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PubMed1998

Women who quit maquiladora work on the U.S.-Mexico border: assessing health, occupation, and social dimensions in two transnational electronics plants.

This cohort study of 725 women examined the health, occupational, and social factors that contribute to quitting work in two transnational electronics maquiladoras (assembly plants) in Tijuana, Mexico. The estimated cumulative probabilities of quitting were 68% and 81% by 1 and 2 years of employment. After adjusting for other factors, women who had a history of smoking or surgery and those who returned to work after a paid leave due to illness were more likely to quit. In contrast, women with a history of chronic illness had lower quitting rates. The nationality of the company and the work shift also significantly influenced quitting rates, but demographic characteristics and health care visits did not have a significant effect. Women selectively leave maquiladora employment, often due to health-related events. The healthy worker effect is difficult to measure in a mobile population with high turnover.

Adult↗
PubMed2004

Work-related musculoskeletal disorders: the epidemiologic evidence and the debate.

The debate about work-relatedness of musculoskeletal disorders (MSDs) reflects both confusion about epidemiologic principles and gaps in the scientific literature. The physical ergonomic features of work frequently cited as risk factors for MSDs include rapid work pace and repetitive motion, forceful exertions, non-neutral body postures, and vibration. However, some still dispute the importance of these factors, especially relative to non-occupational causes. This paper addresses the controversy with reference to a major report recently commissioned by the US Congress from the National Research Council (NRC) and Institute of Medicine (IOM) (2001). The available epidemiologic evidence is substantial, but will benefit from more longitudinal data to better evaluate gaps in knowledge concerning latency of effect, natural history, prognosis, and potential for selection bias in the form of the healthy worker effect. While objective measures may be especially useful in establishing a more secure diagnosis, subjective measures better capture patient impact. Examination techniques still do not exist that can serve as a "gold standard" for many of the symptoms that are commonly reported in workplace studies. Finally, exposure assessment has too often been limited to crude indicators, such as job title. Worker self-report, investigator observation, and direct measurement each add to understanding but the lack of standardized exposure metrics limits ability to compare findings among studies. Despite these challenges, the epidemiologic literature on work-related MSDs-in combination with extensive laboratory evidence of pathomechanisms related to work stressors-is convincing to most. The NRC/IOM report concluded, and other reviewers internationally have concurred, that the etiologic importance of occupational ergonomic stressors for the occurrence of MSDs of the low back and upper extremities has been demonstrated.

Ergonomics↗
PubMedDate not supplied

Why dose-response relationships are often non-linear and some consequences.

Given the dependence of many risk assessments on the assumption of linearity of dose-response relationships in human populations, we analyze the circumstances likely to lead to non-linearity and test our hypothesis of the high prevalence of non-linearity by examination of recent literature. METHODS. The analysis of Bross, based on whether irradiated cells die or can manifest malignancy, leads him to generalize that if a single exposure can have one of two (or more) countervailing outcomes, non-linearity of dose-response will result. We list four other common mechanisms which would have similar effects: symptom-stimulated withdrawal from exposures to respiratory irritants; certain aspects of the "healthy worker effect" (especially its obverse-withdrawal from the work force due to illness); selected consequences of the competing risks of long-term disease; and shift in relative strength among multiple independent variables. We then examine recent literature to see how often reports of linear, monotonic, and non-monotonic dose-response relationships occur and discuss the likelihood of countervailing alternate outcomes in selected examples. RESULTS. Non-linear and linear relationships are about equally frequent. Under circumstances where countervailing outcomes are probable, dose-response relationships should be non-linear and often are. These conditions may also lead to non-linear difference equations, which may manifest "chaotic" attributes. CONCLUSIONS. Regulations and policies cannot be routinely derived on the basis of extrapolating linear dose-response relationships for human populations. Although our analysis is oriented principally to epidemiology, similar considerations apply to toxicological studies as well.

Dose-Response Relationship, Drug↗
PubMed1999

Cytogenetic effects from exposure to mixed pesticides and the influence from genetic susceptibility.

Exposure to pesticides remains a major environmental health problem. Health risk from such exposure needs to be more precisely understood. We conducted three different cytogenetic assays to elucidate the biological effects of exposure to mixed pesticides in 20 Costa Rica farmers (all nonsmokers) compared with 20 matched controls. The farmers were also exposed to dibromochloropropane during the early employment years, and most of them experienced sterility/fertility problems. Our data show that the farmers had consistently higher frequencies of chromosome aberrations, as determined by the standard chromosome aberration assay, and significantly abnormal DNA repair responses (p < 0.05), as determined by the challenge assay, but no statistically significant differences in the tandem-probe fluorescence in situ hybridization (FISH) assay (p > 0.05). Genotype analysis indicates that farmers with certain "unfavorable" versions of polymorphic metabolizing genes (cytochrome P4502E1, the glutathione S-transferases mu and theta, and the paraoxonase genes) had significantly more biological effects, as determined by all three cytogenetic assays, than both the farmers with the "favorable" alleles and the matched controls. A unique observation is that, in individuals who had inherited any of the mentioned "unfavorable" alleles, farmers were consistently underrepresented. In conclusion, the Costa Rican farmers were exposed to genotoxic agents, most likely pesticides, which expressed the induction of biological and adverse health effects. The farmers who had inherited "unfavorable" metabolizing alleles were more susceptible to genotoxic effects than those with "favorable" alleles. Our genotype data suggest that the well-recognized "healthy worker effect" may be influenced by unrecognized occupational selection pressure against genetically susceptible individuals.

Adult↗
PubMed1987

Mortality and morbidity selection effects among US veterans.

Previous studies have documented a substantially lower mortality rate among US male veterans, a form of the "healthy worker" effect, but there have been no studies of morbidity selection effects among veterans. In this paper the evidence for mortality selection effects among US male veterans is reviewed, and data from two general health surveys are examined for evidence of a morbidity selection effect. Overall, there are no substantial differences in health characteristics between veterans and nonveterans, thus providing no evidence for a morbidity selection effect; the inclusion of military service-connected disabled veterans in this comparison, however, makes it somewhat problematic. Reconciliation of a clear mortality selection effect for veterans with the lack of evidence for a corresponding morbidity selection effect is attempted.

Adult↗
PubMed1996

The effect of labor force participation on coronary heart disease risk factors among middle-aged women: a cross-sectional study in a Japanese rural district.

This study examined labor force participation as a risk factor for coronary heart disease. The participants were 224 women aged 45 to 64, residing in a rural district in Japan. The working women spent a significantly greater number of working hours (paid and unpaid) and had a more "Westernized" food preference than homemakers. After adjusting for physical, psychosocial, and behavioral covariates, working women had significantly lower systolic blood pressure and blood glucose levels than homemakers. The "healthy worker effect" did not explain these differences. Middle-aged rural Japanese women who worked outside the home were slightly healthier than homemakers, despite their less healthy lifestyle. Total working hours were positively associated with systolic and diastolic blood pressures and total cholesterol in multiple regression analyses, which suggests that work overload has a harmful effect. A more suitable social environment is required if f Japanese working women are to enjoy a healthier life.

Journal Article↗
PubMed1986

Total population study of factors affecting chronic bronchitis prevalence in the coal mining industry of New South Wales, Australia.

The period prevalence of simple chronic bronchitis (SCB) (mucus hypersecretion), defined as chronic cough and sputum production by the MRC respiratory symptom questionnaire administered by occupational physicians and of obstructive chronic bronchitis (OCB) (airflow obstruction) (defined as SCB plus FEV1 less than 80% predicted) have been measured over the period 30 June 1977-30 June 1980 in the entire work force aged between 21 and 60 of the coal industry of New South Wales, Australia (12 357 men). Four dimensional contingency table analysis by a logistic transform method showed highly significant (p less than 0.001) additive affects of age (exposure duration), site of work, smoking, and alcohol consumption on development of overall chronic bronchitis (SCB + OCB). Odds ratios were face work:surface work = 1.78:1, smoker:non-smoker = 4.23:1, alcohol greater than 300 g/wk:alcohol less than 300 g/wk = 2.13:1. There was no evidence for synergistic effects of these factors on the development of mucus hypersecretion. When OCB was analysed separately, the effect of site of work, although in the same direction, was not statistically significant and this was assumed to be due to a "healthy worker" effect or a "swamping" effect of smoking. Age, smoking, and alcohol effects were highly significant (p less than 0.0001) and there was a sharp increase in prevalence of OCB in the age groups 41-50 and 51-60. Odds ratios were face work:surface work = 1.11:1, smoker:non-smoker = 2.66:1, alcohol greater than 300 g/wk:alcohol less than 300 g/wk = 2.91:1. There was no evidence of synergistic effects. These results are consistent with a hypothesis of additive effects of smoking, alcohol, and coal mine dust and fumes on the development of chronic mucus hypersecretion leading to airflow obstruction or a hypothesis of similar additive effects on the development of two separate conditions--mucus hypersecretion with airflow obstruction and mucus hypersecretion without airflow obstruction.

Adult↗
PubMed2003

Age, flight experience, and risk of crash involvement in a cohort of professional pilots.

Federal aviation regulations prohibit airline pilots from flying beyond the age of 60 years. However, the relation between pilot age and flight safety has not been rigorously assessed using empirical data. From 1987 to 1997, the authors followed a cohort of 3,306 commuter air carrier and air taxi pilots who were aged 45-54 years in 1987. During the follow-up period, the pilots accumulated a total of 12.9 million flight hours and 66 aviation crashes, yielding a rate of 5.1 crashes per million pilot flight hours. Crash risk remained fairly stable as the pilots aged from their late forties to their late fifties. Flight experience, as measured by total flight time at baseline, showed a significant protective effect against the risk of crash involvement. With adjustment for age, pilots who had 5,000-9,999 hours of total flight time at baseline had a 57% lower risk of a crash than their less experienced counterparts (relative risk = 0.43, 95% confidence interval: 0.21, 0.87). The protective effect of flight experience leveled off after total flight time reached 10,000 hours. The lack of an association between pilot age and crash risk may reflect a strong "healthy worker effect" stemming from the rigorous medical standards and periodic physical examinations required for professional pilots.

Accident Proneness↗
PubMedDate not supplied

Effects from environmental Mn exposures: a review of the evidence from non-occupational exposure studies.

OBJECTIVE: The risk posed to human health by environmental manganese exposure is unknown. Occupational-exposure outcomes may not extrapolate to environmental exposures due to the healthy worker effect and differences in dosage parameters which may affect the biological response. This paper attempts to combine the existing literature on non-occupational Mn exposures with results from our current study in SW Quebec on environmental Mn exposure (Mergler et al., this issue) within the framework of a biologically-based, dose-response (BBDR) model. BBDR MODEL: The basic BBDR model consists of seven stages relating exposure to health effects. The stages are: 1) sources, 2) applied dose, 3) absorbed dose, 4) target-site dose, 5) toxic event, 6) measurable change, and 7) health outcome. RESULTS: Several air monitoring programs, such as the PTEAM study (Riverside, CA, 1990, mean PM10 Mn outdoor-airborne 24 h average = 0.045 microgram/m3), provided data relevant to the estimation of Mn applied dose, but did not include measures of body burden. Data from the SW Quebec study showed a mean total-particulate airborne Mn concentration of 0.022 microgram/m3 with a range of 0.009 to 0.035 microgram/m3 across four sampling sites, whereas the EPA reference concentration (RfC) is 0.05 microgram/m3. EPA has considered tap water levels to be safe below 200 micrograms/l Mn, and mean Mn tap-water (MnW) level in the participants' homes was 6.38 +/- 11.95 micrograms/l with a range from 0.1 to 158.9 micrograms/l Mn. A previous study of MnW exposure in Greece reported Mn levels in areas with low, medium and high MnW ranging from 4 to 2,300 micrograms/l and a significant association with Mn in hair but not Mn in blood (MnB). The mean absorbed dose of the SW Quebec study participants, as indicated by MnB, was 7.5 +/- 2.3 micrograms/l with a range of 2.5 to 15.9 micrograms/l. Our study and others on environmental Mn exposure did not provide an estimate of target-site dose. However, a significant correlation (r = 0.65) between MnB and signal intensity in T1-weighted MRI images has been reported in liver-disease patients with Parkinson-like signs who had MnB levels as low as 6.6 micrograms/l. Only animal and in vitro studies have provided evidence on the mechanisms of toxicity caused by Mn in the CNS. Several studies reported measurable changes in endpoints suggestive of a Parkinson-like syndrome in subjects with MnB levels ranging from 7.5 to 25.0 micrograms/l. Among other effects on neurobehavioral function observed in the current study was a significant relationship between MnB and the direction and speed of body-sway in men. The effects observed in these participants are sub-clinical and no health outcomes have been diagnosed. However, the Parkinson's disease incidence in the study area was previously reported to be 2-5 times higher than in the rest of Quebec, and several studies indicate that 25-35% of idiopathic Parkinson disease diagnoses are incorrect. Our study, the Greek study, and some clinical studies suggest that the risk of a Parkinson-like syndrome diagnosis may increase with continued Mn exposure and aging. CONCLUSION: The limited data available for the BBDR model point to the need for evidence, particularly on relationships between Mn species, exposure route, MnB with chronic environmental exposure, ageing, and susceptibility factors, to improve human-health risk assessments for chronic, environmental Mn exposure.

Dose-Response Relationship, Drug↗
PubMed2001

Are African-American nuclear workers at lower mortality risk than Caucasians?

This study investigated disparities in worker mortality across race at the Savannah River site (SRS) nuclear facility in Aiken, South Carolina. Standardized mortality ratios were calculated stratified by race (Caucasian, African-American) and gender for specific causes of death, and by race, gender, duration of employment, and follow-up for overall mortality. Race-specific standardized mortality ratios for African-American male workers generally were lower than those for Caucasian male workers, although both groups showed strong healthy worker effects. Nevertheless, African-American male workers generally had higher absolute mortality rates. Understanding why SRS African-American male workers are substantially healthier than their reference population as compared with Caucasian male workers but are less healthy in absolute terms than the SRS Caucasian male workers may provide clues for prevention or intervention. Further, the standardized mortality ratios at the SRS were lower than at the Hanford and Oak Ridge nuclear facilities, which warrants investigation.

Adult↗
PubMed1991

A cross-sectional study of hand/wrist symptoms in female grocery checkers.

A questionnaire was mailed, in 1986, to 1,345 grocery checkers who belonged to one union local in south-central California. Among the 1,058 female respondents (82% response rate), we found a 12% prevalence of hand/wrist symptoms characteristic of carpal tunnel syndrome (CTS). Symptom prevalence was positively associated with age, average work hours per week, years worked as a checker, and use of diuretics. The estimated effect of years worked as a checker was greater for younger subjects than for older subjects, in whom the association reversed, suggesting the selective loss of symptomatic workers from their jobs (a form of the healthy-worker effect). Although no effects were found for specific job-related activities, we estimate that CTS symptoms in at least three of every five symptomatic workers were attributable to occupational exposures.

Adolescent↗
PubMed1991

Assessment of the filtration reserve capacity of the kidney in workers exposed to cadmium.

It has been assessed whether an internal dose of cadmium (Cd), as reflected by a Cd concentration in urine not yet sufficient to induce a significantly increased urinary excretion of various plasma proteins (microproteinuria defined as beta 2-microglobulin in urine greater than 300 micrograms/g creatinine, or retinol-binding protein in urine greater than 300 micrograms/g creatinine, or albumin in urine greater than 15 mg/g creatinine, or a combination of these), may affect the filtration reserve capacity of the kidney. The last was determined by measuring the difference between the baseline creatinine clearance and the maximal creatinine clearance after an acute oral load of protein (400 g of cooked red meat). In total 215 men were examined of whom eventually 87 Cd exposed workers (concentration of Cd in urine greater than 2 micrograms/g creatinine) from zinc/cadmium smelters and 92 control workers (concentration of Cd in urine less than 2 micrograms/g creatinine, absence of microproteinuria, normal fasting serum creatinine) were retained for data analysis performed separately for workers aged less or more than 50 years. Microproteinuria was present in 20 Cd workers, all older than 50. This study confirmed the previous observation that the age related decline of the baseline glomerular filtration rate (GFR) is accelerated in male workers with Cd induced microproteinuria; the same observation was made for the maximal GFR. It was found, however, that a renal Cd burden that had not yet caused microproteinuria did not impair the filtration reserve capacity of the kidney. This study therefore validates the previous estimate of the threshold effect concentration of Cd in urine (10 micrograms/g creatinine) that is intended to prevent the occurrence of microproteinuria in male Cd workers. It should be kept in mind, however, that because of the likely interference of the healthy worker effect, this conclusion may not be directly extrapolated to the general population.

Adult↗
PubMed1986

Time-related factors as potential confounders and effect modifiers in studies based on an occupational cohort.

Time-related factors which are potential confounders and effect modifiers in studies based on an occupational cohort are reviewed. The most frequently considered ones include age at first exposure, duration of exposure, interval from exposure to disease recognition, and age at risk. These factors are related to the "healthy worker effect," which appears to be more pronounced among workers with the longest durations of employment and older ages, at date of hire, but weaker with longer length of follow-up and older age at risk. Hence, use of an internal comparison group may not eliminate bias since confounding will occur if the exposed and unexposed groups differ in their distributions across these factors. It is also shown, using the multistage model of carcinogenesis, that these factors may be important effect modifiers. Fortunately, generally straightforward methods of control exist both for stratified analyses and for the commonly used mathematical modeling approaches. Although no firm recommendations can be made, it would appear to be important to control for length of follow-up in the design or analysis of most studies based on an occupational cohort, and controlling for age at first exposure may also be desirable under many circumstances.

Adult↗
PubMed1991

Health status of hostel dwellers. Part II. Infant mortality and prevalence of diabetes, hypertension and syphilis among adults.

The range of biomedical criteria selected to measure the health status of the residents of the urban migrant council-built hostels of Langa, Nyanga and Guguletu were investigated in a single survey. A single survey method screens health status and provides the opportunity to examine the interrelationship between findings on the different health criteria. Here a high infant mortality rate is examined against a low prevalence of diabetes, hypertension and syphilis and some of the effects of migrant labour on the health status of migrant hostel dwellers are identified. The low prevalence of disease among the Cape Town hostel residents suggests that migrant labour, by sifting out the able-bodied and employable, reproduces a 'healthy worker effect' among the migrant population with access to the city. The high infant mortality rate, in contrast, suggests that the disease burden of the migrants is being carried by the home-base population.

Adult↗
PubMed2006

Occupational tuberculosis: a review of the literature and the local situation.

OBJECTIVE: To review the risks and control of occupation-related tuberculosis. DATA SOURCES: Statutory notification data, local tuberculosis programme data, and census data were reviewed. Literature search of PubMed was performed up to December 2005. STUDY SELECTION: Original and major review articles related to tuberculosis among health care workers and guidelines for prevention were reviewed. DATA EXTRACTION: Relevant data were extracted from our literature review and local sources. DATA SYNTHESIS: Earlier experimental data demonstrated an airborne spread of tuberculosis and a steady state mathematical model for quantification of the transmission risk. In the post-chemotherapy era in developed countries, few studies demonstrated an occupational risk of tuberculin conversion outside of outbreak settings, and few studies were able to conclusively demonstrate an increased risk of active tuberculosis among health care workers. In countries with limited resource, the situation may be different, with a higher tuberculosis incidence among health care workers. Local tuberculosis programme and notification data from the Labour Department did not show an increased risk of active tuberculosis among health care workers. Although administrative control, engineering control, and personal protection are widely accepted control measures, it is difficult to quantify their cost-effectiveness. CONCLUSIONS: Although an increased liability to tuberculosis among health care workers is expected due to the concentration of infectious patients in their environment, prompt diagnosis and initiation of treatment may minimise the risk. A high background rate of disease and possible healthy worker effect may make it difficult to pick up a small risk differential. With the ongoing threat of a nosocomial outbreak, continuing vigilance is called for.

BCG Vaccine↗
PubMed2003

[Effect of occupational exposure and smoking on spirometric tests and symptoms of chronic bronchitis].

The importance of occupational exposure to airborne agents in the development of obstructive lung disease is uncertain. The aim of the study was to evaluate the effects of smoking and of occupational exposure on the lung function and chronic respiratory symptoms. I studied a group of 1239 adults (766 men and 473 women; mean age 44.9 +/- 8.6 yrs; current smokers 42.1%, lifetime nonsmokers 41.6%) working in 5 factories in the Bielsko-Biala area. Simple spirometric test (FEV1, FVC, FEV1%FVC) and a questionnaire on chronic respiratory symptoms, smoking habits and occupational exposures were applied. Respiratory symptoms and lung function were studied in relation to years of occupational exposure and adjusted for smoking habit. Occupational exposure was reported by 35.7% (n = 442) participants (dust 20.6%; gases or fumes 27.6%; mixed exposure 51.8%), with a mean duration of 20.9 +/- 9.2 years. In all cases concentrations of noxious agents did not exceed allowed levels. The symptoms of chronic bronchitis (cough and phlegm) were present in 12.3% and airflow limitation (FEV1% FVC < 0.7) in 6.9% of subjects. The significant relation of respiratory symptoms and bronchial obstruction to smoking was confirmed. No significant association between occupational exposure and ventilatory function or respiratory symptoms was found in a whole group. Smoking--specific analysis showed that current smokers appeared to be more susceptible to the effects of professional exposure. It was expressed in lower lung function indices and significantly higher odds ratios for airflow limitation or chronic respiratory symptoms for smokers exposed compared to nonexposed. Sufficient evidence of health selection processes known as a "healthy smoker" and a "healthy worker" effects were revealed.

Adult↗
PubMed1995

Hand-arm vibration in tropical rain forestry workers.

Working conditions and health hazards including vibration syndrome related to forestry work using chain-saws were studied in Papua New Guinea and Indonesia. The subjects comprised 291 workers including 97 chain-saw operators. The health examination consisted of peripheral circulatory and sensory tests in the upper extremities. The vibration spectrum measured at the handle of the chain-saw indicated that these acceleration levels would lead to a moderately high risk of hand-arm vibration syndrome (HAVS). The peripheral circulatory function tests revealed dysfunction after more than five years vibration exposure. However, in general, the results of the function tests and subjective complaints showed fewer health problems compared to those of Japanese forestry workers. The reason of such differences of vibration effects seem to be the following: (1) warmer climate (more than 25 degrees C throughout the year), (2) young workers and short work experience. (3) short time vibration exposures on working days in the natural forests, (4) seasonal changes in logging work (5) healthy workers effects. Thus, we found no clear evidence that the workers of our study suffered from HAVS. A principal component analysis was applied. The factor score of the components of the reactive dynamics of peripheral circulation differed significantly after more than five years' exposure. On the other hand, we cannot deny the possibility that subclinical dysfunction of peripheral circulation may be caused by chain-saw operation in the tropics in future. Further investigations on the HAVS among forestry workers in the tropic environment are needed.

Adult↗
PubMed2001

Multicenter field trial on possible health effects of toluene. III. Evaluation of effects after long-term exposure.

In rotogravure industry, contributing considerably to mass color printing of catalogues and magazines, toluene is still extensively used as paint solvent, and many printers have been exposed to this chemical for several decades. Information on adverse health effects associated with long-term toluene exposure is still controversial. In a multi-center study, adverse health effects possibly associated with long-term toluene exposure were evaluated. In 12 rotogravure factories, 1226 male volunteers were recruited, and sufficient information on exposure and on medical data was compiled for about 1077 of them. Evaluations included: physical examination, standard tests of psycho-physiological and psycho-motoric performances, self-report of subjective symptoms, and data on a variety of laboratory blood tests. The medical data were correlated with the length (months) of toluene exposure, and a rough estimate of the extent of exposure (i.e. highly exposed printers and their helpers versus employees working at locations with low or negligible toluene exposure). A small reference group (n=109) was selected from companies of the paper industry. When linear regression curves were calculated (test results versus duration of exposure), extremely low overall coefficients of determination (r(2) adj.) of a few percent were estimated within the data clouds, with sometimes statistically significant P-values. Closer analyses revealed a strong influence of the confounding factor age, no clustering of abnormal values of highly toluene-exposed volunteers, and the vast majority or all values of the highly and long-term toluene-exposed participants staying within the reference ranges. Thus, no medical relevance of P-values <0.05 could be recognized in this evaluation, and there may have been some border-line deviations or results largely occurring by chance in the large trial. In a small cluster of the many rotogravure printers toluene-exposed for more than 20 years, the highest systolic blood pressure values of the study were found, but many possible confounding factors were not taken into account. Data on acute exposure and possible effects are presented in accompanying papers (Neubert et al., 2001a, Neubert et al., 2001b). Restricting the conclusions to the end points evaluated as well as the apparent limitations of the evaluation, no evidence was found that long-term occupational toluene exposure extending over several decades in the rotogravure industry in the Western part of Germany was convincingly associated with chronic adverse health effects or convincingly altered surrogate markers in still working male volunteers. Several peculiarities and pitfalls arising when interpreting medical data associated with such a type of environmental exposure must be considered. Reversibility of alterations previously induced at higher levels of toluene-exposure, as well as a healthy workers effect, cannot be excluded for some of the medical end points evaluated.

Adult↗