireland) ANIMAL STUDY: Balmori A.2005. Spain (The behavior of the white stork) Johansson O. Sweden (Thiroid biopsies in rats ). Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital EMF – EHS CAUSAL RELATIONSHIP ETIOPATOGENESIS

13. ETIOPATOGENESIS DONT EXISTS The problem is REAL but there isnt an established causal relationship between EHS symptoms and EMF Health policy organization WHO: WHO 2004, Prague (published 2006) propose a new name for EHS people: ELECTROMAGNETIC FIELD ATTRIBUTED SYMPTOMS: like multichemical attributed symptoms is idiopathic environmental intolerance (IEI), term originate on 1996, in Berlin at the International Program of Chemical Safety of the WHO. This position is based on provocation tests review Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital EMF – EHS CAUSAL RELATIONSHIP

14. DONT EXISTS 2 PROVOCATION TEST REVIEW 1) Rubin Y 2005, UK Author identify all blind or double blind provocation studies for EHS to answer the follwing questins: are people who are apparently hypersensitive to weak EMFs better et detecting these fields under blind or boubleblind condition than non hypersensitive individuals. He valuate total number of correct discrimination between active and sham and/or self reported symptom of 13 provocation studies with visual display, 7 provocation studies with cell phone and 1 base station, 11 provocation studies with ELF (7) and varying frequency (4). Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital EMF – EHS CAUSAL RELATIONSHIP ETIOPATOGENESIS

15. DONT EXISTS Even recognizing that the results of these studies will determine whether any more search in this area is needed and list methodological advises, conclude this systematic review could find no robust evidence to support the existence of a biophysical hypersensitivity to EMF Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre HospitalETIOPATOGENESIS EMF – EHS CAUSAL RELATIONSHIP

16. DONT EXISTS 2) Seitz H. 2005, Germany Author reviewed about EHS and subjective health complains associated with electromagnetic field of mobile phone communication. 11 papers and 2 reports had a quality criteria: 7 observational studies ( 2 base station and 4 mobile phone exposure) and 6 experimental studies (1 base station and 5 mobile phone exposure). Conclusion: …the greater part of these studies is not able to address the issue of causality between exposure and outcome in order to obtain more insights in the phenomenon EHS an interdisciplinary research is needed… Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre HospitalETIOPATOGENESIS EMF – EHS CAUSAL RELATIONSHIP

17. DONT EXISTS WHO despite the criticism of the same authors use these 2 review like a demonstration that there isnt causality between EMF and EHS. The principal criticism are: methodological: low number of studied subjects that reducing the significance; There are different modalities of choice of sample; (Schröttner, 2007) describes different results depending of the recruitment of people; Absence of health controls (Rubin); Major number of studies with ELF than RF; Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre HospitalETIOPATOGENESIS EMF – EHS CAUSAL RELATIONSHIP

18. DONT EXISTS Variability of the EMF in the environment of the experiment; amagnetic room is not used and the electromagnetic background indoor and outdoor level is not considered; it contributes with exposed used EMF source to EHS and control subjects reaction. For example the ELF exposure reduces the pain threshold even on not EHS (Ghione, 2004. Italy); Variability of examined subject: the sensibility threshold is varying day by day (Leitgeb, 2003) and the study must considerate this variation. Time to appearance and disappearance of symptoms is varying in the same or different subjects. Use of Health outcome not measurable and objective Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre HospitalETIOPATOGENESIS EMF – EHS CAUSAL RELATIONSHIP

19. Pain threshold of an exposure to 37 Hz emf (Ghione et al. 2004) Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

20. The Epidemiology 1-3% of population (Hillert L. 2002, Levallois 2002); (self help groups say about 10%) Most frequently women (not all studies); All ages even children and elderly ( Roosli most frequently between 40 and 70 years old); Often associated to multichemiosensibility (MCS); The cultural level for someone indifferent, for other a level most elevated; Premorbid situations: cranial or spinal trauma, electroshock, metallic implants (Sick 2003, HPA); Trend increasing: De Carlo 2006.USA 25% of population can become EHS in 2016; Hardell, 2006, Sweden: 50% of population can become EHS in 2009. Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

21. Hardell L. 2007 Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

22. Electromagnetic sources Exposure mode: residential, personal and working (telecomunication, security staff, weld staff, hairdresser, power station, office staff) Beginning sources Beginning sources (Health Protection Agency, Irvine 2004) TV and computer monitors; Electricity (power-lines, power stations, wirings, household appliances) Mobile telephony (base stations, cell phones, wireless), radio and TV installations, radar Trigger sources (association experience) Artificial: low frequency, high frequency, (indoor – outdoor); Artificial: low frequency, high frequency, (indoor – outdoor); Natural: volcanic area, meteo conditions; Natural: volcanic area, meteo conditions; Electrostatic charges (synthetic clothes, objects, environment ionizing with positive charge, near power lines, indoor); Electrostatic charges (synthetic clothes, objects, environment ionizing with positive charge, near power lines, indoor); (noises, ultra-infrasound), sun light, laser; (noises, ultra-infrasound), sun light, laser; (ionizing radiations); (ionizing radiations); Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

23. Compliance with the present guidelines may not necessarily preclude interference with, or effects on, medical devices such as metallic prostheses, cardiac pacemakers and defibrillators, and cochlear implants. Interference with pacemakers may occur at levels below the recommended reference levels. Advice on avoiding these problems is beyond the scope of the present document but is available elsewhere (UNEP/WHO/IRPA 1993) Pag. 3 ICNIRP Guidelines GUIDELINES FOR LIMITING EXPOSURE TO TIME- VARYING ELECTRIC,MAGNETIC, AND ELECTROMAGNETIC FIELDS (up to 300 GHz ) Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital International Commission on Non-Ionizing Radiation Protection

24. Appear with the exposure Dissapear with removal from electromagnetic sources The symptoms Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

25. General: weakness, easy exhaustibility, indefinite indisposition, sensation of cold, intolerance to cold; Neurologic: headache, burning, piercing, lancinanting, osteomuscular pain, stiffness, muscular miolonic yerk and shakes, tremors, insomnia, non refreshing sleep, invertion of the rhythm sleep – waking; Psychological: depression, irritability, hostility, anxiety, lost of control; Cognitive: lost of memory, low concentration; Ocular: burning, irritability, visual difficulty, light intolerance. Symptoms : the manifestations (Bergdahl 1995-1998, Hillert 1999, Stender 2002, Roosli 2004, Associazioni di ES ) Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

26. Symptoms : the manifestations (Bergdahl 1995-1998, Hillert 1999, Stender 2002, Roosli 2004, Associazioni di ES ) Oto vestibolar: excess of auditive sensibility, auricular constipation, tinnitus (noise on the ears), space disorientation, vertigo; Nasal: iperosmium Cardiovascular: instability of blood pressure, palpitation, cutaneous vessel lability (pallor or irritation); Respiration: thoracic oppression, short and/or irregular breath, breath pauses; Digestive: much or less appetite, thirst, nausea, indigestion, hiccup; Cutaneous: cutaneous reaction, fast nail-hair growth. Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

27. Localized generalized Reversible continous irreversible Time to appear: few minutes, some hours Duration: short or long (even months) No differences related to trigger or beginning sources; Geographic differences. Symptoms: the characteristics Symptoms: the characteristics (FEB, russian studies) Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

28. Physiopathology Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD. Internal Medicine Department Effects on hypersensitive people Venice Mestre Hospital

29. Physiopathology Alterations of autonomic nervous system Perception Schmelz et al, 1994: low frequency emf can activate branches of fiber C of human skin usually insensitive to the stimulus. Schmelz et al, 1994: low frequency emf can activate branches of fiber C of human skin usually insensitive to the stimulus. Hocking, 2004:cell phone users hypersensitive at auricular level presents alterations of fiber C; Hocking, 2004:cell phone users hypersensitive at auricular level presents alterations of fiber C; Ghione et al, 2004: noted a lowering of the pain threshold in normal males exposed to 37 Hz as regards the controls. Ghione et al, 2004: noted a lowering of the pain threshold in normal males exposed to 37 Hz as regards the controls.Answer Sandstrom et al, 2003: have demonstrated alterations of the cardiac frequency in EHS, exposed to emf as regards the controls; Sandstrom et al, 2003: have demonstrated alterations of the cardiac frequency in EHS, exposed to emf as regards the controls; Ghione et al, 2004: demonstrated alterations of arterial pressure and cardiac frequence in health males exposed to emf as regards the controls; Ghione et al, 2004: demonstrated alterations of arterial pressure and cardiac frequence in health males exposed to emf as regards the controls; Beale et al, 1997: noted psychological effects in population exposed to low frequency; Beale et al, 1997: noted psychological effects in population exposed to low frequency; Rea, 1991: noted pupillary alterations in EHS Rea, 1991: noted pupillary alterations in EHS Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

30. Natural history Hygiene and Medicine of work Institute, Science Academy of URSS, 1965 Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

31. Natural history Natural history (Bergqvist e Vogel Sweden, 1997) Stage 1 Temporary symptoms Usually the subjects heard speaking of the EHS existence and think that its possible to be associated to their symptoms; Stage 2 The symptoms persists and intensity increasing, duration, number: the association with emf become sure and can get an avoid behavior; Stage 3 This stage is lived by few persons. Often are reported symptoms neurovegetative near many emf sources. Avoiding can take extreme measures. Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

32. Diagnosis C c 1. Clinical criterion: there not exists standard criterion yet. Now the diagnosis is based on the symptoms refered by the subject and on the exclusion by the medical doctor of other psychiatric or organic diseases (WHO Report, Prague congress, 2004). Eltiti et al. 2006, have done a questionaire with validations 2. Provocation test (review Rubin 2005 and Seitz 2005) now there not exists validate provocation tests. Anyway see the limits of these tests described before.

33. 3. Tests: lab (characterization of lymphocytes, fractionated dosage urinary melatonin, hormonal dosage, liver, other tests); Instrumental (EEG, ECG sec. Holter, Holter blood pressure, EMG, ERG, VEP, laser doppler, electro dermal activity, other tests); Limits Many tests are normal if there isnt emf exposure; There are not standardized it mean are not defined the sesitivity and the specificity; Utility Can be useful for exclude other pathologies.Diagnosis Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

34. Prognosis Generalized EHS: worse than localized; (Stenberg 2002, Eriksson 1997) The 3rd stage described by russian studies is irreversible. Survival unknown; Handicap: 10% of EHS have symptoms that can compromise the social, family, working life and the activities of daily life. Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

35. EHS: what to do ? Traditional medicine Swedish studies (Hillert L, Graz- Austria 1998, reported by HPA UK 2005 Prevention of the EHS with information Medical visit at first symptoms: tests at first symptoms and certification af disability (only in Sweden the EHS is recognized like disability). Advise if the symptoms persists behavior therapy, antidepressive drugs, shiatsu, hypnosis Avoiding emf without isolate Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

36. EMF: what to do ? Non conventional medicine Individual solutions (WHO says this is not necessary, Prague, 2004) but for many EHS are very useful: shielding grounding avoiding Public solutions: 2 positions WHO say there is no indication that lowering internationally accepted limits would reduce the prevalence of symptoms attributed to EMF. Santini R. 2006 advise EHS lives in a EMF environmental which tend to zero. Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

37. EHS: what to do ? Roosli 2005, Switzerland: questionnaire results : Solutions: avoiding 67 % shielding 25 % Results: no result 25 % a little better 37 % much better 29 % Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

38. Shielding material from EMF Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

39. Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

40. Power in V/m of GSM (1800-1900 Mhz) in residential area Level of voice telephone cover 0.00194 V/m Level measured in Italian cities ~6 V/m Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

41. Italian Association of Electrosensitive (from 2005) 100 persons; 100 persons; 70% women; 70% women; age: 12-80 years old; age: 12-80 years old; Autoimune tiroiditis 50% of women; Autoimune tiroiditis 50% of women; metallic prostheses; beginning soucrces RF,MW 95% Begin of EHS 96-97 Generalized 100% MCS associated 10% Graveness:100% change life style at the work, society and family Based on: Italian Constitution; UN rules about disability 1993; International Accord for Human Rights We asked recognizing of EHS like disease and disability. Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

42. Galileo Galilei 1564-1642 Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital

43. We need many Galileo Galilei for a free science… Venice, december 17th, 2007. ISPESL & ICEMS Anna Zucchero MD Internal Medicine Department Effects on hypersensitive people Venice-Mestre Hospital