PRIMARY CARE
ENVIRONMENTAL
AND OCCUPATIONAL
HEALTH HAZARDS
GUIDE
o O
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NYC.
Health Systems Agency of New York City
111 Broadway
New York, New York 10006
(212)577-0550
Acknowledgements
This publication was developed for the Health Systems Agency by the following
individuals. Institutions are listed for identification purposes only.
Dana Alston
American Red Cross,
New York City
William Becker, M.D.
Methodist Hospital of Brooklyn,
New York City
Pyser Edelsack
Sophie Davis School of
Biomedicaf Education,
City College of New York
Louisa Fennell, R.N., M.A., M.P.H.
Sunset Park Neighborhood Health Center
Brooklyn, New York
Arthur Frank, M.D., Ph.D.
Mount Sinai School of Medicine,
City University of New York
Bernard Goldstein, M.D.
New York University School of Medicine
Staff:
Vincent M. Coluccio,
Sherry N. Koehler
Betsy Kagey, M.S.P.H.
Downstate Medical Center,
State University of New York
George J. Kupchik, Dr. Eng. Sc.
Hunter College, City
University of New York
Deborah Ann Nagin, M.P.H.
New York State School of '
Industrial and Labor Relations,
Cornell University
Allen Silverstone, Ph.D.
Memorial Sloan Ketlering Cancer Center,
New York
Martin Schiffer, M.D.
North Central Bronx Hospital
Bronx, New York
Robert Young, M.D.
Montefiore Hospital and Medical Center,
Bronx, New York
HSA Task Force on
Environmental and
Occupational Health:
"Robert J. Palese,
Chairman
Grant assistance for development of this publication was provided by the Office of Toxic
Substances of the United States Environmental Protection Agency (Grant No
T900925010.)
1980
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To the Primary Care Practitioner:
This guide provides a quick reference about the
environment and work-relatedness of disease.
Its purpose is to alert the practitioner to the role of
environmental and occupational factors in the etiology
of diseases and to aids in their diagnosis,
The Booklet Includes:
• An overview of the problem,
• A list of common signs and symptoms,
• A sample environmental and occupational history form
that can be photocopied for inclusion in all patients'
records,
• A table of selected toxic exposures and manifestations,
• Agencies and organizations serving as resources,
• Recommended desk-top references on the subject of
environmental and occupational medicine.
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An Introduction to
Environmental and Occupational
Health Hazards
New developments in technology and energy production and rising levels
of chemical manufacturing and disposal are increasing the quantity of
potentially hazardous substances in the environment. Additionally, non-
biodegradable materials and longlived radioactive products have
magnified the scope and duration of pollutant problems and their impacts
on human health.
Over the past decade, a substantial number of health problems have
been traced to exposures to hazardous substances in the workplace,
home, and community environments. Diseases which have received
widespread attention, such as lead poisoning and asbestosis, serve to
illustrate the causal relationship between environmental and occupationaf
exposure and human disease. Mortality from cancer is rising, and there is
growing scientific consensus that 70-90 percent of all cases are
attributable to environmental factors. These include worksite exposures
and other environmental factors such as smoking, diet, and the physical
environments of home, school, and community.
The practitioner will face a variety of problems in the diagnosis of
environment and occupation-related diseases:
• Many symptoms, even though they are common to a number of
problems, may be specifically related to environmental and
occupational exposures and should be considered in the differential
diagnosis.
• Some exposures result in immediate effects or effects which develop
within a short period of time (e.g., CO, chlorine, food poisoning).
Other exposures produce chronic effects which appear long after
initial exposure (e.g. mercury, noise, radiation).
• Effects-of exposure to combinations of substances may be
synergistic. An example of this type of interaction is cigarette
smoking and exposure to asbestos dust. It is known that smokers
who work with asbestos are at increased risk of lung cancer.
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• Susceptibility to environmental exposures varies from person to
person.
• Relationship between a patient's job title and toxic exposures may
be obscure. The practitioner may need to probe beyond the patient's
job title to discover actual work practices and exposures, such as
the proximity of the individual to paints, solvents and cleaning
compounds, welding and grinding operations, pesticides, etc.
• The complex environment provides a mixture of stressors and
ambient pollutants in air and water (S02, hydrocarbons, pesticides,
fertilizers, noise, RGB's, etc.), which may give rise to health problems
or augment occupational exposures.
• Family members may be exposed to toxic substances brought home
on workers' clothing or hair.
Given the difficulties of the practitioner's task, awareness and
suspicion are the greatest "weapons" in tracking down environmentally
and occupational^ induced disease. The practitioner must take an
environmental and occupational history on each patient. A sample form
is included in this booklet. Once the history has been taken, it is necessary
to relate the symptoms to possible toxic exposures. The tables and
supplementary information contained in this guide will be an aid in
evaluation.
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Commonly observed signs and symptoms should be considered as
potential indicators of toxic exposure:
System or Site
General:
Dermatological:
Head (eye/ear/nose/throat):
Signs and Symptoms
Weight loss, change in appetite,
fatigue, new sleep difficulties,
irritability
Skin rashes, allergies, sores
Hearing loss, eye problems,
headaches, change in taste,
rhinitis
Chest:
Heart:
Abdominal:
Reproductive System:
Shortness of breath, asthma,
cough and sputum production
Chest pain, circulatory changes
Nausea and vomiting, constipation
Infertility, miscarriages, birth
defects
Musculo-Skeletal:
Central Nervous System:
Back pain, joint pain
Weakness, tremors, personality
changes, headaches
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Environmental and
Occupational History Form
The following history form is adapted
from one currently in use at the
Mount Sinai Hospital in New York
City. It may be freely photocopied and
should be included with individual
patient's records. The form will assist
the practitioner in gathering
information on a patient's work, home,
and community environments.
The patient is the primary source
of information about his or her
environment. While the patient may
not have specific knowledge about
toxic substances or easily recall past
exposures, it is the practitioner's role
to work with the patient to develop
this relevant information.
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PATIENT ENVIRONMENTAL/OCCUPATIONAL HISTORY FORM
Date Taken: Patient Name:
1. WORKPLACE
Current Work (i.e., carpenter, housewife, police officer, etc.)
Name and address of company or employer (if any)
How long at this job?
General description of work
Any contact with dusts, fumes, vapors, gases, chemicals, radiation, pressure, excessive noise, vibration, temperature
extremes?
Any adverse effects noted? (Describe)
Previous Work Years Description of Work Exposures
First regular job
Next regular job
Next regular job
Next regular job
Next regular job
Vacation jobs
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"Second" jobs
Temporary work
Work in military services
2. HOME AND COMMUNITY
Are there any conditions in your home which you think may affect your health (use of aerosol sprays, chemicals or
cleaning agents, recent reconstruction, painting, etc.)?
Does anyone in family work in a trade where hazardous materials could have been brought home (i.e., asbestos, lead,
beryllium, vinyl chloride, etc.)?
Did you ever live near a plant, shipyard, mine, chemical (petroleum) factory, dumpsite?
Did you ever live near a busy highway, street or gas station? __
Hobbies involving adverse exposures: (furniture refinishing, arts and crafts, etc.):
3. CIGARETTES:
Ever smoke? . If yes, age started . On average, number/day . Current smoking, number/day
If stopped, how long .
Cigars/pipe:
Ever smoke? . Current smoking, amount , If stopped, how long?
4. COMMENTS:
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ENVIRONMENTAL/OCCUPATIONAL HEALTH
Organ System
(Primarily Affected)
Manifestations
Acute and Chronic
This table is a guide to
potential health effects from
exposure to hazardous agents
In the workplace, home, and
community environments.
Exposures are frequently most
intense in the work setting, but
hazardous materials used in
the workplace may also be
brought Into the home. In
addition, Individuals In the
community are exposed to
toxic substances found in air,
soil, water, foods and
consumer products.
This table should be used
In conjunction with the
environmental and
occupational history obtained
from the patient. While not all-
inclusive, the table will assist
in determining the environment
and work-relatedness of the
patient's symptoms. Individual
allergic responses, extreme
hypersusceptible reactions,
and communicable diseases
are not Included in the table.
Also omitted are hazards
attributable, at least In part, to
personal habits, I.e., smoking,
drinking, drug use, personal
hygiene, poor nutrition, etc.
Skin
Respiratory
System
Cardiovascular
System
Gastrointestinal
System
Genitourinary
System
Nervous System
Auditory System
Ophthalmic System
Reproductive
System
Hematological
System
Nasal Cavity and
Sinuses
Dermatitis
Chloracne
Skin Cancer
Acute pulmonary edema and
pneumonitis
Asthma
Chronic lung disease
Lung cancer
Arrhythmias
Angina
Intermittent claudication
Arteriosclerosis
Adbominal pain, nausea
Vomiting, diarrhea, bloody
stools
Hepatic necrosis
Hepatic cancer
Hepatic fibrosis
Aminoaciduria
Chronic renal disease
Bladder cancer
Headache/convulsions/coma
Extrapyramidal disorders
Peripheral neuropathy
Hearing loss (and stress
reactions)
Eye irritation
Cataracts
Spontaneous abortions
Birth defects
Infertility
Pancytopenia and aplasia
Acute myelogenous leukemia
Lymphadenopathy, anemia,
buboes.
Inflammation
Cancer
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HAZARDS AND MANIFESTATIONS
Environments and Practices Conveying an
Increased Risk of Developing Disease
Chemical and Physical Agents
Electroplating; photoengraving; metal cleaning;
wood preserving; food preserving; contact with
foods and cosmetics; use of household
chemicals and soaps.
Hydrocarbon solvents; beryllium;
arsenic, zinc oxide, PCB, nickel,
dioxane, soap, pentachlorophenol,
bismuth, alcohol, drugs.
Construction and insulation; textile
manufacturing; painting; arc-welding; meat
wrapping; animal handling; in-flight airline
services; radiological work; exposure to traffic
exhausts, dust, and industrial air pollution;
improper ventilation and heating.
Exposure to traffic exhaust; diesel engine
operation; sewage treatment; cellophane and
plastic manufacturing; motor vehicle repairing;
extreme hot/cold; contact with synthetic film
and hazardous agents in art and hobby
supplies; pest extermination.
Arsenic, asbestos, chromium, iron
oxide, ionizing radiation, beryllium,
ozone, nitrogen oxides, textile
dusts, nickel, carbonyl, aerosolized
plastics (e.g., vinyl chloride, teflon),
dusts, fumes, vapors.
Carbon monoxide, hydrogen
sulfide, barium, organophosphates,
freon, glues and solvents, heat and
cold.
Jewelry making; dry cleaning; refrigerant
manufacturing; food processing; chemical
handling; printing; contact with lead-based
paints and components of batteries and
electrical equipment; consumption of
improperly handled food.
Heavy metals (e.g., lead,
cadmium), carbon tetrachtoride,
chlorinated hydrocarbons,
phosphorus, beryllium, arsenic,
nitrosamines, vinyl chloride,
aflatoxin, bacterial toxin.
Plumbing; soldering; exterminating; textile
manufacturing; contact with components of
batteries.
Cadmium, lead, mercury, organic
dyes, halogenated hydrocarbons.
Wood working; painting; exposure to traffic
exhausts; fireproofing; plumbing; soldering;
manufacturing of textiles and petrochemicals;
contact with pesticides and battery components;
consumption of improperly prepared food.
Mercury, manganese, lead, carbon
monoxide, boron, fluoride,
organophosphates, hexane,
organic solvents, wood
preservatives (pentachlorophenol).
Subway operations; metal working;
construction; activities involving loud music.
Loud noise, high frequency noise.
Petroleum refining; chemical handling; paper
production; laundering; contact with
photographic films: glass blowing.
Nitrogen oxides, acetic acid,
formaldehyde, radiation.
Operating room procedures; contact with
pesticides and contact with battery
components.
Anesthetic gases, ionizing and
non-ionizing radiation, lead, chemicals
(dioxane), pesticides (DBCP).
Dye manufacturing; dry cleaning; chemical
handling; contact with hazardous agents in art
and hobby supplies; contact with rodent
excreta, rodent bites
Benzene, arsenic, organic dyes,
arsine, nitrates, drugs, lead.
Welding; photoengraving; manufacturing of
glass, pottery, linoleum, textile, wood and leather
products; contact with battery components.
Arsenic, selenium, chromium,
nickelcarbonyl, wood.
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RESOURCES
in the New York City Area for Information
and Assistance
Various government and non-government agencies have been established to
disseminate environmental and occupational health and safety information.
The following is a list of resources in the New York City area that may be
contacted by the health care practitioner as well as the patient or concerned
citizen.
1
The National Institute for Occupational and Safety and Health
(NIOSH)
NIOSH is a division of the U.S. Public Health Service responsible for
educating professionals and conducting research on the effects and
control strategies of occupational hazards.
! NIOSH can provide (1) technical and non-technical publications on
occupational health and safety problems, and (2) technical or con-
sultative services related to specific occupational health problems.
Contact NIOSH for information regarding:
• research and testing related to toxic substances,
• protective equipment,
• effective testing procedures for evaluation of the workplace.
NIOSH
26 Federal Plaza
33rd Floor (Rm. 3300)
New York, N.Y. 10007
Phone: (212)264-2485
NIOSH provides technical support to twelve Educational Resource Cen-
ters (ERCs) throughout the country (see below.)
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RESOURCES
The Educational Resource Center (ERC)
Contact ERC regarding:
• development of degree and continuing medical education programs
• training in all areas of occupational safety and health
ERC
Environmental Sciences Laboratory
Mt. Sinai School of Medicine
1 Gustave Levy Place
New York, N.Y 10024
Phone: (212) 650-6777 (Edwin Holstein, M.D.)
The Occupational Safety and Health Administration (OSHA), U.S.
Department of Labor.
OSHA develops standards for occupational safety and health, and
enforces these standards through an inspection procedure. In the New
York City area, inspections are carried out by the five area offices which
cover the five boroughs and Long Island.
OSHA also publishes many non-technical publications which ad-
dress employer/employee rights and responsibilities under the Act,
OSHA procedures, and OSHA standards.
Communicate with OSHA when:
• you believe the need for Federal regulatory action is called for in the
area of occupational safety and health
OSHA
Region II
1515 Broadway
New York, N.Y. 10036
Phone: (212)399-5754
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RESOURCES
The New York Committee for Occupational Safety and Health
(NYCOSH)
NYCOSH is an independent organization composed of trade unionists,
workers, health and legal professionals, and educators working in the
area of occupational health and safety.
NYCOSH offers materials geared to workers' needs, seminars,
workshops, and conferences for both professionals and non-professionals.
Contact NYCOSH for information regarding:
• technical support in evaluation and control of health hazards,
« educational programs for local unions,
• preventive training for medical students and professionals.
NYCOSH
P.O. Box 3285, Grand Central Sta.
New York, N.Y. 10017
Phone: (212)349-6478
Center for Occupational Hazards (COH)
COH publishes a newsletter, operates an information center, and can
provide information on various occupational health problems and tech-
niques for control. The Art Hazards Project is presently the strongest
element of COH.
COH should be contacted for information regarding:
• occupational health hazards of chemicals, particularly chemicals
used by artists and craftspersons.
COH
5 Beekman Street
New York, N.Y. 10038
Phone: (212)227-6220
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RESOURCES
Poison Control Center; New York City Department of Health
The Poison Control Center should be contacted for information on:
• chemical agents involved in cases of poisoning
• poisoning treatment information (to physicians)
• initial first aid (to the general public)
The Poison Control Center
New York City Department of Health
455 First Avenue
New York, N.Y. 10016
Phone: (212) 340-4494 (24 hr. service)
The Women's Occupational Health Resource Center (WOHRC)
WOHRC, in affiliation with Columbia's School of Public Health,
addresses women's occupational health and safety needs. The
center offers a research service, library, bi-monthly newsletter, fact
sheets, workshops, conferences and speakers' bureau.
The Women's Occupational Health Resource Center
School of Public Health
Columbia University
60 Haven Avenue, B-1
New York, N.Y. 10032
Phone: (212) 694-3464
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REFERENCES
This handbook is meant to serve as an initial aid and reference only. Individual
situations and patient complaints will often lead the practitioner to seek
detailed information. The following reference books and information sources
wilt be extremely valuable. Sources included in this list will help direct both the
health practitioner and the patient to multiple additional references pertaining
to specific problems.
Occupational Diseases—A Guide to their Recognition, Revised Edition,
June, 1977; U.S. Department H.E.W., DHEW Publication No. 79-116; edited by
S. Kusnetz and M, Hutchinson, GPO Stock No. 017-033-00266-5.
Superintendent of Documents
U.S. Government Printing Office
Washington, D.C. 20402 $5.25*
NIOSH/OSHA Pocket Guide to Chemical Hazards; DHEW (NIOSH) Pub-
lication No. 78-210. GPO Stock No. 017-033-00342-4.
Superintendent of Documents (see above) $5.00*
A Guide to the Work-Relatedness of Disease—Revised Edition, DHEW
(NIOSH) Publication No. 79-116.
PUBLICATION DISSEMINATION, DTS
National Institute for Occupational
Safety and Health
4676 Columbia Parkway
Cincinnati, Ohio 45226 FREE*
(When writing, please refer to Publication No.)
Occupational Lung Diseases—An Introduction, American Lung Associa-
tion, May, 1979.
American Lung Association
1740 Broadway
New York, New York 10019 FREE*
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REFERENCES
The following group of references are distributed by private publishing
houses. Each reference is followed by its publisher's address although any of
the books may be ordered through a medical bookstore.
Hunter, Donald: The Diseases of Occupations; 1978 6th edition
Little, Brown & Co.
34 Beacon Street
Boston, MA 02106 $75.00*
Zenz, Carl: Occupational Medicine: Principles and Practical
Applications, 1975.
Yearbook Medical Publishers
35 East Wacker Drive
Chicago, Illinois 60601 $55.00*
Waldbott, George L: Health Effects of Environmental Pollutants, Second
Edition, 1978.
The C.V. Mosby Company
11830 Westline Industrial Drive
St. Louis, MO. 63141 $14.95*
Hamilton, Alice, & Harriet Hardy: Industrial Toxicology, Third Edition, 1974.
Publishing Sciences Group, Inc.
411 Massachusetts Avenue
Acton, Mass. 01720 $26.00*
Saxe, N.I.: Dangerous Properties of Industrial Materials, 4th Edition, 1975
Van Nostrand Reinhold Co.
135 West 50th Street
New York, N.Y. 10020
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REFERENCES
Additional sources may be obtained from libraries and not-for-profit agencies
including the following:
The Labor Safety and Health Institute (LSHI)
The LSHI publishes workbooks and maintains a library on job safety and
health information which may be used by appointment.
LSHI
377 Park Avenue South
New York, N.Y. 10016
Phone: (212) 689-8959
Health PAC
Health PAC is an independent, not-for-profit public interest center concerned
with monitoring and interpreting the health system. Health PAC publishes
reports and bulletins on various occupational health issues, i.e., asbestosis,
black lung, byssinosis, etc.
Health PAC
17 Murray Street
New York, N.Y 10016
Phone: (212) 267-8890
National Institute for Occupational Safety and Health (NIOSH)
NIOSH is the information dissemination branch of the Occupational Safety
and Health Administration under the U.S. Department of Health, Education
and Welfare. Numerous publications on occupational and environmental
health issues are available, free, upon request.
Publications Dissemination, DTS
National Institute for Occupational
Safety and Health
4676 Columbia Parkway
Cincinnati, Ohio 45226
(A "New Publications" list will be sent upon request.)
'Prices subject to change.
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