Abstract
For both type 1 and type 2 diabetes mellitus, the rates have been increasing in the United States and elsewhere; rates vary widely by country, and genetic factors account for less than half of new cases. These observations suggest environmental factors cause both type 1 and type 2 diabetes. Occupational exposures have been associated with increased risk of diabetes. In addition, recent data suggest that toxic substances in the environment, other than infectious agents or exposures that stimulate an immune response, are associated with the occurrence of these diseases. We reviewed the epidemiologic data that addressed whether environmental contaminants might cause type 1 or type 2 diabetes. For type 1 diabetes, higher intake of nitrates, nitrites, and N-nitroso compounds, as well as higher serum levels of polychlorinated biphenyls have been associated with increased risk. Overall, however, the data were limited or inconsistent. With respect to type 2 diabetes, data on arsenic and 2,3,7,8-tetrachlorodibenzo-p-dioxin relative to risk were suggestive of a direct association but were inconclusive. The occupational data suggested that more data on exposure to N-nitroso compounds, arsenic, dioxins, talc, and straight oil machining fluids in relation to diabetes would be useful. Although environmental factors other than contaminants may account for the majority of type 1 and type 2 diabetes, the etiologic role of several contaminants and occupational exposures deserves further study.
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- Andresen E. M., Lee J. A., Pecoraro R. E., Koepsell T. D., Hallstrom A. P., Siscovick D. S. Underreporting of diabetes on death certificates, King County, Washington. Am J Public Health. 1993 Jul;83(7):1021–1024. doi: 10.2105/ajph.83.7.1021. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Assan R., Perronne C., Assan D., Chotard L., Mayaud C., Matheron S., Zucman D. Pentamidine-induced derangements of glucose homeostasis. Determinant roles of renal failure and drug accumulation. A study of 128 patients. Diabetes Care. 1995 Jan;18(1):47–55. doi: 10.2337/diacare.18.1.47. [DOI] [PubMed] [Google Scholar]
- Barnett A. H., Eff C., Leslie R. D., Pyke D. A. Diabetes in identical twins. A study of 200 pairs. Diabetologia. 1981 Feb;20(2):87–93. doi: 10.1007/BF00262007. [DOI] [PubMed] [Google Scholar]
- Bartoli D., Battista G., De Santis M., Iaia T. E., Orsi D., Tarchi M., Pirastu R., Valiani M. Cohort study of art glass workers in Tuscany, Italy: mortality from non-malignant diseases. Occup Med (Lond) 1998 Oct;48(7):441–445. doi: 10.1093/occmed/48.7.441. [DOI] [PubMed] [Google Scholar]
- Blair A., Decoufle P., Grauman D. Causes of death among laundry and dry cleaning workers. Am J Public Health. 1979 May;69(5):508–511. doi: 10.2105/ajph.69.5.508. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Bloomgarden Z. T. European Association for the Study of Diabetes Annual Meeting, 1999: complications of diabetes. Diabetes Care. 2000 Sep;23(9):1423–1428. doi: 10.2337/diacare.23.9.1423. [DOI] [PubMed] [Google Scholar]
- Bodington M. J., Muzulu S. I., Burden A. C. Spatial clustering in childhood diabetes: evidence of an environmental cause. Diabet Med. 1995 Oct;12(10):865–867. doi: 10.1111/j.1464-5491.1995.tb00387.x. [DOI] [PubMed] [Google Scholar]
- Calvert G. M., Sweeney M. H., Deddens J., Wall D. K. Evaluation of diabetes mellitus, serum glucose, and thyroid function among United States workers exposed to 2,3,7,8-tetrachlorodibenzo-p-dioxin. Occup Environ Med. 1999 Apr;56(4):270–276. doi: 10.1136/oem.56.4.270. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Cranmer M., Louie S., Kennedy R. H., Kern P. A., Fonseca V. A. Exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) is associated with hyperinsulinemia and insulin resistance. Toxicol Sci. 2000 Aug;56(2):431–436. doi: 10.1093/toxsci/56.2.431. [DOI] [PubMed] [Google Scholar]
- Cuzick J., Sasieni P., Evans S. Ingested arsenic, keratoses, and bladder cancer. Am J Epidemiol. 1992 Aug 15;136(4):417–421. doi: 10.1093/oxfordjournals.aje.a116514. [DOI] [PubMed] [Google Scholar]
- Dahlquist G. G., Blom L. G., Persson L. A., Sandström A. I., Wall S. G. Dietary factors and the risk of developing insulin dependent diabetes in childhood. BMJ. 1990 May 19;300(6735):1302–1306. doi: 10.1136/bmj.300.6735.1302. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Dahlquist G. G., Källen B. A. Time-space clustering of date at birth in childhood-onset diabetes. Diabetes Care. 1996 Apr;19(4):328–332. doi: 10.2337/diacare.19.4.328. [DOI] [PubMed] [Google Scholar]
- Dahlquist G. Environmental risk factors in human type 1 diabetes--an epidemiological perspective. Diabetes Metab Rev. 1995 Apr;11(1):37–46. doi: 10.1002/dmr.5610110104. [DOI] [PubMed] [Google Scholar]
- Douen A. G., Jones M. N. Phenylarsine oxide and the mechanism of insulin-stimulated sugar transport. Biofactors. 1990 Jul;2(3):153–161. [PubMed] [Google Scholar]
- Elliott S. J., Eyles J., DeLuca P. Mapping health in the Great Lakes areas of concern: a user-friendly tool for policy and decision makers. Environ Health Perspect. 2001 Dec;109 (Suppl 6):817–826. doi: 10.1289/ehp.01109s6817. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Enan E., Lasley B., Stewart D., Overstreet J., Vandevoort C. A. 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) modulates function of human luteinizing granulosa cells via cAMP signaling and early reduction of glucose transporting activity. Reprod Toxicol. 1996 May-Jun;10(3):191–198. doi: 10.1016/0890-6238(96)00021-4. [DOI] [PubMed] [Google Scholar]
- Flanders W. D., Lin L., Pirkle J. L., Caudill S. P. Assessing the direction of causality in cross-sectional studies. Am J Epidemiol. 1992 Apr 15;135(8):926–935. doi: 10.1093/oxfordjournals.aje.a116388. [DOI] [PubMed] [Google Scholar]
- Franco G., Malamani T., Piazza A. Glucose tolerance and occupational exposure to carbon disulphide. Lancet. 1978 Dec 2;2(8101):1208–1208. doi: 10.1016/s0140-6736(78)92197-9. [DOI] [PubMed] [Google Scholar]
- Gladen B. C., Longnecker M. P., Schecter A. J. Correlations among polychlorinated biphenyls, dioxins, and furans in humans. Am J Ind Med. 1999 Jan;35(1):15–20. doi: 10.1002/(sici)1097-0274(199901)35:1<15::aid-ajim3>3.0.co;2-z. [DOI] [PubMed] [Google Scholar]
- Helgason T., Ewen S. W., Ross I. S., Stowers J. M. Diabetes produced in mice by smoked/cured mutton. Lancet. 1982 Nov 6;2(8306):1017–1022. doi: 10.1016/s0140-6736(82)90052-6. [DOI] [PubMed] [Google Scholar]
- Helgason T., Jonasson M. R. Evidence for a food additive as a cause of ketosis-prone diabetes. Lancet. 1981 Oct 3;2(8249):716–720. doi: 10.1016/s0140-6736(81)91048-5. [DOI] [PubMed] [Google Scholar]
- Hemmings S. J., Spafford D. Neonatal STZ model of type II diabetes mellitus in the Fischer 344 rat: characteristics and assessment of the status of the hepatic adrenergic receptors. Int J Biochem Cell Biol. 2000 Aug;32(8):905–919. doi: 10.1016/s1357-2725(00)00019-4. [DOI] [PubMed] [Google Scholar]
- Henriksen G. L., Ketchum N. S., Michalek J. E., Swaby J. A. Serum dioxin and diabetes mellitus in veterans of Operation Ranch Hand. Epidemiology. 1997 May;8(3):252–258. doi: 10.1097/00001648-199705000-00005. [DOI] [PubMed] [Google Scholar]
- Hopenhayn-Rich C., Biggs M. L., Smith A. H. Lung and kidney cancer mortality associated with arsenic in drinking water in Córdoba, Argentina. Int J Epidemiol. 1998 Aug;27(4):561–569. doi: 10.1093/ije/27.4.561. [DOI] [PubMed] [Google Scholar]
- Hoque B. A., Mahmood A. A., Quadiruzzaman M., Khan F., Ahmed S. A., Shafique S. A., Rahman M., Morshed G., Chowdhury T., Rahman M. M. Recommendations for water supply in arsenic mitigation: a case study from Bangladesh. Public Health. 2000 Nov;114(6):488–494. [PubMed] [Google Scholar]
- Kadowaki T. Insights into insulin resistance and type 2 diabetes from knockout mouse models. J Clin Invest. 2000 Aug;106(4):459–465. doi: 10.1172/JCI10830. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Kaprio J., Tuomilehto J., Koskenvuo M., Romanov K., Reunanen A., Eriksson J., Stengård J., Kesäniemi Y. A. Concordance for type 1 (insulin-dependent) and type 2 (non-insulin-dependent) diabetes mellitus in a population-based cohort of twins in Finland. Diabetologia. 1992 Nov;35(11):1060–1067. doi: 10.1007/BF02221682. [DOI] [PubMed] [Google Scholar]
- Karam J. H., Lewitt P. A., Young C. W., Nowlain R. E., Frankel B. J., Fujiya H., Freedman Z. R., Grodsky G. M. Insulinopenic diabetes after rodenticide (Vacor) ingestion: a unique model of acquired diabetes in man. Diabetes. 1980 Dec;29(12):971–978. doi: 10.2337/diab.29.12.971. [DOI] [PubMed] [Google Scholar]
- Katz R. M., Jowett D. Female laundry and dry cleaning workers in Wisconsin: a mortality analysis. Am J Public Health. 1981 Mar;71(3):305–307. doi: 10.2105/ajph.71.3.305. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Kostraba J. N., Gay E. C., Rewers M., Hamman R. F. Nitrate levels in community drinking waters and risk of IDDM. An ecological analysis. Diabetes Care. 1992 Nov;15(11):1505–1508. doi: 10.2337/diacare.15.11.1505. [DOI] [PubMed] [Google Scholar]
- Law G. R., McKinney P. A., Staines A., Williams R., Kelly M., Alexander F., Gilman E., Bodansky H. J. Clustering of childhood IDDM. Links with age and place of residence. Diabetes Care. 1997 May;20(5):753–756. doi: 10.2337/diacare.20.5.753. [DOI] [PubMed] [Google Scholar]
- Longnecker M. P., Klebanoff M. A., Brock J. W., Zhou H., Collaborative Perinatal Project (CPP) Polychlorinated biphenyl serum levels in pregnant subjects with diabetes. Diabetes Care. 2001 Jun;24(6):1099–1101. doi: 10.2337/diacare.24.6.1099. [DOI] [PubMed] [Google Scholar]
- Longnecker M. P., Michalek J. E. Serum dioxin level in relation to diabetes mellitus among Air Force veterans with background levels of exposure. Epidemiology. 2000 Jan;11(1):44–48. doi: 10.1097/00001648-200001000-00010. [DOI] [PubMed] [Google Scholar]
- Mandrup-Poulsen T. Diabetes. BMJ. 1998 Apr 18;316(7139):1221–1225. doi: 10.1136/bmj.316.7139.1221. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Marsh G. M., Enterline P. E., McCraw D. Mortality patterns among petroleum refinery and chemical plant workers. Am J Ind Med. 1991;19(1):29–42. doi: 10.1002/ajim.4700190105. [DOI] [PubMed] [Google Scholar]
- McMichael A. J., Spirtas R., Gamble J. F., Tousey P. M. Mortality among rubber workers: Relationship to specific jobs. J Occup Med. 1976 Mar;18(3):178–185. doi: 10.1097/00043764-197603000-00012. [DOI] [PubMed] [Google Scholar]
- McMichael A. J., Spirtas R., Kupper L. L. An epidemiologic study of mortality within a cohort of rubber workers, 1964-72. J Occup Med. 1974 Jul;16(7):458–464. [PubMed] [Google Scholar]
- Mertz W. Chromium in human nutrition: a review. J Nutr. 1993 Apr;123(4):626–633. doi: 10.1093/jn/123.4.626. [DOI] [PubMed] [Google Scholar]
- Mokdad A. H., Ford E. S., Bowman B. A., Nelson D. E., Engelgau M. M., Vinicor F., Marks J. S. Diabetes trends in the U.S.: 1990-1998. Diabetes Care. 2000 Sep;23(9):1278–1283. doi: 10.2337/diacare.23.9.1278. [DOI] [PubMed] [Google Scholar]
- Montanaro F., Ceppi M., Demers P. A., Puntoni R., Bonassi S. Mortality in a cohort of tannery workers. Occup Environ Med. 1997 Aug;54(8):588–591. doi: 10.1136/oem.54.8.588. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Morgan D. P., Lin L. I., Saikaly H. H. Morbidity and mortality in workers occupationally exposed to pesticides. Arch Environ Contam Toxicol. 1980;9(3):349–382. doi: 10.1007/BF01057414. [DOI] [PubMed] [Google Scholar]
- Morgenstern H. Ecologic studies in epidemiology: concepts, principles, and methods. Annu Rev Public Health. 1995;16:61–81. doi: 10.1146/annurev.pu.16.050195.000425. [DOI] [PubMed] [Google Scholar]
- Morikawa Y., Nakagawa H., Ishizaki M., Tabata M., Nishijo M., Miura K., Kawano S., Kido T., Nogawa K. Ten-year follow-up study on the relation between the development of non-insulin-dependent diabetes mellitus and occupation. Am J Ind Med. 1997 Jan;31(1):80–84. doi: 10.1002/(sici)1097-0274(199701)31:1<80::aid-ajim12>3.0.co;2-3. [DOI] [PubMed] [Google Scholar]
- O'Rahilly S. Science, medicine, and the future. Non-insulin dependent diabetes mellitus: the gathering storm. BMJ. 1997 Mar 29;314(7085):955–959. doi: 10.1136/bmj.314.7085.955. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Onkamo P., Vänänen S., Karvonen M., Tuomilehto J. Worldwide increase in incidence of Type I diabetes--the analysis of the data on published incidence trends. Diabetologia. 1999 Dec;42(12):1395–1403. doi: 10.1007/s001250051309. [DOI] [PubMed] [Google Scholar]
- Ott M. G., Zober A., Germann C. Laboratory results for selected target organs in 138 individuals occupationally exposed to TCDD. Chemosphere. 1994 Nov-Dec;29(9-11):2423–2437. doi: 10.1016/0045-6535(94)90411-1. [DOI] [PubMed] [Google Scholar]
- Park R. M., Mirer F. E. A survey of mortality at two automotive engine manufacturing plants. Am J Ind Med. 1996 Dec;30(6):664–673. doi: 10.1002/(SICI)1097-0274(199612)30:6<664::AID-AJIM3>3.0.CO;2-R. [DOI] [PubMed] [Google Scholar]
- Parslow R. C., McKinney P. A., Law G. R., Staines A., Williams R., Bodansky H. J. Incidence of childhood diabetes mellitus in Yorkshire, northern England, is associated with nitrate in drinking water: an ecological analysis. Diabetologia. 1997 May;40(5):550–556. doi: 10.1007/s001250050714. [DOI] [PubMed] [Google Scholar]
- Pastides H., Austin R., Lemeshow S., Klar J., Mundt K. A. A retrospective-cohort study of occupational exposure to hexavalent chromium. Am J Ind Med. 1994 May;25(5):663–675. doi: 10.1002/ajim.4700250506. [DOI] [PubMed] [Google Scholar]
- Pazderova-Vejlupková J., Lukás E., Nemcova M., Pícková J., Jirásek L. The development and prognosis of chronic intoxication by tetrachlordibenzo-p-dioxin in men. Arch Environ Health. 1981 Jan-Feb;36(1):5–11. doi: 10.1080/00039896.1981.10667598. [DOI] [PubMed] [Google Scholar]
- Pesatori A. C., Zocchetti C., Guercilena S., Consonni D., Turrini D., Bertazzi P. A. Dioxin exposure and non-malignant health effects: a mortality study. Occup Environ Med. 1998 Feb;55(2):126–131. doi: 10.1136/oem.55.2.126. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Peschke E., Ebelt H., Brömme H. J., Peschke D. 'Classical' and 'new' diabetogens--comparison of their effects on isolated rat pancreatic islets in vitro. Cell Mol Life Sci. 2000 Jan 20;57(1):158–164. doi: 10.1007/s000180050505. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Rahman M., Axelson O. Diabetes mellitus and arsenic exposure: a second look at case-control data from a Swedish copper smelter. Occup Environ Med. 1995 Nov;52(11):773–774. doi: 10.1136/oem.52.11.773. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Rahman M., Tondel M., Ahmad S. A., Axelson O. Diabetes mellitus associated with arsenic exposure in Bangladesh. Am J Epidemiol. 1998 Jul 15;148(2):198–203. doi: 10.1093/oxfordjournals.aje.a009624. [DOI] [PubMed] [Google Scholar]
- Rahman M., Wingren G., Axelson O. Diabetes mellitus among Swedish art glass workers--an effect of arsenic exposure? Scand J Work Environ Health. 1996 Apr;22(2):146–149. doi: 10.5271/sjweh.123. [DOI] [PubMed] [Google Scholar]
- Schwartz E. A proportionate mortality ratio analysis of pulp and paper mill workers in New Hampshire. Br J Ind Med. 1988 Apr;45(4):234–238. doi: 10.1136/oem.45.4.234. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Smith A. H., Goycolea M., Haque R., Biggs M. L. Marked increase in bladder and lung cancer mortality in a region of Northern Chile due to arsenic in drinking water. Am J Epidemiol. 1998 Apr 1;147(7):660–669. doi: 10.1093/oxfordjournals.aje.a009507. [DOI] [PubMed] [Google Scholar]
- Spiegelhalder B., Preussmann R. Occupational nitrosamine exposure. 1. Rubber and tyre industry. Carcinogenesis. 1983 Sep;4(9):1147–1152. doi: 10.1093/carcin/4.9.1147. [DOI] [PubMed] [Google Scholar]
- Steenland K., Piacitelli L., Deddens J., Fingerhut M., Chang L. I. Cancer, heart disease, and diabetes in workers exposed to 2,3,7,8-tetrachlorodibenzo-p-dioxin. J Natl Cancer Inst. 1999 May 5;91(9):779–786. doi: 10.1093/jnci/91.9.779. [DOI] [PubMed] [Google Scholar]
- Stupar J., Vrtovec M., Kocijancic A., Gantar A. Chromium status of tannery workers in relation to metabolic disorders. J Appl Toxicol. 1999 Nov-Dec;19(6):437–446. doi: 10.1002/(sici)1099-1263(199911/12)19:6<437::aid-jat600>3.0.co;2-8. [DOI] [PubMed] [Google Scholar]
- Suskind R. R., Hertzberg V. S. Human health effects of 2,4,5-T and its toxic contaminants. JAMA. 1984 May 11;251(18):2372–2380. [PubMed] [Google Scholar]
- Takahashi K., Okubo T. A prospective cohort study of chromium plating workers in Japan. Arch Environ Health. 1990 Mar-Apr;45(2):107–111. doi: 10.1080/00039896.1990.9935934. [DOI] [PubMed] [Google Scholar]
- Tsai S. M., Wang T. N., Ko Y. C. Mortality for certain diseases in areas with high levels of arsenic in drinking water. Arch Environ Health. 1999 May-Jun;54(3):186–193. doi: 10.1080/00039899909602258. [DOI] [PubMed] [Google Scholar]
- Tseng C. H., Tai T. Y., Chong C. K., Tseng C. P., Lai M. S., Lin B. J., Chiou H. Y., Hsueh Y. M., Hsu K. H., Chen C. J. Long-term arsenic exposure and incidence of non-insulin-dependent diabetes mellitus: a cohort study in arseniasis-hyperendemic villages in Taiwan. Environ Health Perspect. 2000 Sep;108(9):847–851. doi: 10.1289/ehp.00108847. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Tsuda T., Nagira T., Yamamoto M., Kume Y. An epidemiological study on cancer in certified arsenic poisoning patients in Toroku. Ind Health. 1990;28(2):53–62. doi: 10.2486/indhealth.28.53. [DOI] [PubMed] [Google Scholar]
- Vena J., Boffetta P., Becher H., Benn T., Bueno-de-Mesquita H. B., Coggon D., Colin D., Flesch-Janys D., Green L., Kauppinen T. Exposure to dioxin and nonneoplastic mortality in the expanded IARC international cohort study of phenoxy herbicide and chlorophenol production workers and sprayers. Environ Health Perspect. 1998 Apr;106 (Suppl 2):645–653. doi: 10.1289/ehp.98106645. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Verge C. F., Howard N. J., Irwig L., Simpson J. M., Mackerras D., Silink M. Environmental factors in childhood IDDM. A population-based, case-control study. Diabetes Care. 1994 Dec;17(12):1381–1389. doi: 10.2337/diacare.17.12.1381. [DOI] [PubMed] [Google Scholar]
- Virtanen S. M., Jaakkola L., Räsänen L., Ylönen K., Aro A., Lounamaa R., Akerblom H. K., Tuomilehto J. Nitrate and nitrite intake and the risk for type 1 diabetes in Finnish children. Childhood Diabetes in Finland Study Group. Diabet Med. 1994 Aug-Sep;11(7):656–662. doi: 10.1111/j.1464-5491.1994.tb00328.x. [DOI] [PubMed] [Google Scholar]
- Wareham N. J., O'Rahilly S. The changing classification and diagnosis of diabetes. New classification is based on pathogenesis, not insulin dependence. BMJ. 1998 Aug 8;317(7155):359–360. doi: 10.1136/bmj.317.7155.359. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Weiland S. K., Mundt K. A., Keil U., Kraemer B., Birk T., Person M., Bucher A. M., Straif K., Schumann J., Chambless L. Cancer mortality among workers in the German rubber industry: 1981-91. Occup Environ Med. 1996 May;53(5):289–298. doi: 10.1136/oem.53.5.289. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Wilson G. L., Mossman B. T., Craighead J. E. Use of pancreatic beta cells in culture to identify diabetogenic N-nitroso compounds. In Vitro. 1983 Jan;19(1):25–30. doi: 10.1007/BF02617990. [DOI] [PubMed] [Google Scholar]
- Wingren G., Persson B., Thorén K., Axelson O. Mortality pattern among pulp and paper mill workers in Sweden: a case-referent study. Am J Ind Med. 1991;20(6):769–774. doi: 10.1002/ajim.4700200608. [DOI] [PubMed] [Google Scholar]
- Wojtczak-Jaroszowa J., Jarosz D. Health complaints, sicknesses and accidents of workers employed in high environmental temperatures. Can J Public Health. 1986 May-Jun;77 (Suppl 1):132–135. [PubMed] [Google Scholar]
- Wong O., Brocker W., Davis H. V., Nagle G. S. Mortality of workers potentially exposed to organic and inorganic brominated chemicals, DBCP, TRIS, PBB, and DDT. Br J Ind Med. 1984 Feb;41(1):15–24. doi: 10.1136/oem.41.1.15. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Wong O., Ragland D. R., Marcero D. H. An epidemiologic study of employees at seven pulp and paper mills. Int Arch Occup Environ Health. 1996;68(6):498–507. doi: 10.1007/BF00377876. [DOI] [PubMed] [Google Scholar]
- Zober A., Ott M. G., Messerer P. Morbidity follow up study of BASF employees exposed to 2,3,7, 8-tetrachlorodibenzo-p-dioxin (TCDD) after a 1953 chemical reactor incident. Occup Environ Med. 1994 Jul;51(7):479–486. doi: 10.1136/oem.51.7.479. [DOI] [PMC free article] [PubMed] [Google Scholar]