occupational illness

1128 THE NEW ENGLAND JOURNAL OF MEDICINE Oct. 26, 1995

CURRENT CONCEPTS

OCCUPATIONAL ILLNESS

L

EE

S

COTT

N

EWMAN

, M.D.

From the Occupational and Environmental Medicine Division and the Pulmo-nary Division, National Jewish Center for Immunology and Respiratory Medi-cine, and the Departments of Medicine and Preventive Medicine and Biometrics,University of Colorado School of Medicine — all in Denver. Address reprint re-quests to Dr. Newman at Rm. D-104, National Jewish Center for Immunologyand Respiratory Medicine, 1400 Jackson St., Denver, CO 80206.

Supported in part by grants (HL27353 and ES06538) from the Public HealthService.

W

ORKPLACE exposures to hazardous materialscause or aggravate diseases as common and di-

verse as asthma, cancer, dermatitis, and tuberculosis.

1

Crude estimates of the number of new cases of occupa-tional disease in the United States range from 125,000to 350,000 per year,

2-4

in addition to 5.3 million work-related injuries. The economic cost is estimated to ex-ceed $60 billion annually.

2,5-7

Occupational disordersoccur in industry and agriculture, both as underrec-ognized endemic diseases and in sporadic epidemics.With modernization, occupational hazards have shift-ed from factories and mines to include hospitals and of-fice buildings.

Patients perceive industrial toxins as threateningtheir health and safety.

8

In one study, 17 percent of 534patients seen in a primary care clinic thought theirhealth problems were work-related; 75 percent reportedprevious exposure to one or more recognized toxicagents.

9

Occupational factors have been implicated inover 10 percent of all admissions to general internalmedicine wards in hospitals; the proportion is evenhigher when the primary illness is either respiratory ormusculoskeletal.

10

Pediatricians encounter occupationaldisorders both because some children work and be-cause parents may “foul the nest” with toxins carriedhome on work clothes.

11

Occupational diseases are preventable. A missed di-

agnosis means a lost opportunity for meaningful clin-ical intervention.

12,13

From a broader public healthperspective, each patient with a work-related illness rep-resents a “sentinel health event,” whose recognitioncould lead to disease prevention if the case is tracedback to the workplace hazards that caused it.

13

From aneconomic perspective, the failure to prevent occupa-tional disease results in costly, unnecessary health careafter the fact.

Unfortunately, because relatively few physicians arespecifically trained to recognize or prevent occupation-ally induced illness,

2,14-16

the association between occu-pational risks and disease may be missed. When physi-cians fail to ask patients about their work, work-relatedailments may be incorrectly attributed to nonoccupa-tional causes, unnecessary tests may be ordered, pa-tients may be referred to consultants equally unpre-pared to connect work-related exposures to disease,

and an opportunity may be missed to protect otherswho are at risk.

The identification of clusters of work-related diseaseby physicians is a time-tested means of uncovering andultimately preventing occupational illness,

17

exemplifiedby the recent recognition of multidrug-resistant tuber-culosis in health care workers,

18

asthma in office work-ers,

19

and repetitive-motion injuries among grocerycheckout workers.

20

In an era of cost containment,high-efficiency and high-volume medical practice, andmanaged care, many practitioners feel that they lackthe time, expertise, and resources to prevent occupa-tional illness.

Recent progress in the field of occupational and en-vironmental medicine has led to a better understandingof the most efficient strategies for recognizing a widevariety of work-related ailments. The key to detectingoccupational illness is to suspect the diagnosis. Work-related disease is obvious when the patient reports anacute, traumatic injury on the job. When the ailmentresults from repetitive motion or from long-term ormultiple exposures, however, detection may be moredifficult. In such circumstances, the diagnosis of work-related illness hinges principally on the quality of theoccupational and environmental history.

9

T

HE

O

CCUPATIONAL

AND

E

NVIRONMENTAL

H

ISTORY

Obtaining the occupational history is a two-partprocess consisting of a few routine questions to screenfor associations between work and the patient’s chiefsymptoms, followed by more detailed follow-up ques-tioning if the answers arouse clinical suspicion. Thequestions and topics outlined in Figure 1 require nospecial knowledge of toxicology or of industrial proc-esses. If asked of all patients as part of each medicalhistory, however, they provide important leads. Mostphysicians can stop their inquiries after these questionsif the replies are uniformly negative.

Greater certainty about the effects of past andpresent workplace exposure on a patient’s health comesfrom detailed questioning (Fig. 1). In many practices,patients complete health questionnaires before seeingthe physician, but few of these surveys systematicallycollect information about the patient’s work history andhistory of exposure. By adding questions to such aquestionnaire (Table 1), the clinician can obtain reli-able and valid information on occupational exposurewithout sacrificing time spent with the patient.

9,21

Re-cently, several questionnaire templates have been pub-lished to encourage their widespread use.

16,21-23

Even when asked, patients frequently underestimate

the extent of exposure or neglect to tell the physicianabout critical work processes that may entail risk.

24-26

Both employees and employers may be misinformedor unaware of chemical names and toxic effects.

24

Few-er than 20 percent of industrial chemicals in the Unit-ed States have been adequately tested for toxicity tohumans,

27

despite a congressional mandate for thetesting of new chemicals under the Toxic SubstancesControl Act of 1976. Clinicians should initially empha-size only those questions that help determine the like-

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Vol. 333 No. 17 CURRENT CONCEPTS 1129

lihood that the illness is not work-related. Detailed in-quiry about each past or present exposure, specifictoxins, and work practices can be reserved for later vis-its if it seems warranted. Recent publications offer fur-ther instruction in the nuances of taking the occupa-tional history.

22,28

T

HE

O

CCUPATIONAL

H

ISTORY

AND

THE

C

LINICAL

A

SSESSMENT

Occupational exposure can affect any organ, anddisorders caused by such exposure often masqueradeas common ailments.

1

My approach is, first, to formu-late an accurate clinical diagnosis (e.g., peripheral neu-ropathy); second, to conduct the clinical tests needed toexclude common, nonoccupational causes of the dis-order (e.g., blood glucose measurements); and, third,routinely to consider occupational causes in the differ-ential diagnosis. Table 2 summarizes clinical clues thatpoint to the likelihood that an illness is work-related.Once armed with a clinical diagnosis, the physiciancan use major textbooks to determine the most com-monly recognized environmental causes of the condi-tion. In the case of peripheral neuropathy, these in-clude exposure to lead, acrylamide, and naphthalene.

13

Several resource books describe work processes, enu-merate the typical chemical exposures in common jobs,and list common chemicals and their potential effectson health.

29,30

In practice, most physicians may consult a special-

ist in occupational and environmental medicine whenthe initial evaluation raises the suspicion that the pa-tient’s disease or injury is linked to the workplace (seethe Appendix for sources of information and assist-ance). Specialists will take a more detailed occupa-tional and environmental history and, if possible andwhen indicated, conduct a work-site assessment. Bycoordinating efforts with industrial hygienists, occupa-tional health nurses, and others, these specialists can

Table 1. Essential Elements of the Occupational History andQuestionnaire.

Current or most recent work and exposure history

Job title; type of industry; name of employerYear work started and year work finished (if not currently employed)Description of job (what is a typical workday), especially the parts of the job the

patient believes may be potentially hazardousCurrent work hours and any shift changesCurrent exposure to dust, fumes, radiation, chemicals, biologic hazards, or phys-

ical hazardsProtective equipment used (clothes, safety glasses, hearing protection, respirator,

or gloves)Other employees at the workplace who have similar health problems

Earlier employment history

Job chronology, working backward from the current or most recent jobThe same information as above for each job previously held

Major types of exposure associated with clinical illness

GasesCorrosive substances (acids, alkalis)Dyes and stainsDusts and powdersAsbestos, other fibersInfectious agentsInsecticides and pesticidesMetals and metal fumesOrganic dusts (cotton, wood, biologic

matter)Plastics

SolventsPetrochemicals (coal, tar, asphalt,

petroleum distillates)Physical factors (noise, lifting, ther-

mal stress, vibration, repetitive motion)

Emotional factors (stress)Radiation (electromagnetic fields,

x-ray radiation, ultraviolet radia-tion)

Figure 1. The Initial Clinical Approach to the Recognition of Illness Caused by Occupational Exposure.

1. The Quick Survey

2. Detailed Questioning Based on Initial Suspicion

Chief Symptom and History of Present Illness• “What kind of work do you do?”• “Do you think your health problems are related to your work?”• “Are your symptoms better or worse when you’re at home or at work?”

Review of Systems

• “Are you now or have you previously been exposed to dusts, fumes, chemicals, radiation, or loud noise?”

Review of Exposure, with theQuestionnaire as a Guide

• More about the current job: description of a typical day• Review of job chronology and associated exposures

Examination of the Link betweenWork and the Chief Symptom

• Clinical clues (Table 2)• Exploration of the temporal link in detail• “Do others at work have similar problems?”

Self-Administered Questionnairefor All Patients (Table 1)

• Chronology of jobs• Exposure survey

amass important data on the nature and extent of a pa-tient’s exposure. Appropriate clinical consultation andwork-site investigation can lead to primary or second-ary prevention. A consultant may advise a company totake one or more of the following steps: (1) substituteless hazardous materials, (2) improve engineering con-trols — for example, by modifying ventilation systemsor improving the ergonomic design of the workstation,(3) provide workers with protective equipment againstexposure to substances that cannot be adequately con-trolled, (4) use administrative controls, such as re-ducing the number of workers engaged in inherentlyhazardous tasks, and (5) introduce screening programs




to detect and treat occupational disorders at early stag-es. Companies vary in their willingness to follow suchsuggestions, in part because of the initial cost of im-plementing preventive measures. Such suggestions, how-ever, may be taken seriously when employers considerthe health of their workers and the potential social

and legal ramifications if efforts are not made to cor-rect problems.

L

EARNING

M

ORE

ABOUT

E

XPOSURE

Even without visiting the work site, a physician maybe able to collect data about the types of exposure in

Table 2. Clues to the Recognition of Occupational Disease.

C

LUES

C

OMMENTS

E

XAMPLES

Job title or type of industry Patients may be obviously at high risk or may work in hazardous industries where certain disorders occur at higher than average frequency.

Tuberculosis in health care workers. Lead toxicity in radiator-repair shops.

Description of work tasks Job titles are misleading and often fail to reflect work-place hazards; a description of a usual day at work is more helpful.

Asthma in a taxidermist that turns out to be caused by the spraying of sensitizing iso-cyanate-containing polyurethane foams into molds.

Major employment opportunities in the region

In areas with one or more large employers, many patients share common exposures, increasing thelikelihood that work-related disease clusters will be recognized.

Bronchitis and pneumoconiosis in coal-mining regions.

The most common toxic expo-sures in local industries

The index of suspicion for certain work-related illnesses should be high because of the types of exposures and associated health effects in the largest local industries.

Latex-induced dermatitis in a local glove-manu-facturing plant or in a hospital.

Bladder cancer in rubber-manufacturing workers exposed to benzidine and naphthylamines.

Coworkers who are sick or caseclusters noticed in a clinicalpractice

Clusters of disease are often a helpful clue to both endemic and epidemic work-related illness.

Viral hepatitis among workers in a child-care center.

Nasal cancer among woodworkers.Past exposure to long-latency

agentsRecognizing an important past exposure to toxic com-

pounds helps the physician make the causal link to new symptoms of delayed onset.

Asbestosis, lung cancer, or mesothelioma in a former naval-shipyard worker with exertional dyspnea who has a history ofexposure to asbestos.

Pattern of disease onset The onset of symptoms may be related to a change in employment, a change in job duties, or a changein the type or use of hazardous materials.

New-onset angina after the use of a methylene chloride–containing paint stripper that is metabolized to carbon monoxide in blood.

Pattern of aggravation of symptoms

There may be changes in symptoms during the workday or during the workweek or improvement during weekends and vacations.

Improvement in hand paresthesias and wrist pain in a computer-terminal operator when on vaca-tion, with recurrence on return to work.

Unusual combination of multi-organ symptoms and signs

Multiorgan and systemic symptoms usually prompt con-cern about endocrine, infectious, drug-related, and autoimmune disorders; occupational–environmen-tal exposures to toxins should also be considered.

Psychiatric, neurologic, and hematopoietic symp-toms and spermatogenic dysfunction due to the concentration of inhaled or ingested manganese in mitochondrial-rich tissues in workers in welding, mining, and oreextraction.

Unusual distribution of disease within an organ

The distribution of pathologic effects in an organ is often related to the area of most direct or intense contact with an occupational hazard.

Rashes selectively involving the face, scalp, neck, and hands but sparing nonexposed parts of the body due to contact dermatitis in the workplace.

Susceptible organ systems Certain organs are more prone to occupational diseaseor to the aggravation of preexisting diseases be-cause they

are the portal of entry for or in direct contact with injurious agents;

detoxify or filter toxins;are sites of bioaccumulation of toxic agents;are especially sensitive to the effects of toxic agents

because of the rate of cell division or specializedcellular functions; or

are susceptible to injury by repetitive activity (cumu-lative trauma).

Skin, mucous membranes, respiratory tract, audi-tory tract.

Liver, kidney.Bone, liver, central nervous system.Lymphoid–hematopoietic system, reproductive

organs, the fetus.

Joints, muscles, carpal tunnel.

Demographically “wrong” patient When disease occurs in an unlikely person, one should consider occupational agents that can produce the same symptoms, signs, and pathologic consequences.

Lung cancer in a lifelong nonsmoker due to past asbestos exposure, coke-oven emissions, or arsenic from a smelter.

The “usual suspects” are innocent When commonly recognized causes of illness have been eliminated from the differential diagnosis, the like-lihood of an occupational and environmental cause rises.

Hepatitis in a nonalcoholic, non–drug-using pa-tient with no risk factors and negative serologic tests caused by a workplacehepatotoxin.

Idiopathic disease Before assigning the designation “etiology unknown,” one should exclude environmental and occupa-tional causes.

Chronic beryllium disease masquerading as sar-coidosis in a patient who machines metalsor ceramics or prepares dental alloys.

Disease that does not respond to

conventional medical therapy

In many instances of occupational disease, the problem has no chance of cure if the patient continues to be

exposed.

“Baker’s asthma” in a corticosteroid-dependent patient who works as a baker and that could improve or be cured by avoidance of high-

molecular-weight antigens in flour dust.




the patient’s workplace. The Occupational Safety andHealth Administration (OSHA) of the Department ofLabor requires that employees receive information aboutthe hazardous chemicals used in their jobs throughappropriate labeling, training programs, and MaterialSafety Data Sheets, which describe the products’ in-gredients, known health hazards, recommended pre-cautions for handling the products safely, and permis-sible exposure limits. If the employer is in compliancewith OSHA regulations, the patient should be able tolocate the Material Safety Data Sheet and bring it tothe physician’s office. Under federal right-to-know leg-islation, physicians are entitled to receive MaterialSafety Data Sheets from the manufacturer, distributor,or patient’s employer on request. Consider the exam-ple of an endoscopy technician whose dermatitis wor-sened at work and improved on weekends. The occupa-tional history generated a list of substances to whichthe technician might have been exposed, including “in-strument sterilization solution.” On request, the em-ployer supplied the data sheet that showed glutaralde-hyde to be a major constituent of the solution; thischemical was later confirmed to have caused the rash.Material Safety Data Sheets do not reflect how theproduct is used by the patient or the extent of expo-sure. They are sometimes vague and overly general indescribing toxic effects of chemicals, they often empha-size acute rather than long-term effects on health, andthey may omit data on proprietary chemicals. Nonethe-less, they can prove useful, especially when they in-clude chemicals for which toxicologic profiles havebeen published.

31

Detailed information concerning the major health

effects of specific chemicals can be obtained from text-books, through telephone consultations with the staffof public health agencies, and by consultation withprofessionals (see the Appendix). Computers have rev-olutionized access to toxicologic data through on-lineand CD-ROM services. Excellent resources includethe National Library of Medicine, the home of Toxline,Medline, Toxnet (which incorporates the HazardousSubstances Data Bank), Chemline, and ChemID; theNational Institute for Occupational Safety and Health(NIOSH) Registry of Toxic Effects of Chemical Sub-stances (RTECS); the Environmental Protection Agen-cy’s Integrated Risk Information System (IRIS); OSHAregulations, documents, and technical information onCD-ROM; and Micromedix TOMES Plus InformationSystem.

32,33

Recently, OSHA announced a new tele-phone and fax system for obtaining access to brief sum-mary documents. The Internet provides access to manyof these agencies and data bases (see the Appendix).

Discussing workplace conditions with the patient’semployer can be helpful, but before doing so, the phy-sician should obtain the patient’s consent. The physi-cian must not divulge confidential information aboutthe patient’s health problems to employers or insurers.They are entitled to know only about any necessary re-strictions on the patient’s ability to perform his or herjob. A corporate medical director, occupational health

nurse, health and safety officer, industrial hygienist, ormanager may provide valuable information about spe-cific exposures and help investigate work conditions.Labor representatives may know about similarly affect-ed workers and may have information relevant to thepatient’s concern about health and safety. Public healthagencies, including state and county health depart-ments, OSHA, the Mine Safety and Health Administra-tion (MSHA), and NIOSH may conduct an investiga-tion when a physician reports a sentinel health event.Employees or employers can request an inspection byOSHA, MSHA, or NIOSH (they may do so anonymous-ly). OSHA and MSHA enforce compliance with federalhealth and safety standards and may levy penalties forinfractions. Unfortunately, not all federal standards aresufficiently protective, and enforcement can be erratic.Through evaluations of health hazards in work sites,NIOSH conducts research and makes recommenda-tions that can improve workplace practices, but it hasno enforcement authority.

In attempting to confirm the role of current exposurein the patient’s illness, a physician can restrict the pa-tient’s work temporarily and observe any objective orsubjective change in the patient’s medical condition.Spontaneous improvement following such a trial helpsestablish that the workplace caused or aggravated theillness, but lack of improvement does not necessarilyexonerate the workplace.

B

IOLOGIC

M

ARKERS

Some of the greatest progress in occupational medi-cine has been made in the development of new biologicassays that reflect the patient’s exposure, toxin-specifichealth effects, or individual susceptibility to toxins.

34

Ifproperly used, a biologic marker can confirm that ex-posure has occurred, as in the case of lead in the circu-lation indicated by the whole-blood lead concentrationand by the zinc protoporphyrin assay. But even seem-ingly well-established biologic markers may be mislead-ing. People with divergent histories of exposure mayhave similar blood lead concentrations. Not all investi-gators agree about the particular blood lead value thatpredicts disease or that should trigger therapeutic inter-vention.

35

Promising new methods, such as bone leadmeasurement by K x-ray fluorescence, may provide bet-ter estimates of long-term cumulative exposure and therelation of such exposure to disease.

36,37

As part of the emerging understanding of immune

mechanisms, assays to measure the immunotoxic ef-fects of environmental agents have proliferated rapid-ly.

38

The blood beryllium lymphocyte-proliferation testillustrates the potential power of an immune biologicmarker.

39

This in vitro test of beryllium-specific hyper-sensitivity is sensitive and specific for chronic berylliumdisease, which is most commonly found in workers em-ployed in metal machining in the aerospace and de-fense industries, thus making it possible to correct er-roneous diagnoses of sarcoidosis and to screen largenumbers of workers with a biologically relevant indica-tor of the cell-mediated immune response.

40

Few such




biologic markers have undergone sufficient validationto merit clinical use, however. Caution should be exer-cised in the application of nonspecific, poorly reproduc-ible, or nonvalidated immunologic tests, such as T-cellphenotyping, to the diagnosis of controversial clinicalillnesses such as multiple chemical sensitivity.

41

People vary in their ability to inactivate endogenous

and exogenous toxins, partly because of polymor-phisms in metabolic enzyme systems. Such genetic dif-ferences influence susceptibility to lung and bladdercancers caused by carcinogens such as polycyclic aro-matic hydrocarbons.

42

Genetic markers of such poly-morphisms could be used to identify workers who areless able than others to metabolize foreign substancesand could potentially predict susceptibility to environ-mental carcinogens. Similarly, a genetic marker locatedwithin the HLA-DP locus identifies a subgroup of theexposed people who are at increased risk for chronicberyllium disease.

43

Theoretically, such tests of geneticsusceptibility could contribute to disease prevention byincreasing medical monitoring of workers at high riskfor early signs of toxic effects. But even if the ethicaland practical issues could be resolved, these tests wouldnot obviate the need to reduce exposure to hazardoussubstances for all workers.

44-46

C

LINICAL

M

ANAGEMENT

OF

O

CCUPATIONAL

I

LLNESS

In addition to prescribing appropriate medical orsurgical treatment for occupational disorders, physi-cians make other decisions that affect the patient’sprognosis, psychological and social well-being, em-ployability, opportunities for job advancement, futureearning potential, and insurability. One of the mostimportant decisions is whether the patient can returnto work. In exposure-induced occupational diseases,work restriction may offer the best hope for cure orcontrol of disease, but it often results in economichardship or job loss. In cumulative trauma disorders,such as carpal tunnel syndrome, early, graduated re-turn to work through modified duty improves the med-ical outcome.

47,48

Before deciding to recommend jobrestriction or return to work, the physician should doc-ument the degree of impairment, weigh the seriousnessof the illness, learn what specific tasks the patientwould need to perform at work, consider whether theseduties and future exposures will aggravate, accelerate,or permanently worsen the condition, determine the ap-propriate time for the return to work, and counsel thepatient about the implications of work modification forboth health and employment. When the causative ex-posure is an allergen, as in isocyanate-induced asthma,returning the patient to a “nonexposed job” in the sameplant is likely to worsen the disease and increase the re-quirement for medication.

49

Common mistakes on thepart of physicians include restricting patients’ work orallowing them to return to their jobs before learningenough about ongoing exposures and tasks at work, er-roneously assuming that gloves, respirators, and otherforms of protective equipment are sufficiently effective,

and failing to provide enough information to patientsand their employers to help them define meaningfulwork restrictions.

Understanding the rudiments of the workers’ com-pensation system is crucial if physicians are to managework-related disorders properly. In the United States,workers’ compensation is a “no-fault” insurance systemthat is supposed to ensure the payment of medical ex-penses and lost wages and compensation for lost earn-ing potential when an employee’s medical condition iseither caused by or substantially aggravated by his orher job. In exchange, employees relinquish the right tosue their employers for most work-related health prob-lems. Primary care physicians are frequently asked todetermine whether a patient has a work-related illnessor injury and is either temporarily or permanently im-paired. When an occupational disorder is diagnosed,the physician should tell the patient, advise him or herto contact the employer to file a report of injury or ill-ness, and carefully document the diagnosis. Studiesshow that physicians often neglect to document the pa-tient’s work history

10,50

and rarely provide sufficient in-formation to enable a legal judgment to be made forpurposes of compensation, thus impeding an alreadyslow process.

51

Documentation should include the med-ical basis for the diagnosis of a work-related disorder,the evidence of impairment, treatment and rehabilita-tion requirements, and any proposed modification inthe patient’s work.

If the occupational illness is likely to be permanent,the physician will be asked to determine the percentageof “permanent impairment of the whole person.” Thisassessment forms the legal basis for the determinationof compensation to the injured worker. In most states,physicians are not expected to assess the effect of theimpairment on job performance (disability), but only todescribe accurately and quantify the physical effect ofillness and to determine whether modifications wouldbe needed if the worker were to return to his or her job.The evaluation of the degree of impairment requires fa-miliarity with standardized medical guidelines.

52

Manyphysicians become frustrated by the paperwork or areintimidated by the possibility of a legal embroglio afterthe diagnosis of work-related conditions. Physicians,however, can help both their patients and the workers’compensation system by being objective and by usingthe best available standardized criteria for impair-ment.

52

Under managed-care arrangements, primary care

physicians are assuming more responsibility for themanagement of occupational illness and injury. Statelaws vary in whether they allow the employer or the in-jured worker to select the physician who will treat thework-related condition. When designated as the healthcare provider for a patient who has been awarded work-ers’ compensation, the physician functions as in mostmanaged-care systems, attending to the insurer’s re-porting requirements and rules for preapproval of test-ing and treatment. This “gatekeeper” approach to cost




control may help reduce the economic burden to theworkers’ compensation system. Far greater savings wouldbe realized if managed-care programs took the initia-tive in the primary prevention of occupational disease.Unfortunately, few workers’ compensation insurancecarriers or managed-care systems take the approachthat cases of occupational illness should prompt themto encourage employers to modify work practices, pre-vent unnecessary injury and illness, and thereby avertcostly medical testing and treatment.

I am indebted to Cecile M. Rose, M.D., M.P.H., and to Lori Szczu-kowski, M.D., for helpful discussions and for reviewing an earlier ver-sion of the manuscript; to Jenifer Lloyd, D.V.M., M.S.P.H., for techni-cal assistance; and to Nina Eads for assistance in the preparation ofthe manuscript.

A

PPENDIX

Sources of Information and Assistance in the Clinical Evaluation of Occupational Disorders

Agency for Toxic Substances and Disease Registry (ATSDR), 1600Clifton Rd. NE, Atlanta, GA 30333. Telephone: (404) 639-6000 (Di-vision of Toxicology); (404) 639-6206 (Division of Health Education).Internet address: http://atsdr1.atsdr.cdc.gov:8080/atsdrhome.html/(last accessed 9/18/95). Part of the U.S. Public Health Service, theATSDR provides toxicologic profiles through the Division of Toxicol-ogy and clinically useful Case Studies in Environmental Medicineconcerning common chemicals.

American College of Occupational and Environmental Medicine(ACOEM), 55 W. Seegers Rd., Arlington Heights, IL 60005-3919.Telephone: (708) 228-6850. The ACOEM lists physicians who areboard-certified in occupational–environmental medicine and mem-bers of the college; it also conducts educational programs on occupa-tional health, impairment, and the workers’ compensation system.

Association of Occupational and Environmental Clinics (AOEC),1010 Vermont Ave., Suite 513, Washington, DC 20005. Telephone:(202) 347-4976. The AOEC is a network of academically based oc-cupational–environmental medicine clinics throughout the UnitedStates. Member clinics provide professional training, community ed-ucation about toxic substances, exposure and risk assessment, clinicalevaluation, and consultation. Clinicians can contact the AOEC officefor clinical referrals to assist in the diagnosis, management, therapy,and prevention of occupational disorders.

Center for Safety in the Arts, 5 Beekman St., Rm. 820, New York, NY10038. Telephone: (212) 227-6220.

Chem Trek Non-Emergency Services Hotline: (800) 262-8200. Thishotline refers callers to companies that manufacture chemicals and tostate and federal agencies for health and safety information and infor-mation regarding regulations.

Indoor Air Quality Information Clearinghouse, P.O. Box 37133,Washington, DC 20013-7133. Telephone: (800) 438-4318.

Job Accommodation Network. Telephone: (800) 526-7234; (800)232-9675; (800) 526-2262 (in Canada). This network offers ideas foremploying and accommodating handicapped persons in the work-place. Consultants who are knowledgeable about types of disabilitiesare available to discuss the Americans with Disabilities Act as well asthe information physicians are and are not required to release to em-ployers about patients with disabilities.

MotherRisk Program, Hospital for Sick Children, 555 University Ave.,Toronto, ON M5G 1X8, Canada. Telephone: (416) 813-6780. This pro-gram counsels callers about the safety of exposures to drugs, chemicals,infectious agents, or radiation during pregnancy or breast-feeding.

National Pesticide Telecommunications Network, Agricultural Chem-istry Extension, Oregon State University, 333 Weniger Hall, Corvallis,OR 97331-6502. Telephone: (800) 858-7377.

National Institute for Occupational Safety and Health (NIOSH),Robert A. Taft Laboratories, 4676 Columbia Pkwy., Cincinnati,OH 45226-1998. Telephone: (800) 356-4674. Internet address: http://www.cdc.gov/niosh/homepage.html (last accessed 9/18/95). A divi-sion of the Department of Health and Human Services and part ofthe Federal Centers for Disease Control and Prevention, NIOSH pro-vides information about substance toxicity and workplace hazards.Physicians should have Material Safety Data Sheets available whencalling, if possible. The health-hazard evaluation program can inves-tigate work sites at which physicians, employees, or employers suspectwork-related illness and injury to have occurred. NIOSH offers train-ing in occupational safety and health and funds university-based Ed-ucational Resource Centers that conduct continuing-medical-educa-tion courses and serve as referral sources in the assessment ofoccupational and environmental health problems.

Occupational Safety and Health Administration (OSHA), Depart-ment of Labor, 200 Constitution Ave., NW, Washington, DC 20210.Telephone: (202) 219-8148 (general information); (202) 219-9308(compliance office); (202) 219-4667 (publications). Fax: (900)555-3400 (OSHA FAX). Internet address: http://www.osha-slc.gov/(last accessed 9/18/95). OSHA promulgates standards for health andsafety in the workplace, investigates compliance, and issues citations.The publications-distribution office has articles about many occupa-tional diseases (look under local Department of Labor listings for lo-cal or regional offices). OSHA FAX is a fax-on-demand data-baseservice providing brief documents such as OSHA news releases, factsheets, and publication listings, for a nominal telephone charge.

Office of Disease Prevention and Health Promotion, National HealthInformation Center, P.O. Box 1133, Washington, DC 20013-1133.Telephone: (800) 336-4797; (301) 565-4167 (Washington, D.C. area).The office is a source of information and referral for health questionsfrom health educators, health professionals, and the general public.

Physician Line and LungLine, National Jewish Center for Immunolo-gy and Respiratory Medicine, 1400 Jackson St., Denver, CO 80206.Telephone: (800) 652-9555 (Physician Line); (800) 222-5864 (Lung-Line). Internet address: http://www.njc.org/ (last accessed 9/18/95).These services provide telephone consultation for physicians and pa-tients seeking information on lung and allergic disorders, includingthose related to exposure to environmental and occupational toxins.

Poison Control Centers. The American Association of Poison ControlCenters certifies regional centers (listed in local telephone directo-ries). Many provide useful information about the toxicity and healtheffects of hazardous exposures. The quality of assistance is enhancedif the physician can provide names of specific chemicals.

Teratogen Exposure Registry and Surveillance (TERAS), Depart-ment of Pathology, Brigham and Women’s Hospital, 75 Francis St.,Boston, MA 02115. Telephone: (617) 732-6507 (Fred Bieber, M.D.).TERAS maintains information networks for consultation and evalua-tions concerning the effects of toxic agents on the fetus.

R

EFERENCES

1. Cullen MR, Cherniack MG, Rosenstock L. Occupational medicine. N EnglJ Med 1990;322:594-601, 675-83.

2. Rosenstock L, Rest KM, Benson JA Jr, et al. Occupational and environmen-tal medicine: meeting the growing need for clinical services. N Engl J Med1991;325:924-7.

3. Bureau of Labor Statistics. Occupational injuries and illnesses in the U.S.by industry, 1984. In: Department of Labor bulletin. Washington, D.C.:Government Printing Office, 1986.

4. Pollack ES, Keimig DG, eds. Counting injuries and illnesses in the work-place: proposals for a better system. Washington, D.C.: National AcademyPress, 1987.

5. Fahs MC, Markowitz SB, Fischer E, Shapiro J, Landrigan PJ. Health costsof occupational disease in New York State. Am J Ind Med 1989;16:437-49.




6. Neumark D, Johnson RW, Bresnitz EA, Frumkin H, Hodgson M, Needle-man C. Costs of occupational injury and illness in Pennsylvania. J OccupMed 1991;33:971-6.

7. National Safety Council. Accident facts: 1992 edition. Chicago: NationalSafety Council, 1992.

8. Baxter RH. Some public attitudes about health and the environment. Envi-ron Health Perspect 1990;86:261-9.

9. Schwartz DA, Wakefield DS, Fieselmann JF, Berger-Wesley M, Zeitler R.The occupational history in the primary care setting. Am J Med 1991;90:315-9.

10. Gennart J-P, Hoet P, Lison D, Lauwerys R, Coche E, Lambert M. Impor-tance of accurate employment histories of patients admitted to units of in-ternal medicine. Scand J Work Environ Health 1991;17:386-91.

11. Brooks DR, Davis LK, Gallagher SS. Work-related injuries among Massa-chusetts children: a study based on emergency department data. Am J IndMed 1993;24:313-24.

12. Landrigan PJ, Baker DB. The recognition and control of occupational dis-ease. JAMA 1991;266:676-80.

13. Rutstein DD, Mullan RJ, Frazier TM, Halperin WE, Melius JM, Sestito JP.Sentinel health events (occupational): a basis for physician recognition andpublic health surveillance. Am J Public Health 1983;73:1054-62.

14. Levy BS. The teaching of occupational health in United States medicalschools: five-year follow-up of an initial survey. Am J Public Health 1985;75:79-80.

15. Castorina JS, Rosenstock L. Physician shortage in occupational and envi-ronmental medicine. Ann Intern Med 1990;113:983-6.

16. American College of Physicians. Occupational and environmental medi-cine: the internist’s role. Ann Intern Med 1990;113:974-82.

17. Fleming LE, Ducatman AM, Shalat SL. Disease clusters: a central and on-going role in occupational health. J Occup Med 1991;33:818-25.

18. Menzies D, Fanning A, Yuan L, Fitzgerald M. Tuberculosis among healthcare workers. N Engl J Med 1995;332:92-8.

19. Hoffman RE, Wood RC, Kreiss K. Building-related asthma in Denver officeworkers. Am J Public Health 1993;83:89-93.

20. Barnhart S, Rosenstock L. Carpal tunnel syndrome in grocery checkers: acluster of work-related illness. West J Med 1987;147:37-40.

21. Rosenstock L, Logerfo J, Heyer NJ, Carter WB. Development and valida-tion of a self-administered occupational health history questionnaire. J Oc-cup Med 1984;26:50-4.

22. Frank AL, Balk SJ, eds. Case studies in environmental medicine: taking anexposure history. ATSDR monograph 26. Atlanta: Agency for Toxic Sub-stances and Disease Registry, 1992.

23. Levy BS, Wegman DH, eds. Occupational health: recognizing and prevent-ing work-related disease. 2nd ed. Boston: Little, Brown, 1988.

24. Joffe M. Validity of exposure data derived from a structured questionnaire.Am J Epidemiol 1992;135:564-70.

25. Bond GG, Bodner KM, Sobel W, Shellenberger RJ, Flores GH. Validation ofwork histories obtained from interviews. Am J Epidemiol 1988;128:343-51.

26. Bourbonnais R, Meyer F, Theriault G. Validity of self reported work history.Br J Ind Med 1988;45:29-32.

27. National Research Council. Toxicity testing: strategies to determine needsand priorities. Washington, D.C.: National Academy Press, 1984.

28. American College of Occupational and Environmental Medicine. Recom-mended library for occupational and environmental physicians. J OccupMed 1994;36:779-83.

29. Hathaway G, Procter NH, Hughes JP, Fischman M, eds. Chemical hazardsof the workplace. 3rd ed. New York: Van Nostrand Reinhold, 1991.

30. Sullivan JB Jr, Krieger GR, eds. Hazardous materials toxicology: clini-cal principles of environmental health. Baltimore: Williams & Wilkins,1992.

31. Himmelstein JS, Frumkin H. The right to know about toxic exposures: im-plications for physicians. N Engl J Med 1985;312:687-90.

32. Bresnitz EA, Rest KM, Miller N. Clinical industrial toxicology: an approachto information retrieval. Ann Intern Med 1985;103:967-72. [Erratum, AnnIntern Med 1986;104:290.]

33. Alston PG. Environment online: the greening of databases, Part 2: scientificand technical databases. Data Base 1991;14:34-52.

34. Schulte PA. Contribution of biological markers to occupational health. AmJ Ind Med 1991;20:435-46.

35. Osterloh J. Are we plumb crazy? West J Med 1994;161:187-90.36. Hu H, Pepper L, Goldman R. Effect of repeated occupational exposure to

lead, cessation of exposure, and chelation on levels of lead in bone. Am JInd Med 1991;20:723-35.

37. Kosnett MJ, Becker CE, Osterloh JD, Kelly TJ, Pasta DJ. Factors influenc-ing bone lead concentration in a suburban community assessed by noninva-sive K x-ray fluorescence. JAMA 1994;271:197-203.

38. Subcommittee on Immunotoxicology. Biologic markers in immunotoxicol-ogy. Washington, D.C.: National Academy Press, 1992.

39. Mroz MM, Kreiss K, Lezotte DC, Campbell PA, Newman LS. Reexamina-tion of the blood lymphocyte transformation test in the diagnosis of chronicberyllium disease. J Allergy Clin Immunol 1991;88:54-60.

40. Kreiss K, Wasserman S, Mroz MM, Newman LS. Beryllium disease screen-ing in the ceramics industry: blood lymphocyte test performance and expo-sure-disease relations. J Occup Med 1993;35:267-74.

41. Board on Environmental Studies and Toxicology. Multiple chemical sensi-tivities. Washington, D.C.: National Academy Press, 1992.

42. Hirvonen A. Genetic factors in individual responses to environmental expo-sures. J Occup Environ Med 1995;37:37-43.

43. Richeldi L, Sorrentino R, Saltini C. HLA-DP

b

1 Glutamate 69: a geneticmarker of beryllium disease. Science 1993;262:242-4.

44. Council on Ethical and Judicial Affairs, American Medical Association. Useof genetic testing by employers. JAMA 1991;266:1827-30.

45. Newman LS. To Be

2

�

or not to Be

2

�

: immunogenetics and occupational ex-posure. Science 1993;262:197-8.

46. Van Damme K, Casteleyn L, Heseltine E, et al. Individual susceptibility andprevention of occupational diseases: scientific and ethical issues. J OccupEnviron Med 1995;37:91-9.

47. Derebery VJ, Tullis WH. Delayed recovery in the patient with a work com-pensable injury. J Occup Med 1983;25:829-35.

48. Rempel DM, Harrison RJ, Barnhart S. Work-related cumulative trauma dis-orders of the upper extremity. JAMA 1992;267:838-42.

49. Paggiaro PL, Vagaggini B, Bacci E, et al. Prognosis of occupational asthma.Eur Respir J 1994;7:761-7.

50. Windau J, Rosenman K, Anderson H, et al. The identification of occupa-tional lung disease from hospital discharge data. J Occup Med 1991;33:1060-6.

51. Cornes P, Aitken RCB. Medical reports on persons claiming compensationfor personal injury. J R Soc Med 1992;85:329-33.

52. Guides to the evaluation of permanent impairment. 4th ed. Chicago: Amer-ican Medical Association, 1993.

Massachusetts Medical SocietyRegistry on Continuing Medical Education

To obtain information on continuing medical education courses in the New England area, callbetween 9:00 a.m. and 12:00 noon, Monday through Friday, (617) 893-4610 or in

Massachusetts 1-800-322-2303, ext. 1342.



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