The ABCs of Medical
Surveillance
1
The Role of Surveillance in Occupational
Health

Systematic monitoring of health events and exposures in
working populations to prevent and control occupational
hazards and their associated diseases and injuries
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Essential Functions
 To gather information on cases of occupational diseases/injuries
and on workplace exposures
 To distill and analyze data
 To intervene on the basis of data to alter the factors that
produced health events and hazards
 To disseminate organized data to necessary parties: workers,
unions, employers, government agencies, the public
2
Role of Medical Surveillance in Occupational
Health
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Public Health Surveillance:
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Population-based
Undertaken by government agencies
Medical Surveillance:
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Ongoing application of medical tests and procedures to individual
workers who may be at risk for occupational morbidity to
determine whether a disorder may be present
Can detect patterns of occupational illness in program participants
Medical screening: If an individual/population is exposed to a
toxin with known effects and the tests and procedures are highly
targeted to detect the likely presence of one or more effects in
these persons
Hazard Surveillance: monitoring of exposure to chemical agents,
physical hazards or radiation in the workplace
3
The Occupational and Environmental History and
Physical Examination
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Examinations:
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Preplacement
Periodic medical surveillance/medical screening
Return to work assessments
Exit examinations
Evaluation for specific occupational exposures
Occupational History:
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List all jobs held and approximate dates of employment
Significant changes in job duties; second jobs
“Have you ever worked with or been exposed to any of the
following…?”
Environmental history: home environs, water source, heating
source, indoor combustion sources, pets, hobbies, work of family
members
4
Preplacement Examinations
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Evolved from a “preemployment:” or exclusionary exam to
Preplacement/Postoffer
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Targeted examination, job focus, business necessity
Americans with Disability Act 1990
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“Otherwise qualified” individuals with disabilities cannot be excluded from
employment if they can perform the essential functions of the job, with or
without reasonable accommodations.
“Physical disability”: an impairment that substantially limits a major life activity
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“Essential Job Functions”:
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“Disability” is defined after mitigating factors are addressed, i.e. medications,
prosthetics
Fundamental – not performed as needed , or occasional; employer decision
Job description – physical tasks as determined by a job analysis specialist
If leaving out a certain function changes the job in a significant manner, than it
is an essential function.
“Reasonable accommodations:
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If a candidate is unable to perform the essential functions of the job
Employers responsibility to determine undue hardship
5
Preplacement Examinations
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Fitness for duty evaluation:
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Determines whether a previously hired employee who was able to perform
the essential functions of the job is still able to safety perform these
essential functions.
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Evaluation post clearance from PCP for non-occup issue

Examining physician should have access to the employees pertinent
medical and personnel records in order to conduct evaluation

If employee will not sign for release of records, may proceed with examination

If disabled or unfit for duty, document the restrictions/limitations

Employer decides if accommodation exists
6
The Medical Surveillance Examination
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>30% of the US workforce receives periodic occupational
health examinations
Screening: 2o prevention which focuses on the individual
for the early diagnosis and treatment
Surveillance: 1o prevention focusing on identification and
elimination of the causes of disease; aggregates info from
individuals to examine patterns within a population.
In accordance with OSHA standard
Many employers conduct programs for hazards without
standards.
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The potential toxicity of ~80% of the chemicals used in the
workplace has not been evaluated in humans or in vivo or in
vitro test systems.
7
OSHA Medical Surveillance Requirements
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Acrylonitrile 29 CFR 1910.1045
Arsenic (inorganic) 29 CFR 1918
Asbestos 29 CFR 1910.1001
Benzene 29 CFR 1910.10288
Beryllium Federal Register 64:253:68853-68914
Bloodborne Pathogens 29 CFR 1910.1030
1,3 Butadiene 29 CFR 1910.1051
Cadmium 29 CFR 1910.1027
Cotton Dust 29 CFR 1910.1027
Diesel Exhaust 30 CFR 72
EEOC/ADA
Ethylene oxide 29 CFR 1910.1047
Formaldehyde 29 CFR 1910.1048
Lead 29 CFR 1910.1025
Methylene Chloride 29 CFR 1910.1052
Noise 29 CFR 1910.95
Record Keeping 29 CFR 1904
Respirator Protection 29 CFR 1910.134
Vinyl Chloride 29 CFR 1910.1017
8
Other Chemicals and Substances
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Acetic Acid
Acrolein
Asphalt/Asphalt Fume
Carbon Disulfide
Carbon Monoxide
Ceramic Fibers
Chlorine
Cholinesterase-Inhibiting Substances
(Pesticides)
Cyanides
Cytotoxic Drugs
Fluoride
Gasoline
Glutaraldehyde
Hydrogen Fluoride
Hydrogen Chloride
Hydrogen Peroxide
Isocyanates
Malathion
Manganese/Manganese Fumes
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Mercury (inorganic)
Metal working fluids
Nickel
Nitrogen dioxide
Ozone
Peracetic acid
Phenol and phenolic compounds
Proteolytic enzymes
Psyllium
Silica (Crystalline)
Silver
Sodium Hydroxide
Soldering
Solvents
Sulfur dioxide
Toluene/Xylene
Triethylamine
Trimellitic anhydride
Zinc Oxide Fumes (Metal Fume Fever)
9
Respirator Protection Standard

Components of the program
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All employees required to wear respirators must take part in the
company’s training program prior to use, annually and with
changes in workplace or type or respirator
Program administrator:
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Oversees hazard assessment, respirator selection, respirator care
and maintenance, medical evaluation, fit testing, employee training,
respirator use, program assessment, record keeping
Nine components:
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Respirator selection, medical evaluation, fit testing, emergency
activities, maintenance procedures and schedules, adequacy of air
quality, quantity/flow for respirators, training regarding respiratory
hazards, and limitation of respirator fit/use/maintenance, evaluation of
effectiveness of the program
10
Respirator Protection Standard

Prior to respiratory selection, employer reviews worker exposures, job
demands and potential adverse effects of interactions; focus on
engineering and administrative controls
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Qualitative vs quantitative testing:
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Qualitative: negative pressure air-purifying respirators (fit factor of 100 or
less) and all positive pressure respirators
Quantitative: used for all respirators
Isoamyl acetate (banana oil), saccharin or Bitrex solution, irritant smoke (
not recommended by NIOSH)
Procedures for IDLH (Immediately Dangerous to Life and Health)
environment: standby personnel must be equipped with respirators
and rescue equipment
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consider all oxygen deficient atmospheres as IDLH
SCBA required for interior structural firefighting
11
Respirator Protection Standard:
Medical Evaluation
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Recommend inclusion of questionnaire, single view chest
x-ray and PFT.
Periodic examinations:
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usually annual questionnaire +/- PFT
CXR: every 5 years or as medically indicated
For workers with lesser exposures: OSHA questionnaire only and
examinations every 2 years
The employer must ensure that a follow-up medical examination is
provided for an employee who gives a positive response to any
question contained in Part A, Section 2, questions 1-8

Tobacco, seizures, diabetes, allergic reactions, claustrophobia,
trouble smelling odors, lung disease, CAD, Medications, Problems
with respirator use. (eye irritation, skin allergies/rashes, anxiety,
weakness/fatigue)
12
Respirator Protection Standard:
Medical Evaluation
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The American National Standards Institute (ANSI), The
National Institute for Occupational Safety and Health
(NIOSH) and ACOEM suggest medical evaluations at
time-based intervals based on worker age and the type of
respirator used.
The American Thoracic Society (ATS) recommends that
workers with respiratory symptoms, workers > 45 years
wearing SCBA and workers > 55 years old have PFTs.
Exercise stress testing (EST):
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> 10 METS without EKG changes unlikely to have clinically
significant CAD
American College of Sports Medicine: Prior to vigorous exercise,
EST for healthy men >40, healthy women >50, persons with 2 or
more cardiac risk factors, or persons with known disease
13
Respirator Protection Standard:
Medical Evaluation

American Academy of Family Practice recommend
exercise ECGs for jobs linked to police safety and require
high cardiovascular performance.
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DOT, NRC, FAA recommend screening certain classes of
workers for asymptomatic heart disease.
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ANSI recommends those who use SCBA or a re-breather
respiratory in strenuous work conditions for EST
14
Age-based Recommended Medical Evaluation
Frequency
AGE
<35
Light to
Moderate Work
Every 5 years
Strenuous work
with SCBA
Every 3 years
35-45
Every 2 years
Every 18 months
>45
Every year
Every year
McClellan, Schusler: Guide to the Medical Evaluation for Respirator Use. Table 3-4, p 59, 2000.
15
Spirometry Interpretation –Obstructive Lung
Disease
 Is FEV1/FVC%pred> LLN (lower limit of normal)?
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YESnot obstructed; IF NO
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Is FEV1%pred> LLN?
 YESborderline obstruction; IF NO
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Is FEV1 (60%pred - <LLN)?
 YESMild obstruction; IF NO
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Is FEV1%(41-59%pred)?
 YESModerate obstruction; IF NO
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Is FEV1< 40%pred?
 YES Severe obstruction
16
Spirometry Interpretation – Restrictive Lung
Disease
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If FEV1/FVC%pred WNL, with FVC < LLN mixed
obstructive/restrictive pattern
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Is FVC%pred> LLN?
 YES Not restricted; IF NO
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Is FVC (60%pred- <LLN)?
 YESMild restriction; IF NO
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Is FVC (51-59% pred)?
 YESModerate restriction: IF NO
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Is FVC < 50% pred?
 YES Severe restriction
17
Lower Limit of Normal for Spirometric Percent Predicted Values from
Knudson Prediction Equation
FEMALE
FVC
76.9%
75.2%
FEV1
70.3%
77.9%
FEV1/FVC%
FEF25-75
85.9%
85.9%
55.3%
59.2%
AGE
FVC
FEV1
FEV1/FVC%
FEF25-75
25-39
81.1%
79.1%
86.9%
55.3%
40-69
73.4%
77.2%
86.9%
40.3%
AGE
25-39
40-69
MALE
McClellan, Schusler: Guide to the Medical Evaluation for Respirator Use.
Table 3-6, p 63, 2000.
18
Respirator Protection Standard:
Medical Decision Making
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Seizures:
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PCPs written opinion
May be approved for respirator use if seizure free for 6-12 months
without impairment or symptoms, no med side effects
May approve: History of early childhood seizure due to fever, isolated
seizure > 5years ago or multiple seizures > 10years ago without
recurrence off medication
Controlled seizure activity (no seizure on/of med in the last year)
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Poorly controlled (changing meds, Workplace exposure to triggers, side
effects from meds
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PCP opinion, non IDLH environment, exam for SCBA, med eval for IDLH
Medical eval, neurologist letter, accommodations or denial
DOT, NFPA 1582: epileptic conditions are disqualifying unless
identifiable precipitant, normal EEG, normal neuro exam, seizure free 1
year off meds, neurologist’s statement
19
Respirator Protection Standard:
Medical Decision Making
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Diabetes
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Episodic, unpredictable impairment of psychomotor abilities due to
hypoglycemia presents the greatest endocrinologic concern for
respirator use
Majority of people with Type 1experience between 1-2
hypoglycemic episodes
Minimum of 17% of people receiving conventional insulin
treatment have a least one severe hypoglycemia episode per year
Issues: shift work, irregular meals, erratic exercise and difficulty
maintaining a regular medication schedule
Driving simulators: driving performance deteriorates significantly
when blood glucose drops below 65mg/ml  Impairs judgment
about physical capabilities
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At least 50% of drivers with low BS decide to drive at least 50% of the
time
20
Plastics, Rubbers and Resins:
Acrylonitrile, 1,3 Butadiene, Vinyl Chloride, Carbon Disulfide
 Acrylonitrile
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Manufacture of acrylic fibers, rubber-like materials, pesticides
OSHA PEL 2ppm, 10ppm ceiling (15minutes)
Health Effects
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Route of exposure: inhalation and skin
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Potent mucous membrane irritant; skin blistering
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Metabolized to cyanide: cyanide/thiocyanate in
blood/urineweakness,asphyxia, death
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Suspected human colon/lung carcinogen
Medical Surveillance: at least annually
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skin, respiratory tract, GI, neurolook for nausea vomiting, dizziness,
weakness, CNS signs that may indicate exposure
CXR, Occult blood for workers>40yrs
Respirator program
Biological monitoring: thiocyanate levels
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Mean postshift urine levels of 11.4mg/l8 hr avg exposure of 4.2ppm
Chronic human toxicity: 16-100ppm for 20-45 min nasal irritation, H/A ,
nausea, fatigue
21
Plastics, Rubbers and Resins:
Acrylonitrile, 1,3 Butadiene, Vinyl Chloride, Carbon Disulfide
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1,3 Butadiene
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Exposure occurs primarily through inhalation during monomer/polymer production
OSHA PEL 1ppm (TWA), 15 minute STEL of 5ppm, action level 0.5ppm
Health Effects:
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Liquidskin burns, frost bite; Gas mucous membrane irritant, blurred vision,
cough, drowsiness
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Anesthetic at high concentrations
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Human/animal carcinogens: leukemia and lymphosarcoma; male/female
reproductive toxicity and embryo toxicity in animals; infertility, miscarriage,
anemia
Medical Surveillance:
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> PEL on 10 or > days/yr
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> PEL on > 30days/yr for 10 or more years
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> the action level on 60 or more days/yr for 10 or more years
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Above 10ppm on 30 or more days in any past year
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Any employee exposed in an emergency situation
 Medical screening no later than 48 hours after the exposure
 CBC within 48 hours of the exposure, repeated monthly for 3 months
22
1,3 Butadiene (cont)
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Medical Surveillance:
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Health questionnaire yearly, emphasis on blood disorders
Exam focused on lymphatic system, liver, spleen, skin
Respirator standard
CBC with diff and platelet count
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Before employees assuming duties in a job with BD exposure,
Every 3 years after the initial physical exam or at the discretion of
health professionals
At time of reassignment to an area where exposure is below the
action level
At termination of employment if 12 months have elapsed since last
physical examination
23
Plastics, Rubbers and Resins:
Acrylonitrile, 1,3 Butadiene, Vinyl Chloride, Carbon Disulfide
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Vinyl Chloride
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Primary use is production of Polyvinyl Chloride
OSHA PEL 1ppm (8 hr TWA); STEL 5ppm (15 minutes)
Health Effects:
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Historically – narcosis, acroosteolysis (resorption of the terminal phalanges)

1970s epidemiological studies showed link to hepatocellular injury and
angiosarcoma of the liver
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Pneumoconiosis: high dust exposure >10mg/m3
Medical Surveillance:
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History: alcohol use, hepatitis, exposure to hepatotoxic drugs/materials, blood
transfusions
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Exam: liver, spleen, kidneys, skin, connective tissues and respiratory
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Examine annually; if working with VC/PVC manufacturing for 10 years or
longer, must be examined every 6 months
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Lab findings:
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Elevated liver enzymes/alkaline phosphatase,
Fasting levels of serum bile acids/urinary coproporphyrins – indicators of
early chemical industry
Alpha glutamyl transpeptidase level ~vinyl chloride exposure, greater
specificity
Liver US – periportal fibrosis among highly exposed workers.
Biomarkers: p63 and DNA adducts under investigation
24
Plastics, Rubbers and Resins:
Acrylonitrile, 1,3 Butadiene, Vinyl Chloride, Carbon Disulfide
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Carbon Disulfide (not federally mandated)
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Intermediate for other chemical (I.e. carbon tetrachloride) and products
(cellophane, rayon viscose fibers, adhesives, herbicides); manufacture of
optical glass
OSHA PEL 20ppm (8 hr TWA); STEL 30ppm; 30minutes maximum
allowable exposure 100ppm; IDLH (immediately dangerous to life and
health) 500ppm
Health effects:
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Foul odor desensitizes olfactory system
Skin and Inhalation: skin irritation, mucous membranes (esp eyes), CN deficits, peripheral
neuropathy, paresthesias, unsteady gait and dysphagia; Nerve damage does not resolve
with end of exposure
Extreme intoxication – parkinsonism-like syndrome, psychosis and suicide
May accelerate the development or worsen heart disease – risk decreased with removal
Eyes: microaneuryms
Ears: high frequency hearing loss/ vestibular symptoms of vertigo and nystagmus
Effects libido; women at <10ppm menstrual abnormalities, spontaneous AB, premature
births
No carcinogenicity
25
Carbon Disulfide (continued)
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Medical Surveillance:
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History/exam: eyes, skin, central and peripheral nervous systems,
CAD, liver, kidneys
History and physical exam every 3-5 years
Biological monitoring:
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Preshift urines for 2-thiothiazolidine-4-carboxylic acid (TTCA)
Spot urine of 0.95 mmol per mole of Cr proposed as a reliable
indicator of recent exposure
5mg corresponds to an 8 hr TWA
26
Healthcare: Formaldehyde and Ethylene Oxide
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Formaldehyde
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Backbone of chemical industry
Tissue preservative and disinfectant; construction and insulation
materials, cosmetics, fertilizer, textiles, foundries, pesticides/fumicides,
ink, photography and others
OSHA PEL 0.75ppm 8-hr TWA; STEL 2ppm (15min); Action level
0.5ppm; IDLH (Immediately dangerous to life and health) 100ppm
Health Effects:
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1ppm – potent irritant of eyes, skin, mucous membranes and
respiratory tract

Dermatitis, sensitization
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Lungs: rapid absorption and excreted as formic acid; bronchitis,
allergic/asthmatic reactions, pulmonary edema
 Sensitization: occupational asthma associated with formaldehyde
resin dust

Probable human carcinogen – lung, nasopharyngeal, malignant
melanoma, pancreatic cancer in embalmers

Neuropsychologic issues; spontaneous abortion (cosmetologists/lab
workers with use of disinfectants and formalin); delayed conception in
woodworkers
27
Formaldehyde (continued)
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Medical surveillance
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Focus on respiratory, skin, eyes and mucous membranes and to
allergens/allergic reactions
General medical questionnaire; exam focused on eyes, skin,
mucous membranes and upper respiratory tract
Baseline PFT and annually
Respirator Standard
Biological Monitoring
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Urinary formate: useful with ambient concentration of >1ppm
Low level exposure during embalming associated with
cytogenetic changes in epithelial cells of the mouth and in blood
lymphocytes; may be useful biologic monitoring
28
Healthcare: Formaldehyde and Ethylene Oxide
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Ethylene Oxide (ETO)
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Manufacture of ethylene glycol (antifreeze, polyester, film, bottle),
detergents, textile chemicals, pesticide, hospital sterilant, medical
products
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Mostly used in closed operations (<1ppm)
Potential exposure: maintenance, repair, product sampling,
loading/unloading transport tanks
~0.02% of production used for sterilization in hospitals; NIOSH
estimates that 75,000 health care workers have potential
exposure to ETO.
Field surveys of hospital gas sterilizers have generally found 8 hr
TWA exposures <1ppm; opening sterilizer, transfer of sterilized
instruments to central supply, tank changes
OSHA PEL 1ppm TWA, 5ppm excursion limit (15min)
NIOSH: REL <0.1ppm TWA; 5ppm ceiling (10min/d)
29
Ethylene Oxide (continued)
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Health Effects:
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Ether-like odor, but odor threshold 700ppm
Absorbed through skin, respiratory tract
Binds to DNA; may cause cellular mutation
Irritating to eyes, respiratory tract, skin, respiratory depression at
high concentrations
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URI irritation between 200-400ppm
>1000ppm may cause H/A, nausea, dypsnea, vomiting, drowsiness,
weakness, incoordination
Splashes can cause burns
Reproductive toxicity men and women: increase spontaneous AB
and preterm birth
Human carcinogen-lymphatic/ hematopoietic, stomach
Neuropsychiatric, neuropathy
Occupational asthma
30
Ethylene Oxide (continued)
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Medical Surveillance
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Exposed at or above action level for at least 30 days during the
past year; upon termination of employment, reassigned to a work
area with ETO exposure below the action level; emergency
exposure of signs and symptoms
Pulmonary, hematologic, neurologic, reproductive systems
Initial white blood cell count and periodically if exposure >0.5ppm
8-hr TWA or of intermittent exposures exceed 5ppm
 Consistent changes in CBC have not been demonstrated
 Can see elevated numbers of eosinophils, RBC, HCT
Biological monitoring
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Increased chomosomal aberrations
31
Solvents/Paints
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Benzene
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Core of aromatic hydrocarbons;
Aromatics include benzene, toluene (methyl benzene), xylene
(dimethyl benzene), ethyl benzene, cumene (isopropyl benzene)
styrene ( vinyl benzene)
Half of benzene used to synthesize ethyl benzene for production
of styrene.
Toluene/Xylene principally used in paints adhesives and
pesticides.
OSHA PEL 1ppm 8-hr TWA
STEL 5ppm over 15 minute period
Action level 0.5ppm
32
Benzene (continued)
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Health Effects
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Acute anesthetic, respiratory tract irritation, dermatitis,
neurobehavioral dysfunction
Benzene: bone marrow, aplastic anemialeukemia (acute neuro
behavior
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No evidence that substituted benzenes have any of the myelotoxic
effects.
Toluene: renal tubular acidosis, cerebellar ataxia
Toluene/xylene: raise auditory thresholds in animal at low level
Benzene: human carcinogenicity
33
Benzene
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Medical Surveillance:
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All employees who are or may be exposed to benzene at or above
the action level for 30 days or more per year and employees
engaged in certain manufacturing must have surveillance
Past exposure to benzene and other heme toxins, blood
dyscrasias (hematologic neoplasms, genetic heme abnormalities),
renal or liver dysfunction, medicines, previous exposure to
ionizing radiation and marrow toxins.
Annual physical examination for signs related to blood disorders;
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CBC, WBC with differential, quantitative thrombocyte count, indices
(MCV, MCH, MCHC)
Emergency exposure: provide end of shift urinary phenol within 72
hours; urine specific gravity is to be corrected to 1.024.

If urinary phenol = to or > than 75mg/l, CBC, RBC count, WBC with
diff and thrombocyte count monthly for 3 months.
34
Solvents/Paints

Methylene chloride:
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Paint remover, manufacture of urethrane film
OSHA 8-hr TWA PEL of 25 ppm and STEL of 125 ppm
Health effects – Inhalation hazard

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CNS depression: coordination/alertness
Cardiac toxicity: Metabolized to CO – susceptible individuals include
persons with heart disease and those with risk factors for hear
disease
Liver toxicity
Medical surveillance
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At or above the action level (1/2 PEL) on 30 or more days per year or
above the 8-hr TWA PEL or the STEL 10 or more days per week.
Neuro, skin, hematologic, liver disease, heart disease, risk factors for
cardiac disease.
35
Methylene Chloride (continued)

Medical surveillance (continued)

Annual updates of the medical/work histories for each affected
employee

Physical examinations, including lab surveillance


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45 yrs or older within 12 months of initial surveillance or any subsequent
surveillance
<45 years within 36 months of initial surveillance or subsequent
surveillance
If employee leaves the employers workplace to is reassigned to an area
where exposure to MC is consistently at or below the action level and
STEL, medical surveillance must be made available at that time if 6 months
or more have elapsed since the last medical surveillance.
Must provide opinion concerning whether exposure to MC may
contribute to or aggravate the employees existing cardiac, hepatic,
neurology, dermal disease and whether employee has any other
medical condition that would place him at increased risk of material
impairment from exposure to MC
36
Metals – Arsenic, Beryllium, Cadmium, Lead,
Mercury (inorganic)

Arsenic
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

Elemental, trivalent, pentavalent – most common inorganic forms
Most reports of acute/chronic toxicity – arsenic trioxide

Pentavalent  trivalent
Arsine gas- extremely potent/acute poison; used in microelectronics and
in the manufacture of gallium arsenide substrates
Arsenic trioxide/pentoxide used in pesticides
Metallic arsenic – alloy for hardening lead in battery grids, bearing, and
cable sheaths
Exposure: maintenance, manufacture, flu dust (smelting)
Environment: average daily intake: 10-50ug/d; drinking water standard
10ppb, organic arsenic compounds present in seafood – not metabolized,
excreted unchanged
37
Arsenic (continued)






Ingestion and inhalation; limited skin absorption
Taken up by RBCliver, kidney, muscle, bone, skin, hair
As: OSHA PEL and ACGIH TLV 0.01mg/m3 TWA
Arsine: OSHA PEL and ACGIH TLV 0.05ppm
Health Effects:
 Irritation to skin, eyes, mucous membranes
 GI (fluid loss, bleeding)
 Nervous system: Neuropathies, weakness, paralysis
 Cardiomyopathy, peripheral vascular disease
 Lung Cancer, leukemia, lymphoma, angiosarcoma of the liver
Medical Surveillance:
 Absorbed trivalent arsenic is metabolized to dimethlarsinic acid
(DMA) and monomethylarsonic (MMA) and excreted in the urine
with a half-life of 10 hrs
 Organic arsenic cpds excreted unchanged in the urine
38
Arsenic (continued)

Medical Surveillance

Preplacement surveillance






Periodic surveillance



For workers exposed to inorganic arsenic for at least 30 days per year
Focus on history of smoking history and evidence of respiratory disease
CXR – PA view
Nasal and skin exams
Respiratory standard: exposed above action level (5ug/m3)
For covered employees <45 years old with < 10 years employment in areas
exceeding the action level; annual interim history
For other covered employees, interim history, physical exam and lab studies
every 6 months
Lab studies:



Measure DMA, MMA eliminate confusion over dietary sources or organic
arsenic compounds
Nonexposed workers<10ug/g Cr
Workers exposed to 0.01mg/m will have level of 50ug/g Cr
39
Metals – Arsenic, Beryllium, Cadmium, Lead,
Mercury (inorganic)

Beryllium







Production of hard, corrosion-resistant alloys for use in the
aerospace industry; nuclear reactors, ceramics, semiconductors
Mining of beryllium ore is not associated with adverse health
effects; use of beryllium compounds, especiallly beryllium oxide
carries substantial risk of disease
Exposure to minute ultrafine particles, rather than total mass/dose
is key factor in sensitization
OSHA PEL 2.0ug/m3;NIOSH REL not to exceed 0.5ug/m3; ACGIH
TLV 0.2ug/m3
Poorly absorbed after inhalation, ingestion or skin
Retained in lung, deposited in bone, liver and
spleenNoncaseating granulomas
Slow renal excretion; confirms exposure, levels usually
undetectable in nonexposed individuals.
40
Beryllium (continued)


Health effects:

Acute exposure: irritant effects on eyes, mucous membranes, respiratory tract;
tracheobronchitis, chemical pneumonitis, pulmonary edema; after skin contact
irritant/allergic dermatitis, granuloma

Chronic exposure: exertional dypsnea, fatigue, wt loss, rales, lymphadenopathy,
clubbing, pulmonary HTN

Lung cancer in humans; lung cancer, osteogenic sarcoma in animals
Medical Surveillance

Preplacement:

Medical/occupational histories: previous or anticipated exposure

Respiratory standard as appropriate

Physical exam: skin, eyes, respiratory tract

CXR – B reader, PFT

Be-induced lymphocyte proliferation (Be-LPT): confirms sensitization

Periodic:




Annually for beryllium workers, every 3 years for beryllium associated workers
Hx, PE, Respiratory Questionnaire
Be-LPT
CXR every 5 years
41
Metals – Arsenic, Beryllium, Cadmium, Lead,
Mercury (inorganic)

Cadmium






Metal plating, solder, smelting (cadmium oxide), battery alloys, pigments,
printing, semiconductors
Present in the diet (liver, shellfish, meat by-products, vegetables),
environmental exposure – exposure to cigarette smoke @ 2ug/day
Absorbed primarily through ingestion; inhalation 10-40%; GI 5%
Renal excretion with t1/2 of 8-30yrs cadmium nephrotoxicity
OSHA PEL – 5ug/m3 at 8 hr TWA; Action level – 2.5ug/m3
Health effects:


Acute inhalation: sore throat, H/A/, myalgia, nausia, fever, metallic taste 
SOB, chemical pneumonitis, respiratory failure; hepatic/renal injuty
Chronic exposure: proteinuria with excretion of LMW proteins (B1, B2
microglobulins) renal stones, bone pain, pulmonary fibrosis, emphysema,
central/peripheral nervous system, human carcinogen (lung, GU,Prostate),
reproductive effects (testicular)
42
Cadmium (continued)

Medical Surveillance

Preplacement::





Medical/Occupational hx: cardiovascular, respiratory,
renal,reproductive, musculoskeletal, hematopoietic
Physical exam: including prostate exam for male >40
CXR/PFT – pulmonary toxicity/respirator use
Kidney, liver, Hb
Annual exam for employees with exposure > 30 days
43
Cadmium (continued)
Actions
Biological Monitoring Result
Annual biological monitoring
Medical exam every 2 year
Urine Cad < 3ug/g Cr
B2-Microglobulin < 300ug/g Cr
Cadmium in blood < 5 ug/L whole blood
Semiannual biological monitoring
Medical exam annually
Exposure assessment
Exposure control
Urine Cad 3-7 ug/g Cr
B2 Microglobulin 300-750 ug/g Cr
Cadmium in blood 5-10 ug/L whole blood
Mandatory removal
Biological monitoring every 3 months
Medical examination every 6 months
Exposure assessment
Urine cadmium >7ug/g Cr
B2-Microglobulin >750ug/g Cr
Cadmium in blood >10ug/L whole blood
44
Metals – Arsenic, Beryllium, Cadmium, Lead,
Mercury (inorganic)




Productions of electrical equipment, instruments, medicinal/skin care
products, lubrication oils
Exposure via inhalation of mercury vapor, ingestion, skin contact
with liquids or salts
ACGIH TLV 0.025mg/m3
Health effects:



CNS, blood, kidneys, liver, respiratory
Mercury vapors: Micromercurialism – weakness, fatigue, weight loss,
mercurial “facies” (tremors), “Mad as a hatter”.
Medical Surveillance




Focus medical/occupational hx: CNS, respiratory, kidneys, skin
Urine Hg history of exposure
Workplace monitoring – urine is first choice
Normal concentrations: nonexposed <0.01mg/L whole blood; <10ug/g Cr
urine; substantial seafood consumption – high blood levels with low urine
levels
45
Mercury (inorganic)
Medical Surveillance
Action
Air Exposure
Urine HG Level
>50ug/m3
>100ug/g creatinine
50ug/m3
75-100ug/g Cr
25-50ug/m3
50-75 ug/g Cr
Monitor monthly
25 mg/m3
35-50ug/gCr
Monitor quarterly
<25ug/m3
<35ug/g Cr
Monitor semiannually
Remove from exposure
until <50
Medical exam if over 150 or
if (2) consecutive levels
exceed 100
Repeat measurement
weekly
Monitor weekly
Perform hygiene
assessment to limit
exposure
46
Metals – Arsenic, Beryllium, Cadmium, Lead,
Mercury (inorganic)

Lead:




Storage batteries, alloys, pipes, cable sheathing solder, paints/plastics, cosmetics,
munitions, glassware, jewelry
Occupational exposure is a result of a combination of inhalation and ingestion
Environmental exposure: auto exhaust, near lead smelters, moonshine, acidic
foods/beverages in ceramics, herbal remedies
Approximately 40% of inhaled lead oxide fume absorbed through the respiratory
tract; GI absorption 5%



Greater GI absorption in infants/children
Iron, Ca deficiencies and high fat diets increase GI absorption
Metabolism:





Bound to RBC’s free fraction in plasma distributed to brain, kidney, liver, skin,
muscle
Crosses the placenta (fetal level ~maternal levels), pregnancy mobilizes lead
Bone is major site of deposition of absorbed lead
Binds to sulfhydryl groups (found in hair and nails)
Excreted primarily via kidney; t1/2 5-10 years
47
Lead

Water soluble alkyl lead compounds are readily absorbed
through skin contact, inhalation or ingestion




Tetraethyl/methyl lead tri alkyl metabolites toxicity
Accumulates in CNS – fat soluble
Ultimately converted to inorganic lead and excreted in urine
Health Effects


Acute: GI (abdominal pain, constipation, N/V tarry stools);
Neurologic manifestations of lead encephalopathy (H/A, confusion,
stupor, coma, seizures); Renal failure/oliguria
Chronic:


Early: Fatigue, irritability, vague GI symptoms, arthralgia/ myalgias
Later: confusion, memory, distal motor neuropathy (wrist/.foot drop);
encephalopathy/seizures/coma; infertility (spermatogenesis,
spontaneous AB); HTN, cardiac conduction, gouty arthritis,
nephropathy
48
Lead

Medical Surveillance
 Focus on lead exposure history, hygiene, GI, heme, renal, repro,
neuro, pulmonary status (respiratory use), BP
 Labs:
 BLL (blood lead level), ZPP, HB/HCT, Cr/UA



BLL – recent exposure (days/weeks); nonexposed: 1-5ug/dl; subtle
effect on central/peripheral nervous system 30-50ug/dl
ZPP – alters heme synthesis increase ZPP

Recent studies: at BLL of 17ug/dl see increase ZPP

Abnormal for @120 days

Represents average lead exposure for past 3 months

Limited usefulness since health effects occur at much lower
levels (CDC recommends <10ug/dl for children)
Chronic exposure:


K-band xray fluorescence of bone is best
EDTA lead mobilization test (>350ug/L) confirms past exposure,
but not lead toxicity
49
Lead

Medical surveillance (continued)

Medical examinations:




Yearly for BLL > 40ug/dl
Prior to assignment
Signs/symptoms of toxicity
Medical surveillance:




Required for exposure to air level > 30ug/m3 for at least one day in 12
months
BLL every 6 months if <40ug/dl
BLL every 2 months if > 40ug/dl until (2) consecutive determinations
are < 40 ug/dl
Monthly during medical removal




For >60ug/dl
Average levels >50ug/dl
Risk of health impairment
May return if (2) consecutive BLL <40ug/dl
50
Welding



Application of heat/pressure to join metal
Primarily manual arc welding used, but automation increasing
Health hazards: metal fumes, particulates, gases, radiation (infrared,
UV), noise, electricity, ergonomic stress
 Main exposure is to iron oxidebenign pneumoconioisis
 Exposure to manganese, fluoride films
 Chromium/Nickel/manganese present in stainless steel alloys
 Stainless steel surface reflects UV radiation  nitrogen oxide,
ozone
 Low hydrogen welding of stainless steel generates high
concentration of fluoride fumes, aluminum oxide formation
 Cadmium containing silver solder generates cadmium
oxideacute lung injury, death
 Soldering: low temp, generally not associated with significant
metal fumes; exposure to lead dust; Rosin- skin sensitizers,
allergic dermatitis
51
Welding (continued)

Acute Exposure:



Photokeratitis: UVB radiation exposure for several seconds- pain,
burning, grit-like feeling; conjunctival injection; punctate depressions over
cornea; self-limited, resolving in several hours
Metal fume fever: i.e. Zn – benign, self limited with delayed onset of 8-12
hours; fever, chills, cough, myalgias, metallic taste
Pulmonary





Upper respiratory irritation: dusts, ozone, aluminum oxide, nitrogen oxides,
cadmium oxide
Asthma: chromium, nickel
Acute lung injury and pulmonary edema: nitrogen oxide, cadmium oxide
Musculoskeletal trauma
Chronic exposure:


Siderosis – accumulation of nonfibrogenic iron oxide particles in the lung
Small increases in lung cancer – chromium and nickel in welding of
stainless steel
52
Mineral Fibers:
Asbestos and Man-Made Mineral Fibers (MMMF)

Asbestos




Thermal and electrical insulation for fireproofing, in cement products such as pipes
and panels
Significant exposure due to demolition of asbestos containing buildings
Generally believed that all forms (serpentine and amphiboles) of asbestos have
these effects:

Serpentine (chrysotile)

90% of asbestos found in the US
 On per fiber basis, highest risk of lung cancer – very long thin fibers

Amphiboles ( amosite, crocidolite, anthophyllite, tremolite)

Most common are chrysotile, amosite, crocidolite
Health effects



Inhalation of fibers: asbestosis, pleural inflammation, mesothelioma and other
lung cancers
No acute symptoms; chronic effect can take up to 40 years to manifest
Non-smoker: 5X increased risk of lung Cancer; Smoker: up to 100x risk
53
Asbestos (continued)


OSHA standard: 0.1 fiber/cm3 of air as an 8hr TWA for fibers longer
that 5 um and having a length to diameter ratio of at least 3:1 or
excursion limit of 1 fiber/cm3 for 30 minutes
Medical Surveillance
 For all workers exposed to asbestos fibers at or above the TWA
or excursion limit
 Preplacement surveillance
 Focus on respiratory system, cardiovascular, GI, PFT’s CXR
 Asbestos questionnaire
 Respirator standard
54
Asbestos (continued)

Periodic surveillance
 Abbreviated OSHA asbestos questionnaire/CXR according to
schedule below
Yrs since
first
exposure
Age 15-35
yrs
Age 35+ to
45
Age 45+
0-10
Every 5 years
Every 5 years
Every 5 years
10+
Every 5 years
Every 2 years
Every 1 year
55
Mineral Fibers:
Asbestos and Ceramic Fibers/Man-Made Mineral Fibers
(MMMF)

Ceramic Fibers




One of a group of insulating materials known as MMMF
Produced from aluminum oxide, silicon oxide and other metal
oxides
PEL for respirable dust is 5mg/m3; Exposure limit of 1fiber/cc as
a TWA for ceramic fibers
Surveillance



Medical/occupational histories with emphasis on the skin and
respiratory tract
Physical exam
Chemistries, blood count, PFT, CXR
56
Hydrofluoric Acid




Intermediate in production of fluorocarbons, aluminum fluoride,
cryolite; in production of uranium hexafluoride; metal cleaning, glass
etching, polishing applications; occupational exposure can occur
both by direct skin contact and by inhalation of fumes
Corrosive: causes calcium precipitation, stimulate nerve endings;
binds body calcium causing life threatening systemic hypocalcemia
after skin exposure or osteosclerotic bone changes after chronic
exposure to HF ions; treat skin exposure with calcium gluconate
Workers with evidence of renal disease, impaired pulmonary
function, scarring of the skin or cornea or osteosclerosis should be
evaluated by a physician and if appropriate, informed of possibility of
increased health risk from HF exposure.
Nonemergent exposures:



UA, skin, cornea exams, hip xray (for males) should be offered
Respiratory irritation: CXR, PFT
Eye complaints: visual acuity/ophthalmological examination
57
Hydrofluoric Acid

Biological monitoring


ACGIH TLV – 3.0ppm 8-hr TWA and STEL 6ppm
Preshift spot urinalysis


Post shift urinalysis



Evaluates accumulation of fluoride
Collect at end of workshift after (4) consecutive days of exposure
If post shift urinary fluoride level exceeds 7.0mg/L, preshift spot
urine samples for analysis should be collected within 2 weeks and
a repeat post shift urinalysis


Collect at start of work shift at least 48 hrs after the last occupational
exposure
If second sample is > the preshift limit of 4.0mg/L or post shift limit of
7.0mg/L, evaluated dietary sources, personal hygiene, basic work
practices and environmental control
Job classification: evaluate all workers urinary fluoride levels on a
group basis – if median post shift urinary fluoride levels >7.0mg/L,
proceed with IH survey
58
Cyanide







Available as gas and technical liquid
(3) most common cyanide salts: sodium, potassium, calcium
Cyanide inhibits transfer of oxygen to cells
OSHA PEL for cyanide salts is 4.7ppm; for potassium cyanide – 10ppm
Acute exposure:

Lesser exposure: irritation of eyes, nose, throat, weakness, H/A, confusion,
respiratory abnormalities, coma, convulsion

Minor symptoms after several minutes at breathing levels of 10-30ppm

Death within an hour at level of 100ppm
Chronic exposure:

Symptoms may persist for several months following cessation of exposure
Surveillance:



Medical and occupational histories to evaluated any chronic effects: H/A,
nausea, dizziness; emphasis on skin, cardiovascular, pulmonary edema
Periodic surveillance on basis of workers exposure potential to cyanides and
judgement of the physician
Treatment: amyl nitrate by inhalation, followed by sodium nitrate
intravenously, then sodium thiosulfate IV
59
Biological Monitoring





Measurement of a chemical, its metabolite, or a nonadverse
biochemical effect in a biological specimen for the purpose of
assessing exposure
Blood, urine, exhaled air
Measures total exposure ( quantity of chemical absorbed regardless
of route of administration) vs workplace exposure (environmental
monitoring)
Assesses the extent of exposure, therefore only an indirect
measurement of risk of health effects as a result of exposure
Necessary conditions to consider biological monitoring





Determinant must be present in blood, urine, exhaled air; suitable for
sampling; acceptable sampling method
Method of analysis should be practical, produce valid reproducible
results over the range of concentrations
Strategy of sample collection produces representative samples
Results can be interpreted
Action required for aberrant result established prior to monitoring
60
Biological Monitoring

Methodology:

Timing of Collection is critical



For chemicals with a short t1/2, the difference between sampling 15
minutes vs 1 hour after the end of exposure may alter the result by as
much as a factor of 10.
Collection methods: proper containers, contamination with
unwashed hands or clothing
Body site sampled

Blood: most accurate


Volatile substances with short t1/2, have a variation in blood level
Urine: easier to sample


24 hour urine most accurate
Spot urine most practical; have to adjust for urine specific gravity or
Creatinine; Highly concentrated (SpG>1.030 or Cr>3g/L) or highly dilute
(Spg<1.010 or CrM0.3-0.5g/L) usually not suitable for monitoring and a
new specimen should be collected
61
Biological Monitoring

Methodology (continued)

Exhaled air


Selecting a Lab




Measurements of chemicals in exhaled air are with mid – exhaled or
end-exhaled
Only national certification in US if for blood lead
California – only state with state certified labs for state mandated
cholinesterase testing for pesticide handlers
WHO has conducted international quality assurance program for
blood lead and urine cadmium determinations
Terminology

No Adverse Health Effect Level: level at which almost all workers will
be free of symptoms, signs and adverse clinical lab test results

Repro and Ca effects are not considered when calculating this level.
62
Biological Monitoring

Terminology (continued)



BEI (Biological exposure indices): level that corresponds to the level
measured in a worker exposed to a substance at the TLV-TWA;
reference biological monitoring levels established by the ACGIH
Clinical Effect Level: level associated with signs, symptoms, abnormal
lab tests
Timing of collection: most important for determination of the No Adverse
Health Effect Level


If t1/2 (rate of elimination of an agent) is short (min-hours), timing of critical; if
long (days to weeks) timing not critical
Relative to standard work day and work week






PNS – Prior to next shift = 16 hrs after last shift
EOS – End of shift = 15-30 minutes after the last exposure
DS – during shift
EWW – end of work week
L2H – last 2 hrs of shift
L4H – last 4 hrs of shift
63
Who Needs the DOT Medical Card?

Federal Motor Carrier Safety Regulations
(FMCSRs):

Commercial Motor Vehicle



16 or more passengers including driver
Transports hazardous materials
Vehicle weight

10,001-26,000 lbs


Medical card
26,001 or greater



Medical card
Drug and alcohol testing
CDL license
64
Automatic Disqualifications




Epilepsy
Hearing loss not correctable by hearing aid
Current diagnosis of alcoholism
Vision deficit


Must have 20/40 both eyes, peripheral vision >
70 degrees
Methadone use
65
Potential Disqualifications








Monocular vision
Hypertension
Loss of limb
Musculoskeletal disorder
Heart condition
Respiratory condition
Psychiatric illness
Controlled substance use

Narcotics, benzodiazepines
66
Insulin Dependent Diabetes Update

September 3, 2003




Type I diabetes no longer automatic disqualifier
Significant documentation and specialist visits
required to complete application for exemption
on part of driver
Must have annual exam by endocrinologist AND
DOT recertification
Must comply with rules for diabetic control as set
forth by FMCSA
http://a257.g.akamaitech.net/7/257/2422/14mar20010800/edocket.access.
gpo.gov/2003/03-22409.htm
67
New Guidelines for Cardiovascular
Conditions

Oct. 2002 Conference on Cardiac Disorders
and CMV drivers



Shorter time for recertification post-MI
Test of cardiac ejection fraction for many
conditions
Implantable defibrillator disqualification
http://www.fmcsa.dot.gov/rulesregs/cardio.htm
68
Blood Pressure Guidelines

Part 391 Federal Register-Qualifications of
Drivers




In effect as of 9/30/04
Diagnosis of hypertension on medication requires
more frequent certification
BP should be measured on 3 separate occasions
while sitting to make determination of high BP
If driver has no history of hypertension and has a
BP of 140/90, he can be certified for up to 2 years
on initial examination.
69
New Blood Pressure Guidelines for
Drivers with Diagnosis of Hypertension

Stage 1: 140/90-159/99


Stage 2: 160/100-179/109



Certify one year
3-month certificate, treat, re-evaluate
If BP at 3 months <140/90 recertify annually
Stage 3: 180/110


No certification until BP 140/90
Then recertify every 6 months
70
Periodic Evaluation of Hypertensive
Drivers

Periodic screening and evaluation for “target
organ” damage





Heart failure
Stroke
Retinopathy
Kidney damage
Coronary artery disease
71
Heart Conditions: Ischemia


Focus: strength of the heart and risk of
irregular heart beat (arrhythmia)
Risk factors:


HTN, tobacco, Chol, LDL, DM, obesity, inactivity,
family history, >60yrs old, male, postmenopausal
women
Truck drivers may have increased number of risk
factors – sedentary job, irregular hours, dietary
habits
72
Heart Conditions: Myocardial Infarction
(MI)

New definition


Joint European Society/American College of
Cardiology Committee in 2000
More people meet criteria for an MI due to
increased accuracy in diagnoses


2 month wait period after MI rather than 3 months




Elevated troponin levels but no elevation of CPK-MB
ETT 4-6 weeks post MI, repeat every 2 years
Ejection fraction must be > 40%
No medication side effects
Recertification annually
73
Heart Conditions: Angina

Annual recertification

ETT at least every 2 years

No angina at rest

Stable blood pressure

No medication side effects
74
Heart Conditions: Percutaneous
Coronary Interventions




RTW 1-week post-procedure for stable
angina, unstable same as MI protocol ( 3
months)
ETT 3-6 months post-procedure and at least
every 3 years
Stable blood pressure
No medication side effects
75
Coronary Artery Bypass Surgery

3 month waiting period

Must be stable on medication for at least 1 month

ETT annually

Resting EKG

Ejection fraction > 40%
76
Heart Conditions: Arrhythmias

Atrial fibrillation and Ventricular Tachycardia





Stable 1 month on medication
Annual certification
Blood thinners not necessarily disqualifying
WPW and Long QT syndrome: automatic
disqualification
Pacemakers


If underlying disease is not disqualifying certify
after 3 months
Annual recertification
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Valvular Heart Disease

Cardiology evaluation


Types:




EKG, chest x-ray, ETT, Echocardiogram
Mitral stenosis, Mitral regurgitation
Aortic stenosis, Aortic regurgitation
If no disqualifying factors (valve area and
symptoms) than annual recertification
Repeat testing may be needed from every 612 months to every 5 years
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Vascular Disease

Abdominal aneurysms




>5cm disqualifying
4-5cm disqualifying if symptomatic or pending
surgery
<4cm – recertify annually if asymptomatic and no
surgery planned; annual Ultrasound to monitor
size
3 month wait after surgery
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Peripheral Vascular Disease

Generally not disqualifying unless resting
pain in lower extremities

3 month waiting period after vascular
surgery

Annual recertification
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Deep Vein Thrombosis

Disqualifying unless adequately treated

On medication at least one month such as
Coumadin with monthly blood testing

Annual recertification
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Heart Transplantation

Can consider certification after 1 year waiting
period

Recertification every 6 months
82
Respiratory Dysfunction



Qualified to drive a commercial motor vehicle if
“…no medical history or clinical diagnosis of a
respiratory dysfunction likely to interfere with
ability to control and drive a CMV.”
Sec.391.41(b)(5)
Impairment in respiratory function under
emergency conditions (when greater oxygen
supply is necessary for performance) may be
detrimental to safe driving
If the medical examiner detects a respiratory
dysfunction that in any way is likely to interfere
with the drivers ability to drive, the driver must be
referred to a specialist for evaluation and
treatment
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Respiratory Dysfunction: Sleep Apnea


Included in the advisory criteria as a
respiratory condition that “may result in
incapacitation”
Resulting daytime somnolence/decreased
alertness is potential cause of MVA



2-4 fold increase in MVA in untreated sleep apnea
New medical exam form addresses sleep
disorders
100,000 – 150,000 commercial drivers have
sleep apnea
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Respiratory Dysfunction: Sleep Apnea

Affects 2-3% of adult males


3 key risk factor




Obese, middle-aged males
BMI>28
Hypertension
Neck size >17” ( increased neck circumference)
Other risk factors


Alcohol
History of snoring
85
Respiratory Dysfunction: Sleep Apnea


If any suspicion – refer for evaluation
Medically unqualified until successfully treated





Surgery
CPAP-waiting period of at least 30 days prior to
certification
Weight loss
Annual Multiple Sleep-Latency Testing
(Polysomnograph)
Follow-up in 1-2 months to assess
effectiveness of treatment
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Other Worker Groups

The Biotech Industry


Healthcare workers


Infectious agents, chemicals, carcinogens, radioisotopes, product
hazards, animal handling, reproductive hazards
Latex allergy, anesthetic gases, chemical hazards, cytotoxic drugs,
ergonomics, bloodborne pathogens
Municipal workers




Sewage workers: biological hazards, bacteria, confined spaces,
chemicals, cancer risk
Police and corrections: stress, ischemic heart disease, BBP, shift work,
chemical hazards, cancer risk
Firefighters: chemical exposure, respiratory issues, physical
requirements, stress, biological exposure
Bridge and Tunnel workers: Vehicular exhaust,/respiratory and cardiac
disease, ergonomics, temperature, noise, shift work, chemicals,
microwave radiation
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References






A Practical Approach to Occupational and Environmental
Medicine, 3rd Ed. McCunney RJ, Rountree PP, eds.
Lippincott Williams and Wilkins, 2003
Current Occupational and Environmental Medicine, 3rd
Ed. LaDou J, McGraw-Hill/Appleton & Lange, 2004
Fundamentals of Industrial Hygiene, 3rd Ed. Plog BA,
Quinlan PJ, eds National Safety Council, 1988
Guide to the Medical Evaluation for Respirator Use.
McLellan R, Schusler K, OEM Press, 2000
Instant Medical Surveillance, Mitchell FL, OEM Press,
2002
A DOT Medical Examination: A Guide to Commercial
Drivers’ Medical Certification, 3rd Ed. Hartenbaum NP,
OEM Press, 2003
88
Be Safe!
Tony Soares, Safety Director
Compensation Solutions, Inc.
tsoares@compsolutionsinc.com
Tel: 1-888-201-5680 Ext. 192
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