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Environmental Medicine: Integrating a Missing Element into Medical Education D Resources: Agencies, Organizations, Services, References, and Tables of Environmental Health Hazards CONTENTS     INTRODUCTION   911     GOVERNMENT AGENCIES   911     Federal Agencies   912     Agency for Toxic Substances and Disease Registry   912     Centers for Disease Control and Prevention   913     Consumer Product Safety Commission   913     Department of Energy   913     Department of Health and Human Services   914     Environmental Protection Agency   914     Food and Drug Administration   915     Health Resources and Services Administration   915     National Cancer Institute   915     National Center for Environmental Health   916     National Institute for Occupational Safety and Health   916     Project EPOCH-Envi   917     NIOSH Educational Resource Centers   918     National Institute of Environmental Health Sciences   919     Environmental/Occupational Medicine Academic Awards   920     National Institutes of Health   921     Nuclear Regulatory Commission   921     Occupational Safety and Health Administration   922

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Environmental Medicine: Integrating a Missing Element into Medical Education     State Agencies   922     State Health Departments and Radon Contacts   922     ASSOCIATIONS AND ORGANIZATIONS   928     American Association of Occupational Health Nurses   928     American Association of Poison Control Centers   928     American Board of Medical Toxicology   931     American College of Obstetricians and Gynecologists   931     American College of Occupational and Environmental Medicine   932     Occupational Physicians Scholarships Fund   932     American College of Preventive Medicine   933     American Lung Association   933     Association of Occupational and Environmental Clinics   933     Association of Teachers of Preventive Medicine   939     Center for Safety in the Arts   939     Committees on Occupational Safety and Health   940     Consortium for Environmental Education in Medicine   940     MotherRisk Program   940     National Association of Physicians for the Environment   941     Pesticide Education Center   941     Physicians for Social Responsibility   941     Society for Occupational and Environmental Health   942     Teratogen Exposure Registry and Surveillance   942     WorldWatch Institute   943     SELECTED TOPICAL RESOURCES   943     COMPUTERIZED INFORMATION SERVICES   944     Internet   944     List Servers   946     Other Gophers Relevant to Environmental Health, Medicine, and Safety   947     Computer-Based Databases   948     GENERAL REFERENCES   950     Books and Reports   950     Curriculum Resources   951

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Environmental Medicine: Integrating a Missing Element into Medical Education     TABLES OF TOXIC CHEMICALS, HEALTH EFFECTS, AND OCCUPATIONAL EXPOSURES   953     Table D-1: Environmental Agents, Their Sources and Potential Exposures, and Adverse Health Effects: Metals and Metallic Compounds, Hydrocarbons, Irritant Gases, Chemical Asphyxiants, and Pesticides   953     Table D-2: Selected Work-Related Diseases, Disorders, and Conditions Associated with Various Agents, Industries, or Occupations: Infections, Malignant Neoplasms, Hematological, Cardiovascular, Pulmonary, Neurological, and Other Disorders   963     Table D-3: Selected Job Categories, Exposures, and Associated Work-Related Diseases and Conditions   969 * * * INTRODUCTION For those readers who are interested in learning more about environmental medicine, or have other resource needs related to environmental medicine, this appendix presents names, addresses, and phone numbers of relevant government agencies and professional associations and organizations, as well as information about computerized information services, and a listing of general references. Several lists of medical schools with federally funded environmental health activities are also provided. Finally, three tables are presented that describe (1) selected environmental agents and their associated sources and potential exposures, (2) selected work-related diseases, disorders, and conditions associated with various agents, and (3) selected job categories, exposures, and associated work-related diseases and conditions. The information presented in this appendix is not intended to be comprehensive or exhaustive, but rather supplemental and complementary. GOVERNMENT AGENCIES Throughout our history, numerous federal and state agencies have been created to address the issues related to safety and health in the workplace, as well as the surrounding environment. Federal and state agencies have become increasingly involved in examining and monitoring the impact of the environment on the health of the public. The following list highlights several of the federal and state agencies currently involved in monitoring, evaluating, and protecting the environment and its relation to public health. Each agency is an invaluable source of information

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Environmental Medicine: Integrating a Missing Element into Medical Education and can readily provide additional resources upon one’s request. The agencies are listed in alphabetical order with federal organizations first, followed by state agencies. Federal Agencies Agency for Toxic Substances and Disease Registry The Agency for Toxic Substances and Disease Registry (ATSDR) was created by Superfund legislation in 1980 as a part of the U.S. Department of Health and Human Services. ATSDR’s mission is to prevent or mitigate adverse human health effects and diminished quality of life resulting from exposure to hazardous substances in the environment. In order to carry out its mission and to serve the needs of the American people, ATSDR conducts activities in public health assessments, health investigations, exposure and disease registry, emergency response, toxicological profiles, health education, and applied research. ATSDR’s Division of Health Education is mandated to assemble, develop, and distribute to the states, medical colleges, physicians, and other health professionals, educational materials on medical surveillance, screening, and methods of diagnosis and treatment of injury or disease related to exposure to hazardous substances. The Division also provides training and education for primary care physicians to diagnose and treat illness caused by hazardous substances and supports curriculum development and applied research in the area of environmental health. The Division has developed a self-study series called Case Studies in Environmental Medicine which uses case studies to guide physicians through the diagnosis and treatment of illnesses related to hazardous substances exposure. Several projects have also been developed and implemented to advance these goals. Some of the programs are described below: State Cooperative Agreements offer funding and assistance to state health departments for developing educational materials and activities in environmental medicine for health care professionals; National Association of County Health Officials Environmental Health Project is a cooperative agreement with ATSDR to conduct instructional sessions and develop supporting materials for local health officials and the medical community concerning the communication of health risks from exposure to hazardous substances; Project EPOCH-Envi is co-sponsored by ATSDR and the National Institute for Occupational Safety and Health (NIOSH). Through the cooperative agreement, a consortium of medical schools works towards introducing curricula in occupational and environmental medicine in primary care residency programs; The National Medical Association (NMA) is the largest organization of African-American physicians in the United States. ATSDR co-sponsors sessions and lectures on environmental health through the NMA’s Regional Environmental Workshops. NMA has recognized the seriousness of environmental contamination in minority communities and is now working with ATSDR to provide training in environmental health for its members.

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Environmental Medicine: Integrating a Missing Element into Medical Education Agency for Toxic Substances and Disease Registry 1600 Clifton Road, N.E. Mail Stop E-28 Atlanta, GA 30333 (404) 639–0501 Emergencies (404) 639–0615 Centers for Disease Control and Prevention The Centers for Disease Control and Prevention (CDC) is charged with protecting the public health of the nation by providing leadership and direction in the prevention and control of diseases and other preventable conditions and responding to public health emergencies. Centers for Disease Control and Prevention 1600 Clifton Road, N.E. Atlanta, GA 30333 (404) 639–3286 Consumer Product Safety Commission The Consumer Products Safety Commission provides information on health and safety effects related to consumer products. It has direct jurisdiction over chronic and chemical hazards in consumer products; assists consumers in evaluating the comparative safety of consumer products; develops uniform safety standards for consumer products and minimizes conflicting state and local regulations; and promotes research and investigation into the causes and prevention of product-related deaths, illnesses, and injuries. Consumer Product Safety Commission East West Towers 4340 East West Highway Bethesda, MD 20814 (301) 504–0580 (800) 638–2772 Department of Energy The Department of Energy (DOE) provides the framework for a comprehensive and balanced national energy plan through the coordination and administration of the energy functions of the federal government. The Department is responsible for long-term, high-risk research and development of energy technology; the marketing of federal power; energy conservation; the nuclear weapons program; energy regulatory programs; and a central energy data collection and analysis program.

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Environmental Medicine: Integrating a Missing Element into Medical Education The Environment, Safety and Health Office of the DOE provides independent oversight of departmental execution of environmental, occupational safety and health, and nuclear/nonnuclear safety and security laws, regulations, and policies; ensures that departmental programs are in compliance with environmental, health, and nuclear/nonuclear safety protection plans, regulations, and procedures; provides an independent overview and assessment of Department-controlled activities to ensure that safety-impacted programs receive management review; and carries out legal functions of the nuclear safety civil penalty and criminal referral activities mandated by the Price-Anderson Amendments Act. Department of Energy 1000 Independence Avenue, S.W. Washington, DC 20585 (202) 586–5000 Department of Health and Human Services The Department of Health and Human Services (HHS) is the Cabinet-level department of the federal executive branch most concerned with people and most involved with then nation’s human concerns. In one way or another—whether it is mailing out social security checks or making health services more widely available—HHS touches the lives of more Americans than any other federal agency. It is literally a department of people saving people, from newborn infants to our most elderly citizens. Department of Health and Human Services 200 Independence Ave., S.W. Washington, DC 20201 (202) 679–0257 Environmental Protection Agency The Environmental Protection Agency (EPA) was established in 1970 in order to permit coordinated and effective governmental action on behalf of the environment. It endeavors to abate and control pollution systematically, by proper integration of a variety of research, monitoring, standard setting, and enforcement activities. As a complement to its other activities, the Agency coordinates and supports research and antipollution activities by state and local governments, private and public groups, individuals, and educational institutions. It also reinforces efforts among other federal agencies with respect to the impact of their operations on the environment, and it is specifically charged with publishing its determinations when those hold that a proposal is unsatisfactory from the standpoint of public health or welfare or environmental quality. In all, the EPA is designed to serve as the public’s advocate for a livable environment.

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Environmental Medicine: Integrating a Missing Element into Medical Education Environmental Protection Agency 401 M Street, S.W. Washington, DC 20460 (202) 260–2090 Food and Drug Administration The Food and Drug Administration (FDA) inspects manufacturing plants and warehouses, collects and analyzes samples of foods, drugs, cosmetics, and therapeutic devices for adulteration and misbranding. Responsibilities also extend to sanitary preparation and handling of foods, waste disposal on interstate carriers, and enforcement of the Radiation Control Act as related to consumer products. Epidemiological and other investigations are conducted to determine causative factors or possible health hazards involved in adverse reactions or hazardous materials accidents. Investigators are located in resident posts in major cities throughout the country. Food and Drug Administration National Headquarters 200 C Street, S.W. Washington, DC 20204 (301) 443–2410 Health Resources and Services Administration Health Resources and Services Administration (HRSA) is responsible for general health services and resource issues relating to issues of access, equity, quality, and cost of care. In order to accomplish this goal, the Administration supports states and communities in their efforts to deliver health care to underserved segments of the population; participates in the federal campaign against AIDS; provides leadership in improving the education, distribution, quality, and use of the health professionals needed to staff the nation’s health care system; tracks the supply of and requirements for health professionals and addresses their competence through the development of a health practitioner data bank; and strengthens the public health system by working with state and local public health agencies. Health Resources and Services Administration 5600 Fishers Lane Rockville, MD 20857 (301) 443–2086 National Cancer Institute The National Cancer Institute (NCI) conducts and funds research on the causes, diagnosis, treatment, prevention, control, and biology of cancer and the rehabilitation of people with cancer.

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Environmental Medicine: Integrating a Missing Element into Medical Education NCI also funds projects for innovative and effective approaches to preventing and controlling cancer, establishes multidisciplinary cancer care and clinical research activities in community hospitals, and supports cancer research training, clinical training, continuing education, and career development. National Cancer Institute National Institutes of Health 9000 Rockville Pike Bethesda, MD 20892 (301) 496–5615 (800) 422–6237/(800) 4CANCER National Center for Environmental Health The mission of the National Center for Environmental Health (NCEH) is to promote health and quality of life by preventing or controlling disease, injury, and disability related to the interactions between people and their environment outside the workplace. To achieve these goals, NCEH directs programs both to prevent the adverse health effects of exposure to toxic substances and to combat the societal and environmental factors that increase the likelihood of exposure and disease. NCEH also works to prevent injuries and diseases resulting from natural or technologic disasters and to prevent birth defects and development disabilities resulting from nutritional deficiencies or exposure to environmental toxins in utero or during early childhood. National Center for Environmental Health Mailstop F29 4770 Buford Highway, N.E. Atlanta, GA 30341–3724 (404) 488–7003 National Institute for Occupational Safety and Health The National Institute for Occupational Safety and Health (NIOSH) was established by the Occupational Safety and Health Act of 1970 to conduct research on occupational diseases and injuries, respond to requests for assistance by investigating problems of health and safety in the workplace, recommend standards to the Occupational Safety and Health Administration (OSHA) and the Mine Safety and Health Administration (MSHA), and train professionals in occupational safety and health. National Institute for Occupational Safety and Health 200 Independence Avenue, S.W. Washington, DC 20201 (800) 356–4674

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Environmental Medicine: Integrating a Missing Element into Medical Education NIOSH Technical Information Branch provides a toll-free technical information service (1– 800–35-NIOSH) that provides convenient public access to NIOSH and its information resources. Callers may request information about NIOSH activities or about any aspect of occupational safety and health. NIOSH Technical Information Branch Robert A. Taft Laboratory Mail Stop C-19 4676 Columbia Parkway Cincinnati, OH 45226–1998 (800) 35-NIOSH Project EPOCH-Envi. In conjunction with ATSDR, NIOSH established Project EPOCH-Envi to provide support and training to medical schools from around the country who wish to implement curricula in occupational and environmental medicine in primary care residency programs. Through this cooperative agreement, Project EPOCH-Envi conducts workshops and training programs for interested medical school faculty. The sessions focus on instructing faculty members how to develop curricula in occupational and environmental medicine. Project EPOCH-Envi National Institute for Occupational Safety and Health Division of Training and Manpower Development Curriculum Development Branch Robert A. Taft Laboratories 4676 Columbia Parkway Cincinnati, OH 45226–1998 (800) 356–4674 In 1992–1993, the following medical schools were involved in Project EPOCH-Envi or represented by faculty members: University of Arkansas College of Medicine University of California, San Francisco, School of Medicine University of Connecticut School of Medicine University of Florida College of Medicine University of Miami School of Medicine Emory University School of Medicine Medical College of Georgia Morehouse School of Medicine University of Illinois College of Medicine at Peoria University of Illinois College of Medicine at Urbana-Champaign University of Illinois College of Medicine at Chicago Loyola University Chicago, Stritch School of Medicine Southern Illinois University School of Medicine University of Massachusetts Medical School University of Missouri, Columbia School of Medicine

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Environmental Medicine: Integrating a Missing Element into Medical Education Saint Louis University School of Medicine University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School Cornell University Medical Center University of Rochester School of Medicine State University of New York at Brooklyn College of Medicine State University of New York at Syracuse College of Medicine Bowman Gray School of Medicine Duke University School of Medicine East Carolina University School of Medicine University of North Carolina at Chapel Hill School of Medicine Medical University of South Carolina College of Medicine University of South Carolina School of Medicine University of Texas Medical Center at San Antonio University of Vermont College of Medicine West Virginia University School of Medicine NIOSH Educational Resource Centers The National Institute for Occupational Safety and Health (NIOSH) funds Educational Resource Centers (ERCs) which conduct research and administer graduate training programs in occupational medicine, occupational health nursing, and industrial hygiene and safety. They also provide continuing education programs for safety and health professionals and outreach programs for the community. ALABAMA Deep South Center for Occupational Health and Safety University of Alabama at Birmingham Elizabeth Murray Continuing Education (205) 934–7178 CALIFORNIA Northern California ERC Center for Occupational and Environmental Health University of California at Berkeley Barbara Plog, Continuing Education (510) 231–5647 Southern California ERC University of Southern California Ramona Cayuela, Continuing Education (213) 740–3995 ILLINOIS Illinois ERC Occupational Health and Safety Center University of Illinois, Chicago Leslie Nickels, School of Public Health (312) 996–7473 MARYLAND Johns Hopkins ERC Johns Hopkins University Department of Environmental Health Sciences Dr. Jacqueline Corn, Continuing Education (410) 955–2609 MASSACHUSETTS Harvard ERC Harvard Educational Resource Center Daryl Bichel, Continuing Education (617) 432–3314

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Environmental Medicine: Integrating a Missing Element into Medical Education MICHIGAN Michigan ERC University of Michigan Center for Occupational Health and Safety Randy Rabourn, Continuing Education (313) 936–0148 MINNESOTA Midwest Center for Occupational Health and Safety University of Minnesota Jeanne Ayers, Continuing Education (612) 221–3992 NEW YORK/NEW JERSEY UMDNJ-Robert Wood Johnson Medical School Barbara Young, Registrar (908) 235–5062 NORTH CAROLINA Occupational Safety and Health ERC University of North Carolina Larry Hyde, Continuing Education (919) 962–2101 OHIO University of Cincinnati ERC University of Cincinnati Department of Environmental Health Judy Jarrell, Continuing Education (513) 558–1730 TEXAS Southwest Center for Occupational Health and Safety Pam Parker, Continuing Education (713) 792–4648 UTAH Rocky Mountain Center for Occupational and Environmental Health University of Utah Connie Crandall, Continuing Education (801 581–5710 WASHINGTON Northwest Center for Occupational Health and Safety University of Washington Jan Schwert, Continuing Education (206) 543–1069 National Institute of Environmental Health Sciences The National Institute of Environmental Health Sciences (NIEHS) is the principal federal agency for biomedical research on the effects of chemical, physical, and biological environmental agents on human health and well-being. The Institute supports research and training focused on the identification, assessment, and mechanism of action of potentially harmful agents in the environment. Research results form the basis for preventive programs for environmentally-related diseases and for action by regulatory agencies. The NIEHS currently sponsors several programs available to the medical school community, individual researchers, and other organizations or centers interested in studying the effects of the

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Environmental Medicine: Integrating a Missing Element into Medical Education Agent Exposure Route of Entry Systems(s) Affected Primary Manifestations Aids in Diagnosis Remarks Chlorine Paper and textile bleaching; water disinfection; chemical manufacturing; metal fluxing; detinning and dezincing iron Inhalation of gas Middle respiratory tract Tracheobronchitis, pulmonary edema, pneumonitis Chest x ray, pulmonary function tests Chlorine combines with body moisture to form acids, which irritate tissues from nose to alveoli. Ozone Inert gas-shielded arc welding; food, water, and air purification; food and textile bleaching; emitted around high-voltage electrical equipment Inhalation of gas Lower respiratory tract Delayed pulmonary edema (generally 6–8 h following exposure) Chest x ray, pulmonary function tests Ozone has a free radical structure and can produce experimental chromosome aberrations; it may thus have carcinogenic potential. Nitrogen oxides Manufacturing of acids, nitrogen containing chemicals, explosives, and more; byproduct of many industrial processes Inhalation of gas Lower respiratory tract Pulmonary irritation, bronchiolitis fibrosa obliterans (“silo filler’s disease”), mixed obstructive-restrictive changes Chest x ray, pulmonary function tests   Phosgene Manufacturing and burning of isocyanates, and manufacturing of dyes and other organic chemicals; in metallurgy for ore separation; burning or heat source near trichloroethylene Inhalation of gas Lower respiratory tract Delayed pulmonary edema (delay seldom longer than 12 h) Chest x ray, pulmonary function tests Isocyanates TDI (toluene diisocyanate) MDI (methylene diphenyldiisocyanate) Hexamethylene diisocyanate and others Polyurethane manufacture; resinbinding systems in foundries; coating materials for wires; used in certain types of paint Inhalation of vapor Predominantly lower respiratory tract Asthmatic reaction and accelerated loss of pulmonary function Chest x ray, pulmonary function tests Isocyanates are both respiratory tract “sensitizes” and irritants in the conventional sense.

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Environmental Medicine: Integrating a Missing Element into Medical Education Asphyxiant gases Simple asphyxiants: nitrogen hydrogen, methane, and others Enclosed spaces in a variety of industrial settings Inhalation of gas CNS Anoxia O2 in environment No specific toxic effect; act by displacing O2 Chemical Asphyxiants Carbon monoxide Incomplete combustion in foundries, coke ovens, refineries, furnaces, and more Inhalation of gas Blood (hemoglobin) Headache, dizziness, double vision Carboxyhemoglobin   Hydrogen sulfide Used in manufacturing of sulfur-containing chemicals; produced in petroleum production; byproduct of petroleum product use; decay of organic matter Inhalation of gas CNS Respiratory center paralysis, hypoventilation PaO2 Pulmonary Respiratory tract irritation Cyanide Metallurgy, electroplating Inhalation of vapor, percutaneous absorption, ingestion Cellular metabolic enzymes (especially cytochrome oxidase) Enzyme inhibition with metabolic asphyxia and death SCN− in urine Pesticides Organophophates: malathion, parathion, and others   Inhalation, ingestions, percutaneous absorption Neuromuscular Cholinesterase inhibition, cholinergic symptoms: nausea and vomiting, salivation, diarrhea, headache, seating, meiosis, muscle fasciculations, seizures, unconsciousness, death Refractoriness to atropine; plasma or red cell cholinesterase As with many acute toxins, rapid treatment of organophosphate toxicity is imperative. Thus, diagnosis is often made based on history and a high index of suspicion rather than on biochemical tests. Treatment is atropine to block cholinergic effects and 2-PAM (2-pyridine-alsoxine methiodide) to reactivate cholinesterase.

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Environmental Medicine: Integrating a Missing Element into Medical Education Agent Exposure Route of Entry Systems(s) Affected Primary Manifestations Aids in Diagnosis Remarks Carbamates: carbaryl (Sevin) and others   Inhalation, ingestion, percutaneous absorption Neuromuscular Same as organophosphates Plasma cholinesterase; urinary 1-naphthol (index of exposure) Treatment of carbamate poisoning is the same as that of organophosphate poisoning except that 2-PAM is contra-indicated. Chlorinated hydrocarbons: chlordane, DDT, heptachlor, chlordecone (Kepone), aldrin, dieldrin, uridine Ingestion, inhalation, percutaneous absorption CNS Stimulation or depression Urinary organic chlorine, or p-chlorophenol acetic acid The chlorinated hydrocarbons may accumulate in body lipid stores in large amounts. Bipyridyls: paraquat, diquat Inhalation, ingestion, percutaneous absorption Pulmonary Rapid massive fibrosis, only following paraquat ingestion   An interesting toxin in that the major toxicity, pulmonary fibrosis, apparently occurs only after ingestion.   SOURCE: Principles and Practice of Environmental Health, A.B.Tarcher, ed., Plenum, New York, 1992.

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Environmental Medicine: Integrating a Missing Element into Medical Education TABLE D-2: Selected Work-Related Diseases, Disorders, and Conditions Associated with Various Agents, Industries, or Occupations: Infections, Malignant Neoplasms, and Hematological, Cardiovascular, Pulmonary, Neurological, and Miscellaneous Disorders Diseases, Disorders, and Conditions Industry or Occupation Agent Infections Anthrax Shepherds, farmers, butchers, handlers of imported hides or fibers, veterinarians, veterinarian pathologists, weavers Bacillus anthraces Brucellosis Farmers, shepherds, vets, lab and slaughterhouse workers Brucella abortus, suis Plague Shepherds, farmers, ranchers, hunters, field geologists Yersinia pestis Hepatitis A Day-care center, orphanage, and mental retardation institution staff, medical personnel Hepatitis A virus Hepatitis B Nurses and aides, anesthesiologists, orphanage and mental institution staffs, medical lab workers, general dentists, oral surgeons, physicians Hepatitis B virus Hepatitis C (formerly included in non-A, non-B) Same as hepatitis A and B Hepatitis C virus Ornithosis Psittacine bird breeders, pet shop and zoo workers, poultry producers, vets Chlamydia psittaci Rabies Veterinarians, game wardens, lab workers, farmers, ranchers, trappers Rabies virus Rubella Medical personnel Rubella virus Tetanus Farmers, ranchers Clostridium tetani Tuberculosis Pulmonary Physicians, medical personnel, medical lab workers Mycobacterium tuberculosis Tuberculosis Silicotuberculosis Quarrymen, sandblasters, silica processors, miners, foundry workers, ceramic industry Silicon dioxide (silica), M. tuberculosis Tularemia Hunters, fur handlers, sheep industry, cooks, veterinarians, ranchers, veterinarian pathologists Francisella tularensis

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Environmental Medicine: Integrating a Missing Element into Medical Education Diseases, Disorders, and Conditions Industry or Occupation Agent Malignant Neoplasms Bladder Rubber and dye workers Benzidine, 1- and 2-naphthylamine, auramine, magenta, 4-aminobiphenyl, 4-nitrophenyl Bone Dial painters, radium chemists and processors Radium Kidney and other urinary organs Coke oven workers Coke oven emissions Liver Vinyl chloride polymerization industry Vinyl chloride monomer Liver hemangiosarcoma Vintners Arsenical pesticides Lung, bronchial, tracheal Asbestos industry, users Topside coke oven workers Uranium and flourspar miners Chromium producers, processors, users Smelters Mustard gas formulators Ion-exchange resin makers, chemists Asbestos Coke oven emissions Radon daughters Chromates Arsenic Mustard gas Bis(chloromethyl)-ether, chloromethyl methyl ether Nasal cavity Woodworkers, furniture makers Boot and shoe industry Radium chemists and processors, dial painters Chromium producers, processors, users Nickel smelting and refining Hardwood dusts Unknown Radium Chromates Nickel Asbestos Peritoneal, pleural mesothelioma Asbestos industry, users Asbestos Scrotal Automatic lathe operators, metalworkers Coke oven workers, petroleum refiners, tar distillers Mineral, cutting oils Soots and tars, tar distillates Hematological Disorders Agranulocytosis or neutropenia Workers exposed to benzene Explosives, pesticide industries Pesticide, pigment, pharmaceutical industries Benzene Phosphorous Inorganic arsenic

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Environmental Medicine: Integrating a Missing Element into Medical Education Diseases, Disorders, and Conditions Industry or Occupation Agent Anemia Aplastic Explosives manufacturing Workers exposed to benzene Radiologists, radium chemists, dial painters TNT Benzene Ionizing radiation Anemia Hemolytic, nonautoimmune Whitewashing and leather industry Electrolytic processes, arsenical ore smelting Plastics industry Dye, celluloid, resin industries Copper sulfate Arsine Trimellitic anhydride Naphthalene Leukemia Acute lymphoid Rubber industry Radiologists Unknown Ionizing radiation Leukemia Acute myeloid Workers exposed to benzene Radiologists Benzene Ionizing radiation Leukemia Erythroleukemia Workers exposed to benzene Benzene Methemoglobinemia Explosives, dye industries Aromatic amino and nitro compounds (e.g., aniline, TNT, nitroglycerin) Cardiovascular Disorders Angina Auto mechanics, foundry workers, wood finishers, traffic control, driving in heavy traffic Carbon monoxide Arrhythmias Metal cleaning, solvent use, refrigerator maintenance Solvents, fluorocarbons Raynaud’s phenomenon (secondary) Lumberjacks, chain sawyers, grinders, chippers Vinyl chloride polymerization Whole-body or segmental vibration Vinyl chloride monomer Pulmonary Disorders Alveolitis (extrinsic, allergic) Farmer’s lung bagassosis, bird-breeder’s lung, suberosis, maltworker’s lung, mushroom worker’s lung, maple bark disease, cheese-washer’s lung, coffee-worker’s lung, fish-meal-worker’s lung, furrier’s lung, sequoiosis, woodworker’s lung, miller’s lung Various agents Asbestosis Asbestos workers, users Asbestos

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Environmental Medicine: Integrating a Missing Element into Medical Education Diseases, Disorders, and Conditions Industry or Occupation Agent Asthma (extrinsic) Jewelry, alloy, catalyst makers Polyurethane, adhesive, paint workers Alloy, catalyst, refinery workers Solderers Platinum Isocyanates Chromium, cobalt Aluminum soldering flux Phthalic anhydride Formaldehyde Gum arabic Nickel sulfate Flour Trimellitic anhydride Red cedar, wood dusts Bacillus-derived exoenzymes Animal dander Plastic, dye, insecticide makers Foam workers, latex makers, biologists Printing industry Nickel platers Bakers Plastics industry Woodworkers, furniture makers Detergent formulators Animal handlers Beryllium disease (chronic) Beryllium alloy, ceramic, cathode-ray tube, nuclear reactor workers Beryllium Bronchitis, pneumonitis, pulmonary edema (acute) Refrigeration, fertilizer, oil-refining industries Alkali, beach industries Silo fillers, arc welders, nitric acid workers Paper, refrigeration, oil-refining industries Cadmium smelters, processors Plastics industry Ammonia Chlorine Nitrogen oxides Sulfur dioxide Cadmium Trimellitic anhydride Byssinosis Cotton industry Cotton, flax, hemp, cotton-synthetic dusts Pneumoconiosis Coal miners, bauxite workers Coal dust, bauxite fumes Silicosis Mining, metal, and ceramic industries, quarry men, sand blasters, silica processors Silica Talcosis Talc processors Talc Neurological Disorders Cerebellar ataxia Chemical industry Electrolytic chlorine production, battery manufacturing, fungicide formulators Toluene Organic mercury Encephalitis (toxic) Battery, smelter, foundry workers Electrolytic chlorine production, battery manufacturing, fungicide formulators Lead Organic, inorganic mercury

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Environmental Medicine: Integrating a Missing Element into Medical Education Diseases, Disorders, and Conditions Industry or Occupation Agent Neuropathy (toxic and inflammatory) Pesticide, pigment, pharmaceutical industries Arsenic, arsenic compounds Hexane Methyl butyl ketone TNT Carbon disulfide Tri-o-cresyl phosphate Inorganic lead Inorganic mercury Organic mercury Acrylamide Furniture refinishers, degreasers Plastic-coated-fabric workers Explosives industry Rayon manufacturing Plastics, hydraulics, coke industries Battery, smelter, foundry workers Dentists, chloralkali workers Chloralkali, fungicide, battery workers Plastics, paper manufacture Parkinson’s disease (secondary) Manganese processors, battery manufacturing, welders Internal combustion engine industries Manganese Carbon monoxide Miscellaneous Abdominal pain Battery manufacturing, enamelers, smelter, painters, ceramics workers, plumbers, welders Lead Cataract Microwave, radar technicians Explosives industry Radiologists Blacksmiths, glass blowers, bakers Moth repellent formulators, fumigators Explosives, dye, herbicide, pesticide industries Microwaves TNT Ionizing radiation Infrared radiation Naphthalene Dinitrophenol, dinitro-o-cresol Dermatitis (contact, allergic) Adhesives, sealants, and plastics industries, leather tanning, poultry dressing, fish packing, boat building and repair, electroplating, metal cleaning, machining, housekeeping Irritants (cutting oils, solvents, phenol, acids, alkalies, detergents, fibrous glass), allergens (nickel, epoxy resins, chro mates, formaldehyde, dyes, rubber products) Headache Firefighters, foundry workers, wood finishers, dry cleaners, traffic control, driving in heavy traffic Carbon monoxide, solvents

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Environmental Medicine: Integrating a Missing Element into Medical Education Diseases, Disorders, and Conditions Industry or Occupation Agent Hepatitis (toxic) Solvent users, dry cleaners, plastics industry Carbon tetrachloride, chloroform, tetrachloroethane trichloroethylene Phosphorous, TNT Chloronaphthalene 4,4-Methylene-dianiline Ethylene dibromide Cresol Explosives and dye industries Fire and waterproofing additive formulators Plastics formulators Fumigators, gasoline and fire-extinguishers formulators Disinfectant, fumigant, synthetic resin formulators Inner ear damage Various Excessive noise Infertility (male) Formulators Producers, formulators, applicators Kepone 1,2-Dibromo-3-chloropropane Psychosis (acute) Gasoline, seed, and fungicide workers, wood preservation, rayon manufacturing Lead (especially organic), mercury, carbon disulfide Renal failure (acute, chronic) Battery manufacturing, plumbers, solderers Electrolytic processes, arsenical ore smelting Battery manufacturing, jewelers, dentists Fluorocarbon, fire-extinguisher formulators Antifreeze manufacturing Inorganic lead Arsine Inorganic mercury Carbon tetrachloride Ethylene glycol   SOURCE: Principles and Practice of Environmental Medicine, Tarcher, AB, ed., Plenum, New York, 1992.

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Environmental Medicine: Integrating a Missing Element into Medical Education TABLE D-3: Selected Job Categories, Exposures, and Associated Work-Related Diseases and Conditions Job Categories Exposures Work-Related Diseases and Conditions Agricultural workers Pesticides, infectious agents, gases, sunlight Pesticide poisoning, “farmers’ lung,” skin cancer Anesthetists Anesthetic gases Reproductive effects, cancer Animal handlers Infectious agents, allergens Asthma Automobile workers Asbestos, plastics, lead, solvents Asbestosis, dermatitis Bakers Flour Asthma Battery makers Lead, arsenic Lead poisoning, cancer Butchers Vinyl plastic fumes “Meat wrappers’ asthma” Caisson workers Pressurized work environments “Caisson disease,” “the bends” Carpenters Wood dust, wood preservatives, adhesives Nasopharyngeal cancer, dermatitis Cement workers Cement dust, metals Dermatitis, bronchitis Ceramic workers Talc, clays Pneumoconiosis Demolition workers Asbestos, wood dust Asbestosis Drug manufacturers Hormones, nitroglycerin, etc. Reproductive effects Dry cleaners Solvents Liver disease dermatitis Dye workers Dyestuffs, metals, solvents Bladder cancer, dermatitis Embalmers Formaldehyde, infectious agents Dermatitis Felt makers Mercury, polycyclic hydrocarbons Mercuralism Foundry workers Silica, molten metals Silicosis Glass workers Heat, solvents, metal powders Cataracts Hospital workers Infectious agents, cleansers, radiation Infections, accidents Insulators Asbestos, fibrous glass Asbestosis, lung cancer, mesothelioma

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Environmental Medicine: Integrating a Missing Element into Medical Education Job Categories Exposures Work-Related Diseases and Conditions Jack hammer operators Vibration Raynaud phenomenon Lathe operators Metal dusts, cutting oils Lung disease, cancer Laundry workers Bleaches, soaps, alkalies Dermatitis Lead burners Lead Lead poisoning Miners (coal, hard rock, metals, etc.) Talc, radiation, metals, coal dust, silica Pneumoconiosis, lung cancer Natural gas workers Polycyclic hydrocarbons Lung cancer Nuclear workers Radiation, plutonium Metal poisoning, cancer Office workers Poor lighting, poorly designed equipment Joint problems, eye problems Painters Paints, solvents, spackling compounds Neurologic problems Paper makers Acids, alkalies, solvents, metals Lung disorders, dermatitis Petroleum workers Polycyclic hydrocarbons, catalysts, zeolites Cancer, pneumoconiosis Plumbers Lead, solvents, asbestos Lead poisoning Railroad workers Creosote, sunlight, oils, solvents Cancer, dermatitis Seamen Sunlight, asbestos Cancer, accidents Smelter workers Metals, heat, sulfur dioxide, arsenic Cancer Steel workers Heat, metals, silica Cataracts, heat stroke Stone cutters Silica Silicosis Textile workers Cotton dust, fabrics, finishers, dyes, carbon disulfide Byssinosis, dermatitis, psychosis Varnish makers Solvents, waxes Dermatitis Vineyard workers Arsenic, pesticides Cancer, dermatitis Welders Fumes, nonionizing radiation Lead poisoning, cataracts   SOURCE: Principles and Practice of Environmental Medicine, A.B.Tarcher, ed., Plenum, New York, 1992.