GULF WAR and HEALTH
VOLUME 3
FUELS, COMBUSTION PRODUCTS, AND PROPELLANTS
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This study was supported by Contract No. V101(93)P-1637, Task Order No. 25 between the National Academy of Sciences and the Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
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THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M.Alberts is president of the National Academy of Sciences.
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COMMITTEE ON GULF WAR AND HEALTH: LITERATURE REVIEW OF SELECTED ENVIRONMENTAL PARTICIPATES, POLLUTANTS, AND SYNTHETIC CHEMICAL COMPOUNDS
LYNN R.GOLDMAN (Chair), Professor,
Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
MELVYN BRANCH, Joseph Negler Professor of Mechanical Engineering,
Department of Mechanical Engineering, University of Colorado, Boulder, CO
MICHAEL BRAUER, Professor,
School of Occupational and Environmental Hygiene, University of British Columbia, Vancouver, BC
DEBORAH A.CORY-SLECHTA, Director,
Environmental and Occupational Health Sciences Institute, Piscataway, NJ (Resigned January 22, 2004)
MARK EISNER, Assistant Professor,
Department of Medicine, University of California, San Francisco, CA
ERIC GARSHICK, Assistant Professor of Medicine,
Pulmonary and Critical Care Medicine Section, VA Boston Healthcare System, Channing Laboratory, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA
RUSS B.HAUSER, Associate Professor of Occupational Health,
Department of Environmental Health, Harvard School of Public Health, Boston, MA
JOEL KAUFMAN, Associate Professor of Medicine,
Environmental and Occupational Health Sciences, Departments of Medicine and Environmental and Occupational Health Sciences, University of Washington, Seattle, WA
RICHARD MAYEUX, Professor and Director,
Sergievsky Center,
Co-Director,
Taub Institute, College of Physicians and Surgeons, Columbia University, New York, NY
CHARLES POOLE, Associate Professor,
Department of Epidemiology, University of North Carolina School of Public Health, Chapel Hill, NC
BEATE RITZ, Associate Professor,
Department of Epidemiology and Center for Occupational and Environmental Health, School of Public Health, University of California, Los Angeles, CA
JOSEPH RODRICKS, Principal,
ENVIRON Health Sciences Institute, ENVIRON International Corporation, Arlington, VA
RICHARD SCHLESINGER, Chair and Professor,
Department of Biological Sciences, Dyson College of Arts and Sciences, New York, NY
JAMES TAYLOR, Head,
Section of Industrial Dermatology, Department of Dermatology, Cleveland Clinic Foundation, Cleveland, OH
MARK UTELL, Professor,
Departments of Medicine and Environmental Medicine, University of Rochester School of Medicine, Rochester, NY
WILLIAM VALENTINE, Associate Professor,
Department of Pathology, Vanderbilt University Medical Center, Nashville, TN
JUDITH ZELIKOFF, Associate Professor,
Institute of Environmental Medicine, New York University School of Medicine, Tuxedo, NY
STAFF
CAROLYN FULCO, Senior Program Officer
ABIGAIL MITCHELL, Senior Program Officer
MARY PAXTON, Senior Program Officer
MICHELLE CATLIN, Senior Program Officer
CARRIE SZLYK, Program Officer (until December 2003)
MICHAEL SCHNEIDER, Senior Program Associate
JUDITH URBANCZYK, Senior Program Associate
HOPE HARE, Administrative Assistant
DEEPALI PATEL, Research Associate
PETER JAMES, Research Assitant
DAMIKA WEBB, Senior Program Assistant
ROSE MARIE MARTINEZ, Director,
Board on Health Promotion and Disease Prevention
CONSULTANTS
MIRIAM DAVIS, Independent Medical Writer,
Silver Spring, MD
MARK GOLDBERG,
McGill University, Montreal, QC
KATHERINE HOGGATT,
University of California, Los Angeles, CA
JOAN DENCKLA,
Harvard Medical School, Boston, MA
KIT SHAN LEE,
University of British Columbia, Vancouver, BC
EDITOR
NORMAN GROSSBLATT, NRC Senior Editor
REVIEWERS
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
JOHN R.BALMES, San Francisco General Hospital, University of California, San Francisco, CA
ANNECLAIRE J.DE ROOS, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA
ARTHUR L.FRANK, School of Public Health, Drexel University, Philadelphia, PA
PATRICK KINNEY, Mailman School of Public Health, Columbia University, New York, NY
HOWARD KIPEN, Environmental and Occupational Health Sciences Institute, Department of Environmental and Community Medicine, Rutgers, Piscataway, NJ
JANE Q.KOENIG, Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA
FRANCINE LADEN, Channing Laboratory, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
THOMAS MACK, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
JONATHAN PATZ, Global Environmental Health Center for Sustainability and the Global Environment (SAGE), Nelson Institute for Environmental Studies and Department of Population Health Sciences, University of Wisconsin, Madison, WI
SAMUEL POTOLICCHIO, Department of Neurology, George Washington University Medical Center, Washington, DC
PEGGY REYNOLDS, Environmental Health Investigations Branch, California Department of Health Services, Oakland, CA
JONATHAN M.SAMET, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by DAVID J.TOLLERUD, School of Public Health University of Louisville, KY, and M.DONALD WHORTON, WorkCare, Inc., Alameda, CA, who were appointed by the Report Review Committee. They were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
PREFACE
As this report goes to press and our country is engaged in a war in Iraq, it is important to recall the 1990–1991 Gulf War. Engaging around 700,000 US military personnel, the Gulf War was of brief duration and entailed very few casualties among US troops. Yet, as they say, “war is hell”, and our troops were exposed to numerous traumatic events and a multitude of hazardous substances. Not long after the war ended, many of its veterans reported a variety of chronic symptoms. Numerous studies were conducted, most of which corroborated reports of higher rates of signs and symptoms among these veterans. Some of the signs and symptoms have clearly been associated with identifiable medical diagnoses such as post-traumatic stress disorder and depression; others are outside current medical diagnostic classifications.
Veterans have been deeply concerned about whether exposures in the gulf were associated with chronic health problems after the end of the war. In response to their concerns, the Department of Veterans Affairs (VA) and Congress secured the assistance of the Institute of Medicine (IOM) in evaluating the scientific literature regarding exposures that may have occurred in the Gulf War. In a sense, this approach followed a model developed for the Vietnam War, after which there was concern about the possible health effects of exposure to dioxins in Agent Orange. In that case, the work of IOM has played a key role in informing VA decisions regarding compensation for dioxin-related chronic health effects. Following that model, Congress enacted legislation that specifically directed IOM to evaluate the effects of 33 agents; this report covers a small number of the agents: hydrazines, red fuming nitric acid, hydrogen sulfide, oil-fire byproducts, and diesel-heater fumes. In addition, VA requested that we assess potential exposures to fuels that were used in the Gulf War (gasoline, jet fuel, diesel fuel, and kerosene) and their combustion products.
Although we had a relatively small number of substances to review, the scientific literature on air pollutants from fuel combustion, as well as from exposure to fuels, is extensive. IOM appointed a committee with knowledge in the toxicology and epidemiology of fuels and combustion products; it included experts in combustion chemistry, rocket propellants, immunology, pulmonology, cancer, neurosciences, dermatology, and reproductive and developmental toxicology. The committee did not limit itself to studies of Gulf War veterans but rather reviewed all relevant literature with regard to chronic medical effects of exposure. Although the committee focused on epidemiologic studies, which are likely to identify associations between specific exposures and diagnoses in people, it also placed weight on toxicologic studies and on clinical case series that were informative about specific exposure-disease relationships. Along the lines of earlier Gulf War reports, the committee has framed its conclusions in categories of strength of association. Despite the extensive challenge of reviewing the literature and the
diversity of expertise and views among committee members, the committee was able to reach consensus on all conclusions. For that, I am most grateful.
The committee identified several associations between exposures to rocket propellants and combustion products and disease. However, there is some concern among our members about the direction that the process has taken. Many of the substances to which there was potential exposure in the gulf are unique to war service (for example, nerve agents, mustard agents, and rocket propellants), but others are not and may be at least as likely to occur in noncombat military service or in civilian life as in war (for example, fuels, air pollutants, and the solvents and pesticides reviewed in Gulf War and Health, Volume 2: Insecticides and Solvents). Therefore, as the process has evolved from an examination of exposures unique to wartime to exposures that are ubiquitous and may be even greater in civilian life, what are VA and Congress to do with the results of this study? A second troubling issue is the lack of exposure information for individual veterans; given that many risks are clearly exposure-related, it is difficult to use the results of our review to assess whether veterans’ illnesses are due to such exposures. Third, it is important to interpret the results of our review in a larger context of public health and prevention; for example, the committee found some evidence of an association between hydrazine exposure and lung cancer, but there obviously are much larger and better-established associations between lung cancer and other exposures, such as smoking and exposure to radon and asbestos. Given those circumstances, this report cannot answer the question of whether service in the gulf was associated with such exposures and whether specific health outcomes are due to the exposures. Despite those limitations, the committee hopes that its report will be helpful to all who may have been exposed to the substances in question and to those who are considering further research in the subject.
I am deeply appreciative of the expert work of our committee members, and it has been a privilege and a pleasure to work with the IOM staff. Without them, this report would not have been possible.
Lynn Goldman, MD, MPH, Chair
Boxes, Tables, and Figures
BOX 1.1 |
Agents Specified In PL 105–368 and PL 105–277 |
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BOX 4.1 |
Summary of Findings Regarding the Association Between Specific Cancers and Exposure to Fuels and Combustion Products |
FIGURE 4.1 |
Lung cancer and occupations with exposure to combustion products |
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FIGURE 4.2 |
Lung cancer and indoor air pollution from combustion of fuels |
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FIGURE 4.3 |
Lung cancer and ambient air pollution from combustion of fuels |
TABLE ES.1 |
Summary of Findings Regarding the Association Between Exposure to Fuels, Combustion Products, Hydrazines, and Nitric Acid and Specific Health Outcomes |
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TABLE 3.1 |
Chemical Identity and Some Physical and Chemical Properties of Selected Fuels |
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TABLE 3.2 |
Recommended Exposure Limits for Fuels |
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TABLE 4.1 |
Cancers of the Oral Cavity and Oropharynx and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.2 |
Cancers of the Oral Cavity and Oropharynx and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.3 |
Cancers of the Nasal Cavity and Nasopharynx and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.4 |
Cancers of the Nasal Cavity and Nasopharynx and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.5 |
Esophageal Cancer and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.6 |
Esophageal Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.7 |
Stomach Cancer and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.8 |
Stomach Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.9 |
Colon Cancer and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.10 |
Colon Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.11 |
Rectal Cancer and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.12 |
Rectal Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.13 |
Hepatic Cancer and Exposure to Fuels—Selected Epidemiologic Studies |
TABLE 4.14 |
Hepatic Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.15 |
Pancreatic Cancer and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.16 |
Pancreatic Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.17 |
Laryngeal Cancer and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.18 |
Laryngeal Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.19 |
Lung Cancer and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.20 |
Lung Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.21 |
Melanoma Skin Cancer and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.22 |
Melanoma Skin Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.23 |
Non-Melanoma Skin Cancer and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.24 |
Non-Melanoma Skin Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.25 |
Female Breast Cancer and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.26 |
Female Breast Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.27 |
Male Breast Cancer and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.28 |
Male Breast Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.29 |
Female Genital Cancers and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.30 |
Female Genital Cancers and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.31 |
Prostatic Cancer and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.32 |
Prostatic Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.33 |
Brain/CNS Cancers and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.34 |
Brain/CNS Cancers and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.35 |
Ocular Melanoma and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.36 |
Bladder Cancer and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.37 |
Bladder Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.38 |
Kidney Cancer and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.39 |
Kidney Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.40 |
Non-Hodgkin’s Lymphoma and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.41 |
Non-Hodgkin’s Lymphoma and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.42 |
Hodgkin’s Disease and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.43 |
Hodgkin’s Disease and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.44 |
Multiple Myeloma and Exposure to Fuels—Selected Epidemiologic Studies |
TABLE 4.45 |
Multiple Myeloma and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.46 |
Leukemias and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 4.47 |
Myelodysplastic Syndromes and Exposure to Fuels—Selected Epidemiologic Studies |
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TABLE 4.48 |
Myelodysplastic Syndromes and Exposure to Combustion Products—Selected Epidemiologic Studies |
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TABLE 5.1 |
Selected Epidemiologic Studies—Fuel Exposure and Respiratory Outcomes |
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TABLE 5.2 |
Gulf War Veteran Health Studies of Oil-Well Fire Smoke |
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TABLE 5.3 |
Exposure in Smith et al. 2002 |
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TABLE 5.4 |
Key Studies of Asthma |
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TABLE 5.5 |
Key Studies of Chronic Bronchitis |
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TABLE 7.1 |
Selected Epidemiologic Studies—Reproductive Outcomes and Exposure to Fuel |
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TABLE 7.2 |
Preterm Birth and Combustion-Product Exposure |
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TABLE 7.3 |
Low Birthweight or Intrauterine Growth Retardation and Combustion-Product Exposure |
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TABLE 8.1 |
Prevalence of MCS Symptoms in Gulf War and US Population-Based Samples |
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TABLE 8.2 |
Common Triggers and Original Causes Reported by People with Chemical Sensitivity (n=235) Population-Based Sample |
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TABLE 8.3 |
Dermatitis and Fuel Exposure |
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TABLE 8.4 |
Case-Control Studies of Sarcoidosis and Combustion Product Exposure |
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TABLE 9.1 |
Chemical Identity and Selected Physical and Chemical Properties of Hydrazines and Nitric Acid |
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TABLE 9.2 |
Recommended Exposure Limits for Hydrazines and Nitric Acid |
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TABLE 9.3 |
Epidemiologic Studies Related to Exposure to Hydrazines |
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TABLE 9.4 |
Selected Epidemiologic Studies—Health Outcomes and Exposure to Hydrazines |
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TABLE 9.5 |
Epidemiologic Studies Related to Exposure to Nitric Acid |
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TABLE 9.6 |
Selected Epidemiologic Studies—Health Outcomes and Exposure to Nitric Acid |
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TABLE D.1 |
Description of Cohort Studies Related to Exposure to Fuels and Combustion Products |
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TABLE D.2 |
Description of Case-Control Studies Related to Exposure to Fuels and Combustion Products |