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INTERNET DATABASE
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An Internet Database for the Classification and Dissemination of Information
about Hazardous Chemicals and Occupational Diseases
J. A. Brown, MD, MPH
Consultant, Specialized Information Services, National Library of Medicine
Consultant, Energy Employees Occupational Illness Compensation Program,
U.S. Department of Labor
Correspondence to J. A. Brown, 5426 Orca Place NE, Tacoma, WA.
E-mail: [email protected]
ABSTRACT
Background
The amount of information about hazardous agents in the workplace exceeds
the capacity of human memory. There is a need to accurately represent or map
this scientific knowledge for digital storage and retrieval.
Methods
A relational database of hazardous chemicals and occupational diseases was
constructed by first collecting and sifting through the large volume of
information. The information was indexed with a controlled vocabulary and
documented with references to the scientific literature.
Results
The evolving database is available on the website of the National Library of
Medicine. It enables users to browse categories and query by pick lists. Users
can drill down to find specific information that may be useful for intervention
and prevention.
Conclusions
The large amount of information needed to support decisions concerning
occupational exposures and diseases can be distilled, classified, and
summarized in a relational database and disseminated by means of the World
Wide Web to assist in the prevention of work-related diseases.
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INTRODUCTION
Knowledge mapping that links occupational exposures to acute and
chronic diseases can be useful for public health. Knowledge mapping
begins with the big picture, and all of the information is kept in
perspective. The need for knowledge mapping is great because there is so
much information about occupational exposures and diseases; it is easy
to get lost in the details. Thousands of new pages are published daily in
journal articles, book chapters, and Internet websites. The problem today
is how to extract the specific information needed and how to make it
accessible to people who can intervene and prevent disease. [Berner and
Moss, 2005]
One of the first attempts to map the knowledge domain of occupational
hazards for the purpose of disease prevention was made by Rutstein et
al. in 1983 and later updated by Mullan and Murthy in 1991. The authors
introduced the concept of occupational sentinel health events or SHE(O)s.
The 1991 update included 64 occupational diseases linked to causal
agents and associated industries, processes or occupations. "This list may
serve as a framework for occupational health surveillance at the state and
local level. It may also be used as a guide for practicing physicians caring
for patients when there is a question of occupational illness." [Mullan and
Murthy, 1991]
The effectiveness of public health interventions is dependent upon the
collection, analysis, and dissemination of information. [Macgruder et al.,
2005] Modern computer systems can help to make public health decisions
more timely and information-driven. [Friede et al., 1995] The computer's
strength in data storage and computational speed complement the human
strength of general knowledge, creativity, and perspective on the
usefulness of the information. To be useful, the large amount of
information available must be organized into a format that is easy to
query and understand. Otherwise, the quantity of information can be
overwhelming and lead to decisions that are wrong or suboptimal. This
organizing process involves extracting the critical information from the
huge volume of available data. [Parsaye and Chignell, 1993] The
preliminary work done in sifting through the information and classifying it
for digital processing enables users "to focus on the key problems while
ignoring a vast sea of irrelevancy." [O'Carroll et al., 2003]
The author of the current paper has developed a decision-support
relational database called "Haz-Map" to map the knowledge domain of
occupational exposures and diseases. One definition of information is
"data placed in context." [O'Carroll et al., 2003] The goal of the Haz-Map
project is to place each piece of information in the context of the whole
database in the same way that each organ is understood in the context of
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the whole body. Expressed in another way, "Exposure assessment and
health evaluation need to be seen as two pieces of a whole; information
about exposure is required to fully evaluate the health endpoints, and
information about health effects is required to design an appropriate
exposure assessment study." [Seixas, 1996]
The original idea for Haz-Map was, "Why can't we have a relational
database of toxic chemicals and occupational diseases to store and query
information similar to ones used by companies to manage data about
employees, products, and customers? Instead of querying for all
employees with the first name "David" AND living in the city of "Fresno,"
the query will be for all chemicals tagged as potential causes of "Toxic
pneumonitis" AND linked to the Industrial Process "Welding."
MATERIALS AND METHODS
The first step in the project was to collect and distill the facts
needed to prevent occupational diseases. Distilling refers to the process
of sifting through the information for inclusion or exclusion. Only the most
useful information is included. [Parsaye and Chignell, 1993] Next, the
information was classified using a controlled vocabulary of names for
agents, adverse effects, industrial processes, non-occupational activities,
diseases, signs & symptoms, hazardous job tasks, jobs, and industries.
The ability to formulate questions with controlled search terms is one of
the building blocks of evidence-based practice. [Saranto and Tallberg,
2003; Bakken, 2001] Finally, information about each object was
summarized. Summaries document the source of information with
references to the scientific literature.
Using the Microsoft® Access relational database, all of the
information was placed into the fields of eight tables. The information
included chemical, biological, and radiation hazards. Excluded from the
database were hazards caused by noise, cold, heat, repetitive motion,
and other physical hazards. Field values available in Microsoft Access
include text, memo, number, yes/no, and hyperlink.
The first content added was information on about 700 chemicals
from the NIOSH Pocket Guide to Chemical Hazards [National Institute for
Occupational Safety and Health (NIOSH), 1997]. Using the yes/no fields
in the Agents table, each chemical was flagged for the presence or
absence of adverse effects as shown in Table 1. Next, using selected
references from the scientific literature, the author added to the database
any other chemical or biological agents linked to occupational asthma,
toxic pneumonitis, chronic bronchitis, lung cancer, neuropathy,
Parkinson's syndrome, methemoglobinemia, aplastic anemia, hemolytic
anemia, contact dermatitis, chloracne, liver injury, kidney injury, and
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simple or chemical asphyxiation. All agents causing interstitial fibrosis
(pneumoconioses and hypersensitivity pneumonitis) were tagged with
"fibrosis." All agents caustic to the skin or listed in the Chemical Hazards
Response Information System (CHRIS) database [United States Coast
Guard, 2001] as causing burns (first, second, or third degree) were
tagged with "skin burns." All chemicals in the category "Solvents" were
tagged with "CNS Solvent Syndrome." Also tagged on the basis of
categories were "Organophosphate," 'Organochlorine," and "Carbamate"
pesticides. An "Uncoupler" is a chemical like pentachlorophenol that can
cause a hypermetabolic state by poisoning cellular respiration (uncoupling
oxidative phosphorylation).
Table 1. Controlled Vocabulary for Adverse Effects.
Category
Lung Toxin
Neurotoxin
Hematotoxin
Dermatotoxin
Carcinogen
Other Tissue
Toxin
Other Poison
*Adverse Effect
Asthma, Pneumonitis, Chronic Bronchitis, Fibrosis,
and Cancer
Neuropathy, Parkinson's Syndrome, and CNS
Solvent Syndrome
Methemoglobinemia, Aplastic Anemia, and
Hemolytic Anemia
Contact Dermatitis, Chloracne, and Skin Burns
Known, Probable, or Possible
Hepatotoxin, Nephrotoxin, and Reproductive Toxin
Organophosphate, Carbamate, Organochlorine,
Uncoupler, Chemical Asphyxiant, and Simple
Asphyxiant
*When looking at a chemical profile, the Adverse Effects for that chemical
are displayed. The Adverse Effects are also used to query the database.
Following the lead of the American Governmental Conference of
Industrial Hygienists (ACGIH) [2005], chemicals that can cause
methemoglobinemia were divided into primary and secondary. Similarly,
chemicals that can cause hepatic injury were divided into primary and
secondary. A primary agent is one that has been reported to cause
methemoglobinemia or hepatitis in the work environment. A nephrotoxin
is defined as a chemical that is potentially toxic to the kidneys in the
occupational setting.
In addition to adverse effects, the Agents table also has fields to
show pertinent information about properties, thresholds, and exposure
limits. A premium is placed on information that helps the user to
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distinguish between significant and harmless exposures. The information
should help to answer the question, "Given that the worker received a
dose, what is the probability of harm?"
The relationships of the tables in the database are shown in Figure
1. When available, standard classification systems were used: Standard
Occupational Classification (SOC) system for jobs [2000], the North
American Industry Classification System (NAICS) for industries [2002],
and the International Classification of Diseases (ICD-9) for diseases
[2006].
The two levels of information in Haz-Map are chemicals (the
industrial hygiene perspective) and diseases (the epidemiological
perspective). Each industrial process is linked to all agents associated
with that process. Each hazardous job task is linked to all diseases
associated with that job task. Each hazardous job task is also linked with
all jobs and industries associated with that job task.
Signs &
Symptoms
Industries
Occupational
Diseases
Hazardous
Job Tasks
Occupations
Industrial
Processes
*Toxic
Chemicals
Home
Activities
*This is also referred to as the Agents table. Most records are toxic chemicals,
but there are also biological agents in this table, e.g., natural latex rubber.
Figure 1. Two Levels of Information in Haz-Map: Diseases and Agents.
Notice that a bi-directional arrow indicates a many-to-many relationship
between two tables. This enables users to find all chemicals linked to each
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disease and all diseases linked to each chemical. Similarly, they can see all
findings (signs & symptoms) of a disease or all diseases with the finding.
Agents in the database were linked to industrial processes and nonoccupational activities. Linkage indicates the potential for exposure to the
agent. As mentioned earlier, each agent in the database was flagged for
adverse effects including asthma, pneumonitis, neuropathy, anemia,
hepatotoxicity, and skin sensitization. At the chemical level, the concern is the
potential toxic effects of the agents.
At the disease level, the concern is work-related diseases based on case
reports or epidemiologic studies. Occupational diseases in the database were
linked to findings (signs and symptoms of the disease) and hazardous job tasks.
Hazardous job tasks increase workers risk for significant exposure and
subsequent disease. Linkage between job tasks and jobs or industries indicates
an increased likelihood for workers in those jobs or industries to engage in the
hazardous job tasks. In this database, chronic occupational diseases are linked
to both jobs and industries, while acute diseases and infectious diseases are
linked only to jobs. Cancers were not linked to jobs, industries, or findings.
(Studies linking cancer with jobs and industries are historical. It is difficult to
apply these links to current jobs and industries. There is such a wide range of
findings depending on the stage of the cancer. Also, occupational cancers have
such a long latency that diagnosis of a case is not likely to affect prevention.)
Diseases are also linked to agents (chemical or biological). Linkage
between an agent and a disease indicates that sufficient exposure to the agent
is associated with an increased risk of developing the disease. For chronic
diseases, linkage between an agent and a disease means that a causal
relationship has been determined based on human case reports or
epidemiological studies. Carcinogens are linked only if they have been
designated as known human carcinogens by the International Agency for
Research on Cancer (IARC) [2007]. In some cases, IARC does not list the target
organs, but Haz-Map follows the interpretation published in Schottenfeld and
Fraumeni's Cancer Epidemiology and Prevention. [Siemiatycki, 2006]. Acute
diseases, for the most part, are also linked to chemicals based on reports of
cases in humans.
There are three exceptions to the rule that an agent-disease link indicates
human evidence as the basis for the link. The first exception is the disease
"Solvents, acute toxic effect." This disease is linked to all agents in the Major
Category, "Solvents" in the Haz-Map database. Not all organic solvents have
been reported to cause this disease, but it is assumed that all agents in the
Solvents category have the potential to cross the blood-brain barrier and cause
the solvent syndrome. The third exception is the disease "Encephalopathy,
acute toxic." This disease is linked to all chemicals flagged as "Other CNS
Neurotoxin." Similarly, the fourth exception is the disease "Pneumonitis, toxic,"
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which is linked to all chemicals flagged as causing this adverse effect. (Toxic
pneumonitis is both a disease and an adverse effect.) Toxic pneumonitis is
defined as noncardiogenic pulmonary edema induced by acute exposure to
metal fumes or toxic gases and vapors after a spill or confined space accident.
The "major irritant inhalants" are ammonia, bromine, chlorine, chlorine dioxide,
diborane, ethylene oxide, formaldehyde, hydrogen chloride, hydrogen fluoride,
methyl isocyanate, nitrogen dioxide, ozone, phosgene, and sulfur dioxide.
[LaDou, 2007] While human cases have been documented for the major irritant
inhalants, there are many chemicals with similar corrosive effects on tissues
that have the potential to cause toxic pneumonitis if inhaled. For most of these
chemicals, toxic pneumonitis has never been reported in humans. The agentdisease link is not established from human cases but is deduced from animal or
other evidence.
Information from textbooks, journal articles, and electronic databases
was classified and summarized to create the database. A bibliography including
online resources is regularly updated at http://hazmap.nlm.nih.gov/hazref.html.
[National Library of Medicine (NLM), 2007a] This page also shows the reference
labels that are used throughout Haz-Map to reference source material, e.g.,
ATSDR Case Studies. [Agency for Toxic Substances and Disease Registry
(ATSDR), 2007] Several databases were used heavily in the early development
of Haz-Map including Hazardous Substances Data Bank (HSDB) [NLM, 2007b]
ACGIH Documentation of the TLVs and BEIs (ACGIH, 2007), ATSDR ToxProfiles
(ATSDR, 2006), Documentation for Immediately Dangerous to Life or Health
Concentrations (IDLH) [NIOSH, 1995], and NIOSHTIC [NIOSH, 2007]. The early
development of the content also relied on textbooks of occupational medicine.
[LaDou, 2007; Rom, 2007; Rosenstock, 2004; Sullivan and Krieger, 2001; Zenz
et al., 1994] The Mullan and Murthy paper [1991] was used for the initial list of
occupational diseases. Other major sources were Harber et al. [1996], Hendrick
et al. [2002], Stellman [1998], Marks and DeLeo [1997], Kanerva et al. [2000],
Kanerva et al. [2004] Lewis [2002], O'Neil et al. [2006], Mason et al. [2005],
Reigart and Roberts [1999], and Fosberg and Mansdorf [2003]. The list of Malo
and Chan-Yeung [2006] was used for the agents causing occupational asthma.
Frazier and Hage [1998] was the main source for reproductive hazards.
Industrial processes were based on Burgess [1995]. Infectious disease
reference books include Heymann [2004], Guerrant et al. [2006], Gorbach et al.
[2004], and Mandell et al. [2005]. Ionizing radiation as a cause of cancer is
based on Boice [2006], and other occupational cancer is based on Siemiatycki
[2006]. Other databases that have been used extensively in recent years
include ChemIDplus [NLM, 2007c], Occupational Health Guidelines for Chemical
Hazards [NIOSH, 1995], International Chemical Safety Cards [IPCS, 2007],
CAMEO [EPA, 2001], CHEMINFO [CCOHS, 2007], EXTOXNET [Extension
Toxicology Network, 1995], and the North American Emergency Response
Guidebook [U.S. Department of Transportation, 2004].
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RESULTS
The database currently contains 1534 chemical and biological agents, 212
diseases, 122 signs and symptoms, 276 jobs, 104 job tasks, 51 industrial
processes, 621 industries, and 26 non-occupational activities. Current statistics
show 239 chemicals associated with toxic pneumonitis, 387 agents with skin
sensitization, 258 agents with occupational asthma, and 129 agents with
reproductive toxicity.
For the 1534 chemical and biological agents, information includes uses,
adverse effects, associated industrial processes, and threshold values useful for
exposure assessment. For the 224 occupational diseases, information includes
associated symptoms, high-risk job tasks, jobs, and industries. The database
contains a total of 1109 hyperlinks to PubMed at the National Library of
Medicine and other scientific websites. Two hundred and fifty Medical Subject
Heading (MeSH) terms allow instant PubMed searches for articles related to the
disease or finding identified by the term.
In comparison to the original SHE(O) conditions compiled by Mullan and
Murthy, the twenty caused by infections were expanded into 105 occupational
infections with 18 of these in the category of "Travel Infections." Eight SHE(O)
diseases were not added to the database, Silotuberculosis, Tetanus, Talcosis,
Agranulocytopenia, Cerebellar Ataxia, Carpal Tunnel Syndrome, Mononeuritis,
and Noise-Induced Hearing Loss. Acute/chronic renal failure was not included as
a disease, but "nephrotoxin" is one of the adverse effects for agents. The 13
occupational cancers in the SHE(O) list were expanded to 19 cancers, Bladder
Cancer, Bone Cancer, *Brain Cancer, *Colorectal Cancer, *Esophagus Cancer,
Liver Cancer, *Kidney Cancer, Laryngeal Cancer, Leukemia, Lung Cancer,
Melanoma, Pleural Mesothelioma, Peritoneal Mesothelioma, Nasal Sinus Cancer,
*Nasopharynx Cancer, *Pancreatic Cancer, Skin Cancer, *Stomach Cancer, and
*Thyroid Cancer. The current list combines all leukemias, and cancer of the
scrotum is listed as a type of skin cancer. Additional cancers not included in the
SHE(O) list are underlined. The asterisk (*) means that no agents were causally
linked to the cancer in the Haz-Map database.
Additional diseases not in the SHE(O) list are, Chronic Obstructive
Pulmonary Disease (includes Chronic Bronchitis), Irritant-Induced Asthma,
Irritant-Induced Vocal Cord Dysfunction, Oil Acne, Chloracne, Contact Urticaria,
Benign Pneumoconioses, Other Pneumoconioses, Hard Metal Disease, Chronic
Sinusitis, Simple Asphyxiation, Chemical Asphyxiation, Inhalation Fever, and
poisoning by Manganese, Cadmium, Chromium, Mercury, Lead, Arsenic,
Fumigants, Pentachlorophenol, Hydrofluoric Acid, Organochlorines, and
Carbamates/Organophosphates. To the SHE(O) list of four specific forms of
Hypersensitivity Pneumonitis were added 24 more specific types.
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Job tasks are important components to consider when evaluating the
health risks of specific occupations. [Burkhart et al., 1993; McDonald et al.,
2004] In the Haz-Map database, hazardous job tasks link diseases with
occupations and industries. An example of a job task is "Work in microwave
popcorn plant that uses diacetyl for flavoring." This job task is linked to the
disease, "Bronchiolitis Obliterans." Clicking the hyperlink for this disease will
take the user to the NIOSH ALERT page entitled, "Preventing Lung Disease in
Workers Who Use or Make Flavorings." [NIOSH, 2004] This job task is linked to
the following SOC jobs: Food Batchmakers; Food Cooking Machine Operators
and Tenders; Laborers and Freight, Stock, and Material Movers, Hand; and
Mixing and Blending Machine Setters, Operators and Tenders. This job task is
also linked to the following NAICS industry: Other Snack Food Manufacturing.
The content of Haz-Map is continuously revised, updated, and expanded.
At this time, it is published only by the National Library of Medicine at
http://hazmap.nlm.nih.gov/. [2007d] The user-interface provides a text search
function as well as a way to search each table by names or synonyms. Pick lists
and drop-down lists are available, and the user can query the database for all
agents that match an adverse effect AND an industrial process. Also, the user
can query the database for all diseases that match a job AND a finding. Each
chemical record displays chemical properties and adverse effects. Chemical
properties include occupational exposure limits, vapor pressures, odor
thresholds, half-life, lethal concentrations, flammability, etc. Definitions of
chemical properties and adverse effects are available through hyperlinks to the
glossary. The Home page has links to a Help page, a Glossary, and References.
Statistics compiled on the server computer at the Specialized Information
Services Division of the National Library of Medicine show that the Haz-Map
website received 4,165 visitors and 19,988 hits in March 2003 and 64,140
visitors and 522,503 hits in March 2007. For March 2007, the total number of
hits (basically, the number of mouse clicks made to navigate the web site) on
the Haz-Map web were approximately 7% of the total hits for all of the TOXNET
databases that include ChemIDplus, HSDB, and 10 other databases.
During the past two years, the Agent-Disease links from Haz-Map have
been incorporated into the Department of Labor’s Site Exposure Matrices (SEM)
database, currently being used for the Energy Employees Occupational Illness
Compensation Program (EEOICP). "The mission of the Energy Employees
Occupational Illness Compensation Program is to deliver benefits to eligible
employees and former employees of the Department of Energy, its contractors
and subcontractors or to certain survivors of such individuals, as provided in the
Energy Employees Occupational Illness Compensation Program Act." [DOL,
2007a] The latest statistics show that 158,001 claims have been received.
Payments have been made for 37,774 claims, and the total compensation that
has been paid so far is $3,319,637,545. [DOL, 2007b]
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EEOICP is providing financial and technical support for the author to
continue developing the content of Haz-Map consistent with the way it has been
developed in the past. New agents and their health effects are being added to
the database based on chemicals that have been used at Department of Energy
sites where claimants worked. As pointed out by O'Carroll et al., "Decision
support systems can provide preliminary analysis that allows scarce human
resources to focus on the key problems while ignoring a vast sea of
irrelevancy." [2003]
DISCUSSION
Mapping geography is an ancient discipline that came to fruition
after the age of discovery in the 15th century. [Encyclopaedia Britannica
Online. 2007] Mapping knowledge domains is a relatively new art and
science that began with the age of information in the 19th century. [Fisher
et al. 2002] Similarities in both types of mapping are that: 1.) information
must first be collected, sifted, and classified; 2.) concentric design makes
it necessary to draw the big picture first and to add the details as more
information becomes available; 3.) the scale of the map limits the amount
of information that can be included. For example, not every dirt road and
trail is included in most road maps, but only the major thoroughfares.
From this, it should be clear that by design Haz-Map does not include
every disease that has ever been reported in the workplace. Its purpose
is to sift through the voluminous and scattered information as it currently
stands, to summarize the established occupational diseases, both current
and historical, and to show their associated causal agents. It is up to
future mapmakers to build a better map and to fill in the details as more
complete knowledge is gained.
A few words should be said about the intended audience of HazMap. Haz-Map was originally designed by a health and safety professional
for health and safety professionals. With the opportunity to publish the
database on the website of the National Library of Medicine came a new
audience—workers and the general public seeking the facts about workrelated health effects. In this age of information, it is clear that all
information is becoming available, not just to an elite group, but to all
people. Haz-Map is just one of the resources available to help
professionals and non-professionals to make decisions regarding
occupational exposures and diseases. Alongside other resources such as
PubMed searches and new editions of occupational medicine textbooks,
the value of Haz-Map will depend on how well it is updated and
maintained in the coming years.
"Surveillance in occupational health is defined as the systematic collection
and analysis of information concerning hazards, disease, or injury for the
purpose of prevention of occupational disease or injury." It involves "the
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collection of information after an action and the use of that information in a
feedback loop to change the circumstances that lead to the effect of interest."
[Halperin, 1996] Mullan and Murthy described their list of SHE(O)s as a
"framework for occupational health surveillance." [Mullan and Murthy, 1993] In
a similar way, the Haz-Map database plays a role in surveillance. "Health hazard
surveillance is the ongoing collection, analysis, evaluation and dissemination of
information aimed at improving the health, work ability, and well being of
workers." [Kauppinen and Toikkanen, 1999] Effective occupational health
surveillance can benefit the sentinel cases, their coworkers, other workers in the
industry, and people in other settings who were exposed to the agent. [Azaroff
et al., 2002]
One of the roles of surveillance in occupational health is to provide
information to motivate intervention. [Halperin, 1996] Case definitions include
information about signs and symptoms, diagnostic tests, and nonoccupational
causes. Lists of case definitions, like those disseminated by the Haz-Map
database, can foster improved recognition and prevention. [Matte et al., 1989]
Like the SHE(O) list, Haz-Map differs from conventional surveillance systems in
that the information is collected from secondary sources in the medical
literature rather than from the actual health events. The SHE(O) system has
been tied to direct intervention in the SENSOR program. [Matte et al., 1989]
There is no conventional surveillance linked to the Haz-Map database. However,
the new computer technologies have opened doors for public health surveillance
that were not available when the SHE(O) list was first published in 1983 and
updated in 1991. Physicians and scientists, now armed with personal
computers, can distill information from online databases and summarize that
information to improve surveillance. Personal computers also help authors to
manipulate large amounts of data with easy-to-use relational databases and
other software applications used for sorting, classifying, updating, and
disseminating immediately to the people who need to know. Continuously
updated lists of occupational diseases and their case definitions can now be
disseminated directly to health and safety professionals and to workers seeking
information on the Internet about occupational exposures and diseases.
Compared to the past, there is now much more information. Fortunately, there
are also much better tools for processing and communicating that information
to those who can intervene and prevent diseases in the workplace.
ACKNOWLEDGMENTS
The author wishes to thank the following for their assistance: Scott Barnhart,
Matt Keifer, Carl Brodkin, Noah Seixas (University of Washington), Jeff Burgess
(University of Arizona), Tim Gilmore (Group Health Cooperative), Patricia A.
Stewart (National Cancer Institute), and Moira Chan-Yeung (University of British
Columbia). The author has been receiving financial assistance from the U.S.
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National Library of Medicine since 2000 and from the Department of Labor since
2006.
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