Review Reports - ELF-MF Exposure, Actual and Perceived, and Associated Health Symptoms: A Case Study of an Office Building in Tel Aviv-Yafo, Israel

Round 1

Reviewer 1 Report

The reviewed manuscript presents an analysis of the impact of the magnetic field on the health of employees in a large office building, located near a major high voltage powerline in the city of Tel Aviv, Israel. The paper includes of two fundamental parts: The first part consists of measuring the magnetic field. The second part is a survey addressed to the employees of the building. On the basis of the survey, the authors of the study drew far-reaching conclusions. Research on the influence of the magnetic field on human health and well-being is extremely difficult and time-consuming research. The survey is an unreliable indicator. Headaches, frustration, anxiety, exhaustion, and weakness can be caused by the atmosphere in the workplace. There are also other electrical devices in the building that emit a magnetic field. Moreover, the authors of the study did not provide any genetic tests.

Moreover, the manuscript requires thorough editorial changes, for example:

· Abstract and conclusions sections should be completely revised.

· The references section is not numbered, which worsens the readability of the work.

· I don't feel qualified to judge about the English language but I think that the whole paper should be corrected by native speaker.

Author Response

Authors’ responses to reviewers’ comments and suggestions

We would like to thank the reviewers for their responses, which, as we feel, have helped to improve the manuscript. Below are the reviewers’ comments and suggestions followed by our responses in color.

Reviewer #1

The paper can be further improved from following aspects:

(1) The survey is an unreliable indicator. Headaches, frustration, anxiety, exhaustion, and weakness can be caused by the atmosphere in the workplace

Population surveys, based on questionnaires, are a research tool that is commonly used in environmental studies and is considered to be valid and reliable (Garcia-Rea & LePage, 2010). The present survey was based on the World Health Organization’s Quality of Life Questionnaire (WHOQL-100), which is widely used worldwide (see e.g., Skevington et al., 2004; WHO- Quality of Life-BREF ,1991,1996,1998). Using this questionnaire, the study demonstrated significant links between several health symptoms and ELF-MF exposure, either measured of perceived. Importantly, the analysis controlled for several potential confounders, including age, gender, etc. As the detected associations were found to be statistically significant, it is thus unlikely that they are related to any other causes, rather than ELF-MF exposure (p<1%).

(2) There are also other electrical devices in the building that emit a magnetic field

As we currently elaborate in the paper (see p. 3, 2^th paragraph), during the measurement process, monitoring devices were placed on the work desks of the employees and insured with protection stickers that prevented changes in the device settings.” As we further elaborate in the paper (see Lines 89-96)," The instruments were placed on the desks of employees, but as far as possible from electrical appliances (such as, radios, power supplies, electric transmitters, internal power lines, microwave ovens, speakers, etc.), to avoid interferences. In Appendix B, we report an exsample of the measurment devices’ location on a typical buiding floor. The 24-hour measurements were performed in each location, with an interval of 1 minute. The total exposure was then evaluated for each location by averaging the data recorded between 7AM and 7PM, that is, during the employees’ working hours "

(3) the authors of the study did not provide any genetic tests.

Genetic tests are an important research tool, but they are not commonly used in epidemiological studies, a the present one, and this research is not an exception.

(4) the manuscript requires thorough editorial changes, for example: Abstract and conclusions sections should be completely revised.

The whole manuscript has been proof-edited, and Abstract and conclusions have been revised.

(5) The references section is not numbered, which worsens the readability of the work.

The references have been numbered.

(6) I don't feel qualified to judge about the English language but I think that the whole paper should be corrected by native speaker.

The paper has been edited by a native English speaker.

Reviewer 2 Report

TITLE

---------------------------------

ELF-MF Exposure, Actual and Perceived, and Health Symptoms among Employees in a Large Office Building in Tel Aviv, Israel.

REVIEW DATE

-----------------------------------

16/07/2022

Dear Authors, the work is very nice but you should invest more effort in improving the work.

Minor questions

Line 59: QOL: this acronym is repeated is repeated

Line 66: WHO: this acronym is repeated

Line 68: please substitute "T" by lower case

Line 68: the same with the acronym EHS, it is not necessary to indicate "electromagnetic-hypersensitivity" again

Line 138, 143: the references are missing

Line 165: please correct "days.he"

Lines 190; correct "50-69 yo age group"

What is OR, and SE??

There are many typo errors with lowercase and uppercase letters.

The commas are situated in places where they should not appear, it is a bit chaotic

Major questions

- You should include a photograph with the measurement devices, and a graph with the measurement setup

- You indicate the name of the spectrum analyzer, I suppose you have also used an antenna, please indicate the type of antenna

- You should indicate more details about the protocol of measurement, what are the point of measurement per floor, etc...? You should indicate a map of each floor with the points of measurement.

- How long does the period of measurement last?

- The references are not current.

In general, the work is quite poor, you should provide a better Conclusion Section, and explain better the Methods and Materials Section, your work need a deep review in order to be published.

Comments for author File: Comments.pdf

Author Response

Authors’ responses to reviewers’ comments and suggestions

Reviewer #2

The paper can be further improved from following aspects:

Line 59: QOL: this acronym is repeated is repeated

The text has been rechecked and repeated definitions of the acronyms and abbreviates have been removed.

(2)Line 66: WHO: this acronym is repeated

The text has been rechecked and repeated definitions of the acronyms and abbreviates have been removed.

(3) Line 68: please substitute "T" by lower case

The text has been rechecked and substituted as the reviver suggested not needed any more (see Line 70)

(4)Line 68: the same with the acronym EHS, it is not necessary to indicate "electromagnetic-hypersensitivity" again

The text has been rechecked and repeated definitions of the acronyms and abbreviates have been removed.

(5)Line 138, 143: the references are missing

L138-143 in the original version of the paper describe location of the study site, for which no references are needed.

(6)Line 165: please correct "days.he"

Corrected to “days” (see Line 102).

(7)Lines 190; correct "50-69 yo age group"

Corrected to the “50-69 years old group”

(8)What is OR, and SE??

Transcribed as Odds Ratio (OR) and Standard error (SE) in the instance of these terms’ first occurrence (see Line 190)

(9)There are many typo errors with lowercase and uppercase letters.

The paper has been edited and all the typos corrected.

(10)The commas are situated in places where they should not appear, it is a bit chaotic

The paper has been edited and all the typos corrected.

Major questions

(11)- You should include a photograph with the measurement devices, and a graph with the measurement setup

Pictures of the measurement devices used in the study and their specifications have been placed in Appendix A (see p. 14-15)

(12)- You indicate the name of the spectrum analyzer, I suppose you have also used an antenna, please indicate the type of antenna

for measurements, we used a Spectran NF-5030 version 5 (NF-5035) spectrum analyzer, manufactured by Aaronia AG, and a TM-192D EMF meter, manufactured by Tenmars Electronics Co., Ltd. The latter device has a 3D magnetic-field measurement coil, not an antenna. Pictures of the measurement devices used in the study and their specifications have been placed in Appendix A (see p. 14- line 337)

(13)- You should indicate more details about the protocol of measurement, what are the point of measurement per floor, etc...? You should indicate a map of each floor with the points of measurement.

We added maps of the building’s typical floors, with the locations of the measurement devices (see Appendix B, Maps of typical building floors showing locations in which measurement devices were placed Pages 16-30)

"A total of 487 measurements were performed by a certified engineer who used 40 measurement devices simultaneously on each floor. The measurement protocol followed the guidelines prepared by the Commissioner of the Environmental Radiation Office, Israel Ministry of Environmental Protection (31). Each morning, the instruments were moved to another floor. The instruments were placed on the desks of employees, but as far as possible from electrical appliances (such as, radios, power supplies, electric transmitters, internal power lines, microwave ovens, speakers, etc.), to avoid interferences. In Appendix B, we report an exsample of the measurment devices’ location on a typical buiding floor. The 24-hour measurements were performed in each location, with an interval of 1 minute. The total exposure was then evaluated for each location by averaging the data recorded between 7AM and 7PM, that is, during the employees’ working hours. If ELF-MF values were not detected, new measurements were performed in the same location. In total, there were 9 such repeated measurments (1.8%)" (lines 85-97)

"From the information received from the Israel Electric Company, the load on the power line during working weekdays varies in the range of ⁓10%, mainly due to changing demand for electricity in the summer season. Therefore, every day, before starting a new set of measurements, a single measurement was made in the lobby of the 6th floor, to insure that the measurments performed on different days are comparable." (see Lines 98-102).

(14)- How long does the period of measurement last?

As it explicitly stated in the text, " The 24-hour measurements were performed at the desk of each employee, with an interval of 1 minute. The total exposure was evaluated for each location by averaging the data recorded between 7AM and 7PM, to estimate the exposure of employees during their working hours" (see Line 92-95).

(15)- The references are not current.

Several newer references have been added (see pp. 12-13)

(16) In general, the work is quite poor, you should provide a better Conclusion Section, and explain better the Methods and Materials Section, your work need a deep review in order to be published.

The text has been edited, with abstract and conclusions section revised. In particular, sample of floor plans of the building with the location of measurement devices have been added to the M&M section (Appendix B, Maps of typical building floors showing locations in which measurement devices were ), and the following comment was added to the Conclusions section of the paper: "An important conclusion stemming from the results of this analysis is that working near a high voltage power line may result in various health symptoms in both actually exposed and perceived to be exposed individuals, even if the actual exposure is rel-atively low and/or within the established exposure standards. It is thus important to consider these physiological and psychological effects. However, follow-up studies should also attempt to estimate other effects of ELF-MF exposure on, for example, the productivity of employees, the number of visits to physicians, absenteeism, and medi-cations intake"

Reviewer 3 Report

The work is innovative, this study attempts to bridge this gap, by studying health complaints of employees in a large office building, located near a major high voltage powerline in the city of Tel Aviv, Israel. The authors measured with a triaxial sensor coil device, but in the conclusions of the paper and in the abstract no reference is made to these results. It is suggested to indicate the corresponding descriptive data, for example, the mean, minimum and maximum measured value, and the 95th percentile.

Line 72, delete the dot before the reference (WHO 2004), línea 72.

Revise the whole manuscript and correct errors such as “Error! Reference source not found”, for example, line 138.

Line 143, Wikipedia is not a scientific source, remove the citation: (wikepedia,2017) and include a correct citation.

Revise the entire manuscript and correct all typos such as the citation ( Baliatsas et el, 2015) has one space too many, line 132. And in some lines the space is missing: lines 170.

Line 147, Include an explanation of Figure 1 below the title.

Did the equipment used during the measurement process record nondetect values? Indicate the percentage and treatment of such data.

The authors did spot measurements, or they were done in motion while walking.

What was the measurement protocol followed to carry out the measurements? What regulations is the measurement procedure or protocol based on?

It is suggested to include other references and in the discussion section, compare the results of this study with those of other research. Example of suggested references:

1) Kiouvrekis, Y., Alexias, A., Softa, V., Alkhorayef, M., Sulieman, A., Tyrakis, C., and Kappas, C. (2021). Extremely Low Frequency Electromagnetic Exposure Assessment in Schools: A Statistical Analysis of Urban and Semi-Urban Areas. Radiat. Prot. Dosimetry 194, 76–81. https://doi.org/10.1093/rpd/ncab076.

2) Aryana T Amoon, John Swanson Corrado MagnaniChristoffer Johansen, Leeka Kheifets. Pooled analysis of recent studies of magnetic fields and childhood leukemia. Environ Res 2022 Mar;204(Pt A):111993. doi: 10.1016/j.envres.2021.111993. Epub 2021 Sep 3.DOI: 10.1016/j.envres.2021.111993

3) Paniagua, J.M., Jimenez, A., Rufo, M., Gutierrez, J.A., Gomez, F.J., and Antolin, A. (2007). Exposure to extremely low frequency magnetic fields in an urban area. Radiat. Environ. Biophys. 46, 69–76. https://doi.org/10.1007/s00411-006-0081-0.

4) Paniagua, J.M., Rufo, M., Jimenez, A., Pachon, F.T., and Carrero, J. (2015). Exposure estimates based on broadband ELF magnetic field measurements versus the ICNIRP multiple frequency rule. Radiat. Prot. Dosimetry 163, 173–180. https://doi.org/10.1093/rpd/ncu175.

Correct Figure 3, the graph is not formatted correctly, e.g. correct the x-axis labels, "MG" is not understood. In what unit of measurement are the Y-axis values presented?

The authors conclude: An important conclusion stemming from the results of this analysis is that working near a high voltage powerline may result in adverse health effects in the exposed (or perceived to be exposed), by adding physiological and psychological stress to their daily routine. Can you explain and justify this statement? Mention other scientific studies that agree with this statement.

Author Response

Authors’ responses to reviewers’ comments and suggestions

Reviewer #3

The paper can be further improved from following aspects:

(1)The work is innovative, this study attempts to bridge this gap, by studying health complaints of employees in a large office building, located near a major high voltage powerline in the city of Tel Aviv, Israel. The authors measured with a triaxial sensor coil device, but in the conclusions of the paper and in the abstract no reference is made to these results. It is suggested to indicate the corresponding descriptive data, for example, the mean, minimum and maximum measured value, and the 95th percentile.

The descriptive data that the reviewer mentions do appear in Table 1 (see p. 5).

(2)Line 72, delete the dot before the reference (WHO 2004), línea 72.

Deleted from this version of the manuscript)

(3)Revise the whole manuscript and correct errors such as “Error! Reference source not found”, for example, line 138.

The paper has been rechecked and missing references added.

(3)Line 143, Wikipedia is not a scientific source, remove the citation: (wikepedia,2017) and include a correct citation.

Deleted not used (can be replaced with Grigsby (2012))

(4)Revise the entire manuscript and correct all typos such as the citation ( Baliatsas et el, 2015) has one space too many, line 132. And in some lines the space is missing: lines 170.

Rechecked and corrected.

(5) Line 147, Include an explanation of Figure 1 below the title.

The following explanation has been added: Figure 1. Office building under study and the nearby high voltage power line. (see Line 105).

(6) Did the equipment used during the measurement process record non detect values? Indicate the percentage and treatment of such data.

As currently clarified in the text, “. If ELF-MF values were not detected, new measurements were performed in the same location. In total, there were 9 such repeated measurments (1.84%) “.

(7) The authors did spot measurements, or they were done in motion while walking.

As explicitly mentioned in the text, “The 24-hour measurements were performed in each location, with an interval of 1 minute. The total exposure was then evaluated for each location by averaging the data recorded between 7AM and 7PM "(see Lines 93-95).

(8) What was the measurement protocol followed to carry out the measurements? What regulations is the measurement procedure or protocol based on?

As currently clarified in the text, A total of 487 measurements were performed by a certified engineer who used 40 measurement devices simultaneously on each floor. The measurement protocol followed the guidelines prepared by the Commissioner of the Environmental Radiation Office, Israel Ministry of Environmental Protection (31). (see Lines 85-88)

(9) It is suggested to include other references and in the discussion section, compare the results of this study with those of other research. Example of suggested references:

The reference Paniagua, J.M ET EL., 2007) suggested by the reviewer have been added to the reference list and to the relevant places in the text (see Lines 38,338 ).

(10) Correct Figure 3, the graph is not formatted correctly, e.g. correct the x-axis labels, "MG" is not understood. In what unit of measurement are the Y-axis values presented?

As we currently specify, the Y-axis features the average perceived exposure, on a 5 point scale, from no exposure (1) to very high perceived exposure (5), while the X-axis features the density the measured magnetic field in milliGauss (mG). The graph has been reformatted to incorporate this information (see p. 7).

(11) The authors conclude: An important conclusion stemming from the results of this analysis is that working near a high voltage powerline may result in adverse health effects in the exposed (or perceived to be exposed), by adding physiological and psychological stress to their daily routine. Can you explain and justify this statement? Mention other scientific studies that agree with this statement.

As we currently comment in the revised version of the paper, the study results coincide with the results reported by Porsius et al. (2014) and Baliatsas et al. (2011), according to which non-specific physical symptoms, such as anxiety, hostility, headache, and fatigue, are frequent in people, who work or live near a high voltage power line, often resulting in inability to work effectively due to the reported symptoms. Our results are also in line with the results reported by Porsius et al. (2014), who revealed a range of non-specific physical symptoms due to ELF-MF radiation exposure. Anxiety, hostility, headache, fatigue, difficulties of concentrating, vertigo, weakness, dizziness, attention disorders, and nervousness associated with electromagnetic hypersensitivity, that is symptoms revealed by this study, are also well documented (Rubin et al, 2010, Kato & Johansson, 2012).”

References added to the reference list:

Belyaev, Igor, Dean, Amy, Eger, Horst, Hubmann, Gerhard, Jandrisovits, Reinhold, Kern, Markus, Kundi, Michael, Moshammer, Hanns, Lercher, Piero, Müller, Kurt, Oberfeld, Gerd, Ohnsorge, Peter, Pelzmann, Peter, Scheingraber, Claus and Thill, Roby. "EUROPAEM EMF Guideline 2016 for the prevention, diagnosis and treatment of EMF-related health problems and illnesses" Reviews on Environmental Health, vol. 31, no. 3, 2016, pp. 363-397

Rubin GJ, Nieto-Hernandez R, Wessely S. Idiopathic environmental intolerance attributed to electromagnetic fields (formerly 'electromagnetic hypersensitivity'): An updated systematic review of provocation studies. Bioelectromagnetics. 2010;31(1):1-11.

World Health Organization (WHO) (2005) Electromagnetic hypersensitivity [Available from: https://www.who.int/peh-emf/publications/facts/fs296/en/].

Baliatsas C, Van Kamp I, Lebret E, Rubin GJ. Idiopathic environmental intolerance attributed to electromagnetic fields (IEI-EMF): a systematic review of identifying criteria. BMC Public Health. 2012; 12:643.

Yasuko Kato, Olle Johansson, Reported functional impairments of electrohypersensitive Japanese: A questionnaire survey, Pathophysiology, Volume 19, Issue 2,, 2012, Pages 95-100,

World Health Organization (WHO) Quality of Life-BREF (WHOQOL-BREF). 1991.

World Health Organization. WHOQOL-BREF: introduction, administration, scoring and generic version of the assessment. Field trial version ed1996.

World Health Organization. WHOQOL user manual. 1998.

World Health Organization (WHO). WHO workshop on electrical hypersensitivity. Prague, Czech Republic; 2004.

Kaszuba-Zwoinska J, Gremba J, Galdzinska-Calik B, Wojcik-Piotrowicz K, Thor PJ. Electromagnetic field induced biological effects in humans. Przegl Lek. 2015;72(11):636-41.

Christos Baliatsas, John Bolte, Joris Yzermans, Gert Kelfkens, Mariette Hooiveld, Erik Lebret, Irene van Kamp, Actual and perceived exposure to electromagnetic fields and non-specific physical symptoms: An epidemiological study based on self-reported data and electronic medical records, International Journal of Hygiene and Environmental Health,

Volume 218, Issue 3, 2015, Pages 331-344,

Round 2

Reviewer 1 Report

Graphically, the paper looks terrible. The information in appendix a and b is completely unnecessary. Nor have I received satisfactory responses from the authors.

Author Response

Dear Sir,

thank a lot for your time and care, we wish you all the best,

We apologize for incontinence with the visual look of the previous version of the manuscript, attributed to the fact that the editorial system showed all the accumulated changes. In the present vision of the manuscript all the changes have been accepted.
The information in Appendices A and B was added as other reviewers requested it. Therefore, we cannot drop them, unfortunately.
Although we did our best to address your previous comments and suggestions as comprehensively as possible, please let us know if you think that we have missed something.

thanks

best regards'

Liran

Reviewer 2 Report

Dear Authors the work has been significantly improved. Now, it is well written, and the structure is correct. But there are some minor errors:

- Please update the list of organizations to which the authors belong, each organization must match a single line

- There are some errors with the acronyms, for example, in the Discussion Section it is not need to indicate MCS or NSHs, beacuse they are only used once.

- Other question is about the references, in the Discussion Section you indicate "Baliatsas et al. (2015)", and in other part you indicate [24]. You should uniform the format to indicate the references

Author Response

Dear Authors the work has been significantly improved. Now, it is well written, and the structure is correct. But there are some minor errors:

We appreciate such a kind assessment of our work.

Please update the list of organizations to which the authors belong, each organization must match a single line

The information was updated.

(3)- There are some errors with the acronyms, for example, in the Discussion Section it is not need to indicate MCS or NSHs, because they are only used once.

The acronyms the reviewer mentioned have been deleted.

(3)- Other question is about the references, in the Discussion Section you indicate "Baliatsas et al. (2015)", and in other part you indicate [24]. You should uniform the format to indicate the references

The citation format has been correct throughout the text

Reviewer 3 Report

Much of the manuscript has been modified, several paragraphs have been deleted and new ones added, and some data are missing. Two tables have been deleted from the corrected manuscript: Table 4. Regression estimates for various health conditions (Method - multiple logistic regressions controlled for seniority; exposure variable - measured ELF-MF Magnetic fields in mG) and Table 6. Regression estimates for various health conditions (Method - multiple logistic regression, controlled for seniority; exposure variable - perceived ELF-MF Magnetic fields exposure), from the original manuscript. The paragraphs containing the explanations of these tables have also been deleted. Figure 3. Average levels of perceived exposure calculated for actual exposure categories and Figure 4. Odds ratios and 95% confidence intervals measured and perceived Magnetic fields levels, etc. have been removed. Could you explain why so many changes and what is the reason?

Appendices A1 to A15 are included, it is suggested to reference them in the manuscript and to include some labels in these figures, indicating in which part of the floor the measurements were taken.

Table 3. Associations between measured and perceived ELF-MF exposure and health symptoms (method: ordinary logistic regression) is cut off, only part of the "95% CI" column is shown. Please correct the formatting and show the complete table.

Finally, it is recommended to express all results with three significant figures, this allows the reader to understand more easily and to be more precise in the results. It is recommended to cite the following article. Ramirez-Vazquez, R., Escobar, I., Franco, T., Arribas, E., 2022. Physical units to report intensity of electromagnetic wave. Environ. Res. 204, 112341. https://doi.org/10.1016/j.envres.2021.112341.

Author Response

Much of the manuscript has been modified, several paragraphs have been deleted and new ones added, and some data are missing. Two tables have been deleted from the corrected manuscript: Table 4. Regression estimates for various health conditions (Method - multiple logistic regressions controlled for seniority; exposure variable - measured ELF-MF Magnetic fields in mG) and Table 6. Regression estimates for various health conditions (Method - multiple logistic regression, controlled for seniority; exposure variable - perceived ELF-MF Magnetic fields exposure), from the original manuscript. The paragraphs containing the explanations of these tables have also been deleted. Figure 3. Average levels of perceived exposure calculated for actual exposure categories and Figure 4. Odds ratios and 95% confidence intervals measured and perceived Magnetic fields levels, etc. have been removed. Could you explain why so many changes and what is the reason?

Tables 3-6 of the original version of the manuscript were merged into Table 3 of the new version. All the essential information contained in Tables 4 and 6 now appears in Table 3, which is more compact. As Figures 3-4 repeated the information that currently appears in Table 3, they were also dropped. Concurrently, Figure 4 has been restored in the revised paper (see p. 7).

Appendices A1 to A15 are included, it is suggested to reference them in the manuscript and to include some labels in these figures, indicating in which part of the floor the measurements were taken.

Appendices B1-B15 are currently referenced in the text (see p. 2 , Line 81, and places in which the survey equipment was placed are currently marked in these appendices by black dots (see pp. 12-19).

The table is question has been reformatted and currently appears in the text correctly (see p. 6).

Finally, it is recommended to express all results with three significant figures, this allows the reader to understand more easily and to be more precise in the results.

The following paragraph has been added to the conclusion section of the paper (see p. 9):

The main findings of this study can be summarized and follows:

The analysis revealed no significant association between instrumentally measured and perceived ELF-MF exposure which implies that individuals cannot detect actual ELF-MF exposure accurately;
The analysis revealed that the feelings of weakness, headache, frustration and worries were associated with both measured and perceived ELF-MF exposures, while perceived ELF-MF exposure was also found to be associated with eye pain and irritation, sleepiness, as well as dizziness and ear pain.
As we conclude, working near a high voltage power line appears to produce not only psychological but also physiological effects, and should thus become a public health concern.
It is recommended to cite the following article. Ramirez-Vazquez, R., Escobar, I., Franco, T., Arribas, E., 2022. Physical units to report intensity of electromagnetic wave. Environ. Res. 204, 112341. https://doi.org/10.1016/j.envres.2021.112341.

The article was cited in the text (see p. 2) and added to the reference list (see p. 21).