GULF WAR and HEALTH

VOLUME 3

FUELS, COMBUSTION PRODUCTS, AND PROPELLANTS

Committee on Gulf War and Health: Literature Review of Selected Environmental Particulates, Pollutants, and Synthetic Chemical Compounds

Board on Health Promotion and Disease Prevention

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
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Gulf War and Health: Fuels, Combustion Products, and Propellants - Volume 3 GULF WAR and HEALTH VOLUME 3 FUELS, COMBUSTION PRODUCTS, AND PROPELLANTS Committee on Gulf War and Health: Literature Review of Selected Environmental Particulates, Pollutants, and Synthetic Chemical Compounds Board on Health Promotion and Disease Prevention INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Gulf War and Health: Fuels, Combustion Products, and Propellants - Volume 3 THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 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. International Standard Book Number 0-309-09527-1 (Book) International Standard Book Number 0-309-54736-9 (PDF) Library of Congress Control Number: 200109510 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Lockbox 285, Washington, DC 20055; (800) 624–6242 or (202) 334–3313 (in the Washington metropolitan area); http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright 2005 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Gulf War and Health: Fuels, Combustion Products, and Propellants - Volume 3 “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Adviser to the Nation to Improve Health

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Gulf War and Health: Fuels, Combustion Products, and Propellants - Volume 3 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. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm.A.Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V.Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M.Alberts and Dr. Wm.A.Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Gulf War and Health: Fuels, Combustion Products, and Propellants - Volume 3 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

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Gulf War and Health: Fuels, Combustion Products, and Propellants - Volume 3 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

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Gulf War and Health: Fuels, Combustion Products, and Propellants - Volume 3 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.

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Gulf War and Health: Fuels, Combustion Products, and Propellants - Volume 3 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

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Gulf War and Health: Fuels, Combustion Products, and Propellants - Volume 3 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

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Gulf War and Health: Fuels, Combustion Products, and Propellants - Volume 3 CONTENTS     EXECUTIVE SUMMARY   1      Charge to the Committee   1      Committee’s Approach to Its Charge   3      Categories of Association   4      Human Health Outcomes   6      Summary of Conclusions   6 1   INTRODUCTION   12      Scope of this Volume   13      Charge to the Committee   14      Committee’s Approach to Its Charge   15      Organization of the Report   16      References   17 2   CONSIDERATIONS IN IDENTIFYING AND EVALUATING THE LITERATURE   18      Identification of the Literature   19      Epidemiologic Studies   20      Inclusion Criteria   21      Considerations in Assessing the Strength of the Evidence   22      Categories of Association   25      References   27 3   UNCOMBUSTED FUELS AND COMBUSTION PRODUCTS: BACKGROUND INFORMATION   28      Uncombusted Fuels   28      Combustion Products   39      Individual Susceptibility   49      Interactions   50      References   50 4   CANCER   60      Cancers of the Oral Cavity and Oropharynx   61      Cancers of the Nasal Cavity and Nasopharynx   66      Esophageal Cancer   70      Stomach Cancer   72      Colon Cancer   74      Rectal Cancer   76      Liver Cancer   78      Pancreatic Cancer   79      Laryngeal Cancer   80      Lung Cancer   85

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Gulf War and Health: Fuels, Combustion Products, and Propellants - Volume 3      Malignant Melanoma of the Skin   94      Non-Melanoma Skin Cancers   98      Female Breast Cancer   101      Male Breast Cancer   102      Female Genital Cancers (Cervical, Endometrial, Uterine, and Ovarian)   104      Male Genital Cancers (Prostatic and Testicular)   105      Nervous System Cancers   107      Ocular Melanoma   110      Bladder Cancer   111      Kidney Cancer   119      Non-Hodgkin’s Lymphoma   127      Hodgkin’s Disease   130      Multiple Myeloma   132      Leukemias   137      Myelodysplastic Syndromes   140      Summary of Conclusions   142      Tables   144      References   223 5   RESPIRATORY OUTCOMES   240      Fuels and Respiratory Outcomes   241      Combustion Products and Respiratory Outcomes   243      References   270 6   CARDIOVASCULAR DISEASE   277      Fuels and Cardiovascular Disease   278      Combustion Products and Cardiovascular Disease   278      References   284 7   REPRODUCTIVE AND DEVELOPMENTAL OUTCOMES   288      Studies of Birth Defects in Gulf War Veterans   288      Fuels and Reproductive and Developmental Outcomes   290      Combustion Products and Reproductive and Developmental Outcomes   297      References   313 8   OTHER HEALTH OUTCOMES   317      Neurologic Outcomes   317      Multiple Chemical Sensitivity   325      Dermatologic Outcomes   331      Sarcoidosis   337      References   341 9   HYDRAZINES AND NITRIC ACID   347      Toxicology   348      Epidemiologic Studies   360      References   390

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Gulf War and Health: Fuels, Combustion Products, and Propellants - Volume 3 A   CONCLUSIONS FROM GULF WAR AND HEALTH VOLUMES 1 AND 2   398 B   LITERATURE SEARCHES   403 C   TYPES OF EPIDEMIOLOGIC STUDIES   405      Experimental Studies in Animals: Animal Models   405      Experimental Studies in Humans: Randomized Controlled Trials   406      Controlled Epidemiologic Studies (Observational)   406      Comments on the Nature of the Gulf War Studies   410      References   411 D   DESCRIPTIVE TABLES OF CANCER STUDIES   413      References   457     INDEX   465 Boxes, Tables, and Figures BOX 1.1   Agents Specified In PL 105–368 and PL 105–277   13 BOX 4.1   Summary of Findings Regarding the Association Between Specific Cancers and Exposure to Fuels and Combustion Products   142 FIGURE 4.1   Lung cancer and occupations with exposure to combustion products   87 FIGURE 4.2   Lung cancer and indoor air pollution from combustion of fuels   88 FIGURE 4.3   Lung cancer and ambient air pollution from combustion of fuels   89 TABLE ES.1   Summary of Findings Regarding the Association Between Exposure to Fuels, Combustion Products, Hydrazines, and Nitric Acid and Specific Health Outcomes   7 TABLE 3.1   Chemical Identity and Some Physical and Chemical Properties of Selected Fuels   30 TABLE 3.2   Recommended Exposure Limits for Fuels   32 TABLE 4.1   Cancers of the Oral Cavity and Oropharynx and Exposure to Fuels—Selected Epidemiologic Studies   144 TABLE 4.2   Cancers of the Oral Cavity and Oropharynx and Exposure to Combustion Products—Selected Epidemiologic Studies   145 TABLE 4.3   Cancers of the Nasal Cavity and Nasopharynx and Exposure to Fuels—Selected Epidemiologic Studies   147 TABLE 4.4   Cancers of the Nasal Cavity and Nasopharynx and Exposure to Combustion Products—Selected Epidemiologic Studies   147 TABLE 4.5   Esophageal Cancer and Exposure to Fuels—Selected Epidemiologic Studies   148 TABLE 4.6   Esophageal Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies   149 TABLE 4.7   Stomach Cancer and Exposure to Fuels—Selected Epidemiologic Studies   150 TABLE 4.8   Stomach Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies   151 TABLE 4.9   Colon Cancer and Exposure to Fuels—Selected Epidemiologic Studies   152 TABLE 4.10   Colon Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies   153 TABLE 4.11   Rectal Cancer and Exposure to Fuels—Selected Epidemiologic Studies   154 TABLE 4.12   Rectal Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies   155 TABLE 4.13   Hepatic Cancer and Exposure to Fuels—Selected Epidemiologic Studies   156

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Gulf War and Health: Fuels, Combustion Products, and Propellants - Volume 3 TABLE 4.14   Hepatic Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies   156 TABLE 4.15   Pancreatic Cancer and Exposure to Fuels—Selected Epidemiologic Studies   157 TABLE 4.16   Pancreatic Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies   157 TABLE 4.17   Laryngeal Cancer and Exposure to Fuels—Selected Epidemiologic Studies   158 TABLE 4.18   Laryngeal Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies   159 TABLE 4.19   Lung Cancer and Exposure to Fuels—Selected Epidemiologic Studies   163 TABLE 4.20   Lung Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies   164 TABLE 4.21   Melanoma Skin Cancer and Exposure to Fuels—Selected Epidemiologic Studies   184 TABLE 4.22   Melanoma Skin Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies   185 TABLE 4.23   Non-Melanoma Skin Cancer and Exposure to Fuels—Selected Epidemiologic Studies   187 TABLE 4.24   Non-Melanoma Skin Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies   187 TABLE 4.25   Female Breast Cancer and Exposure to Fuels—Selected Epidemiologic Studies   188 TABLE 4.26   Female Breast Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies   189 TABLE 4.27   Male Breast Cancer and Exposure to Fuels—Selected Epidemiologic Studies   190 TABLE 4.28   Male Breast Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies   190 TABLE 4.29   Female Genital Cancers and Exposure to Fuels—Selected Epidemiologic Studies   191 TABLE 4.30   Female Genital Cancers and Exposure to Combustion Products—Selected Epidemiologic Studies   192 TABLE 4.31   Prostatic Cancer and Exposure to Fuels—Selected Epidemiologic Studies   193 TABLE 4.32   Prostatic Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies   194 TABLE 4.33   Brain/CNS Cancers and Exposure to Fuels—Selected Epidemiologic Studies   195 TABLE 4.34   Brain/CNS Cancers and Exposure to Combustion Products—Selected Epidemiologic Studies   197 TABLE 4.35   Ocular Melanoma and Exposure to Combustion Products—Selected Epidemiologic Studies   197 TABLE 4.36   Bladder Cancer and Exposure to Fuels—Selected Epidemiologic Studies   198 TABLE 4.37   Bladder Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies   200 TABLE 4.38   Kidney Cancer and Exposure to Fuels—Selected Epidemiologic Studies   207 TABLE 4.39   Kidney Cancer and Exposure to Combustion Products—Selected Epidemiologic Studies   210 TABLE 4.40   Non-Hodgkin’s Lymphoma and Exposure to Fuels—Selected Epidemiologic Studies   212 TABLE 4.41   Non-Hodgkin’s Lymphoma and Exposure to Combustion Products—Selected Epidemiologic Studies   214 TABLE 4.42   Hodgkin’s Disease and Exposure to Fuels—Selected Epidemiologic Studies   215 TABLE 4.43   Hodgkin’s Disease and Exposure to Combustion Products—Selected Epidemiologic Studies   216 TABLE 4.44   Multiple Myeloma and Exposure to Fuels—Selected Epidemiologic Studies   216

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Gulf War and Health: Fuels, Combustion Products, and Propellants - Volume 3 TABLE 4.45   Multiple Myeloma and Exposure to Combustion Products—Selected Epidemiologic Studies   218 TABLE 4.46   Leukemias and Exposure to Combustion Products—Selected Epidemiologic Studies   220 TABLE 4.47   Myelodysplastic Syndromes and Exposure to Fuels—Selected Epidemiologic Studies   221 TABLE 4.48   Myelodysplastic Syndromes and Exposure to Combustion Products—Selected Epidemiologic Studies   222 TABLE 5.1   Selected Epidemiologic Studies—Fuel Exposure and Respiratory Outcomes   243 TABLE 5.2   Gulf War Veteran Health Studies of Oil-Well Fire Smoke   248 TABLE 5.3   Exposure in Smith et al. 2002   251 TABLE 5.4   Key Studies of Asthma   265 TABLE 5.5   Key Studies of Chronic Bronchitis   268 TABLE 7.1   Selected Epidemiologic Studies—Reproductive Outcomes and Exposure to Fuel   290 TABLE 7.2   Preterm Birth and Combustion-Product Exposure   299 TABLE 7.3   Low Birthweight or Intrauterine Growth Retardation and Combustion-Product Exposure   303 TABLE 8.1   Prevalence of MCS Symptoms in Gulf War and US Population-Based Samples   326 TABLE 8.2   Common Triggers and Original Causes Reported by People with Chemical Sensitivity (n=235) Population-Based Sample   331 TABLE 8.3   Dermatitis and Fuel Exposure   333 TABLE 8.4   Case-Control Studies of Sarcoidosis and Combustion Product Exposure   338 TABLE 9.1   Chemical Identity and Selected Physical and Chemical Properties of Hydrazines and Nitric Acid   349 TABLE 9.2   Recommended Exposure Limits for Hydrazines and Nitric Acid   352 TABLE 9.3   Epidemiologic Studies Related to Exposure to Hydrazines   364 TABLE 9.4   Selected Epidemiologic Studies—Health Outcomes and Exposure to Hydrazines   372 TABLE 9.5   Epidemiologic Studies Related to Exposure to Nitric Acid   375 TABLE 9.6   Selected Epidemiologic Studies—Health Outcomes and Exposure to Nitric Acid   386 TABLE D.1   Description of Cohort Studies Related to Exposure to Fuels and Combustion Products   414 TABLE D.2   Description of Case-Control Studies Related to Exposure to Fuels and Combustion Products   425

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