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Overview of occupational and environmental health
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Overview of occupational and environmental health
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Literature review current through: Nov 2017. | This topic last updated: Feb 21, 2017.

INTRODUCTION — Environmental and occupational issues have an important place in primary care practice, emergency medicine, pediatrics, and various medical specialties. Work or environmental exposures may be linked to an individual patient's symptoms. A patient's reported environmental exposures may prompt important interventions to prevent future illnesses or injuries, and work-related injuries or illnesses may require physicians to make assessments of impairment, disability, and workers' compensation.

Concerns about chemical or biological terrorism, as well as industrial disasters, have made it imperative that physicians be able to immediately recognize patterns associated with exposures to key chemical agents (such as cyanide and nerve agents) and biological agents (such as anthrax) [1] (see "Chemical terrorism: Rapid recognition and initial medical management" and "Identifying and managing casualties of biological terrorism"). In addition, health care providers and health centers need to have sufficient background to be able to respond to patients with potential exposures from accidental contaminations of drinking water or air, or exposures related to new technologies, such as fracking.

To be effective, physicians need to know how to take a good environmental/occupational history and have a reasonable understanding of common environmentally related illnesses and basics of exposure assessment [2]. In addition, physicians can play an important role in occupational and environmental issues that extend beyond the office practice, preventing occupational illness in other employees at the work site and promoting general global environmental health [3,4].

An overview of occupational and environmental health is found here. Occupational lung disease is discussed in detail separately, as is adult lead poisoning, arsenic toxicity, and female reproductive toxicity. (See "Occupational asthma: Definitions, epidemiology, causes, and risk factors" and "Adult occupational lead poisoning" and "Arsenic exposure and poisoning" and "Overview of occupational and environmental risks to reproduction in females".)

EPIDEMIOLOGY — The full extent of occupational injuries and illness is difficult to measure. In the United States (US), the Bureau of Labor Statistics (BLS), which details statistics based upon surveys of private companies (an underestimate of the true totals), reported that in 2012 there were 4693 fatal work-related accidents (3.2 per 100,000) [5] and 3 million nonfatal injuries and illnesses, or 3.4 per 100 equivalent full-time workers [6]. More than one half of the 3.0 million cases reported were of a more serious nature that involved required days away from work, job transfer, or restricted duties at work.

Analysis of data collected from several data sets (including the BLS) produced the following estimates of annual total occupational injury and illness in the United States (US): 6500 job-related deaths from injury; 13.2 million nonfatal injuries; 60,300 deaths from job-related disease; and 862,200 work-related illnesses [7]. Total costs were estimated to be $171 billion. In a study of health maintenance organization (HMO) members with adult-onset asthma, 21 percent were found to meet criteria for asthma attributable to occupational exposures [8].

Asthma related to work can be asthma that is caused by a specific workplace sensitizer or irritant, and can also be work-exacerbated asthma (WEA) [9,10]. Studies estimate that about 16 percent of all cases of adult-onset asthma are caused by occupational exposures [9]. Work-exacerbated asthma, which is the worsening of asthma due to work, is common and estimated to have a median prevalence of 21.5 percent among asthmatic adults [10]. Guidelines are provided that assist health care providers with diagnosing, managing, and preventing occupational asthma [9,11]. (See "Occupational asthma: Definitions, epidemiology, causes, and risk factors".)

Epidemiological studies of first responders and firefighters are worth noting. The World Trade Center (WTC) disaster in the United States in September 2001 produced large exposure to toxic dusts and gases [12,13]. Studies of first responders within one month of the WTC disaster showed bronchial reactivity that was three times higher among those who had been on site the morning of the disaster, compared to those who arrived later. Studies of pulmonary function of rescue workers from the NYC Fire Department during the year following the disaster demonstrated substantial reduction in average FEV1 compared to pulmonary function studies performed five years earlier [14]. Subsequent studies of firefighters have continued to demonstrate changes of airway obstruction [15]. An increased incidence of "sarcoid-like" granulomatous pulmonary disease has been reported among NYC Fire Department workers [16]. A preliminary investigation of cancer incidence in the first seven years afterwards suggested an increased rate among the most highly-exposed responders [17]. Research into health effects of firefighters in general has demonstrated an increase in fatal coronary heart disease when comparing firefighters involved in emergency firefighting duties with those who are not involved in urgent duties [18].

Another area of growing importance and recognition is the role of obstructive sleep apnea (OSA) and vehicle accidents, particularly among commercial vehicle drivers [19-22]. Presence of significant obstructive sleep apnea has been associated with an increase in vehicle accidents [20] and there have been efforts to develop screening methods and predictors to identify drivers with this problem [19]. One of the best predictors is a high BMI, such as >33 to 35 for males, even in the presence of little or no symptoms of sleepiness [19,20]. OSA is a growing problem as the population is increasing in weight, so primary care physicians need to have a low threshold for ordering sleep studies on their obese patients who drive commercial vehicles. (See "Overview of obstructive sleep apnea in adults" and "Drowsy driving: Risks, evaluation, and management".)

The environment can also contribute significantly to illness in both adults and children. The following are some key representative findings:

An important and growing area of attention is children's environmental health. A study examined the contribution of environmental pollutants to the incidence, prevalence, mortality, and costs of pediatric disease in US children by examining lead poisoning, asthma, cancer, and neurobehavioral disorders [23]. The authors developed a model that estimated the environmentally attributable fraction of lead poisoning to be 100 percent; asthma, 30 percent (range 10 to 35 percent); cancer, 5 percent (range 2 to 10 percent); neurobehavioral disorders, 10 percent (range 5 to 20 percent); and the subsequent estimated annual costs to be $54.9 billion [23]. The authors concluded that the high costs of health care attributable to environmental pollution are significant enough to merit a greater investment of funding for research and prevention of pollution. The American Academy of Pediatrics has published a book, Pediatric Environmental Health, that summarizes the epidemiology, clinical aspects, management, and prevention of many diseases and conditions relevant to children [24].

Air pollution has been linked to increased rates of morbidity and mortality, in particular from cardiovascular and respiratory illnesses [25-33]. During the 1980s and 1990s in the US, there was a decrease in the concentration of the fine particulate pollution (PM2.5) by 10 micrograms per cubic meter which was associated with an increased life expectancy of 0.77 year [34]. It was estimated that these reductions could account for as much as 15 percent of the overall increase in life expectancy in the study areas. A 2012 systematic review found an increased risk of myocardial infarction associated with short-term exposure to a variety of air pollutants (carbon monoxide, nitrogen dioxide, and sulfur dioxide); the population attributable risk was estimated as 0.6 to 4.5 percent [33].

Air pollution is also associated with adverse effects on lung development and decreased lung function in children [35-37]. A study in children with and without asthma found that improvements in air quality (decreased levels of nitrogen dioxide and particular matter) were associated with improvements in both forced expiratory volume in 1 second and forced vital capacity between age 11 and 15 [38].

Home environmental exposures to dust mites and cockroaches [39], and work exposures [8,40] appear to have contributed to the increased incidence and mortality of asthma in both adults and children [41]. Concerns continue to be raised about the potential health effects related to dampness and mold in indoor environments [42-44].

On a more worldwide level, pollution has been linked to the buildup of carbon dioxide leading to global warming, climatic changes, and a multitude of adverse human health outcomes [3,45-47]. Climatic and ecological changes have been shown to influence the emergence and reemergence of infectious diseases [48].

Release of chlorofluorocarbon gases used in refrigerators destroys the protective ozone layer in the stratosphere, thereby leading to an increase in ultraviolet radiation and skin cancers, particularly melanoma [3].

Increased attention has been directed at contributions of the built environment (eg, homes, buildings, streets, infrastructure) to adverse effects such as asthma, obesity, lead poisoning, and road traffic accidents. These conditions disproportionately affect poor people and people of color [49-53].

Nanotechnology involves the production and manipulation of materials in near atomic size (1 to 100 nm) to produce new structures, materials, and devices [54,55]. Although this new technology promises advancement in many areas, health concerns are also raised since nanosized manufactured materials begin to exhibit unique properties that affect physical, chemical, and biological behavior. Preliminary animal research suggests that breathing certain types of nanomaterials may affect the respiratory system [56]. Numerous workers continue to be exposed as this industry expands, and there are efforts to create registries, approaches to medical surveillance, and guidelines for exposure protection. Consumers are also potentially exposed through the use of numerous consumer products such as clothing, sunscreens, and cosmetics, and the US Food and Drug Administration is formulating an approach to regulation [57,58]. This area will continue to evolve over the coming years.

CLINICAL PRESENTATIONS — Environmental and work exposures can cause or aggravate a variety of common diseases such as asthma, carpal tunnel syndrome, dermatitis, hepatitis B, and cancer. In many cases, the work- or environment-related illnesses do not have unique clinical presentations: asthma caused by latex allergy does not differ from asthma precipitated by a cat allergy; median nerve entrapment related to repetitive motions has the same constellation of symptoms and signs as carpal tunnel syndrome due to pregnancy; headache due to carbon monoxide poisoning can be mistaken for severe tension headache or migraine. Symptoms related to hazardous exposures can appear as complaints involving any body system and mimicking ordinary medical diseases (table 1 and table 2). Some exposures cause immediate or subacute symptoms (such as allergic reactions and acute chemical reactions), while others lead to more delayed effects (such as cancer or pneumoconiosis). The distinguishing feature is the linkage to an environmental or occupational exposure. The occupational and environmental history can be the critical first step in recognizing, treating, and preventing environmental/occupational illnesses and injuries.

OCCUPATIONAL AND ENVIRONMENTAL HISTORY — The first step in the occupational/environmental history is a survey of all patients, including relevant questions and attention to the chief complaint (or diagnosis) for clues suggesting a relationship to activities at work or at home (algorithm 1) [59-61]. Questions may include a list of current and longest held jobs, a brief current job description, and inquiries about changes in or concerns regarding exposures or hazards at work or at home.

In looking for a temporal relationship to work, it is better to start with non-suggestive questions such as, "Are your symptoms better or worse at home or at work? Weekends or work days?" rather than more leading questions such as, "Does work make you sick?" Any suggestion that the symptoms may be related to recent or past exposures, or to some change in environment, either at work or at home, then precipitates a more detailed series of questions to obtain additional information about potential exposures and timing of work- or environment-related symptoms.

In some cases the screening occupational environmental survey reveals suggestive temporal relationships pointing to the role of environmental/work factors: the painter who has been scraping old paint and has abdominal pain (lead poisoning?); the lab technician who gets hand itching and a rash when she puts on latex gloves (allergy?); the mother and other family members who develop headaches in the fall that are worse in the morning and when at home (carbon monoxide poisoning due to a faulty furnace?).

Some cases of acute poisoning present with the sudden onset of characteristic signs and symptoms ("toxidromes"), due to accidental or deliberate release of toxicants, which need prompt recognition and treatment, frequently before diagnostic laboratory tests of the poison can be obtained [1]. As an example, persons presenting with miosis, dim vision, eye pain, rhinorrhea, headache, sweating, and diarrhea should raise strong suspicions of overdose with a cholinesterase inhibitor, such as an organophosphate pesticide or sarin nerve gas. When a religious cult released a toxic nerve gas in the subway system in Tokyo, 5000 persons required emergency treatment, and 11 died [62]. (See "Chemical terrorism: Rapid recognition and initial medical management".)

Finding a clear temporal relationship between symptoms and exposure is useful, but it is also important to realize that in some cases current exposures do not always lead to immediate symptoms. As examples:

A car painter may have worked for months at his job before developing a dry hacking cough that occurs during or after work. He might be experiencing bronchospasm from exposure to toluene diisocyanate (TDI), a well-known sensitizing agent, and one of the chemical components in the car lacquer that he sprays. In the case of allergic responses, it may take months of exposure before sensitization and clinical allergy develops. Once the asthma occurs, symptoms can sometimes extend beyond the work period, and then be triggered by a range of irritants. (See "Occupational asthma: Clinical features and diagnosis".)

Symptoms of hyperreactive airways (persistent dry cough and shortness of breath) may develop after a single large exposure to an irritant such as chlorine gas or sulfur dioxide. This has been termed "reactive airways disease syndrome" or "RADs" [63]. Some firefighters and rescue workers exposed to a variety of inhaled materials during and after the collapse of the World Trade Centers developed severe cough and persistent bronchial hyperreactivity [14,64-66]. Most recently the term "irritant-induced occupational asthma" has been used, which has less stringent criteria than "RADS", and also includes cases with induced airway symptoms after one or more exposures [9,11]. (See "Reactive airways dysfunction syndrome and irritant-induced asthma".)

Symptoms related to current exposures may improve on non-work days or vacations early in the course of illness, a helpful clue to the potential relationship with work. However, prolonged exposure can lead to the persistence of symptoms beyond the work week. As an example, aching in the wrist and hand of a stitcher due to repetitive wrist flexion and pinching might initially resolve with rest in the evenings or on weekends. Once carpal tunnel syndrome or chronic tendonitis develops, the symptoms can persist into non-work time and be aggravated by other activities such as sewing or gardening. Furthermore, other diseases such as cancer or asbestosis may occur with a long latency (15 to 30 years from the time of exposure to the onset of the disease). (See "Asbestos-related pleuropulmonary disease".)

Some diagnoses, termed "sentinel health events" (SHE), are more likely to be linked to current or past jobs. A SHE (occupational) is a disease, disability, or untimely death that is occupationally related and whose occurrence may provide the impetus for evaluation and interventions that prevent future cases [67,68]. A patient diagnosed with a SHE, such as pulmonary tuberculosis, asthma, contact dermatitis, bladder cancer, peripheral neuropathy, or pulmonary fibrosis, would be another prompt to taking a more detailed occupational/environmental history in pursuit of potential underlying (preventable) exposures. Sometimes, recognition of unusual presentations, particularly when seen in groups of workers, leads to discovery of new diseases, such as a cluster of employees in a nylon flocking plant who presented with interstitial lung disease ("flock workers lung") [69,70] and groups of workers from a plant producing microwave popcorn who developed bronchiolitis obliterans ("popcorn lung") found to be caused by a butter flavoring additive, diacetyl [71,72].

The occurrence of an illness in an unexpected person (eg, lung cancer in a nonsmoker) should prompt the clinician to delve further into potential contributing environmental or occupational exposures. In another situation, work or home exposures may appear to worsen an underlying medical illness. Symptoms with no clear etiology may indicate toxicological etiologies.

The practitioner needs to proceed with more detailed questioning once there is a suspicion that symptoms could be related to occupational or environmental conditions. Questions should include the place of employment and products manufactured. The worker should describe the tasks he/she performs, the agents handled, and the working conditions. Getting more information about chemical exposures can be initiated with obtaining the generic names of the agents used. This can be accomplished by having the patient bring in a label or a Material Safety Data Sheet (MSDS); the latter is the manufacturer's description of the product's generic name, ingredients, known health hazards, and recommendation for safe handling. These sheets vary in accuracy and completeness [59,73]. MSDS's can be obtained from the manufacturer or employer, and some can be found on internet sites (one good source is from the Vermont Safety Information Resources). Information about health effects related to these toxins can also be found by consulting other sources, such as poison control centers (1-800-222-1222), consultants, agencies, and useful references.

Once it is clear what is being handled, the next question is whether or not there is an opportunity for actual exposure. The patient should describe how a substance is handled: What are the operating or cleanup practices? What protective measures are used? What type of ventilation and exhaust is provided? Does the worker need to wear a respirator, and if so, is it the proper respirator, and is it worn and properly maintained? A good source for information about respirators can be found at the NIOSH website. Then consider the mode of entry: Is it inhaled? Is it ingested by eating at the workplace? Is there skin contact? Is there use of protective clothing or appropriate gloves to prevent skin absorption? Are other workers exposed? Do others have any symptoms?

It is also helpful to consider if the person exposed may be particularly vulnerable to the exposure. A person with renal disease, as an example, exposed to lead at acceptable (regulatory) air levels, might accumulate higher levels of lead than expected because of decreased ability to excrete it through the kidneys. A pregnant woman might be exposed to toxins, such as lead or carbon monoxide, at doses that would not be dangerous to her, but would be harmful to the developing fetus, who is more sensitive to the adverse effects. (See "Overview of occupational and environmental risks to reproduction in females".)

Exposures also can occur inside or outside of the home. Household exposures may result from the use of household chemicals, performance of certain hobbies, home remodeling, or bringing home contaminated work clothing (table 3 and table 4). A household products database is available on the National Library of Medicine website, and provides health effect information on over 4000 consumer brands.

The home, as well as surrounding air, water, and soil can be contaminated by nearby industrial plants, commercial business, or dump sites, or through disasters such as hurricanes, flooding or earthquakes. Depending upon the patient's complaints, inquiry about home insulation, heating and cooling systems, home cleaning agents, pesticide use, water supply, water leaks, recent renovations, air pollution, hobbies, hazardous waste contamination, spills, floods, or other exposures may be warranted. The potential for exposure to children should be considered if possible home and neighborhood exposures are identified.

Pediatric environmental health history — A child's physiology and behavior puts him or her at an increased risk for adverse effects from many toxins. Most attention concerning environmental exposures to children previously centered upon lead and second-hand cigarette smoke. More recently there has been increasing awareness about the potential health effects of other exposures, including chemical allergens and irritants (eg, formaldehyde resins), indoor and outdoor air pollutants, pesticides, and other toxins [36,74]. The pediatric history involves asking screening questions at the initial visit and follow-up visits that are relevant to the child's developmental stage. Questions are directed toward describing the home or other environments frequented by the child, as well as the parents' jobs [24]. (See "Secondhand smoke exposure: Effects in children".)

DOCUMENTING AND QUANTIFYING EXPOSURE — If the history raises concerns about exposures, it is usually necessary to measure the exposure in order to assess the level of risk and/or relationship to any symptoms. Documenting and quantifying exposures can involve performing biological monitoring tests of the affected person as well as evaluating the work or environmental site. The practitioner may find it helpful to seek assistance from specialists such as occupational/environmental medicine specialists, toxicologists, governmental agencies, and industrial hygienists.

Within the office setting the patient can be tested for evidence of exposure in body fluids (biological monitoring) or of adverse health effects upon target organs. The practitioner must know what agent to look for, the desirable test medium (urine, blood, hair, tissue), appropriate timing, and influences upon test results [75].

Carboxyhemoglobin is a blood test that indicates exposure to carbon monoxide; the measurement of a carboxyhemoglobin should be performed as soon as possible after exposure since the half-life of carbon monoxide in the body is approximately 250 to 320 minutes when breathing room air. (See "Carbon monoxide poisoning".)

Arsenic is excreted rapidly in the urine within a few days; it is a good marker for recent but not past exposure. Recent consumption of seafood can lead to increases in total urine arsenic due to the contribution of nontoxic forms of organified arsenic, thereby leading to mistaken interpretations of elevated arsenic levels. The solution is to speciate urine arsenic into inorganic and organic arsenic, if elevated levels are identified. (See "Arsenic exposure and poisoning".)

Some chemicals are detected by measurement of metabolites. As an example, several biological monitoring tests have been proposed for evaluating exposure to the solvent toluene, including measurements of the urine metabolites hippuric acid, benzoic acid, and o-cresol [75].

Hair analysis performed by commercial laboratories for multiple toxins and elements have been found to be of poor reliability and accuracy, and have little applicability in the primary care setting [76,77].

Laboratory tests may also be performed to look for toxic effects or end-organ damage. As an example, a blood lead concentration could be ordered to assess exposure, and BUN and creatinine to look for effects upon the kidneys. Pulmonary function tests and a chest radiograph would be ordered to assess the effects of past asbestos exposure on the lungs. (See "Asbestos-related pleuropulmonary disease".)

Some providers give a chelating agent (such as dimercaptosuccinic acid [DMSA]) to measure urinary metals, compare those results to a healthy, non-provoked population, and then make interpretations about body burden and metal toxicity. This is a practice that is not evidence-based, and as noted in the American College of Medical Toxicology position statement: "post-challenge urinary metal testing has not been scientifically validated, has no demonstrated benefit, and may be harmful when applied in the assessment and treatment of patients in whom there is concern for metal poisoning" [78,79].

Examination of the environmental or occupational site can be performed by governmental agencies, such as the Occupational Safety and Health Administration (OSHA) or the Environmental Protection Agency (EPA), or by private consultants such as certified industrial hygienists. Air sampling is performed with area or personal sampling devices to get results that can lead to estimates of exposure based upon an average eight-hour exposure. Many regulatory standards such as OSHA permissible exposure limits (PELs) are based upon eight-hour, time-weighted averages. Toxins can be measured in air, water, soil, and from surfaces.

In some cases, the correlation between exposure levels (in the environment or the body) and health effects is good, and in other cases poor. Lead, as an example, can be measured in air (micrograms/cubic meter) with a reasonable correlation between air levels and blood leads measured in exposed individuals. Although there is considerable individual variation, there is a general correlation between recent lead exposure and acute responses in adults. Generally, there are little or no acute clinical effects from recent exposures leading to blood leads below 20 micrograms/dL; gastrointestinal symptoms may occur with levels of 50 micrograms/dL and above; and anemia seen with levels above 80 micrograms/dL. In contrast, manganese levels (of potential importance since an organic form of manganese, methylcyclopentadienyl manganese tricarbonyl (MMT) has been used as a gasoline additive) measured in the air are poorly correlated with measurement in the blood. In general, blood levels of manganese do not correlate well with the appearance of the adverse side effects of manic-depressive symptoms and parkinsonism. (See "Adult occupational lead poisoning".)

Assessment of musculoskeletal stresses can be performed qualitatively by observing the workers performing job tasks, and more quantitatively with biomechanical analyses performed by an ergonomics expert.

MAKING A CAUSAL CONNECTION BETWEEN EXPOSURE AND ILLNESS — Making the causal connection between an exposure and the patient's symptoms requires consistency between the known adverse effects of the toxic agent and the nature of the illness; the presence of an appropriate temporal relationship between exposure and effect; and a sufficient exposure to cause the presumed effect. There are a number of excellent written resources describing the health effects of various exposures [80-89], as well as agencies and consultants to whom the primary care clinician can turn for assistance in this process.

Poison Control is another resource that provides quick information about chemical toxins (1-800-222-1222). There has been a great deal of publicity about health effects and exposure to damp environments and mold, and there are several excellent resources that summarize current information and approaches [90-93].

FOLLOW-UP — It is important to consider whether others have been exposed and need to be evaluated and treated once the diagnosis of a work- or environment-related illness has been made. It may be necessary to make an intervention to decrease or eliminate exposures in order to prevent illness in others. The physician may find it necessary to alert the company medical department, a company health and safety committee, or the state public health or labor department. It is often necessary to obtain additional exposure information to follow up on the initial leads. OSHA performs work site inspections routinely on a priority basis, or at the request of a current worker or management. Fines may be levied in some cases if OSHA standards are violated.

Other consultative sources include academically affiliated occupational health clinics (Association of Occupational and Environmental Clinics), board certified occupational and environmental medicine specialists (American College of Occupational and Environmental Medicine), Pediatric Environmental Health Specialty Units, and worker education/advocacy groups such as Coalition for Safety and Health (COSH) groups. The National Institute for Occupational Safety and Health (NIOSH) can provide the practitioner with toxicological information and perform health hazard evaluations of workers to detect work-related health problems. Industrial hygienists from private consulting groups or from workers' compensation carriers can conduct worksite evaluations and monitoring and advise about interventions. The practitioner may find it useful to contact the local state Department of Environmental Protection or city departments of public health for environmental problems.

The practitioner can also help an affected worker obtain workers' compensation when justified. The definition of "work-related" may vary by state, but usually implies that it is more likely than not that some activity at work precipitated, hastened, aggravated, or contributed to the injury or illness. The workers' compensation system is state-based; the practitioner needs to become familiar with the state regulations of his or her practice. Workers' compensation can provide benefits for work time lost, permanent disability, medical care expenses, and rehabilitation.

Efforts to control home environmental exposures can also be helpful. As an example, practitioners can advise asthmatic patients on measures to reduce environmental triggers. In a study of children with asthma, interventions that resulted in reducing levels of cockroach allergen and dust mite allergen in the bedroom were significantly correlated with reduced complications from asthma [94].

SUMMARY — Environmental and occupational issues have an important place in primary care practice, emergency medicine, pediatrics, and various medical specialties. Work or environmental exposures may be linked to an individual patient's symptoms. A patient's reported environmental exposures may prompt important interventions to prevent future illnesses or injuries.

Environmental and work exposures can cause or aggravate a variety of common diseases such as asthma, carpal tunnel syndrome, dermatitis, hepatitis B, and cancer. In many cases, the work- or environment-related illnesses do not have unique clinical presentations. Some exposures cause immediate or subacute symptoms (such as allergic reactions and acute chemical reactions), while others lead to more delayed effects (such as cancer or pneumoconiosis). (See 'Clinical presentations' above.)

The first step in the occupational/environmental history is a survey of all patients, including relevant questions and attention to the chief complaint (or diagnosis) for clues suggesting a relationship to activities at work or at home (algorithm 1). Questions may include a list of current and longest held jobs, a brief current job description, and inquiries about changes in or concerns regarding exposures or hazards at work or at home. (See 'Occupational and environmental history' above.)

If the history raises concerns about exposures, it is usually necessary to measure the exposure in order to assess the level of risk and/or relationship to any symptoms. Documenting and quantifying exposures can involve performing biological monitoring tests of the affected person as well as evaluating the work or environmental site. (See 'Documenting and quantifying exposure' above.)

It is important to consider whether others have been exposed and need to be evaluated and treated once the diagnosis of a work- or environment-related illness has been made. It may be necessary to make an intervention to decrease or eliminate exposures in order to prevent illness in others. (See 'Follow-up' above.)

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