o  O

Health Systems Agency of New York City
111 Broadway
New York, New York 10006
 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
 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,
Grant assistance for development of this publication was provided by the Office of Toxic
Substances of the United States Environmental  Protection Agency (Grant No

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'

• 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.

 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

    • 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.

    • Susceptibility to environmental exposures varies from person to

    • 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

Commonly observed signs and symptoms should be considered as
potential indicators of toxic exposure:
System or Site
Head (eye/ear/nose/throat):
Signs and Symptoms
Weight loss, change in appetite,
fatigue, new sleep difficulties,
Skin rashes, allergies, sores
Hearing loss, eye problems,
headaches, change in taste,
Reproductive System:
Shortness of breath, asthma,
cough and sputum production
Chest pain, circulatory changes
Nausea and vomiting, constipation
Infertility, miscarriages, birth
Central Nervous System:
Back pain, joint pain

Weakness, tremors, personality
changes, headaches

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.

Date Taken:                            Patient Name:
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

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	

"Second" jobs
Temporary work
Work in military services
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.):
Ever smoke?	. If yes, age started	. On average, number/day	.  Current smoking, number/day
If stopped, how long	.
Ever smoke?	. Current smoking, amount	  ,  If stopped, how long?	

                              Organ System
                              (Primarily Affected)
                         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.
Nervous System
Auditory System
Ophthalmic System
Nasal Cavity and
                         Skin Cancer
                         Acute pulmonary edema and
                         Chronic lung disease
                         Lung cancer
                         Intermittent claudication
Adbominal pain, nausea
Vomiting, diarrhea, bloody
Hepatic necrosis
Hepatic cancer
Hepatic fibrosis
Chronic renal disease
Bladder cancer
Extrapyramidal disorders
Peripheral neuropathy
Hearing loss (and stress
Eye irritation
Spontaneous abortions
Birth defects
Pancytopenia and aplasia
Acute myelogenous leukemia
Lymphadenopathy, anemia,

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
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
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
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.

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
The National Institute for Occupational and Safety and Health
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.
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.)

     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
     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
     Region II
     1515 Broadway
     New York, N.Y. 10036
     Phone: (212)399-5754

    The New York Committee for Occupational Safety and Health
    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.
    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.
    5 Beekman Street
    New York, N.Y. 10038
    Phone: (212)227-6220

    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

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.
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*

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

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.
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.