Đang tải... (xem toàn văn)
(BQ) Part 1 book “Current occupational and environmental medicine” has contents: The practice of occupational medicine, international occupational and environmental health, migration and occupational health, the occupational & environmental medical history, electronic health records,…. And other contents.
Copyright © 2014 by McGraw-Hill Education All rights reserved Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a data base or retrieval system, without the prior written permission of the publisher ISBN: 978-0-07-180816-3 MHID: 0-07-180816-7 The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-180815-6, MHID: 0-07-180815-9 eBook conversion by codeMantra Version 1.0 All trademarks are trademarks of their respective owners Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark Where such designations appear in this book, they have been printed with initial caps McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and sales promotions or for use in corporate training programs To contact a representative, please visit the Contact Us page at www.mhprofessional.com Notice Medicine is an ever-changing science As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work Readers are encouraged to confirm the information contained herein with other sources For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration This recommendation is of particular importance in connection with new or infrequently used drugs TERMS OF USE This is a copyrighted work and McGraw-Hill Education and its licensors reserve all rights in and to the work Use of this work is subject to these terms Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill Education’s prior consent You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited Your right to use the work may be terminated if you fail to comply with these terms THE WORK IS PROVIDED “AS IS.” MCGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE McGraw-Hill Education and its licensors not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free Neither McGraw-Hill Education nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom McGraw-Hill Education has no responsibility for the content of any information accessed through the work Under no circumstances shall McGraw-Hill Education and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise Contents Authors Preface Section I Occupational Health The Practice of Occupational Medicine Joseph LaDou, MS, MD Robert J Harrison, MD, MPH International Occupational and Environmental Health Joseph LaDou, MS, MD Migration and Occupational Health Marc B Schenker, MD, MPH The Occupational & Environmental Medical History Robert J Harrison, MD, MPH Karen B Mulloy, DO, MSCH Electronic Health Records Sachin Kapoor, DO, MBA, MPH Workers’ Compensation Joseph LaDou, MS, MD James Craner, MD, MPH Disability Management & Prevention Jordan Rinker, MD, MPH Robert Eric Dinenberg, MD, MPH Mauro Zappaterra, MD, PhD Glenn Pransky, MD, MOH Section II Occupational Injuries Musculoskeletal Injuries Anthony C Luke, MD, MPH C Benjamin Ma, MD Shoulder, Elbow, & Hand Injuries David M Rempel, MD, MPH Mohana Amirtharajah, MD Alexis Descatha, MD, PhD 10 Back and Lower Extremity Injuries Anthony C Luke, MD, MPH C Benjamin Ma, MD 11 Management of Chronic Pain Diana Coffa, MD Wolf Mehling, MD 12 Eye Injuries Allan J Flach, PharmD, MD 13 Hearing Loss Robert Dobie, MD 14 Injuries Caused by Physical Hazards Peter D Lichty, MD, MOH 15 Ergonomics & the Prevention of Occupational Injuries David M Rempel, MD, MPH Ira L Janowitz, MPS, PT, CPE Section III Occupational Illnesses 16 Medical Toxicology Timur S Durrani, MD, MPH, MBA Kent R Olson, MD 17 Clinical Immunology Jeffrey L Kishiyama, MD 18 Occupational Hematology Michael L Fischman, MD, MPH Hope S Rugo, MD 19 Occupational Cancer Michael L Fischman, MD, MPH Hope S Rugo, MD 20 Occupational Infections Timur S Durrani, MD, MPH, MBA Robert J Harrison, MD, MPH 21 Occupational Skin Disorders Kazeem B Salako, MBBS, MRCP Mahbub M.U Chowdhury, MBChB, FRCP 22 Upper Respiratory Tract Disorders Dennis J Shusterman, MD, MPH 23 Occupational Lung Diseases John R Balmes, MD 24 Cardiovascular Toxicology Timur S Durrani, MD, MPH, MBA Neal L Benowitz, MD 25 Liver Toxicology Robert J Harrison, MD, MPH 26 Renal Toxicology German T Hernandez, MD Rudolph A Rodriguez, MD 27 Neurotoxicology Yuen T So, MD, PhD 28 Female Reproductive Toxicology Sarah Janssen, MD, PhD, MPH 29 Male Reproductive Toxicology Sarah Janssen, MD, PhD, MPH Section IV Occupational and Environmental Exposures 30 Metals Richard Lewis, MD, MPH Michael J Kosnett, MD, MPH 31 Chemicals Robert J Harrison, MD, MPH 32 Solvents Robert J Harrison, MD, MPH Rachel Roisman, MD, MPH 33 Gases & Other Airborne Toxicants Ware G Kuschner, MD Paul D Blanc, MD, MSPH 34 Pesticides Michael A O’Malley, MD, MPH Section V Program Management 35 Occupational Mental Health & Workplace Violence Marisa Huston, MA, MFT Robert C Larsen, MD, MPH 36 Substance Use Disorders Marisa Huston, MA, MFT Stephen Heidel, MD, MBA 37 CBRNE Preparedness Marek T Greer, MD, MPH Richard Lewis, MD, MPH 38 Occupational Safety Peter B Rice, CSP, CIH, REHS 39 Industrial (Occupational) Hygiene Peter B Rice, CIH, CSP, REHS The majority of toxic agents in Table 29–4 have been examined in occupational settings where exposures tend to be of higher concentrations than those encountered in the environment and relatively easier to document In the literature, most occupational events involving high-level exposures and documented adverse reproductive effects have occurred in male workers (eg, dibromochloropropane and exogenous estrogens) In addition, known reproductive hazards have been encountered environmentally from long-term use and disposal by industry, as well as from acute releases Declining Semen Quality and Environmental Factors Several studies have noted a historical decrease in sperm count, with one report providing data as far back as 50 years Over time, the method for evaluating sperm count (unlike the other semen-quality parameters) has not changed and is thought to be less susceptible to chronologic changes in laboratory technique However, most of these retrospective trend analyses have been conducted at fertility centers that include semen donors, vasectomy candidates, or infertility clinic patients and thus may not be representative of the general male population Furthermore, geographic differences and lack of information for known risk factors usually are associated with these older studies Despite these limitations, various studies demonstrate decreased sperm concentrations in many European countries and in various US regions The International Study of Semen Quality in Partners of Pregnant Women found significant differences in mean sperm count between men in Copenhagen, Paris, Edinburgh, and Turku, Finland In the United States, a four-city prenatal clinic study (Los Angeles, Minneapolis, Columbia, Missouri, and New York City) is being conducted that uses identical clinical evaluation, data collection, and semen analysis techniques as the European study Preliminary findings from the US study show a significantly lower sperm count among fertile men in Columbia, Missouri, in comparison with those in the other three cities It is interesting to note that Columbia is in a more agricultural area than the other cities Possible explanations given for the lower sperm count include estrogen exposure in utero, diet, lifestyle factors, and environmental pollution as a result of the increased worldwide use of chemicals (especially compounds with estrogen-like activity; see Chapter 43) Further follow-up of these multicenter studies will help to better explain this difference Dibromochloropropane DBCP (1,2-dibromo-3-chloroporpane) is noteworthy for its role in the first documented outbreak of a male reproductive hazard in the workplace DBCP is a nematocide that is associated with reproductive and developmental abnormalities in animals These animal effects include oligospermia, asthenospermia, and testicular and seminiferous tubule atrophy Workers exposed to DBCP in chemical production facilities have shown exposuredependent testicular toxicity The following associations have been noted in DBCP-exposed workers: azoospermia, oligospermia, increased plasma FSH levels, and histologic abnormalities of the testicular tissue (decrease or absence of germ cells in seminiferous tubules) Decreased fertility was experienced among workers with testicular changes, and the most extreme FSH elevations were found in workers who did not recover after a period of no exposure Thus this compound represents one of the few well-established male reproductive toxicants and provided the stimulus for subsequent increased activity in male-mediated reproductive research in the work setting Lead Lead is one of the most studied occupational and environmental agents and has a broad range of effects on multiple organ systems Male reproductive effects have been found with both organic and inorganic lead exposures Organic lead compounds, unlike the inorganic form, can be absorbed dermally Sexual dysfunction (eg, decreased libido, abnormal erectile function, and premature ejaculation) has been noted in case reports after ingestion of fuels containing organic lead A case series of tetraethyl lead– intoxicated men revealed reversible semen abnormalities: oligospermia, azoospermia, asthenospermia, and teratospermia Inorganic lead case reports have noted decreased libido (including erectile problems) and abnormal ejaculations Endocrine changes (decreased testosterone and increased LH levels) have been observed in clinic-based case series In men not exposed to high levels of lead, detectable lead concentrations in sperm have been reported that are less than those found in whole blood but greater than those of serum Epidemiologic studies have used semen analyses to better quantify male reproductive outcomes A cross-sectional survey of 150 male lead battery workers was conducted in Romania Blood lead levels ranged from 23 to 75 μg/dL, with a mean lead exposure duration of 3.5 years Oligospermia, asthenospermia, and teratospermia were noted in a dose-response fashion There were certain methodologic problems with this study: (1) Both masturbation and coitus interruptus were allowed in semen collection The latter method is not normally accepted because of the potential of semen mixing with the body fluids of the partner (2) No environmental exposure data were presented (3) The dose-response curve was constructed allowing multiple results from the same subject (4) The controls included 50 plant technicians and office workers who were not assessed for comparability This study provided the basis for the consideration of reproductive effects in establishing the Occupational Safety and Health Administration (OSHA) lead standard Lead exposure was evaluated among 18 battery workers and 18 cement workers in Italy There was a statistically significant decrease in median sperm count and an increase in the prevalence of oligospermia among the battery workers Participation rates were low, with 47% for the exposed and 22% for the comparison group The exposed group had a mean blood lead level (BLL) of 61 μg/dL and a mean zinc protoporphyrin (ZPP) level of 208 μg/dL In contrast, the nonexposed group had a mean BLL of 18 μg/dL and a mean ZPP of 24 μg/dL Oligospermia was noted at a BLL as low as 40 μg/dL In summary, semen abnormalities (ie, oligospermia, asthenospermia, and teratospermia) have been detected in the blood lead range of 40–139 μg/dL Also, hormonal disturbances have been documented for men at BLLs as low as 44 μg/dL (testosterone) and 10 μg/dL (FSH and/or LH) Endocrine Disruptors The term endocrine disruptor is used to refer to a variety of manufactured chemicals that may cause health abnormalities by interfering with the normal hormonal balance of humans or animals The most commonly studied chemicals that may fit this category are polychlorinated biphenyls (PCBs), dioxins, and persistent pesticides The four main disease categories attracting the most attention in endocrine disruptors research are reproductive, carcinogenic, neurologic, and immunologic health outcomes Because of the complexity of the male reproductive system, each of these diseases may have an impact on this system There appears to be an increased incidence for endocrine-mediated cancers such as breast, testicular, and prostate tumors Thus far no specific chemical has been identified as the cause for the increase in these tumors Current studies are concentrating on several suspect chemical groups that may act via an endocrine-mediated neurotoxicity: PCBs, dioxins, DDT, and other chlorinated pesticides and metals It should be noted that for the male reproductive system to function normally, an intact neurologic system is necessary Thus the results of these studies may have an impact on related reproductive research The suggestion of possible immunosuppression comes from the fact that certain endocrine disruptors (eg, DES, PCBs, and dioxins) alter the types of lymphocytes present in the bloodstream Laboratory animals and wildlife have demonstrated such changes in association with exposure to DES, PCBs, carbamate, organochlorine pesticides, and organic and heavy metals As was noted earlier, infection and associated immunologic disturbances are considered a risk factor for male infertility There are well-documented reports of human reproductive effects (semen abnormalities) from exposure to endocrine disruptors For example, kepone exposure at a US pesticide factory led to workers with oligospermia DES use during pregnancy can increase the incidence of non-malignant genital abnormalities in both male and female offspring Also, wildlife and experimental animals with offspring showing feminization, demasculinization, and abnormalities in sexual behavior and development demonstrate endocrine-disrupting chemicals in their environment Further studies are being conducted to better understand this situation Phthalates represent a newer type of chemical being considered as an endocrine disruptor The CDC National Report on Human Exposure to Environmental Chemicals has shown that urinary phthalate metabolites are detectable in the general population at all ages and in different regions of the country Phthalates are used in the production of hundreds of items, such as food packaging, plastic clothing, personal care products, detergents, adhesives, and vinyl flooring More recent research looked at boys aged 2–36 months old and found that concentrations of four phthalate metabolites (prenatal urinary monoethyl, mono-n-butyl, monbenzyl, and monoisobutyl phthalates) were inversely related to anogenital distance Also, the median concentrations for each of the metabolites associated with short anogenital distance and incomplete testicular descent are below the corresponding median levels seen among women in the National Exposure Survey Animal studies support this potentially hazardous human health effect These preliminary results may suggest that current widespread exposure to phthalates may cause human male reproductive damage at levels found in the general population Another endocrine disruptor with possible male reproductive effects is 2,2′4,4′5,5′-hexachlorobiphenyl (CB-153) This chemical is a persistent organochloride pollutant and has been associated with decreased sperm motility among fishermen having a diet high in fatty fish Although the association in this study was not statistically significant, there is much interest in evaluating any possible reproductive effect from this persistent environmental contaminant, as well as other categories of endocrine disruptors REPRODUCTIVE ASSESSMENT The medical evaluation of the patient with a potential exposure to a reproductive hazard follows the traditional components of history taking, physical examination, and laboratory assessment with an emphasis on both health and exposure parameters In addition, special consideration is needed in the assessment, communication, and management of reproductive risk for the patient, as well as possible environmental evaluation and sampling at the worksite or other location of potential exposure Medical Evaluation In the clinical setting, infertility is defined as an inability to conceive after 12 months of unprotected intercourse It is estimated that the cause of infertility is related to male factors in 40% of the affected couples, female factors in 40–50% of the affected couples, and no known etiology in 10–20% of the affected couples For the infertility and adverse pregnancy outcome workup, the female partner needs to be assessed concurrently (see Chapter 28) A full discussion of the diagnosis and treatment of various urologic and other related medical conditions is beyond the scope of this chapter However, the following is a general overview of the types of evaluation techniques that can be used to assess the male reproductive system Medical History The patient interview should cover the following areas: demographic data (eg, both maternal and paternal age if birth outcome is being assessed), general medical history (eg, febrile illnesses, trauma, infections and structural abnormalities of the genitourinary system, and past surgeries), drug use (including medications, street drugs, alcohol, and tobacco), habits (eg, sauna and hot tub use), work history, and reproductive history (eg, past problems of infertility and pregnancies and birth outcomes for each sexual partner) It is important to ask about potential occupational and environmental exposure to any of the known or suspected reproductive hazards cited in Table 29–4 More complete details for an environmental and occupational history can be found in Chapter Physical Examination This examination should focus on the physical integrity of the genital system to rule out any extraneous mass or abnormality and the presence of secondary sex traits (eg, hair growth pattern and possible gynecomastia) A physical abnormality may impede spermatogenesis, ejaculation, and erection (eg, varicocele, hydrocele, hypospadias, and cryptorchism) It is important to evaluate testicular size, prostate tenderness, and the presence of any structural anomalies Testicular size averages 4.6 cm in length (range 3.5–5.5 cm) and 12–25 mL in volume, with the seminiferous tubules accounting for 95% of the testicular volume Hypovirilization and infertility can indicate Klinefelter syndrome (47,XYY, often associated with small testes and occurring in 0.2% of adult men) or viral orchitis Hormonal Profile A number of hormonal tests are available, and selection needs to be based on the medical conditions under consideration A preliminary hormonal profile that can be obtained for field surveys includes FSH, LH (pituitary function), and testosterone (testicular function) For field biologic monitoring surveys, blood samples are relatively easy to collect for hormonal assays, but care must be taken to obtain samples at standardized times to avoid diurnal variability problems The FSH is increased in individuals with azoospermia, such as the DBCP episode With a normal testosterone level and an increased FSH level, a decrease in spermatogenesis occurs, which is usually associated with severe germinal epithelium damage If there is a sperm abnormality with normal LH and testosterone, then an obstruction to the reproductive system can be ruled out If both LH and testosterone are low, then a hypothalamic or pituitary abnormality is likely In the situation where low testosterone and high LH concentrations are seen, there is the possibility of a primary defect at the testicular level When there is a high level of testosterone and a low level of LH, an autonomous or exogenous source of testosterone needs to be considered Finally, having both LH and testosterone elevated would suggest an autonomous LH secretion or resistance to testosterone action One additional hormone being studied for utility in screening situations is inhibin B, which is reduced when damage to the seminiferous tubules occurs Semen Analysis Analysis of semen parameters can be conducted by both traditional and computer-aided semen analysis (CASA) methods The basic parameters of interest are ejaculate volume, sperm count or concentration, motility, morphology, swim velocity (direct measurement obtainable via CASA), and the presence of any suspect toxicant The subsequent normal ranges discussed are to be used as general guidelines for the interpretation of a semen profile There is much variability in the quality of semen analysis by laboratory, and the CASA may not be available at all reproductive/infertility laboratories Because the normal ranges for semen characteristics may vary by laboratory, it is important to review the ranges provided by the laboratory being used The sperm concentration refers to the number of sperm per milliliter of ejaculate, with a normal level of more than 20 million per milliliter Normal ejaculate volumes are 1.5–5.5 mL Sperm motility is the percentage of motile sperm, with a normal sample showing greater than 40% motile sperm Morphology refers to the percentage of normal (oval) and abnormal sperm head, midpiece, and tail shapes The 10 general categories of sperm morphology are oval/normal, microcephalic, macrocephalic, tapered head, double head, headless, no head or tail, amorphous head, immature forms, and abnormal tails Normal morphology is greater than 50% normally shaped sperm if using the World Health Organization (WHO) classification system and greater than 14 if using the stricter Kruger classification When semen analyses are used for epidemiologic or screening purposes, certain aspects need to be addressed There is a need to conduct concurrent motility and count measures because most cells are nonmotile or poorly motile Thus sperm count alone is not recommended For count and motility, it is important to note the time since last ejaculation (48–72 hours maximum for accurate reading) Also, all semen analyses should be conducted at the same laboratory because of the high interlaboratory variability Optimally, a semen sample should be analyzed within hour of production so that the sperm remain viable for analysis A standardized semen collection procedure needs to be established and followed by the individual being evaluated Masturbation is recommended (preferably with no sexual partner, condom, or lubricant use), with the collection of semen in specially provided containers It is extremely important that the entire volume of ejaculate be collected and that the specimen not be subjected to extreme temperatures in transport to the analysis site Multiple samples from the same individual can show much variability; therefore, serial measurements are preferred Most infertility evaluations involve three subsequent samples on separate days Finally, there are three potential barriers to cooperation from individuals being recruited for participation in a study: (1) Highly motivated subjects are needed for the study, yet the individual is usually asymptomatic and may not understand the usefulness of an evaluation (2) Religious and cultural taboos may be encountered (3) There may be a lack of available sperm because of a preexisting medical condition such as vasectomy Other Tests Other male reproductive tests are available for further clinical evaluation but are not usually included in epidemiologic field studies These tests include GnRH challenge, thyroid profile, testicular biopsy, postcoital test, and spermoocyte interaction Some more recent evaluation methods involve sperm DNA, chromosome and maturity bioassays, and biologic markers for fertilization function (eg, sperm antigen) In azoospermia or severe oligospermia, a testicular biopsy can assess the seminiferous tubules and Leydig cell histology for fibrosis and lack of spermatogenesis The postcoital test involves the interaction of sperm examined in mucus following intercourse If the index sperm penetrates a donor mucus but not the sexual partner’s mucus, the mucus of the sexual partner may be a problem The patient’s sperm is considered abnormal if no penetration of either mucus occurs The sperm-oocyte interaction test uses the zona pellucida of a hamster oocyte to evaluate if the patient’s sperm is able to fuse (the capacitation and acrosomal reaction needed for eventual conception) Antisperm antibodies on the sperm surface are a form of immunologic infertility and sometimes are a result of prior surgical reversal of a vasectomy Furthermore, a wide range of medical tests and assays may be indicated for the underlying medical conditions thought to be present Lastly, the assessment of body burden for certain exposures may be estimated via exhaled breath, blood, urine, semen, and other biologic tissue measurements To allow comparison among different studies, the WHO has published two manuals on a standardized approach to evaluating infertile men One manual deals with the investigational process, diagnosis, and management of infertile males Included are a patient data-collection form and a diagnostic decision flow diagram to facilitate the analysis of data between different clinicians The laboratory manual describes procedures for examining human semen and provides lower limits for the normal range of various tests These lower limits include 2.0 mL for semen volume, 20 million sperm per milliliter for concentration, and 40 million for number of sperm per ejaculate, 50% with progressive motility and 30% with normal morphology Occupational & Environmental Health Consultation The health risk assessment process may prove to be difficult because of inadequate exposure or a lack of toxicologic or medical information It is very helpful to have established professional contacts with expertise in occupational or environmental health consultation when a more difficult risk assessment is involved Potential contacts may include local or state health departments, university medical centers or schools of public health, poison control centers, National Centers for Disease Control and Prevention (CDC, including the National Institute for Occupational Safety and Health and the National Center for Environmental Health), U.S Environmental Protection Agency, Agency for Toxic Substances and Disease Registries, Occupational Safety and Health Administration, and the Association of Occupational and Environmental Clinics Access to online literature databases also can be very useful such as REPROTOX and TERIS Communication Regarding Reproductive Hazards There is an underlying principle that needs to be acknowledged and sensitively dealt with: The threat or actual fact of reproductive dysfunction or adverse reproductive outcome has a profound impact on an individual’s life and his or her family All questions must be answered truthfully and completely A description of the limitations in knowledge may be needed The timing of exposure for the male and of the first contact with the involved female partner is very important Whenever possible, the risk communication is conducted prior to actual exposure in order to intervene at the primary prevention stage The options available for the male worker should be presented in such a way that the medical impact and the economic consequences of decisions are understood and discussed The medical confidentiality of the involved individual should be maintained at all costs If an occupational situation, it is imperative that the employer, involved employee(s), and medical consultant work together in resolving a particular exposure, as well as in developing a general policy on reproductive hazards in the workplace that involves both genders Ideally, this policy should be developed within a health and safety committee composed of representatives from management and labor and consultants in occupational medicine and industrial hygiene Recommendations for Controlling Exposure In the evaluation of the patient, a clinician can play an important consultative role in the control or elimination of exposure in the home, workplace, or other site of high risk Working with the key health personnel or public health officials involved in this process, the following actions may be considered for a given reproductive hazard situation Exposure Reduction or Elimination Replace hazards with safer ones: improved engineering controls, safer work practices, and personal protective equipment Exposure reduction or elimination is the most desirable option and should be attempted in all situations where a reproductive hazard exists Temporary Job Transfer or Removal From Area of Exposure Remove the individual from work environment, residence, or other site where the reproductive hazard exists This option is rarely considered for men considering having children In occupational settings, problems may occur when there is no nonexposed job location This option should be considered when there is a high-risk situation, and exposure reduction/elimination is not possible Disability Leave if Occupational Exposure This option usually is considered by the personal physician for the pregnant woman facing reproductive hazards and to our knowledge has not been used for men Permanent Removal of Individual From Work or Exposure Setting This is the least desirable action in the occupational setting and has been used in the past for female workers For female workers, it is illegal for an employer to terminate an affected woman because of pregnancy An individual may choose to quit work for personal reasons, but it is important to help the individual to evaluate all the other options and to understand the possible consequences In the residential setting, there have been permanent relocation of populations owing to environmental contamination, but this is a rare occurrence The permanent removal of an individual from a residence, work setting, or other exposure site is considered after all the other options have been explored and the individual is comfortable with the possible consequences LEGAL ISSUES & WORKPLACE STANDARDS In the lawsuit International Union, UAW versus Johnson Controls, Inc., the U.S Supreme Court held that an employer violated Title VII’s ban on sex discrimination by excluding from production jobs in a lead-battery factory all women who could not prove their sterility The Court indicated that a policy directed only at fertile women is overt discrimination on the basis of sex regardless of the scientific evidence of heightened safety concerns for mothers or potential mothers In addition, any policies or actions taken by the employer must not violate existing laws prohibiting discrimination on the basis of pregnancy, childbirth, or related medical conditions Employers cannot require that an individual be sterilized as a condition of employment If an employee disabled by pregnancy, childbirth, or a related medical condition transfers to a less hazardous job, an employer must allow the employee to return to the employee’s original job or a similar one when the disability has resolved Thus the workplace must be made safe, and reproductive hazard information must be provided to both men and women OSHA has the mandate to promulgate standards that protect workers from adverse health effects (including reproductive effects) resulting from workplace hazards However, there are only four agents with OSHA standards that are based partially on reproductive effects: dibromochloropropane (DBCP), lead, ethylene oxide, and ionizing radiation It should be recognized that many chemical and physical agents found in the workplace are not covered by an OSHA standard and that those standards that exist for the most part are not based on reproductive endpoints This is why the risk assessment process discussed earlier should be implemented at any worksite that has potential reproductive hazards present REFERENCES Halling J: Semen quality and reproductive hormones in Faroese men: a cross-sectional population-based study of 481 men BMJ Open 2013;3 [PMID: 23457323] Hosni H: Semen quality and reproductive endocrinal function related to blood lead levels in infertile painters Andrologia 2013;45:120 [PMID: 22680063] Iwamoto T: Semen quality of fertile Japanese men: a cross-sectional population-based study of 792 men BMJ Open 2013 Jan 25;3 [PMID: 23355656] Jϕrgensen N: Human semen quality in the new millennium: a prospective cross-sectional population-based study of 4867 men BMJ Open 2012 Jul 2;2(4) [PMID: 22761286] Mocarelli P: Perinatal exposure to low doses of dioxin can permanently impair human semen quality Environ Health Perspect 2011;119:713 [PMID: 21262597] Mocevic E: Environmental mercury exposure, semen quality and reproductive hormones in Greenlandic Inuit and European men: a crosssectional study Asian J Androl 2013;15:97 [PMID: 23223027] NIOSH: Topics on reproductive health http://www.cdc.gov/niosh/topics/repro Ravnborg TL: Prenatal and adult exposures to smoking are associated with adverse effects on reproductive hormones, semen quality, final height and body mass index Hum Reprod 2011;26:1000 [PMID: 21335416] Vwarws :Associations of in utero exposure to perfluorinated alkyl acids with human semen quality and reproductive hormones in adult men Environ Health Perspect 2013;121:453 [PMID: 23360585] SELF-ASSESSMENT QUESTIONS Select the one correct answer to each question Question 1: Semen abnormalities can include a azoospermia (low sperm count) b oligospermia (increased sperm count) c teratospermia (abnormally motile sperm) d asthenospermia (sperm showing decreased motility) Question 2: Male reproductive toxicants a include DBCP, ionizing radiation, mercury, and lead b are of concern only in occupational settings c mostly involve low-level exposures d include DBCP and exogenous estrogens Question 3: DBCP a is a nematocide that is associated with reproductive and developmental abnormalities b exposed workers exhibit azoospermia, oligospermia, and decreased plasma FSH levels c causes decreased sperm fertility among all exposed workers d exposure may result into a permanent azoospermia in some workers Question 4: Inorganic lead a is the only form of lead with male reproductive effects b has been implicated in cases of increased libido c presents in some males as endocrine changes (decreased testosterone and increased LH levels) d is frequently detected in the sperm of workers with low-level exposure Question 5: Phthalates a should not be considered as an endocrine disruptors b metabolites are detectable in the general population at all ages c are associated with short anogenital distance together with incomplete testicular descent d may cause human male reproductive damage at levels found in the general population ... 978-0-07 -18 0 816 -3 MHID: 0-07 -18 0 816 -7 The material in this eBook also appears in the print version of this title: ISBN: 978-0-07 -18 0 815 -6, MHID: 0-07 -18 0 815 -9 eBook conversion by codeMantra Version 1. 0... activities and skills of a national sample J Occup Environ Med 2 010 ;52 :11 47 [PMID: 211 24250] Harber P: Value of occupational medicine board certification J Occup Environ Med 2 013 ;55:532 [PMID: 23 618 887]... with ABPM certification after 19 98 For details on certification, contact American Board of Preventive Medicine 11 1 West Jackson Boulevard, Suite 11 10 Chicago IL 60604 ( 312 ) 939-2276 abpm@theabpm.org