{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T06:44:53Z","timestamp":1788331493136,"version":"build-2803163510"},"reference-count":24,"publisher":"MDPI AG","issue":"18","license":[{"start":{"date-parts":[[2021,9,19]],"date-time":"2021-09-19T00:00:00Z","timestamp":1632009600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>When a study population is relatively healthy, such as an occupational population, epidemiological studies are likely to underestimate risk. We used a case study on the cancer risk of workers with exposure to acid mists, a well-documented carcinogen, to demonstrate that using proportional mortality ratios (PMRs) is more appropriate than mortality ratios in assessing risk in terms of mortality. The study included 10,229 employees of a telecommunication company who worked in buildings with battery rooms. In these buildings, the battery rooms had the highest levels of sulfuric acid in the air (geometric mean = 10.7 \u03bcg\/m3). With the general population in Taiwan as a reference, a decreased standardized mortality ratio (0.42, p &lt; 0.01) from all causes combined, between 1 January 1985 and 31 December 1996, was observed, indicating a healthy worker effect. When we reanalyzed the data using standardized PMR, elevated risks were observed for all cancers combined (1.46, p = 0.01) and cancers of the digestive organs and peritoneum (1.61, p = 0.02), especially stomach cancer (2.94, p = 0.01). The results showed that PMR can detect increases in mortality when a study population is generally healthier than the comparison population and call for further studies on the possible carcinogenic effects of low-level acid mist exposures on the stomach.<\/jats:p>","DOI":"10.3390\/ijerph18189870","type":"journal-article","created":{"date-parts":[[2021,9,20]],"date-time":"2021-09-20T07:52:14Z","timestamp":1632124334000},"page":"9870","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Application of Standardized Proportional Mortality Ratio to the Assessment of Health Risk in Relatively Healthy Populations: Using a Study of Cancer Risk in Telecommunication Workers with Excess Exposure to Acid Mists as an Example"],"prefix":"10.3390","volume":"18","author":[{"given":"Ying-Fong","family":"Ker","sequence":"first","affiliation":[{"name":"Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan"},{"name":"Los Angeles County Department of Public Health, Alhambra, CA 91803, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Perng-Jy","family":"Tsai","sequence":"additional","affiliation":[{"name":"Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3343-3446","authenticated-orcid":false,"given":"How-Ran","family":"Guo","sequence":"additional","affiliation":[{"name":"Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan"},{"name":"Department of Occupational and Environmental Medicine, National Cheng Kung University Hospital, Tainan 704, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,9,19]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1097\/00043764-197603000-00009","article-title":"Standardized mortality ratios and the \u201chealthy worker effect\u201d: Scratching beneath the surface","volume":"18","author":"McMichael","year":"1976","journal-title":"J. Occup. Med."},{"key":"ref_2","unstructured":"International Agency for Research on Cancer (1992). IARC Monographs on the Evaluation of Carcinogenic Risk to Humans, Vol 54, International Agency for Research on Cancer."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"445","DOI":"10.1136\/oem.53.7.445","article-title":"Upper aerodigestive cancer in battery manufacturers and steel workers exposed to mineral acids mists","volume":"53","author":"Coggon","year":"1996","journal-title":"Occup. Environ. Med."},{"key":"ref_4","first-page":"911","article-title":"Lung cancer mortality in workers exposed to sulfuric acid mist and other acid mists","volume":"79","author":"Beaumont","year":"1987","journal-title":"J. Natl. Cancer Inst."},{"key":"ref_5","first-page":"766","article-title":"Incidence of laryngeal cancer and exposure to acid mist","volume":"45","author":"Steenland","year":"1988","journal-title":"Br. J. Ind. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1171","DOI":"10.1016\/S0021-8502(99)00017-8","article-title":"Characteristics of droplets generated by bubble bursting from chromic acid solutions","volume":"30","author":"Kuo","year":"1999","journal-title":"J. Aerosol. Sci."},{"key":"ref_7","unstructured":"Guo, Y.-L., Tsai, P.-J., and Guo, H.-R. (1998). Report on Epidemiologic Study of Chung-Hwa Telecommunication Company, National Cheng Kung University."},{"key":"ref_8","unstructured":"Monson, R.R. (1990). Occupational Epidemiology, CRC Press. [2nd ed.]."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"225","DOI":"10.5271\/sjweh.1585","article-title":"Occupational exposure to sulfuric acid in southern Ontario, Canada, in association with laryngeal cancer","volume":"18","author":"Sosklone","year":"1992","journal-title":"Scand. J. Work Environ. Health"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Colbeth, H.L., Zeig-Owens, R., Hall, C.B., Webber, M.P., Schwartz, T.M., and Prezant, D.J. (2020). Mortality among Fire Department of the City of New York rescue and recovery workers exposed to the World Trade Center Disaster, 2001\u20132017. Int. J. Environ. Res. Public Health, 17.","DOI":"10.3390\/ijerph17176266"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"239","DOI":"10.5271\/sjweh.3118","article-title":"Laryngeal cancer and pickling house vapors","volume":"7","author":"Ahlborg","year":"1981","journal-title":"Scand. J. Work. Environ. Health"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"358","DOI":"10.1093\/oxfordjournals.aje.a113900","article-title":"Laryngeal cancer and occupational exposure to sulfuric acid","volume":"120","author":"Sosklone","year":"1984","journal-title":"Am. J. Epidemiol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"347","DOI":"10.1002\/ajim.4700160403","article-title":"Further follow-up and adjustment for smoking in a study of lung cancer and acid mists","volume":"16","author":"Steenland","year":"1989","journal-title":"Am. J. Ind. Med."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"258","DOI":"10.5271\/sjweh.2053","article-title":"Respiratory cancer among soap production workers","volume":"13","author":"Forastiere","year":"1987","journal-title":"Scand. J. Work Environ. Health"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1080\/00039896.1985.10545904","article-title":"A retrospective cohort mortality study of a phosphate fertilizer production facility","volume":"40","author":"Stayner","year":"1985","journal-title":"Arch. Environ. Health"},{"key":"ref_16","first-page":"85","article-title":"Mortality of workers on an isopropyl alcohol plant and two MEK dewaxing plants","volume":"37","author":"Alderson","year":"1980","journal-title":"Br. J. Ind. Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"90","DOI":"10.5271\/sjweh.1596","article-title":"Mortality study of ethanol and isopropanol production workers at two facilities","volume":"18","author":"Teta","year":"1992","journal-title":"Scand. J. Work Environ. Health"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Steenland, K. (1993). Case Studies in Occupational Epidemiology, Oxford University Press.","DOI":"10.1093\/oso\/9780195068313.001.0001"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"855","DOI":"10.1097\/00043764-199810000-00004","article-title":"Occupational risk factors for cancer of the gastric cardia: Analysis of death certificates from 24 US states","volume":"40","author":"Cocco","year":"1998","journal-title":"J. Occup. Environ. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"781","DOI":"10.1136\/oem.56.11.781","article-title":"Risk of stomach cancer associated with 12 workplace hazards: Analysis of death certificates from 24 states of the United States with the aid of job exposure matrices","volume":"56","author":"Cocco","year":"1999","journal-title":"Occup. Environ. Med."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"331","DOI":"10.5271\/sjweh.2215","article-title":"Mortality among employees of lead battery plants and lead-producing plants, 1947\u20131980","volume":"11","author":"Cooper","year":"1985","journal-title":"Scand. J. Work Environ. Health"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"255","DOI":"10.1002\/1097-0274(200009)38:3<255::AID-AJIM4>3.0.CO;2-8","article-title":"Cancer mortality study of employees at lead battery plants and lead smelters, 1947\u20131995","volume":"38","author":"Wong","year":"2000","journal-title":"Am. J. Ind. Med."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"474","DOI":"10.1001\/jama.1995.03530060048032","article-title":"The relation of gastroesophageal reflux disease and its treatment to adenocarcinomas of the esophagus and gastric cardia","volume":"274","author":"Chow","year":"1995","journal-title":"JAMA"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"139","DOI":"10.15430\/JCP.2019.24.3.139","article-title":"A putative adverse outcome pathway relevant to carcinogenicity induced by sulfuric acid in strong inorganic acid mists","volume":"24","author":"Yang","year":"2019","journal-title":"J. Cancer Prev."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/18\/9870\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T07:02:12Z","timestamp":1760166132000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/18\/9870"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,9,19]]},"references-count":24,"journal-issue":{"issue":"18","published-online":{"date-parts":[[2021,9]]}},"alternative-id":["ijerph18189870"],"URL":"https:\/\/doi.org\/10.3390\/ijerph18189870","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,9,19]]}}}