Document 4a2nN6KEpb1ZxkEgbmNvgzdrj

onfdr I/V^ TEN 7474 31:4001 BIOLOGIC MONITORING Biologic monitoring for certain exposures in the workplace will be conducted periodically as mandated by government regulations or as deemed advisable by the Corporate Medical Director. These exams are required of employees who are subject to specific surveillance criteria promulgated by OSHA. Additionally, biologic monitoring may be initiated as a result of exposure Information developed by the Industrial Hygiene Department, other indications consistent with good occupational medical practice, special health surveys, or to monitor a cohort of controls, etc. When utilized as a routine biologic monitoring exposure, these will usually be performed semi-annually on any effected employees, unless otherwise mandated by an OSHA or other applicable regulation. The identification of job classifications and individual potentially exposed to a given substance or exposure will be determined by plant management and coordinated with the Industrial Hygiene Department. Unfortunately, with the current state of the art, the methodology for useful and specific biologic monitoring is limited for this biologic evaluation of humans in relation to specific exposure. Multiple exposures and/or synergisms that exist in the workplace further compli cate and limit the application of this technique. Hopefully, advances in the near future will expand these capabilities. TEN 7475 31:4002 BIOLOGIC MONITORING (Cont'd.) At present, the number of specific biologic monitoring techniques appropriate to certain exposure in TCI are limited, but new procedures will be incorporated in this Subsection and implemented in the field as soon as these are defined. (24-Y)B16~17 10/30/79 TEN 7476 31:4101 CADMIUM I. NIOSH CRITERIA DOCUMENT FOR CADMIUM II. EXPOSURE A. Permissible Exposure Limits B. Self-Audit Questionnaiire on Cadmium III. MEDICAL SURVEILLANCE A. Medical Examinations B. Biological Monitoring C. Laboratory Data D. Employee Notification IV. CADMIUM EXPOSURE A, Absorption B. Signs and Symptoms TEN 7477 31:4101 CADMIUM I. NIOSH CRITERIA DOCUMENT FOR CADMIUM 11 * EXPOSURE A. Permissible Exposure Limits B. Self-Audit Questionnaiire on Cadmium 111 * MEDICAL SURVEILLANCE A. Medical Examinations B. Biological Monitoring C. Laboratory Data D. Employee Notification IV* CADMIUM EXPOSURE A. Absorption B. Signs and Symptoms TEN 7478 31:4103 X. NIOSH CRITERIA DOCUMENT FOR CADMIUM The Occupational Safety and Health Act of 1970 emphasizes the need to protect the safety of workers exposed to a number of potential health hazards in the workplace. The National Institute of Occupa tional Safety and Health has projected a formal system of research to provide relevant data from which valid criteria for effective standards can be derived. To date, there is no OSHA standard set for cadmium although NIOSH recommends that work exposure to cadmium be controlled. Medical monitoring as well as work environment sampling shall be performed on all employee's occupationally exposed to cadmium above the recommended levels to protect the health and safety of workers over a working lifetime. (NIOSH Criteria for a Recommended Standard Occupational Exposure to Cadmium, U.S. Department of Health, Educa tion, and Welfare. [HEW Publication No. (NIOSH) 76-192.] II. EXPOSURE A. Permissible Exposure Limits Under the adopted ANSI Standard (23.7-5 1970), the federal proposed exposure limit for cadmium fume is 0.1 mg/m^ for an 8-hour time-weighted average (TWA) with an acceptable ceiling of 3 mg/m^ for cadmium dust. The proposed time-weighted average (TWA) is 0.2 mg/m^ for an 8-hour sample. Under the criteria document, NIOSH has recommended that workers should not be exposed to cadmium at a concentration greater than 40 ug/m^ for a 10-hour workday with a ceiling concentration of 200 ug/m^ for any 15-minute sampling period. The American Conference of Governmental Industrial Hygienist (ACGIH) has proposed the Threshold Limit Value, Time-Weighted Average (TLV-TWA) for cadmium fume to be 0.05 mg/m^ for a normal 8-hour workday. The Threshold Limit Value - Short-Term Exposure Limit (TLV-STEL), the maximum concentration to which workers can be exposed for a period of 15 minutes, for cadmium dust is 0.2 mg/m^. Workers are not considered to be occupationally exposed to cadmium if monitoring does not exceed the "Action Level," i.e., half the recommended time-weighted average (TWA) environmental limit or if there is no operation, storage, or handling of cadmium in any form or contamination of workplace air by cadmium from other sources. B. Self-Audit Questionnaire on Cadmium Each TCI plant manager shall complete a detailed "Self-Audit Questionnaire" on cadmium and return it to the Corporate Manager, Industrial Hygiene. This information shall then be forwarded to the Corporate Medical Department or appropriate plant medical facility. TEN 7479 31:4104 The information establishes the number and identities of employees engaged in each process or operation where an exposure to cadmium occurs. The information also includes the frequency, duration, and degree of exposure which occurs. It is through this process that employees exposed to cadmium shall be scheduled for biological monitoring and medical surveillance. These rosters shall be periodically updated by the appropriate plant personnel (supervisors, industrial hygiene personnel, etc.). III. MEDICAL SURVEILLANCE A. Medical Examinations Medical monitoring (surveillance) shall be made available to all workers subject to occupational exposure to cadmium. Medical examinations will be given on an annual basis to new or reassigned employees. The periodic health evaluations performed on TCI employees will suffice for these requirements. These examinations include a detailed work history with particular attention to past cadmium and other heavy metal exposures (occupational and nonoccupational), personal habits (smoking, hygiene), and past respiratory, gastrointestinal, cardiovascular, hematologic, renal, reproductive, and neurological problems. A thorough physical examination with particular attention to respiratory, cardiovascular, renal, hematologic, gastrointestinal, neurological, and reproductive systems will be performed. Blood sampling with TCl's current Metpath Profile 161, with the addition of blood cadmium levels, includes all pertinent data needed. In addition, a 14" x 17" P.A. chest x-ray, and pulmonary function test will be performed to determine forced vital capacity (FVC), forced expiratory volume during the first second (FEV), and (FEVj/FVC) ratios. At the time of the exam, a determination of the worker's ability to work in positive or negative pressure respirators shall be made. B. Biological Monitoring TCI makes available biological monitoring in the form of blood cadmium sampling and analysis for employees exposed to cadmium. Biological monitoring in the form of blood sampling shall be performed at least semiannually for those individuals determined to be occupationally exposed by the Industrial Hygiene Department. As yet, blood cadmium levels have not been set by NIOSH or OSHA. Reference ranges for blood cadmium levels will depend on experience, and NIOSH and OSHA standards as they evolve. It is the intention of TCI to biologically monitor its employees occupationally exposed to cadmium through blood cadmium levels TEN 7480 31:4105 in an effort to monitor their exposure and to further evaluate 'the possibility of toxicity. While there is currently no definitive acceptable blood cadmium level and correlation with exposure, experience and reasonable consensus suggest that there would be no demonstrable clinical findings or adverse health effects below blood levels of 30 ng/ml. C. Laboratory Data The blood samples taken for biological monitoring of cadmium for TCI employees are sent to Metpath Laboratories for analysis. These samples will indicate the proper Metpath blood cadmium sample code. The employees who are monitored will be notified before the blood sample is to be taken. (This notice may be given by the nurse, physician's assistant, foreman, or member of the Personnel Department depending upon the location.) The notice can either be given verbally or by written notice or memo. The medical personnel drawing the blood sample shall then indicate on the Metpath requisition form the name, date, and age of the employee. The name and date should also be recorded on the label of the Metpath Laboratory test tubes (red top corvac tubes). The samples should be centrifuged and sent to Metpath. When the specimen is collected, the employee should be made fully aware of the purpose for giving the sample and be reminded that if the blood cadmium level exceeds the recommended level, a second sample may possibly be required and/or a physical examination indicated. D. Employee Notification Within five (5) working days after the receipt of the results of the biological monitoring, TCI will notify those individuals, in writing, with blood cadmium levels exceeding the recommended level. IV. CADMIUM EXPOSURE A. Absorption There are several modes of entry for cadmium into the body. The most common is by inhalation of dusts and fumes contaminated by cadmium. B. Signs and Symptoms Cadmium is an irritant to the respiratory tract. Acute toxicity is almost always caused by inhalation of cadmium fumes or dust which occurs when cadmium is heated. 03-31-81(3)(R) TEN 7481 31:4106 Inhalation of dust or fumes may cause dryness of the throat, cough, headache, a sense of constriction in the chest, shortness of breath (dyspnea) and vomiting. More severe exposure results in marked lung changes with persistent cough, pain in the chest, severe dyspnea and prostration which may terminate fatally. X-ray changes are usually similar to those seen in bronchopneumonia. The urine is frequently dark. These symptoms are usually delayed for some hours after exposure and fatal concentrations may be inhaled without sufficient discomfort to warn the workman to leave the exposure. Ingestion of cadmium results in sudden nausea, salivation, vomiting and diarrhea and abdominal pain and discomfort. Symptoms begin almost immediately after ingestion. Chronic exposure to cadmium can result in a characteristic form of emphysema which in some instances is not preceded by a history of chronic bronchitis or coughing. Heavy smoking has been reported to considerably increase tissue cadmium levels. Systemic changes due to cadmium absorption include damage to the kidneys with proteinuria, anemia, and elevated sedimentation rate. Of these, proteinuria is most typical. (24-W)A22-26 TEN 7482 LEAD I. INTRODUCTION - OSHA STANDARD FOR LEAD II. EXPOSURE A. Permissible Exposure Limit B. Self-Audit Questionnaire on Lead C. Monitoring III. MEDICAL SURVEILLANCE A. Medical Examination B. Biological Monitoring C. Follow-up Blood Sampling Tests D. Laboratory Data E. Employee Notification F. Recordkeeping IV. LEAD EXPOSURE A. Absorption B. Signs and Symptoms V. POTENTIAL EMPLOYEE EXPOSURE TO LEAD 31:4401 03-31-81(3)C R) TEN 7483 31:4403 LEAD I. INTRODUCTION - OSHA Standard for Lead Despite the extensive knowledge concerning the cause, problems, and prevention of lead poisoning, the disease is still common. However, the incidence of occupational lead poisoning is continually being decreased by improved controls, work practices, and surveillance. The wide use of lead and its compounds has resulted in a substantial part of industrial workers being exposed occasionally or regularly. The Occupational Safety and Health Administration (OSHA) has adopted a Lead Standard (29CFR1910.1025). The effective date of the OSHA Standard is March 1, 1979. II. EXPOSURE A. Permissible Exposure Limit Under the OSHA Standard for Lead, the "Action Level" for airborne concentrations of lead is 30 micrograms per cubic meter (30 ug/m3) averaged over an eight-hour period. The permissible exposure limit (PEL) for employees working in a lead exposure environment is no .greater than at concentrations of 50 micrograms per cubic meter of air (50 u g/m3) averaged over an eight-hour period. If an employee is exposed to lead for more than eight hours in any work day, the permissible exposure limit, as a time-weighted average (TWA) for that day, shall be reduced to the following formula: maximum permissible limit in ug/m3 = 400 r hours worked in the day. At present, the effective date of the OSHA Standard for Lead (29CFR1910.1025) is March 1, 1979. B. Self-Audit Questionnaire on Lead Each TCI plant manager or his designee shall complete a "Self-Audit Questionniare on Lead" and return it to the Corporate Manager, Industrial Hygiene. This information shall then be forwarded to the Corporate Medical Department. The information shall establish and identify the number of employees engaged in each process or operation where an exposure to lead occurs. The information will also include the frequency, duration, and degree of exposure which occurs. It will be through this process that employees exposed to lead shall be scheduled for biological monitoring and medical surveillance. These rosters shall be periodically updated by the appropriate plant personnel (supervisor, industrial hygiene personnel, etc.). TEN 7484 03-31-81(3)(R) 31:4404 C. Monitoring It is required that employees be monitored if exposed to lead above the action level or if any employee complains of symptoms which may be attributable to exposure to lead. Under the OSHA Standard, the employer shall collect full shift (for at least seven continuous hours) personal samples including at least one sample for each shift for each job classification in each work area. If the initial monitoring reveals employee exposure to be below the action level, the measurements need not be repeated unless a change in production process or personnel change results in new or additional lead exposure. If the initial monitoring reveals employee exposure to be at or above the action level but below the permissible exposure limit, the monitoring shall be repeated at least every six months. The monitoring shall continue at the required frequency until at least two consecutive measurements taken at least seven days apart are below the action level. If the initial monitoring reveals that employee exposure is above the permissible exposure limit, the monitoring shall be repeated quarterly. III. MEDICAL SURVEILLANCE A. Medical Examination Under the OSHA Standard for Lead, TCI institutes a Medical Surveil lance Program for all employees who are or may be exposed to lead above the action level for more than 30 days per year. These medical examinations and procedures are performed by or under the supervision of a licensed physician and without cost to the employees. The periodic health evaluations performed on TCI employees on an annual basis will suffice for this requirement of the Lead Standard. These examinations include a detailed work history with particular attention to past lead exposure (occupational and nonoccupational), personal habits (smoking, hygiene), and past gastrointestinal, hematologic, renal, cardiovascular, reproductive, and neurological problems. A thorough physical examination with particular attention to teeth, gums, hematologic, gastrointestinal, renal, cardiovas cular, and neurological systems. Blood sampling with our current Metpath Profile 161, with the addition of blood lead levels, and ZPP blood analyses (or. Profile 163 which includes these additional tests) includes all pertinent and required studies for the OSHA Standard for Lead. TEN 7485 31:4405 B. Biological Monitoring The employer shall make available biological monitoring in the form of blood sampling and analysis for lead and zinc protoporphyrin every six months for employees exposed above the action level for more than 30 days per year. Those employees whose last blood sampling and analysis indicated a blood level at or above 40 ug/lOOg shall be monitored every two months. Biological monitoring in the form of blood sampling shall be performed at least monthly during the removal period of each employee removed from exposure to lead due to elevated blood lead levels. C. Follow-up Blood Sampling Tests Whenever an employee's periodic blood lead levels exceed the numerical criterion for medical removal, the employer shall provide a second blood lead (only) sampling follow-up within two weeks after the employer received the results of the first blood sampling. During the first year after the effective date of the OSHA Standard (March 1, 1979), an employee must be removed from his job and the lead exposure if his periodic and follow-up blood lead samples are at or above 80 ug/lOOg of whole blood. The employer shall return an employee to his former job status when two_ consecutive blood sampling tests indicate that the employee's blood lead level is at or below 60 ug/lOOg of whole blood. The second year following the effective date of the standard, the employer shall remove an employee from work having a blood lead level at or about 70 ug/lOOg of whole blood. The employer shall return the employee to his former job status when.two consecutive blood sampling tests indicate that the employee's blood lead level is at or below 50 ug/lOOg of whole blood. Beginning the third year of the standard and thereafter, the employer shall remove an employee from work if his blood lead samples are at or above 60 ug/lOOg of whole blood. The employer shall return an employee to his former job status when two consecu tive blood sampling tests indicate that the employee's blood lead level is at or below 40 ug/lOOg of whole blood. Beginning with the fifth year following the effective date of the standard, the employer shall remove an employee from work having an exposure to lead at or above the action level on each occasion that the average of the last three blood sampling tests conducted [or the average of all blood sampling tests conducted over the previous six (6) months, whichever is longer] indicate that the employee's blood lead level is at or above 50 ug/lOOg of whole blood. The employer shall return the employee to his former job status when two consec utive blood sampling tests indicate that the employee's blood lead level is at or below 40 ug/lOOg of whole blood. 03-31-81(3) (R) TEN 7486 31:4406 IMPLEMENTATION - MEDICAL REMOVAL BLOOD LEAD (Pb B) Removal Return LEAD IN AIR (Pb A) EFFECTIVE DATE 80 ug/100 ml. 60 ug/100 ml. > 100 3/1/79 >_ 70 ug/100 ml. <50 ug/100 ml. > 50 3/1/80 _> 60 ug/100 ml. <^40 ug/100 ml. > 30 3/1/81 >_ 50 ug/100 ml. _< 40 ug/100 ml. > 30 3/1/83 D. Laboratory Data The blood samples taken for biological monitoring of TCI employees are sent to Metpath Laboratories for analysis. These samples will indicate the proper Metpath blood lead sample code. The employees who are monitored shall be notified before the blood sample is to be taken. (This notice may be given by the nurse, physician's assistant, foreman, or member of the Personnel Department depending upon the location.) The notice can either be given orally or by written memo. The medical personnel (nurse, physician's assistant, M.D.) drawing the blood sample shall then indicate on the Metpath requisition form the name of the employee and the date the sample was drawn. The name and date should also be recorded on the label of the Metpath laboratory test tubes (red top corvac tubes). The samples should be centrifuged and sent to Metpath. When the specimen is collected, the employee should be made fully aware of the purpose for giving the sample and be reminded that if the exposure level is exceeded he will be requested to supply a second sample and possibly be required to take a physical examin ation. When analysis of the samples are completed by Metpath, the results will be sent directly to the specific location and the Corporate Medical Department so that proper action can be taken for those individuals with abnormal results. E. Employee Notification Within five (5) working days after the receipt of the results of the biological monitoring, TCI will notify in writing those individuals with blood lead levels exceeding 40 ug/100 ml. following the effec tive date of the standard. The employee will be notified of his blood lead levels in writing; he shall also be allowed to see and review his examination. In addition, he/she shall be promptly notified of the right to obtain a second medical opinion and be furnished with a copy of a written medical opinion from each examining or consulting physician. The standard also requires temporary medical removal with medical removal protection when employee's blood lead levels exceed the above-mentioned value. The employee shall be provided with full pay and no loss of job status for up to eighteen months. TEN 7487 31:4407 F. Recordkeeping The employee medical record should include the results of airborne exposure monitoring which is supplied to the physician, a copy of the medical examination(s), results of biological monitoring and a copy of the physician's written opinions. Also included should be dates of any job removal and return to former job status with a brief explanation of why and how each removal was accomplished. The employee's medical record is to be retained permanently. All records required to be maintained by this standard will be provided upon request to employees, former employees, representatives designated by the individual employee and the Assistant Secretary. IV. LEAD EXPOSURE A. Absorption There are several modes of entry for lead into the body. The most common is by inhalation of dusts, fumes, mists, or vapors contaminated by lead. Another mode of entry is by ingestion of lead compounds trapped in the upper respiratory tract or intro duced into the mouth on food, tobacco, fingers, or other objects. When lead is ingested, a large majority of it passes through the body unabsorbed and is eliminated in the feces. The greater portion of the lead that is absorbed is caught by the liver and excreted, in part, in the bile. Large amounts of lead must be ingested to cause poisoning. Lead is a cumulative poison, and increasing amounts build up in the body and eventually a point may be reached where signs, symptoms, and/or disability occurs. B. Signs and Symptoms Industrial lead poisoning commonly occurs following prolonged exposure to lead or its compounds. The common clinical types of lead poisoning may be classified according to their clinical picture as alimentary, neuromotor and encephalic. Some cases may be a combination of clinical types. The alimentary type occurs most frequently and is characterized by abdominal discom fort or pain. Severe cases may present actual colic. Other complaints are constipation and/or diarrhea, loss of appetite, metallic taste, nausea and vomiting, lassitude, insomnia, weakness, joint and muscle pains, irritability, headache and dizziness. Pallor, leadline on the gums, pyorrhea, loss of weight, abdominal tenderness, basophilic stippling, anemia, slight albuminuria, increased urinary excretion, and an increase in the lead content of whole blood are clinical findings which may accompany the above symptoms. In the neuromuscular type, the chief complaints is weakness, fre quently of the extensor muscles of the wrist and hand, unilateral or bilateral. Gastroenteric symptoms are usually present, but are 03--31--8l(3)(R) TEN 7488 31:4408 not as severe as in the alimentary type of poisoning. Headache, dizziness, and insomnia are frequently prominent. True paralysis is uncommon and usually is the result of,prolonged exposure. Lead encephalopathy is the most severe, but the rarest manifesta tion of lead poisoning. In the industrial worker, it follows rapid and heavy lead absorption. (Organic lead compounds, such as tetraethyl lead, are absorbed rapidly through the skin as well as through the lungs and are selectively absorbed by the central nervous system.) Encephalopathy begins abruptly and is characterized by signs of cerebral and meningeal involvement. There is usually stupor, progressing to coma, with or without convulsions and often termin ates in death. Excitation, confusion, and mania are less common. In milder cases of shorter duration there may be symptoms of headache, dizziness, somnolence and insomnia. The cerebrospinal pressure may be increased. (24-U)A02-07 TEN 7489 31:4501 MERCURY I. NIQSH CRITERIA DOCUMENT ON MERCURY II. EXPOSURE A. Permissible Exposure Limits B. Self-Audit Questionnaire on Mercury III. MEDICAL SURVEILLANCE A. Medical Examination B. Biological Monitoring C. Laboratory Data D. Employee Notification IV* MERCURY EXPOSURE A. Clinical Signs and Symptoms TEN 7490 31:4503 X. NIOSH CRITERIA DOCUMENT FOR MERCURY The recommendations for occupational exposure to inorganic mercury takes into consideration information and research data on health effects and limited data on technical feasibility. A NIOSH Criteria Document for a recommended standard for Occupational Exposure to Inorganic Mercury has been prepared in accordance with Sections 6(b)7 and 20(a)(3) of the Occupational Safety and Health Act. It is estimated that approximately 150,000 workers are exposed to mercury each year. II. EXPOSURE A. Permissible Exposure Limits Occupational exposure to mercury shall be controlled so that workers are not exposed to inorganic mercury at a concentration greater than 0.05 mg/m^ determined as a time-weighted average (TWA) exposure for an 8-hour workday. B. Self-Audit Questionnaire on Mercury Each TCI plant manager shall complete a "Self-Audit Questionnaire" on mercury and return it to the Corporate Manager, Industrial Hygiene. This information shall then be forwarded to the Corporate Medical Department or appropriate plant medical facility. The information shall establish the number and identities of employees engaged in each process or operation where an exposure to mercury occurs. This information will also include the frequency, duration, and degree of exposure which occurs. In this manner, employees exposed to mercury will be scheduled for biological monitoring and medical surveillance. These rosters shall be periodically revised and updated by the appropriate plant personnel (supervisors, industrial hygiene personnel, etc.). III. MEDICAL SURVEILLANCE A. Medical Examination TCI institutes a Medical Surveillance Program for all employees who are or may be exposed to mercury at concentrations greater than 0.05 mg/m^. The periodic health evaluations performed on TCI employees on an annual basis will place emphasis on any symptoms and signs which may indicate mercury toxicity. These examinations include a detailed history with particular attention to past mercury exposure (occupational and nonoccupational), personal habits (smoking, hygiene), neurological, gastrointestinal, hematologic, renal, reproductive, and cardiovascular problems. TEN 7491 31:4504 A thorough physical examination with particular attention to neurological, hematological, gastrointestinal, renal, and cardiovascular systems will be performed. Blood sampling with our current Metpath Series 161, with the addition of blood mercury levels, will be included. In addition, a chest x-ray, pulmonary function, audiometric and visual screen test will be performed. B. Biological Monitoring TCI shall make available biological monitoring in the form of blood sampling and analysis for mercury on the basis of Industrial Hygiene surveys for those individuals exposed to mercury. Routinely, this monitoring will be performed semiannually on any potentially exposed employee, or more often depending on the results of these blood levels and/or the ambient air concentrations for mercury. C. Laboratory Data The blood samples taken for biological monitoring of TCI employees are sent to Metpath Laboratories for analysis. These samples will indicate the proper Metpath blood mercury sample code. The employees who are monitored shall be notified before the blood sample is to be taken. (This notice may be given by the nurse, physician's assistant, foreman, or member of the Personnel Department depending upon the location.) The notice can either be given verbally or by written memo. Medical personnel drawing the blood sample shall then indicate on the Metpath requisition form the name, date, and age of the employee. The name and date should also be recorded on the label of the Metpath Laboratory test tubes (red top corvac tubes). The samples should be centrifuged and sent to Metpath. D. Employee Notification If the physician feels there is significant alterations in the blood mercury level of the employee, TCI will notify those individuals in writing of these findings. (The concentration of mercury in blood is commonly up to 3 mcg/dl and, when toxicity is present, the concentration is greater than 20 mcg/dl.) IV. MERCURY EXPOSURE A. Clinical Signs and Symptoms Mercury is a general protoplasmic poison. After absorption, it circulates in the blood and is stored in the liver, kidneys, spleen and bone. It is eliminated in the urine, feces, sweat, saliva, and milk. TEN 7492 31:4505 In industrial poisoning, the chief effect is upon the central nervous system and upon the mouth and gums. Colitis has been reported. The cardinal symptoms of industrial mercury poisoning are stomatitis, tremors, and psychic disturbances. Usually, the first complaints are of excessive salivation and pain on chewing; in severe cases, there may be gingivitis, with loosening of the teeth and a dark line on the gum margins resembling the "lead line." In slow poisoning, the salivation may be absent and the only complaint may be dryness of the throat and mouth. Tremor and psychic disturbances are commonly seen in the slow, chronic form of the poisoning; the tremor is of the intentional type, and may be seen when the patient spreads the outstretched fingers or protrudes the tongue, or attempts to perform specified movements. Muscles of the face, hands, and arms are chiefly affected. In more severe cases, there may also be convulsion or shaking movements; writing is frequently illegible. Hyperactive knee jerks and scanning speech may be present in advanced cases. The psychic disturbance includes such changes as loss of memory, insomnia, lack of confidence, irritability, vague fears and depression. The dermatitis produced by fulminate of mercury takes the form of small, discrete ulcers on the exposed parts and is usually accompanied by conjunctivitis and inflammation of the mucous membranes of the nose and throat. (24-W)B06-09 10/23/79 TEN 7493 ORGANOPHOSPHATES (CHOLINESTERASE MONITORING) 31:4601 I. NIOSH CRITERIA DOCUMENT FOR MANUFACTURE AND FORMULATION OF PESTICIDES AND ORGANOPHOSPHATES II. EXPOSURE A. Permissible Exposure Limits B. Self-Audit Questionnaire on Organophosphates III. MEDICAL SURVEILLANCE A. Medical Examinations B. Biological Monitoring C. Laboratory Data D. Employee Notification IV* ORGANOPHOSPHATE EXPOSURE A. Organophosphate Toxicity B. Signs and Symptoms TEN 7494 31:4603 I. ORGANOPHOSPHATES (CHOLINESTERASE MONITORING) A. NIOSH Criteria for Manufacture and Formulation of Pesticides and Organophosphates The National Institute for Occupational Safety and Health (NIOSH) has implemented a formal system of researchj with priorities determined on the basis of specified indices, to provide relevant data from which valid criteria for effective standards can be derived. NIOSH recommends that employee exposure to pesticides in manufacturing and formulating workplaces be controlled. Employee exposure should be controlled to protect the health and safety of employees in manufacturing and formulating facilities over their work lifetime. Emphasis has been placed on work practices, engineering controls, and medical surveillance programs to protect workers from adverse effects of organophosphates and pesticide exposure in manufacturing and formulating operations. The derivation of environmental (workplace air) limits for over 1,500 pesticides active ingredients and various inerts, additives, intermediates and solvents in pesticide and organophosphate manufacturing and formulating cannot be accomplished as quickly or effectively as the design of good work practices and effective engineering controls. The number of materials to be sampled and the complexities of sampling and analysis in monitoring all the organophosphates present would be an almost insurmountable task for many formulators. Exposure to nonairborne organophosphates as a result of splashes, spills, deposits, and handling is not considered in the establishment of an environmental limit. II. EXPOSURE A. Permissible Exposure Limits There are many organic phosphates and a wide variety of uses from pesticides and lubricants, flame retardants, etc. Moreover, many raw materials or products contain various combinations of organophosphate compounds. While exposure limits have been established for many of these, at present, levels have not been determined for others. Representative of organophosphates would be compounds such as parathion and malathion for which exposure limits have been established. The federal standards for parathion and malathion are 0.1 mg/m^ and 15 mg/m^ respectively. NIOSH has recommended a limit for parathion of 0.05 mg/m-* (TWA) and a limit for methyl parathion of 0.2 mg/m^ (TWA). The specific organophosphate substances in any usage or handling of this class of compounds would have to be known and specific monitoring and analytical methodology instituted on that basis. TEN 7495 31:4604 B. Self-Audit Questionnaire on Organophosphates (Pesticides) Each TCI plant manager shall complete a detailed "Self-Audit Questionnaire" on the use of any organophosphate compounds and return it to the Corporate Manager, Industrial Hygiene. This information shall then be forwarded to the Corporate Medical Department or appropriate plant medical facility. The information establishes the number and identity of employees engaged in each process or operation where an exposure to these substances occurs. This information will also include the frequency, duration, and degree of exposure which occurs. In this manner, employees exposed to organophosphates will be scheduled for biological monitoring and medical surveillance. These rosters shall be periodically revised and updated by the appropriate plant personnel (supervisors, industrial hygiene personnel, etc.). III. MEDICAL SURVEILLANCE A. Medical Examinations Medical surveillance shall be made available to all workers subject to occupational exposure to pesticides or other organo phosphates. Medical examinations will be given on an annual basis to new or reassigned employees. The periodic health evaluation performed on TCI employees will include comprehensive medical and work histories with emphasis directed toward the hepatic, renal, hematologic, gastrointestinal, reproductive, central nervous systems, and respiratory diseases. The use of drugs or any illnesses resulting from past exposure to organophos phates will be given special attention. A thorough physical examination with particular attention to the eyes, liver, kidneys, lungs, and the central and peripheral nervous systems, cardiovascular, hematologic, and reproductive system will be performed. Blood sampling with TCI's current Metpath Profile 161 with the addition of cholinesterase levels includes all pertinent data. In addition, a 14" x 17" P.A. chest x-ray, electrocardiogram, and pulmonary function test will be performed to determine forced vital capacity (FVC), forced expiratory volume during the first second (FEV), and (FEV^/FVC) rations. At the time of the exam, a determination of the worker's ability to use negative or positive pressure respirators shall be made. During examinations employees found to have medical conditions such as skin diseases, chronic lung disease, glaucoma, or abnormalities of the central nervous or peripheral systems that could be directly or indirectly aggravated by exposure to organophosphates shall be counseled as to the possible increased risk or impairment of their health from working with these substances. TEN 7496 31:4605 B. Biological Monitoring Red blood cell cholinesterase (RBC) ChE activity shall be measured for determination of a pre-exposure baseline if the employee will potentially be exposed, or for determination of a working baseline if the employee has previously been and will continue to be exposed to oganophosphates. An arbitrary estimate of significance to exposure to organophosphates is demonstrated when the activity of (RBC) ChE is decreased to below 70% of the individual's baseline. The employee shall be advised of such a finding. (Some sources give 2.31 - 3.95 I.U. as a reference range for RBC cholinesterase, but the above reference of shift of levels is generally accepted.) If an increase below 70% of the individual's baseline level is reported, repeat determinations should usually be made promptly to assist in evaluation of potential overexposure. A continuing downward trend would have significance, and laboratory error or analytical accuracy, and other possible causes must be considered. If an employee's (RBC) ChE activity is decreased to below 60% of the employee's normal or baseline level, he shall be removed from potential exposure and placed under medical observation; and usually would not be returned to organophosphate exposure until the RBC cholinesterase levels has increased to above 70%. Organic phosphate poisoning can be ruled out if the red cell cholinesterase is above 50% of normal, or serial tests do not indicate that a decrease of this magnitude has occurred. Symptoms usually do not appear until the red cell cholinesterase has dropped at least to 50% and, at times, as low as 25% of normal. C. Laboratory Data The blood samples taken for biological monitoring of TCI employees are sent to Metpath Laboratories for analysis. These samples will indicate the proper Metpath cholinesterase assay sample code. The employees who are monitored shall be notified before the blood sample is to be taken (this notice may be given by the nurse, physician's assistant, foreman, or member of the Personnel Department depending upon the location). The notice can either be given verbally or by written memo. Medical personnel drawing the blood sample shall then indicate on the Metpath requisition form the name, date, and age of the employee. The name and date should also be recorded on the label of the Metpath Laboratory test tubes (red top corvac tubes). The samples should be centrifuged and sent to Metpath. D. Employee Notification If the physician feels there is significant alteration in the cholinesterase level of the employee when there has been a decrease to below 70% of the employee's baseline value, TCI will notify those individuals in writing of these findings. TEN 7497 31:4606 IV- ORGANOPHOSPHATE EXPOSURE A. Organophosphate Toxicity The organophosphate insecticides are characterized by the similarity of their mechanism of toxic action. They differ widely, however, in inherent toxicity and, to some extent, in rate of absorption and excretion. The organophosphates act as irreversible inhibitors of the enzyme cholinesterase, thereby allowing the accumulation of acetylcholine at nerve endings. They are rapidly absorbed into the body by ingestion, through the intact skin, and by inhalation. Dose and dose-interval affect the speed with which the toxic manifestations occur* Onset of symptoms more than 12 hours after the termination of exposure generally excludes the diagnosis of organophosphate poisoning. B. Organophosphate Poisoning - Signs and Symptoms Mild Organophosphate Poisoning causes symptoms of headache, fatigue, dizziness, blurred vision, excessive salivation, nausea, vomiting, stomach cramps, and diarrhea. The symptoms are similar to those of many diseases not related to organo phosphate or pesticide exposure, such as influenza, heat stroke, heat exhaustion, and gastroenteritis. Moderate to Moderately Severe Organophosphate Poisoning - This type of poisoning causes all of the symptoms found in mild poisoning but, in addition, the patient is unable to walk, often complains of chest discomfort and tightness, exhibits marked miosis (constriction of pupils), and exhibits muscle twitching. These symptoms might be reasonably mistaken for such conditions as pneumonia, myocardial infarction, and encephalitis. Severe Organophosphate Poisoning may result in rapid onset of unconsciousness, local or generalized seizures, and other manifestations of cholinergic crisis. (24-W)B01-05 10/25/79 TEN 7498