Unsolved:Multiple chemical sensitivity

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Multiple chemical sensitivity (MCS), also known as idiopathic environmental intolerances (IEI), is an unrecognized controversial diagnosis characterized by chronic symptoms attributed to exposure to low levels of commonly used chemicals.[1][2] Symptoms are typically vague and non-specific. They may include fatigue, headaches, nausea, and dizziness.

Although these symptoms can be debilitating, MCS is not recognized as an organic, chemical-caused illness by the World Health Organization, American Medical Association, nor any of several other professional medical organization.[3][4][non-primary source needed] Blinded clinical trials show that people with MCS react as often and as strongly to placebos as they do to chemical stimuli; the existence and severity of symptoms is seemingly related to perception that a chemical stimulus is present.[5][6][non-primary source needed]

Commonly attributed substances include scented products (e.g. perfumes), pesticides, plastics, synthetic fabrics, smoke, petroleum products, and paint fumes.[1]

Symptoms

Symptoms are typically vague and non-specific, such as fatigue or headaches. These symptoms, although they can be disabling, are called non-specific because they are not associated with any single specific medical condition. Symptoms are triggered by exposure to a substance that the individual person does not tolerate well.

Symptoms mainly arise from the autonomic nervous system (such as nausea or dizziness) or have psychiatric or psychological aspects (such as difficulty concentrating).[7]

Possible causes

There is a wide agreement among MCS researchers that the cause is not related to any sort of sensitivity to chemicals, but this does not preclude the possibility that the reported symptoms are caused by some other known or unknown factor. Various health care professionals and government agencies are working on giving those who report the symptoms proper care while searching for a cause.[8]

In 2017, a Canadian government Task Force on Environmental Health said that there had been very little rigorous peer-reviewed research into MCS and almost a complete lack of funding for such research in North America.[9] "Most recently," it said, "some peer-reviewed clinical research has emerged from centres in Italy, Denmark and Japan suggesting that there are fundamental neurobiologic, metabolic, and genetic susceptibility factors that underlie ES/MCS."[9]

The US Occupational Safety and Health Administration (OSHA) indicates that MCS is highly controversial and that there is insufficient scientific evidence to explain the relationship between the suggested causes of MCS and its symptoms.[10]

Immunological

MCS was originally promoted as a type of allergy, and later as a type of non-allergic immunological disorder. However, these ideas have largely been rejected. Unlike people with allergic disorders, autoimmune diseases, or immunodeficiences, people with MCS have no objective immunological abnormalities.[11] The absence of immunological abnormalities in people with MCS (such as different white blood cell counts or the presence of abnormal autoantibodies) indicates that the problem lies elsewhere.[11]

People who are experiencing symptoms of MCS do not routinely exhibit the immune markers associated with allergies.[12] In the 1980s and 1990s, some researchers hypothesized that these immune irregularities suggested that MCS was caused by a chemically induced disturbance of the immune system, which resulted in chronic immune dysfunction.[12][1] However, there is no consistent pattern of immunological reactivity or abnormality in MCS.[12][13]

There is also evidence that people with MCS are more likely than controls to have allergies[14]:16 [15][16][17]

Psychological

Several mechanisms for a psychological etiology of the condition have been proposed, including theories based on misdiagnoses of an underlying mental illness, stress, or classical conditioning.[citation needed] Many people with MCS also meet the criteria for major depressive disorder or anxiety disorder.[18][non-primary source needed] Other proposed explanations include somatic symptom disorder,[19][non-primary source needed] panic disorder,[20][non-primary source needed] migraine, chronic fatigue syndrome, or fibromyalgia and brain fog. Through behavioral conditioning, it has been proposed that people with MCS may develop real, but unintentionally psychologically produced, symptoms, such as anticipatory nausea, when they encounter certain odors or other perceived triggers.[21][19][non-primary source needed] It has also been proposed in one study that individuals may have a tendency to "catastrophically misinterpret benign physical symptoms"[22][19][non-primary source needed] or simply have a disturbingly acute sense of smell. The personality trait absorption, in which individuals are predisposed to becoming deeply immersed in sensory experiences, may be stronger in individuals reporting symptoms of MCS.[23][19][non-primary source needed] In the 1990s, behaviors exhibited by MCS sufferers were hypothesized by some to reflect broader sociological fears about industrial pollution and broader societal trends of technophobia and chemophobia.[24][19]

These theories have attracted criticism.[8][25]

In Canada, in 2017, following a three-year government inquiry into environmental illness, it was recommended that a public statement be made by the health department.[26][needs update]

A 2018 systematic review concluded that the evidence suggests that abnormalities in sensory processing pathways combined with peculiar personality traits best explains this condition.[27]

Diagnosis

In practice, diagnosis relies entirely upon the self-reported claim that symptoms are triggered by exposure to various substances.[11]

Many other tests have been promoted by various people over the years, including testing of the immune system, porphyrin metabolism, provocation-neutralization testing, autoantibodies, the Epstein–Barr virus, testing for evidence of exposure to pesticides or heavy metals, and challenges involving exposure to chemicals, foods, or inhalants.[11] None of these tests correlate with MCS symptoms, and none are useful for diagnosing MCS.[11]

The stress and anxiety experienced by people reporting MCS symptoms are significant.[11] Neuropsychological assessments do not find differences between people reporting MCS symptoms and other people in areas such as verbal learning, memory functioning, or psychomotor performance.[11] Neuropsychological tests are sensitive but not specific, and they identify differences that may be caused by unrelated medical, neurological, or neuropsychological conditions.[11]

Another major goal for diagnostic work is to identify and treat any other medical conditions the person may have.[11] People reporting MCS-like symptoms may have other health issues, ranging from common conditions, such as depression or asthma, to less common circumstances, such a documented chemical exposure during a work accident.[11] These other conditions may or may not have any relationship to MCS symptoms, but they should be diagnosed and treated appropriately, whenever the patient history, physical examination, or routine medical tests indicates their presence.[11] The differential diagnosis list includes solvent exposure, occupational asthma, and allergies.[11]

Definitions

Different researchers and proponents use different definitions, which complicates research and can affect diagnosis.[28] For example, the 1987 definition that requires symptoms to begin suddenly after an identifiable, documented exposure to a chemical,[29] but the 1996 definition by the International Programme on Chemical Safety says that the cause can be anything, including other medical conditions or psychological factors.[7][29]

In Japan, MCS is called chemical hypersensitivity or chemical intolerance (化学物質過敏症; kagaku kando), and the 1999 Japanese definition requires one or more of four major symptoms – headaches; malaise and fatigue; muscle pain; joint pain – combined with laboratory findings and/or some minor symptoms, such as mental effects or skin conditions.[7] The defined lab findings are abnormalities in parasympathetic nerves, cerebral cortical dysfunction diagnosed by SPECT testing, visuospatial abnormalities, abnormalities of eye movement, or a positive provocation test.[7]

International Classification of Diseases

The International Statistical Classification of Diseases and Related Health Problems (ICD), maintained by the World Health Organization, is a medical coding system used for billing and statistical purposes. The ICD does not list MCS as a discrete disease.[3]

The American Academy of Allergy, Asthma, and Immunology, the California Medical Association, the American College of Physicians, and the International Society of Regulatory Toxicology and Pharmacology also do not recognize MCS as a single, separate syndrome.[4][30][31]

Management

There is no single proven treatment for MCS.[8] The goal of treatment is to improve quality of life, with fewer distressing symptoms and the ability to maintain employment and social relationships, rather than to produce a permanent cure.[11]

A multidisciplinary treatment approach is recommended.[27] It should take into account the uncommon personality traits often seen in affected individuals and physiological abnormalities in sensory pathways and the limbic system.[27] There is also no scientific consensus on supportive therapies for MCS, "but the literature agrees on the need for patients with MCS to avoid the specific substances that trigger reactions for them and also on the avoidance of xenobiotics in general, to prevent further sensitization."[8][14]:17[32]

Common self-care strategies include avoiding exposure to known triggers, detoxification, and emotional self-care.[11] Healthcare providers can provide useful education on the body's natural ability to eliminate and excrete toxins on its own and support positive self-care efforts.[11] Avoiding triggers, such as by removing smelly cleaning products from the home, can reduce symptoms and increase the person's sense of being able to reclaim a reasonably normal life.[11] However, for other people with MCS, their efforts to avoid suspected triggers will backfire, and instead produce harmful emotional side effects that interfere with the overall goal of reducing distress and disability.[11]

Some studies suggest a special focus on correcting any nutritional deficiencies may be beneficial.[27]

Epidemiology

Prevalence rates for MCS vary according to the diagnostic criteria used.[33] The condition is reported across industrialized countries and it affects women more than men.[8]:37

In 2018, the same researchers reported that the prevalence rate of diagnosed MCS had increased by more than 300% and self-reported chemical sensitivity by more than 200% in the previous decade.[34] They found that 12.8% of those surveyed reported medically diagnosed MCS and 25.9% reported having chemical sensitivities.[34]

A 2014 study by the Canadian Ministry of Health estimated, based on its survey, that 0.9% of Canadian males and 3.3% of Canadian females had a diagnosis of MCS by a health professional.[8]:37[35]

While a 2018 study at the University of Melbourne found that 6.5% of Australian adults reported having a medical diagnosis of MCS and that 18.9 per cent reported having adverse reactions to multiple chemicals.[36][37][38] The study also found that for 55.4 per cent of those with MCS, the symptoms triggered by chemical exposures could be disabling.[37]

Gulf War syndrome

Veterans of the Gulf War attributed to Gulf War syndrome are similar to those reported for MCS, including headache, fatigue, muscle stiffness, joint pain, inability to concentrate, sleep problems, and gastrointestinal issues.[39]

A population-based, cross-sectional epidemiological study involving American veterans of the Gulf War, non-Gulf War veterans, and non-deployed reservists enlisted both during Gulf War era and outside the Gulf War era concluded the prevalence of MCS-type symptoms in Gulf War veterans was somewhat higher than in non-Gulf War veterans.[40] After adjusting for potentially confounding factors (age, sex, and military training), there was a robust association between individuals with MCS-type symptoms and psychiatric treatment (either therapy or medication) before deployment and, therefore, before any possible deployment-connected chemical exposures.[40]

The odds of reporting MCS or chronic multiple-symptom illness was 3.5 times greater for Gulf War veterans than non-Gulf veterans.[41] Gulf War veterans have an increased rate of being diagnosed with multiple-symptom conditions compared to military personnel deployed to other conflicts.[42]

Prognosis

About half of those who claim to be affected by MCS get better over the course of several years, while about half continue to experience distressing symptoms.[11]

History

MCS was first proposed as a distinct disease by Theron G. Randolph in 1950. In 1965, Randolph founded the Society for Clinical Ecology as an organization to promote his ideas about symptoms reported by his patients. As a consequence of his insistence upon his own, non-standard definition of allergy and his unusual theories about how the immune system and toxins affect people, the ideas he promoted were widely rejected, and clinical ecology emerged as a non-recognized medical specialty.[11]

In the 1990s, an association was noted with chronic fatigue syndrome, fibromyalgia, and Gulf War syndrome.[43]

In 1994, the AMA, American Lung Association, US EPA and the US Consumer Product Safety Commission published a booklet on indoor air pollution that discusses MCS, among other issues. The booklet further states that a pathogenesis of MCS has not been definitively proven, and that symptoms that have been self-diagnosed by a patient as related to MCS could actually be related to allergies or have a psychological basis, and recommends that physicians should counsel patients seeking relief from their symptoms that they may benefit from consultation with specialists in these fields.[44]

In 1995, an Interagency Workgroup on Multiple Chemical Sensitivity was formed under the supervision of the Environmental Health Policy Committee within the United States Department of Health and Human Services to examine the body of research that had been conducted on MCS to that date. The work group included representatives from the Centers for Disease Control and Prevention, United States Environmental Protection Agency, United States Department of Energy, Agency for Toxic Substances and Disease Registry, and the National Institutes of Health. The Predecisional Draft document generated by the workgroup in 1998 recommended additional research in the basic epidemiology of MCS, the performance of case-comparison and challenge studies, and the development of a case definition for MCS. However, the workgroup also concluded that it was unlikely that MCS would receive extensive financial resources from federal agencies because of budgetary constraints and the allocation of funds to other, extensively overlapping syndromes with unknown cause, such as chronic fatigue syndrome, fibromyalgia, and Gulf War syndrome. The Environmental Health Policy Committee is currently inactive, and the workgroup document has not been finalized.[45]

The different understandings of MCS over the years have also resulted in different proposals for names.[7] For example, in 1996 the International Programme on Chemical Safety proposed calling it idiopathic environmental illness, because of their belief that chemical exposure may not the sole cause,[28] while another researcher, whose definition includes people with allergies and acute poisoning, calls it chemical sensitivity.[7][clarification needed]

See also

References

  1. ↑ 1.0 1.1 1.2 Genuis, SJ (May 2013). "Chemical sensitivity: pathophysiology or pathopsychology?". Clinical Therapeutics 35 (5): 572–7. doi:10.1016/j.clinthera.2013.04.003. PMID 23642291. 
  2. ↑ Sorg, Barbara A. (1999). "Multiple Chemical Sensitivity: Potential Role for Neural Sensitization". Critical Reviews in Neurobiology 13 (3): 283–316. doi:10.1615/CritRevNeurobiol.v13.i3.30. PMID 10803638. 
  3. ↑ 3.0 3.1 Sears, Margaret E. 2007. "The Medical Perspective on Environmental Sensitivities." Note: The opinions expressed in this report are those of the author and do not necessarily reflect the views of the Canadian Human Rights Commission.
  4. ↑ 4.0 4.1 Gots RE (1995). "Multiple chemical sensitivities--public policy". J. Toxicol. Clin. Toxicol. 33 (2): 111–3. doi:10.3109/15563659509000459. PMID 7897748. "The phenomenon of multiple chemical sensitivities is a peculiar manifestation of our technophobic and chemophobic society. It has been rejected as an established organic disease by the American Academy of Allergy and Immunology, the American Medical Association, the California Medical Association, the American College of Physicians, and the International Society of Regulatory Toxicology and Pharmacology. It may be the only ailment in existence in which the patient defines both the cause and the manifestations of his own condition.". 
  5. ↑ J. Das-Munshi, G. J. Rubin, S. Wessely, Multiple chemical sensitivities: A systematic review of provocation studies, Journal of Allergy and Clinical Immunology, 118, pp.1257-1264 (2006)
  6. ↑ "Double-blind placebo-controlled provocation study in patients with subjective Multiple Chemical Sensitivity (MCS) and matched control subjects". Clin Toxicol 46 (5): 443–9. 2008. doi:10.1080/15563650701742438. PMID 18568800. http://mediatum.ub.tum.de/doc/694041/document.pdf. 
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 Katoh, Takahiko (2018). "Multiple Chemical Sensitivity (MCS): History, Epidemiology and Mechanism" (in Japanese). Nihon Eiseigaku Zasshi (Japanese Journal of Hygiene) 73 (1): 1–8. doi:10.1265/jjh.73.1. ISSN 1882-6482. PMID 29386440. 
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 Task Force on Environmental Health (2017). Time for leadership: recognizing and improving care for those with ME/CFS, FM and ES/MCS. Phase 1 report. Toronto, Ontario: Ministry of Health and Long-Term Care; 2017.
  9. ↑ 9.0 9.1 Task Force on Environmental Health (2017). Time for leadership: recognizing and improving care for those with ME/CFS, FM and ES/MCS. Phase 1 report. Toronto, Ontario: Ministry of Health and Long-Term Care; 2017. p. 53.
  10. ↑ "Safety and Health Topics | Multiple Chemical Sensitivities". Osha.gov. http://www.osha.gov/SLTC/multiplechemicalsensitivities/index.html. Retrieved 2014-06-08. 
  11. ↑ 11.00 11.01 11.02 11.03 11.04 11.05 11.06 11.07 11.08 11.09 11.10 11.11 11.12 11.13 11.14 11.15 11.16 11.17 11.18 Harrison, Robert (2014). "Multiple Chemical Sensitivity". Current Occupational & Environmental Medicine (Fifth ed.). New York: McGraw-Hill Education/Medical. pp. 819–826. ISBN 978-0-07-180816-3. OCLC 898477589. 
  12. ↑ 12.0 12.1 12.2 "A Scientific Review of Multiple Chemical Sensitivity: Identifying Key Research Needs.". Canberra, Australia: National Industrial Chemicals Notification and Assessment Scheme, Australian Government. 2010. pp. 21-22. http://test.nicnas.gov.au/Media/Latest_News/MCS.asp. "A classical allergic reaction involves a specific cell or antibody-mediated response that alerts the body to the allergen and results in changes to some immunological parameters (such as increased serum IgE, IgG, complement levels or lymphocyte counts) that can be measured biochemically. Early immunological testing of MCS patients did not find levels of immunoglobulins, complement, B-cell, T-cell or T-cell subsets in MCS subjects outside normal limits that would indicate either allergic sensitisation or aberrant immune reactivities (Terr, 1986). Subsequent studies have reported out of range values in individual MCS patients for immunoglobulins, complement components, peripheral blood lymphocyte subsets, activated T cells or abnormal serum antibodies to tissue antigens and chemical-protein conjugates (Thrasher et al. 1990; Fiedler et al., 1992; Heuser et al. 1992; Kipen et al. 1992; Levin and Byers, 1992; Rea et al. 1992). However, across these studies, there were no consistent findings suggestive of immunological reactivity in MCS." 
  13. ↑ Labarge XS, McCaffrey RJ (2000). "Multiple chemical sensitivity: a review of the theoretical and research literature". Neuropsychol Rev 10 (4): 183–211. doi:10.1023/a:1026460726965. PMID 11132100. 
  14. ↑ 14.0 14.1 "Actualizacion de la Evidencia Cientifica sobre Sensibilidad Quimica Multiple (SQM)". Madrid: Ministerio de Sanidad, Servicios Sociales e Igualdad. https://www.sergas.es/Asistencia-sanitaria/Documents/953/Actualizaci%C3%B3n%20de%20la%20evidencia%20cient%C3%ADfica%20sobre%20sensibilidad%20qu%C3%ADmica%20m%C3%BAltiple.pdf. 
  15. ↑ Hybenova M, Hrda P, Prochazkova J, Stejskal V, Sterzl I (2010). "The role of environmental factors in autoimmune thyroiditis". Neuro Endocrinol Lett 31 (3): 283–9. PMID 20588228. 
  16. ↑ Ziem G, McTamney J (1997). "Profile of patients with chemical injury and sensitivity". Environ Health Perspect 105 (Suppl 2): 417–36. doi:10.2307/3433348. PMID 9167975. 
  17. ↑ Nogue S, Fernandez-Sola J, Rovira E, Montori E, Fernandez-Huerta JM, Munne P (2007). "Multiple chemical sensitivity: study of 52 cases". Med Clin (Barc) 129 (3): 96–8. doi:10.1157/13107370. PMID 17594860. 
  18. ↑ "Patients with multiple chemical sensitivities in an occupational health clinic: presentation and follow-up". Arch. Environ. Health 50 (6): 425–31. 1995. doi:10.1080/00039896.1995.9935978. PMID 8572720. 
  19. ↑ 19.0 19.1 19.2 19.3 19.4 "Evidence for overlap between idiopathic environmental intolerance and somatoform disorders". Psychosom Med 67 (6): 921–9. 2005. doi:10.1097/01.psy.0000174170.66109.b7. PMID 16314597. http://www.psychosomaticmedicine.org/cgi/pmidlookup?view=long&pmid=16314597. 
  20. ↑ "Panic response to sodium lactate infusion in patients with multiple chemical sensitivity syndrome". J Allergy Clin Immunol 99 (4): 570–4. 1997. doi:10.1016/s0091-6749(97)70086-1. PMID 9111504. 
  21. ↑ Hetherington, Lh; Battershill, Jm (2013-01-01). "Review of evidence for a toxicological mechanism of idiopathic environmental intolerance". Human & Experimental Toxicology 32 (1): 3–17. doi:10.1177/0960327112457189. ISSN 1477-0903. PMID 23060407. 
  22. ↑ "Idiopathic Environmental Intolerance May Have Psychological Component". Medscape.com. http://www.medscape.com/viewarticle/411615. Retrieved 2008-01-13. 
  23. ↑ "Evidence for a specific link between the personality trait of absorption and idiopathic environmental intolerance". J. Toxicol. Environ. Health Part A 71 (11–12): 795–802. 2008. doi:10.1080/15287390801985687. PMID 18569578. 
  24. ↑ Shorter, E (1997). "Multiple chemical sensitivity: pseudodisease in historical perspective". Scandinavian Journal of Work, Environment, and Health 23 (Supplement 3): 35–42. PMID 9456064. 
  25. ↑ Tuuminen, Tamara (2018). "Multiple Chemical Sensitivity". Journal of Occupational and Environmental Medicine 60 (8): e429. doi:10.1097/JOM.0000000000001369. PMID 29851734. 
  26. ↑ Task Force on Environmental Health (2017). Time for leadership: recognizing and improving care for those with ME/CFS, FM and ES/MCS. Phase 1 report. Toronto, Ontario: Ministry of Health and Long-Term Care; 2017.p.17
  27. ↑ 27.0 27.1 27.2 27.3 Viziano, A.; Micarelli, A.; Pasquantonio, G.; Della-Morte, D.; Alessandrini, M. (November 2018). "Perspectives on multisensory perception disruption in idiopathic environmental intolerance: a systematic review.". Int Arch Occup Environ Health 91 (8): 923–935. doi:10.1007/s00420-018-1346-z. PMID 30088144. https://www.researchgate.net/profile/Alessandro_Micarelli2/publication/326880068_Perspectives_on_multisensory_perception_disruption_in_idiopathic_environmental_intolerance_a_systematic_review/links/5b6c81e9299bf14c6d97c770/Perspectives-on-multisensory-perception-disruption-in-idiopathic-environmental-intolerance-a-systematic-review.pdf. 
  28. ↑ 28.0 28.1 International Programme on Chemical Sensitivity (February 1996). "Report of Multiple Chemical Sensitivities Workshop". Berlin, Germany. https://apps.who.int/iris/bitstream/handle/10665/63109/PCS_96.29.pdf. 
  29. ↑ 29.0 29.1 Rossi, Sabrina; Pitidis, Alessio (February 2018). "Multiple Chemical Sensitivity: Review of the State of the Art in Epidemiology, Diagnosis, and Future Perspectives" (in en-US). Journal of Occupational and Environmental Medicine 60 (2): 138–146. doi:10.1097/JOM.0000000000001215. ISSN 1076-2752. PMC 5794238. https://journals.lww.com/joem/fulltext/2018/02000/multiple_chemical_sensitivity__review_of_the_state.5.aspx. 
  30. ↑ "Multiple chemical sensitivity syndrome". Am Fam Physician 58 (3): 721–8. September 1998. PMID 9750540. http://www.aafp.org/afp/980901ap/magill.html. 
  31. ↑ Council on Scientific Affairs, American Medical Association (1992). "Clinical ecology.". JAMA 268 (24): 3465–7. doi:10.1001/jama.268.24.3465. PMID 1460738. "No evidence based on well-controlled clinical trials is available that supports a cause-and-effect relationship between exposure to very low levels of substances and the myriad symptoms reported by clinical ecologists to result from such exposure.… Until such accurate, reproducible, and well-controlled studies are available, the American Medical Association Council on Scientific Affairs believes that multiple chemical sensitivity should not be considered a recognized clinical syndrome.". 
  32. ↑ A Scientific Review of Multiple Chemical Sensitivity: Identifying Key Research Needs. Published in 2010 by the National Industrial Chemicals Notification and Assessment Scheme, Australian Government. Canberra, Australia http://test.nicnas.gov.au/Media/Latest_News/MCS.asp
  33. ↑ "1.1.2 Studies on the prevalence of MCS in other countries." A Scientific Review of Multiple Chemical Sensitivity: Identifying Key Research Needs. Published in 2010 by the National Industrial Chemicals Notification and Assessment Scheme, Australian Government. Canberra. http://test.nicnas.gov.au/Media/Latest_News/MCS.asp
  34. ↑ 34.0 34.1 Steinemann A. National Prevalence and Effects of Multiple Chemical Sensitivities. J Occup Environ Med 2018;60(3): e152-e6.
  35. ↑ Canadian Community Health Survey (CCHS) 2014, Ministry of Health and Long-Term Care Share File, Statistics Canada.
  36. ↑ Pigatto PD, Guzzi G. Prevalence and Risk Factors for MCS in Australia. Preventive Medicine Reports 2019.
  37. ↑ 37.0 37.1 "Common chemical products making Australians sick, study finds". The University of Melbourne Newsroom. 2 July 2018. https://about.unimelb.edu.au/newsroom/news/2018/july/common-chemical-products-making-australians-sick-study-finds. 
  38. ↑ Steinemann A (2018). "Prevalence and effects of multiple chemical sensitivities in Australia". Prev Med Rep 10: 191–4. doi:10.1016/j.pmedr.2018.03.007. PMID 29868366. 
  39. ↑ "After more than 10 years of Gulf War Veteran medical evaluations, what have we learned?". American Journal of Preventive Medicine 26 (5): 443–452. 2004. doi:10.1016/j.amepre.2004.02.006. PMID 15165662. 
  40. ↑ 40.0 40.1 "Multiple chemical sensitivity syndrome: symptom prevalence and risk factors in a military population". Arch. Intern. Med. 160 (8): 1169–76. April 2000. doi:10.1001/archinte.160.8.1169. PMID 10789611. 
  41. ↑ "Systematic review of multi-symptom conditions in Gulf War veterans." Multi-symptom illnesses, unexplained illness, and Gulf War Syndrome"". Psychological Medicine 36 (6): 735–747. 2006. doi:10.1017/s0033291705006975. PMID 16438740. http://orca.cf.ac.uk/6803/1/Systematic_review.pdf. 
  42. ↑ "Multi-symptom illnesses, unexplained illness, and Gulf War Syndrome". Philosophical Transactions of the Royal Society B 361 (1468): 543–551. 2006. doi:10.1098/rstb.2006.1815. PMID 16687260. 
  43. ↑ Donnay, Albert H (1999). "On the Recognition of Multiple Chemical Sensitivity in Medical Literature and Government Policy". International Journal of Toxicology 18 (6): 383–392. doi:10.1080/109158199225099. https://journals.sagepub.com/doi/pdf/10.1080/109158199225099. 
  44. ↑ Indoor Air Pollution: An Introduction for Health Professionals. Co-sponsored by: The American Lung Association (ALA), The Environmental Protection Agency (EPA), The Consumer Product Safety Commission (CPSC), and The American Medical Association (AMA). 1994. http://www.epa.gov/iedweb00/pubs/hpguide.html#faq1. Retrieved 2008-06-30. "[D]efinition of the phenomenon is elusive and its pathogenesis as a distinct entity is not confirmed....The current consensus is that in cases of claimed or suspected MCS, complaints should not be dismissed as psychogenic, and a thorough workup is essential. Primary care givers should determine that the individual does not have an underlying physiological problem and should consider the value of consultation with allergists and other specialists." 
  45. ↑ Interagency Workgroup on Multiple Chemical Sensitivity (1998-08-24), A Report on Multiple Chemical Sensitivity (MCS), Web.health.gov, http://web.health.gov/environment/mcs/, retrieved 2014-06-08 

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