Document Ozp5EqGEVqkwzqMLema79EpkM

25 BRF 0295 HAZARDS WORK EXPOSURE HISTORY AND __ _____________ REQUIREMENTS_______ PRE EMPLOYMENT M E D IC A L PERSONAL BLOODLUNG ._____________________________________________ REQUIREMENTS CM O CM w wCO CO CO CO CO CO CO W >* p p pp s OW co co coco co co co co CJ w p ss 33 3M ZQ W P CWO WCO WCO oo C CO QOO WM2U<W<j iH1J 3 M Pd 3 H CO w >* i i I HAZARDS BRF 0296 I <11 CM 0 MEDICAL TESTING ________________ _________REQUIREMENTS CO 3 si oiMs ca,, Ho l-S I*. 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Hi cr-n| CJ *,,i '1 H erS,i* V 2 >M Pi Q OCJ 05 O CM>J E M cHn CJ PI CO a 2 H4 HI < CJ 4 CQ cn < M O r-4 V/ h-i H4 CO /"s CvMv H8 re 2 0 Pi BRF 0298 ;m83o hi REFERENCE FILE Legend Notation Du?t` 14 point Ootljlc. May ;^a..Ha2idous To Yoqr.Keaithl . sura as soon as practicable,but.not late? thaa~6 days ofihe finding.The/employea shall alto be timely notified of the cor rective action being taken. medical information related to occupa tional exposure to asbestos fibers. [Section 1910.100l(j)(6)(ii) amended at 45 FR 35212, May 23, 1980, effective August Spacing between lines sball .be ait lease (J) Medtcal examinations--it) Gen 21, 1980; corrected by 45 FR 54333, August equal'to the height ot the upper of any eral. The employer shallprovide or make 15. 1980] 6 two lines. available at his cost, medtcal examina (2) Caution labels---tt) labeling. Cau tions relative to exposure to asbestos re tion labels shaU be affixed to all raw quired by this paragraph. materials, mixtures, scrap, waste, debris, (2) Preplacement. The employer shall 1910.1002 Coal tar- pilch volatiles; in and other products containing asbestos provide or make available to each ofhis terpretation of term. fibers, or to their containers, except that no label Is required where asbestos fibers have been* modified by a bonding agent, coating, binder, or other material so that during any reasonably foreseeable use, handling, storage.dlsposal, processing, or transportation, no. airborne concentra employees, within 30 calendar days fol lowing his first employment in an occupation exposed -to airborne con centrations of asbestos fibers, a compre hensive medical examination, which shall include, as a minimum, a chest roent genogram (posterior-anterior 14 x 17 As used in See. 1910.1000 (Tabic 7.-1), coal tor pitch volatiles include the fused poly cyclic hydrocarbons which volatilize from the distillation residues of coal, petroleum, wood, and other organic mat ter. Uons-of asbestos fibers in excess ..of the inches), a history to elicit symptom exposure Unfits prescribed, in paragraph atology of- respiratory - disease, . arid f'l9iai003 4-Nitrobiphenyl. (to- of this section willbe rdeased. >. (il) label specifications. The caution laiyia required by subdivision (i) of this subparagraph shall be printed In letters, of sufficient size and contrast as to be readily visible and legible. The label shall, state: CumoK - Contains Asbestos Fibers Avoid Creating Dust Breathing Asbestos Dust May Cause Serious Bodily Harm (til Housefceeplna--(i1 Cleaning. All external surfaces in any place of employ ment shall be maintained free of accu mulations of asbestos fibers if.-with their. dispersion, there would be an excessive concentration.. pulmonary function tests to Include forced vital capacity (FVC) and, forced expiratory volume at 1 second (FEVuk '(3)' Annual examinations. On or be fore January 31, 1973, and at least an nually thereafter,-every employer shall provide, or make available, comprehen sive medical examinations to each of his employees engaged in occupations ex posed to airborne concentrations of as bestos fibers. Such annual examination shall include,- as a minimum, a chest roentgenogram (posterior-anterior 14 x 17 inches), a history-to elicit symptom atology of respiratory disease, and pulmonary function tests to include forced vital capacity (FVC) and forced expiratory volume at 1 second (FEVi.o), . (a) Scope and application. (1) This section applies to any area In which 4-Nitrobiphenyl, Chemical Abstracts (Service Registry Number 92933 is manu factured, processed, repackaged, re leased, handled, or stored, but shall not apply to transshipment in sealed con tainers, except for the labeling require ments under paragraphs (e) (2), (3), and (4) of this section. (2) This section shall not apply to solid or liquid mixtures containing less than 0.1 percent by weight or volume of 4-Nitrobiphenyl. <b) Definitions. For the purposes of this section: Cl) "Absolute filter" is one capable of retaining 99.97 percent of a piono disperse aerosol of 03 pm particles. <2l Waste disposal. Asbestos waste, (4) Termination of employment. The (2) "Authorized employee" means an scrap, debris, bags|: containers, equip employer shall provide, or make avail employee whose duties require him to be ment, and asbestos-contaminated cloth able, within 30 calendar days before or In the regulated area and who has been ing, consigned for disposal, which-may after the termination of employment of Specifically assigned by the employer. produce in any reasonably foreseeableuse, handling, storage,-processing, dis posal, or transportation airborne concen trations of asbestds fibers in excess of the exposure limits prescribed in paragraph (b) of this section shall be collected and disposed of In sealed impermeable bags, or other closed,' impermeable containers. <i> Recordkeeping--(1) Exposure rec ords. Every employer shall maintain rec ords of any personal or environmental monitoring required by this section. Rec ords shall be maintained for a period of at least 20 years and shall be made avail able upon request to the Assistant Sec retary of Labor for Occupational Safety and Health, the Director of the National Institute for Occupational Safety and Health, and to authorized representa any employee engaged in an occupation exposed: to airborne .concentrations of asbestos flbers.a comprehensive medical, examination which shall include, as a minimum, a chest roentgenogram (pos terior-anterior 14 x 17 inches), a history to elicit symptomatology of respiratory disease, and pulmonary function tests to include forced vital capacity (FVC) and forced expiratory volume at 1 second (FEVio). (5) Reeiit~edminattbns. "No medtdSF examination -Is required of any em ployee. if- adequate records show that the-' employee has been' examined in ac cordance with this paragraph within the past 1-year period. (6> Medical. records--(i) Mairite- (3) "dean change room" means a room where employees put on' clean' Clothing and/or protective equipment in Bn environment free of 4-Nitrobiphenyl. The clean change room shall be con tiguous to and have an entry from a shower room, when the shower room facilities are otherwise required in"lhls: section. (4) "dosed system" means an opera tion Involving 4-Nitrobiphenyl where containment prevents the release of 4Nltrciblphenyl into regulated areas, nonremulated areas, or the external environ ment,. (5) "Decontamination" means the in activation of 4-Nitrobiphenyl or its said .disposal.. tives of either. nance. Employers of employees examined (6) "Director" means the Director, [1910.1001(0(1) amended at 41 FR 11505, pursuant to this paragraph shall cause National 'Institute for Occupational March 19, 19761 to be maintained complete and accurate; Safety and Health, or any person di records of all such medical examina rected by him or the Secretary of Health, (2) Access. Employee exposure records required by this paragraph shall be pro tions. Records- shall be retained' by employers for at least 20 years. Education, and Welfare to act for the Director. vided upon request to employees, designated representatives, and the Assistant Secre tary in accordance with 29 CFR 1910.20 (a)-(e) and (g)-(l). (ii) Access. Records of the medical examinations required by this paragraph shall be provided upon request to em (7) "Disposal" means the safe re moval of 4-Nitrobiphenyl from the work environment. (8) "Emargency" means an imforseen [Section 1910.1001 (i)(2> amended at 45 ployees, designated representatives, and circumstance or set of circumstances re- FR 35212, May 23, 1980, effective August the Assistant Secretary in accordance with .milting In the release of 4-Nitrobl'phenyl 21, 1980] 29 CFR 1910.20(a)-(e) and (g)-(i). These which may result In exposure to or con records shall also be provided upon the tact with 4-Nitrobiphenyl. X3^Employee notification. Any em ployee found to have been exposed- ttfcnajy tlme'-to: airborne concentrations of AabeoW ras-'flbers lh excess' of the limlta- poeH request to the Director of NIOSH. Any physician who conducts a medical exam ination required by this paragraph shall furnish to the employer of the examined (9) "External environment" means any environment. external to regulated and nonregulated areas. (10) "Isolated system" means a fully scribed in paragraph (b) of this section employee all the information specifically enclosed structure other than the vessel shall be notified in writing of the.expo* required by this paragraph, and any othcr c .containment of 4-Nitrobiphenyl, Occupationol Safety & Health Reporter tSec. )910.)003|b) 110)1 60 BRF 0299 31:8424 L 7 WOoiu <0*- c* n <-'/) rc-<c /o' lot/ rKf a.^a6 paiht ~ fr&rr REFERENCE FILE (2) Cleaning floors. <t) Floors and ture `controlled, positive pressure, fil moved from exposure to lead due to an other surfaces where lead accumulates may not be Cleaned by the use of com pressed air. (11) Shoveling, dry or wet sweeping and brushing may be used only where vacuuming or other equally effectivemethods have been tried and found not to be effective. (3) Vacuuming. Where vacuuming, methods are selected, the vacuums shall be used and emptied In a manner which minimizes the reentry of lead into the workplace. [Section 1910.1025(h)(2)(ii) corrected at <4 FR 5446, January 26, 1979, effective Feb ruary 24,1979] (Section 1910.1025(h) effective date was March 31,1979, to extent that employersmust acquire vacuums to comply, according to action by U.S. Court of Appeals for District of Columbia Circuit (44 FR 14554, March 13. 1979)| (1) Hygiene facilities and practices. tered dir supply, and are readily acces sible to employees. (iti> The employer shall assure that employees who work in areas where their airborne exposure to lead is above the PEL without regard to the use of a respirator wash their hands and face prior to eating, .drinking, smoking or applying cosmetics. tlv) The employer shall assure that employees do not enter lunchroom fa cilities with protective work clothing or equipment unless surface lead dust has been removed by vacuuming, downdraft booth, or other cleaning method. (5) Lavatories. The employer shall provide an adequate number of Iavar tory facilities which comply with .1910.141(d) (1) and (2) of this Part. elevated bleed lead level. (11) Follow-up blood sampling tests. Whenever the results of a blood lead level test indicate th^t an employee's blood lead level exceeds the numerical criterion for medical removal under paragraph (k)UXi), the employer shall provide a second (follow-up) blood sampling test within two weeks after the employer receives the results of the first blood sampling test. (lii) Accuracy of blood lead level sam pling and analysis. Blood lead level sampling and analysis provided pursu ant to this section shall have an accu racy (to a confidence level of 95 per cent) within plus or minus 15 percent or -6 jig/lOOra). whichever Is greater, and shall be conducted by a laboratory licensed by the Center for Disease Control, United States Department of Health, (1) The employer shall assure that in areas where employees are exposed to lead above the PEL, without regard to the use of respira tors, food or beverage is not present or consumed, tobacco products are not [Sections 1910.1025(1X1), (i)(2), (i)(3) (i) and and (i)(4)(i) and (ill) amend ed, and (iK6) deleted, at 44 FR 5446, Janu ary 26, 19/9, effective February 24, 1979] present or used, and cosmetics are not (j) Medical surveillance. (1) General. applied, except in change rooms, (i> The employer .shall Institute a lunchrooms; and showers required medical surveillance program for all under paragraphs (i)(2)-:(I)(4) of this employees who are or may be exposed, section. above the.action level for more than (2) Change rooms, (1) The employer- 30 days per year. shaU provide' clean change rooms for employees who work in areas where their airborne exposure to lead is above the (ii) The employer shall assure'that all medical examinations and proce PEL, without regard to the use of res pirators. dures are performed by or under the supervision of a licensed physician. (U) The employer shall assure that change rooms are equipped with sepa rate storage facilities for protective work clothing and equipment and for street clothes which prevent cross-con (ill) The employer shall provide the required medical surveillance including mul tiple physician review under paragraph (j)(3)(iii) without cost to employees and at a reasonable time and place. tamination. t2> Biological monitoring. --(I) (3) Showers. (1) The.employer shall Blood lead and ZPP level sampling- assure that employees who work, ini and analysis. The employer shall, areas where their airborne exposure to lead make available biological monitoring Education and Welfare (CDC) or which has received a satisfactory grade in bloo.v ad proficiency testing from CDC in the or twelve months. (iv)' Employee notification. Ws Kin five wording days after the receipt of biological monitoring results, the em ployer shall notify in.writing each em ployee whose blood lead level exceeds 40 jig/100 g: (A) of that employee's blood lead level and (B) that The standard requires temporary medical removal with Medical Removal Protec tion benefits when an employee's blood lead level exceeds the numerical criterion for medical removal under paragraph (k)(l)(i) of this section. (3) Medical examinations and consultalions.--(i)Frequency. The employ er shall make available medical exami nations and consultations to each em ployee covered under paragraph. (JXDCi) of this section on the follow ing schedule: is above the PEL, without regard' to in the form* of" blood sampling and (A) At least annually for each em the use of respirators, shower , at the analysis for lead and zinc protopor- ployee for whom a blood sampling test end of the work shift. ' phyrin levels to each employee cov conducted at any time during the pre (ii) The employer shall provide ered, under paragraph (jKIKU of this ceding 12 months indicated a blood shower facilities in accordance with section on the following schedule: lead level at or above 40 yg/100 g; 1910.141(d)(3) of this Part (Al At least every 6 months to each (B) TPrior to assignment for each em (iii) The employer shall assure that- employee covered under paragraph ployee being assigned for the first employees who are required to shower (JXi)(i) of this section; time to an area in which airborne con pursuant to paragraph <i)(3)(i> do not leave the workplace wearing any cloth ing or equipment worn during the work shift. (4) Lunchrooms, (i) The employer shall provide lunchroom facilities- for employees who work in areas where their airborne exposure to lead is above the PEL, without regard to the use of respira tors. (B) At least every two months for. centrations of lead are at or above the .action level; - each employee whose last blood sam pling and analysis indicated a blood (C> As soon as possible, upon notifi Jead level at or above 40 pg/100 g of cation by an employee"either that the Whole blood. This frequency shall con tinue until two consecutive blood sam ples and analyses indicate a blood lead level below 40 p.g/100 g of whole blooc^ and employee has developed signs or symp toms commonly associated with lead intoxication, that the employee de sires medical advice concerning tlie ef fects of current or past exposure to lead on the employee's ability to pro (ii) The employer shall assure thal (C> At least monthly during the re-, create a healthy child, or that the em lunchroom facilities have a tempera- moval period of each employee re- ployee has demonstrated difficulty in Occupational Safety fi. Health Rcpoiter (Sec. 1910.1025(j}{3] (i|(C)l BRF 0300 TOXIC SUBSTANCES S-159 31:8425 breathing during a respirator fitting (B) The employer shall promptly to any other toxic substance (If appli test or during use: and notify an employee of the right to cable); (D) As medically appropriate for seek a second medical opinion after (4) A description, of any personal, each employee either removed -from each occasion that an Initial physician protective equipment used or to be exposure to lead due to a risk, of sus conducts A medical examination or used; taining material impairment to health, consultation pursuant to this section. (5) Prior-blood lead determinations; or otherwise limited pursuant to a The employer may condition its par and - final medical determination. ticipation hip and payment for, the (C) AH prior Written medical opin <ii> Content Medical examinations multiple physician review mechanism ions concerning the employee In the1 made available pursuant to paragraph upon the employee doing the follow employer's possession or control. <jX3KiKAMB) of this section shall in ing within fifteen (15) days after re (B> The employer shall provide the clude the following elements: ceipt of the foregoing notification, or foregoing Information to a second or (A) A detailed work history and a medical history, with particular atten receipt of the initial physician's writ third physician conducting a medical ten opinion, whichever is later: - examination or . consultation under tion to past lead exposure (occupation (f) The employee informing the cm-, this section upon request cither by the al and non-occupatlonal), personal ployer that he or she intends to seek a second or third"physician, or by the-- habits (smoking, hygiene}, and past second medical opinion, and employee. gastrointestinal, hematologic, renal, cardiovascular, reproductive and neu rological problems; (B) A ..thorough physical examina tion. with particular attention to teeth, gums, hematologic, gastrointes tinal, renal, cardiovascular, and neuro logical systems. Pulmonary status should be evaluated if respiratory pro tection will be used: (C) A blood pressure measurement; (D> A blood sample and analysis which determines: (1) Blood lead level; (21 The employee Initiating steps to make an appointment with a second physician. <v) Written medical opinions. (A) The employershall obtain and furnish the employee with a copy of a written medical opinion from each examining, (C) If the findings, determinations or consulting physician which contains or recommendations of the second the following information: physician differ from those of the ini (f) The physician's opinion as to tial physician, then the employer and whether the employee has any detect the employee shall assure that efforts ed medical condition which would are made for the two physicians to re place the employee at Increased risk of solve any disagreement. material impairment of the employee's- (D) If the two physicians have been unable to- quickly resolve their dis agreement, then the employer and the health from exposure to lead; (2) Any recommended special protec tive measures to be provided to the employee through thetr respective employee, or limitations to be placed (2) Hemoglobin and hematocrit de terminations. red cell indices, and. ex amination of peripheral smear mor phology; 13) Zinc protoporphyrin; physicians shall designate a third phy sician: (f > To review any findings, determi nations or recommendations of the upon the employee's exposure to lead; CJ> Any recommended limitation upon the employee's use of respira tors, including a determination of whether the employee can wear `a (4) Blood urea nitrogen: and, (5) Serum creatinine; (E) A routine urinalysis with micro scopic examination; and prior physicians; and powered air purifying respirator if a (2) .To conduct such examinations, physician determines that the employ consultations, laboratory tests, and dis ee cannot wear a negative pressure res cussions with the prior physicians as pirator; and the third physician deems necessary to (4) The- results of the blood lead de (F) Any laboratory or other test resolve the disagreement of the prior terminations. which the examining physician deems physicians. (B) The employer shall instruct each necessary by sound medical practice. The content of medical examinations made available pursuant to paragraph (j)(3)(iKC)-(D) of this section shall be determined by an examining physician and. if requested by an employee, shall include pregnancy testing or labora tory evalua.tion.of male fertility. <iii> Multiple physician. reviena medi anism. (A) If the employer selects the initial physician who conducts anymedical examination or consultation, provided to an employee under this; section, the employee may. designate a second physician: Cl) To review any findings, determW nations or recommendations of the ini (E) The employer shall act consist examining to: and consulting physician ent with the findings, determinations and recommendations of the third physician, unless the employer and the employee reach an agreement which is otherwise consistent with the recommendations of _at least one of. the three physicians. (1) -Not reveal either in the written opinion, or in any other means of com munication with the employer, find ings, Including laboratory results, or diagnoses unrelated to an employee's occupational exposure to lead; and (2) Advise the employee of any medi (iv) Information provided to examin cal condition, occupational or nonoc- ing and consulting physicians. (A) cupatkmal. which dictates further The employer shall provide an initial medical examination or treatment. physician conducting a medical exami (vi> Alternate Physician Determina nation or consultation under this sec tion Mechanisms. The employer and tion with the following information: an employee or authorized employee (;) A copy of this regulation for lead includ representative may agree upon the use ing all Appendices; of any expeditious alternate physician determination mechanism in Hcu of tial physician; and (2) A description of the affected em the multiple physician review mecha (2) To conduct such examinations, consultations, and laboratory tests us ployee's duties as they relate to the nism provided by this paragraph so employee's exposure; long as the alternate mechanism oth the second physician deems necessary- (2) The employee's exposure level or erwise satisfies the requirements ctw to facilitate this review. anticipated exposure level to lead and tainted, in this paragraph. 12-11-80 ISce. 1910.1025(j){3)(tfi)) Published by THE BUREAU OF NATIONAL AFFAIRS. INC.. WASHINGTON. D.C. 20037 BRF 0301 TOXIC SUBSTANCES 'leajx (LomT> $OiK>*At'-CAST P*<t. s-isi 31:8437 Appendix C to Section 1910.1025-- Medical Surveillance Guidelines Introduction The primary purpose oi the Occupational_Safety and Health Act of 1970 is to assure, so far as possible, safe and healthful working conditions for every working man and woman. The occupational health standard for inorganic lead was promulgated to protect workers exposed to inorganic lead including metallic lead, all inorganic lead compounds and organic lead soaps. Under this final standard in effect as of March 1.1979, occupational exposure to inorganic lead* is to be limited to SO pg/m* (micrograms per cubic meter) based on an 8 hour time-weighted average (TWA). This level of exposure eventually must be achieved through a combination of engineering, work practice and other administrative controls. Periods of time ranging from 1 to 10 years are provided for different industries to implement these controls. The schedule which is based on individual industry considerations is Section 1 provides a detailed action level of 30 pg/m'TWA for more description of the monitoring procedure inducting the required frequency of blood testing for exposed workers, provisions for medical removal protection (MRP), the recommended right of the employee to a second than 30 days each year. This program consists of periodic blood sampling and medical evaluation to be performed on a schedule which is defined by previous laboratory results, worker complaints or medical opinion, and notification and concerns, and the dinical assessment of recordkeeping requirements of the the examining physician. employer. A discussion of the requirements for respirator use and respirator monitoring and OSHA's position on prophylactic chelationtherapy are also included in this section. Under this program, the blood lead level of all employees who are exposed to lead above the action level of 30 pgjn is to be determined at least every six months. The frequency is increased to Section 2 discusses the toxic effects and clinical manifestations of lead poisoning and efiects of lead every two months for employees whose last blood lead level was between 40 pg/lOOg whole blood and the level intoxication on enzymatic pathways in heme synthesis. The adverse effects on both male and female reproductive capacity and on the fetus are also discussed. requiringemployee medical removal to be discussed below. For employees who are removed from exposure to lead due to nn elevated blood lead, a new blood Section 3 outlines the recommended medical evaluation of the worker exposed to inorganic lead including lead level must be measured monthly. A zinc protoporphyrin (ZPP) measurement is strongly recommended on each details of the medical history, physical occasion that a blood lead level examination, and recommended measurement i3 made. ZPP monitoring is laboratory tests, which are based on the one of several requirements of the given in Table 1. Until these controls are toxic effects of lead as discussed in in place, respirators must be used to Section 2. standard that has been temporarily stayed by pending litigation over the meet the 50 pg/m* exposure limit Hie standard also provides for a program of biological monitoring and medical surveillance for all employees exposed to levels of inorganic lead above the action level of 30pg/m* (TWA) for more than 30 days per year. The purpose of this document is to outline the medical surveillance provisions of the standard for inorganic lead, and to provide further information to the physician regarding the examination and evaluation of workers exposed to inorganic lead. (Section 1910.1025, Appendix C footnote added at 44 FR 68827, November 30, 1979] Section 4 provides detailed information concerning the laboratory tests available for the monitoring of exposed workers. Included also is a discussion of the relative value of each lead standard. Unless otherwise noted In this document, all provisions of the standard pertaining to medical surveillance and medical removal protection are currently in effect. test and the limitations and precautions An annual medical examination and . which are necessary in the consultation performed under the interpretation of the laboratory results. guidelines discussed in Section 3 is to be [Section 1910.1025, Appendix C corrected made available to each employee for at 44 FR 68827, November 30, 1979] whom a blood test conducted at any time during the preceding 12 menths /. Medical surveillance and monitoring requirements for workers exposed to inorganic lead indicated a blood lead level at or above 40 fig/100 g. Also, an examination is to be'given to all employees prior to their assignment to an area in which airborne Under the occupational health lead concentrations reach or exceed the standard for inorganic lead, a program action leveL In addition, a medical The term inorganic lead used throughout the medical surveillance appendices is meant to be synonymous with the definition of lead set forth in the standard. of biological monitoring and medical surveillance is to be made available to all employees exposed to lead above the Table 1 examination must be provided as soon as possible after notification by an employee that the employee has developed signs or symptoms commonly associated with lead intoxication, that Effective date the employee desires medical advice Permissible airborne lead levels by Industry (pg/mV t. Primary lead production...-........^.. ....... ___ 2. Secondary lead production.......... .. 3. Lead-acid battery manufacturing_____ ___, , - ,, -...... 4. Nonforrous foundries............................. ........ ___ 5. Lead pigment manufacturing......... ................. ................... - 6. All other industries.....__ __ __ ____________ . ................ Mar. 1, 1979 200 200 200 200 200 200 Mar. 1, Mar. 1. toeo 1981 200 200 200 200 200 109 100 100 200 200 50 50 Mar. 1. 1982 100 100 100 too 100 50 Mar. 1, 1984 100 50 50 50 50 50 Mar. 1, 1989 (final) 50 50 50 50 50 50 regarding lead exposure and the ability to procreate a healthy child, or that the employee has demonstrated difficulty in breathing during a respirator fitting test or during respirator use. An examination is also to be made available to each employee removed from exposure to Airborne levels to bo achieved without reliance or respirator protection through a combination of engineering, work practice lead due to a risk of sustaining material and other administrative controls. While these controls aro being implemented respirators must bo used to meet tho 50 pQ/m* impairment to health, or otherwise exposure limiL j/, V 1-31-80 [Sec. 1910.1025, Appendix Cl Published by THE BUREAU OF NATIONAL AFFAIRS, INC., Washington. D.C. 20037 29 BRF 0302 31:8438 REFERENCE FILE Table 2 Effective <Me Mar. 1,197S- Mar. 1.1980 Mar. 1.1981 Mar. 1,1882 Mar. 1.1983 (final) A. Blood lead level requiring employee medical removal (level mud &80|ig/tOO g_ _>70jm/100 g_ >60 (ig/100 g.. >60fig/l00g.- _60pg/100 g or average ol last three Mood sam be confitmed with aecood todowcp Mood lead level within two aSples or Mood samples ovsr previous B months weeks of tinl report) (whtdwvar is over a longer tme period) Is S3 pg/ too g or greater unless Iasi Mood sample is 40 8. Frequency which employee* exposed to action level ol lead (30 pg/tOOgorleos. pg/m' THU mua have Mood lead level checked (ZPP is else ittiongty feeorvnendad In each occasion that a blood lead is ob tained.!: 1. Lastblood lead leval less than 40 ng/IOQ g ..... ---- Every 0 months. Every 6 months. Every 6 months. Every B months. Every GmorRhv 2. last Mood lead level between 40 frg/ioog and level ' Every 2 month*. Every 2 months. Every 2ionths. Every 2 months. Every 2 months- requiring madicsl removal (see A abovek 3. Dnployess removed from exposure to lead because ol an Every Imonti. Every 1 month- Every t month. Every t month- Every t month, erevsfad blood fead teveL . (XPmrvsiMa estxxneexposure IrrVI torworkare removed Irore work <IOOpg/mIE <50pg/m8 <30jrg/m*8 <30|ig/m*S <30 pg/m*8 hr TWA due to an elevated Mood lead level (without regiid to respirator hr IWA. IwTWA. . hr TWA. hr TWA. O. Blood lead level eonflnnedwtave aeeand Mood ensyile. at which <60 pg/100 g__ <50 pg/100 g--<40 pg/100 g_c<0|igS100g_<4<) pg/100 g. employee may taksn lo wok. Parmlttiblo exposure without ** ~ " ' " regwd to respirator prctaction Is Ssted by industry In'Table t Note.--When merScal opinion IrxSeates that an employee is si risk of material impairment tom exposure to lead, the physician can remove an empteyeo from exposures exceeding the action level (or less) or recommend special protective measures es deemed appropriate and necessary. Medical monitoring during the medical removal period can bo more stringent than noted in the table above if the physician so specifies. Return lo work or removal 61 Boxtalions and special protections is permitted when the physician Indicates trip! tha worker Is no longer al risk ol material tmpabment {S6ction 191o.1025, Appendix C, Table 2 corrected at 44 FR 68827, November 30, 1979} limited or specially protected pursuant whichever encompasses the longest time employee whose blood lead level to medical recommendations. period, equals or exceeds 50 pg/100 g, ' exceeds 40 pg/100 g. In addition each unless the last blood sample indicates a Buch employee is to be informed that the Results of biological monitoring or the blood lead level at or below 40 pg/100 g standard requires medical removal with recommendations of an examining in which case the employee need not be MRP benefits, discussed below, when an physician may necessitate removal of an removed. Medical removal is to continue employee's blood lead level exceeds the employee from further lead exposure until two consecutive blood lead levels above defined limits. pursuant to the standard's medical removal protection (MRP) program. The object of the MRP program is to provide temporaiy medical removal to workers either with substantially elevated blood lead levels or otherwise at risk of sustaining material health impairment from continued substantial exposure to lead. The following guidelines which are summarized in Table Z were created under the standard for the temporary removal of an exposed employee and his or her subsequent return to work in an exposure area. Under the standard's ultimate worker removal criteria, a worker is to be removed from any work having any eight hour TWA exposure to lead of 30 fig/m3 or more whenever either of the following circumstances apply: (1) a blbod lead level of 60 pg/100 g or greater is obtained and confirmed by a second follow-up blood lead level performed within two weeks after the employer receives the results of the first blood sampling test, or (2) the average of the previous three blood lead determinations or the average of all are 40 pg/100 g or less. During the first two years that the ultimate removal .criteria are being phased in, the return criteria have been set to assure that a worker's blood lead level has substantially declined during the period of removal. From March 1, 1979 to March 1, I960, the blood lead level requiring employee medical removal is 80 pg/100 g. Workers found to have a confirmed blood lead at this level or.greater need only be removed from work having a daily 8 hour TWA exposure to lead at or above 100 pg/m\ Workers so removed are to be returned to work when their blood lead levels are at or below 60 pg/100 g of whole blood. From March 1,1980 to March l, 1981, the blood lead level requiring medical removal is 70 pg/100 g. During this period workers need only be removed from jobs having a daily 8 hour TWA exposure to lead at or above 50 pg/m3 and are to be returned to work when a level of 50 pg/100 g is achieved. Beginning March 1.1981, return depends on a worker's blood lead level declining to 40 pg/100 g of whole blood. In addition to the above blood lead' level criteria, temporary worker removal may also take place as a result of medical determinations and recommendations. Written medical opinions must be prepared after each examination pursuant to the standard. If the examining physician includes a medical finding, determination or opinion that the employee has a medical condition which places the employee at increased risk of material health impairment from exposure to lead, then the employee must be removed from exposure to lead at or above the action levet Alternatively, if the examining physician recommends special protective measures for an employee (e.g., use of a powered'air purifying respirator) or recommends limitations on an employee's exposure to lead, then the employer must implement these recommendations.* Recommendations may be more stringent than the specific provisions of the standard. The examining physician, therefore, is given broad flexibility to tailor special protective procedures to the needs"of blood lead determinations conducted As part of the standard, the employer individual employees. This flexibility during the previous six months, is required to notify in writing each extends to the evaluation and Occupational Safety & Health Reporter fSec. 1910.1025, Appendix C] BRF 0303 TOXIC SUBSTANCES 15l 31:8439 management of pregnant workers and opinion concerning potential lead that an employee is at risk of material male and female workers who are poisoning or toxicity. If an employee health impairment. This is based on the planning to raise children, Baaed on the wishes a second opinion, he or she can numerous inadequacies of respirators history, physical examination, and make an appointment with a physician including skin rash where the facepiece i laboratory studies, the physician might of his or her choice. This second makes contact with the skin, recommend special protective measures physician will review the findings, unacceptable stress to breathing in some or medical removal for an employee recommendations or determinations of workers with underlying who is pregnant or who is planning to the first physician and conduct any cardiopulmonary impairment, difficulty conceive a child when, in the examinations, consultations or tests in providing adequate fit. the tendency physician's judgment, continued deemed necessary in an attempt to for respirators to create additional exposure to lead at the current job make a final medical determination. If hazards by interfering with vision, would pose a significant risk. The return the first and second physicians do not hearing, and mobility, and the of the employee >to his or herformer job agree in their assessment they must try difficulties of assuring the maximum status, or the removal of special to resolve their differences..If they effectiveness of a complicated work' protections or limitations, depends upon cannot reach an agreement then they practice program involving respirators. the examining physician determining must designate a third physician to Respirators do, however, serve a useful that the employee Is no longer at resolve the dispute. This multiple function where engineering and work increased risk of material impairment or physician review mechanism has been practice controls are inadequate by that special measures are no longer needed. temporarily stayed during the pending litigation, but OSHA recommends that ft providing supplementary, interim, or short-term protection, provided they are ' During the period of any form of special protection or removal, the employer must maintain the worker's earnings, seniority, and other employment rights and benefits (as though the worker had not been removed) for a period of up to IS months. This economic protection will maximize meaningful worker participation in the medical surveillance program, and is appropriate as part of the employer's overall obligation to be used if disputes arise over medical determinations. The employer must provide examining and consulting physicians with the following specific information: a copy of the lead regulations and all appendices, a description of the employee's duties as related to exposure, the exposure level to lead and any other toxic substances (if applicable), a description of personal protective equipment used, blood lead levels, and all prior written medical opinions regarding the employee in the properly selected for the environment in which the employee will be working, properly fitted to the employee, maintained and cleaned periodically, and worn by the employee when required. In its final standard on occupational exposure to inorganic lead, OSHA has prohibited prophylactic chelation. Diagnostic and therapeutic chelation are permitted only under the supervision of a licensed physician with appropriate provide a safe and healthful workplace. The provisions of MRP benefits during ' the employee's removal period may, employer's possession or control. The employer must also obtain from the physician and provide the employee medical monitoring in an acceptable clinical setting. The decision to initiate chelation therapy must be made on an j however, be conditioned upon participation in medical surveillance. with a written medical opinion containing blood lead levels, the individual basis and take into account the severity of symptoms felt to be a On rare occasions, an employee's physicians's opinion as to whether the result of lead toxicity along with blood blood lead level may not acceptably employee is at risk of material lead levels, ZPP levels, and other decline within 18 months of removal. impairment to health, any recommended laboratory tests as appropriate. EDTA. ' This situation will arise only in unusual protective measures for the employee if and penicillamine which are the primary circumstances, thus the standard relies further exposure is permitted, as well as chelating agents used in the therapy of on an individual medical examination to any recommended limitations upon an occupational lead poisoning have determine how to protect such an employee's use of respirators. significant potential side effects and employee. This medical determination is Employers must instruct each their use must be justified on the basis to be based on both laboratory values, physician not to reveal to the employer of expected benefits to the worker. including lead levels, zinc in writing or in any other way his or her Unless frank and severe symptoms are protoporphyrin levels, blood counts, and findings, laboratory results, or diagnoses present, therapeutic chelation is not other tests felt to be warranted, as well which are felt to be unrelated to recommended given the opportunity to as the physician's judgment that any occupational lead exposure. They must remove a worker from exposure and symptoms or findings on physical also instruct each physician to advise allow the body to naturally excrete examination are a result of lead toxicity. the employee of any occupationally or accumulated lead. As a diagnostic aid, The medical determination may be that non-occupationally related medical the chelation mobilization test using the employee is incapable of ever safely condition requiring further treatment or CA-EDTA has limited applicability. returning to his or her former job status. evaluation. According to some investigators, the test The medical determination may provide The standard provides for the use of can differentiate between lead-induced additional removal timepast 18 months respirators where engineering and other and other nephropathies. The test may for some employees or specify special primary controls have not been fully also provide an estimation of the mobile protective measures to be implemented. implemented. However, the use of fraction of the total body lead burden. The lead standard provides for a respirator protection shall not be used in Employers are required to assure that multiple physician review in cases lieu of temporary medical removal due accurate records are maintained on where the employee wishes a second to elevated blood lead levels or-findings exposure monitoring, medical 1-31-80 {Sec. 1910.1025, Appendix Cj Published by THE BUREAU OF NATIONAL AFFAIRS, INC., Washington, D.C. 20037 BRF 0304 , 31:8440 REFERENCE FILE surveillance, and medical removal for effects to the parents and developing to the later stages of clinical disease, each employee. Exposure monitoring fetus. The adverse effects of lead on disruption of these enzyme processes and medical surveillance records must reproduction are being actively over a working lifetime is considered to be kept for 40 years or the duration of researched and OSHA encourages the be a material impairment of health. employment plus 20 years, whichever is physician to remain abreast of recent longer, while medical removal records must be maintained for die duration of employment AH records required under the standard must be made available upon request to the Assistant Secretary of Labor for Occupational .Safety and Health and die Director of the National fpstihite for Occupational Safety and Health. Employers must also make environmental and biological monitoring and medical removal records available to affected employees and to former employees or their authorized employee representatives. Employees or their specifically designated representatives have access to their entire medical surveillance records. In addition, the standard requires that the employer inform all workers exposed to lead at or above the action level of the provisions of the standard and all its appendices, the purpose and developments in the area to best advise pregnant workers or workers planning to conceive children. The spectrum of health effects caused by lead exposure can be subdivided, into Eire developmental stages: normal, physiological changes of uncertain significance, pathophysiological . changes, overt symptoms (morbidity), and mortality. Within this process there are no sharp distinctions, but rather a continuum ofeffects. Boundaries between categories overlap due to the unde variation of individual responses and erqposures in Hie working population. OSHA's development of the lead standard focused on pathophysiological changes as well as later stages of disease. 1. Heme Synthesis Inhibition, The earliest demonstrated effect of lead One of the eventual results ofleadinduced inhibition of enzymes in the heme synthesis pathway is anemia which can be asymptomatic tf mild but associated with a wide array of symptoms including dizziness, fatigue, and tachycardia when more severe. Studies have Indicated that lead levels as low as 50 fig/100 g can be associate.d with a definite decreased hemoglobin, ' although most cases of lead-induced anemia, as well as shortened red-cell survival times, occur at lead levels exceeding 80 pg/lGOg; Inhibited hemoglobin synthesis is more common in chronic cases whereas shortened .erythrocyte life span is more common In acute cases. In lead-induced anemias, there is usually a reticulocytosis along with the presence of basophilic stippling, and ringed sideroblasts, although none of the description of medical surveiUance and involves its ability to inhibit at least two above are pathognomonic for lead- provisions for medical removal enzymes of the heme synthesis pathway induced anemia. protection if temporary removal is at very low blood levels. Inhibition of required. An understanding of the delta aminolevulinic acid dehydrase 2. NeurologicalEffects. Inorganic lead potential health effects of lead exposure (ALA-D) which catalyzes the has been found to have toxic effects on by all exposed employees along with conversion of delta-aminolevulinic acid both the central and peripheral nervous full understanding of their rights under (ALA) to protoporphyrin is observed at systems. The earliest stages of lead- the lead standard is essential for an a blood lead level below 20 /xg/100 g induced central nervous system effects effective monitoring program. whole blood. At a blood lead level of 40 first manifest themselves in the form of [Section 1910.1025, Appendix C(I) cor ug/100 g, more than 20% of the behavioral disturbances and central rected at 44 FR 68827, November 30, population would have 70% inhibition of. nervous system symptoms including 1979] ALA-D. There is an exponential irritability, restlessness, insomnia and increase in ALA excretion at blood lead other sleep disturbances, fatigue, II. Adverse health effects ofinorganic levels greater than 40 pg/lOO g. vertigo, headache, poor memory, tremor, lead Another enzyme, ferrochelatase, is Although the toxicity of lead has been also inhibited at low blood lead levels. known for 2,000 years, the knowledge of Inhibition of ferrochelatase leads to the complex relationship between lead exposure and human response is stiU being refined. Significant research into the toxic properties of lead continues throughout the world, and it should be anticipated that our understanding of thresholds of effects and margins of safety will be improved in future years. The provisions of the lead standard are founded on two prime medical judgments: first, the prevention of adverse health effects from exposure to lead throughout a working lifetime increased free erythrocyte protoporphyrin (FEP) in the blood which can then bind to zinc to yield zinc protoporphyrin. At a blood lead level of SO (tg/100 g or greater, nearly 100% of the population will have an increase in FEP. There is also an exponential relationship between blood lead levels greater than 40 pg/100 g and the associated ZPP level, which has led to the development of the'ZPP screening test for. lead exposure. depression, and apathy. With more severe exposure, symptoms can progress to drowsiness, stupor, hallucinations, delerium. convulsions and coma. The most severe and acute form of lead poisoning which usually follows ingestion or inhalation of large amounts of lead is acute encephalopathy which may arise precipitously with the onset of intractable seizures, coma, cardiorespiratory'arrest, and death within 48 hours. While there is disagreement about what exposure levels are needed to produce the earliest symptoms, most requires that worker blood lead levels While the significance of these effects experts agree that symptoms definitely be maintained at or below 40 pg/100g is subject to debate, it is OSHA's can occur at blood lead levels of 60 jig/ and second, the blood lead levels of position that these enzyme disturbances 100 g whole blood and therefore workers, male or female, who intend to are early stages of a disease process recommend a 40 ftg/lOO g maximum. parent in the near future should be which may eventually result in the The central nervous system effects maintained below 30 pg/100 g to clinical symptoms of lead poisoning. frequently are not reversible following minimize adverse reproductive health Whether or not the effects do progress discontinued exposure or chelation Occupational Safety &. Health Reporter tSec. 1910.1025, Appendix Cl 32 BRF 0305 TOXIC SUBSTANCES S-151 31:8441 therapy and when improvement does glomeruli and dilated and atrophied blood are comparable to concentrations occur, it is almost always only partial. proximal tubules; all represent end stage of lead in the umbilical cord at birth. The peripheral neuropathy resulting kidney disease. Azotemia can be Transplacental passage becomes from lead exposure characteristically progressive, eventually resulting in frank detectable at 12-14 weeks of gestation involves only motor function with uremia necessitating dialysis. There is and increases until birth. minimal sensory damage and has a occasionally associated hypertension There is little direct data on damage marked predilection for the extensor and hyperuricemia with or without gout to the Telus from exposure to lead but it muscles of the most active extremity. Early kidney disease is difficult to is generally assumed that the fetus and The peripheral neuropathy can occur. detect The urinalysis is normal in early newborn would be at least as with varying degrees of severity. The lead nephropathy and the blood urea susceptible to neurological damage as earliest and mildest form which can be nitrogen and serum creatinine increase young children. Blood lead levels of 60- detected in workers with blood lead onlywhen two-thirds of kidney function 60fig/ioo g in children can cause levels as low as 50 pg/100 g is is lost Measurement of creatinine significant neurobehavioral impairments manifested by slowing of motor nerve clearance can often detect earlier and there is evidence of hyperactivity at conduction velocity often without disease as can other methods of blood levels as low as 25ug/l00 g, clinical symptoms. With progression of measurement ofglomerular nitration (Sven the overall body of literature the neuropathy there is development of rate.'An abnormal Ca-EDTA concerning the adverse health effects of painless extensor muscle weakness mobilization test has been used to lead in children, OSHA feels that the usually involving the extensor muscles differentiate between lead-induced and Mood lead level in children should be of tiie fingers and hand in the most other nephropathies, but this procedure maintained below 30pg/l00 g with a active upper extremity, followed in Is not widely accepted. A form of population mean of 15 pg/100 g. Blood severe cases by wrist drop or, much less Fanconi syndrome with aminoaciduria, lead levels in the fetus and newborn commonly, foot drop. glycosuria, and hyperphosphaturia likewise should not exceed 3Opg/l00g. In addition to slowing of nerve indicating severe Injury to the proximal Because of lead's ability to pass conduction, electrothyographical studies renal tubules is occasionally seen in through the placental barrier and also in patients with blood lead levels children. because of the demonstrated adverse greater than 50 pg/100 g have 5. Reproductive effects. Exposure to effects of lead on reproductive function demonstrated a decrease in the number lead can have serious effects on in both the male and female as well as of acting motor unit potentials, an reproductive function in both males and the risk of genetic damage of lead on increase in the duration of motor unit females. In male workers exposed to both the ovum end sperm, OSHA potentials, and spontaneous lead there can be a decrease in sexual recommends a 30 pg/100 g maximum pathological activity including drive, impotence, decreased ability to permissible blood lead level in both fibrillations and fascicnlations. Whether produce healthy sperm, and sterility. males and females who wish to bear these effects occur at levels of 40 pg/100 Malformed sperm (teratospermia), children. g is undetermined. decreased number of sperm 6. Other toxic effects. Debate and While the peripheral neuropathies can (hypospermia), and sperm with research continue on the effects of lea l occasionally be reversed with therapy, decreased motility (asthenospermia) can on the human body. Hypertension In again such recovery is not assured all occur. Teratospermia has been noted frequently been noted in occupations iy particularly in the more severe at mean blood lead levels of 53 pg/100 g exposed individuals although it is neuropathies and often improvement is and hypospermia and asthenospermia at difficult to assess whether this is due to only partial. The lack of reversibility is 41 pg/100 g. Furthermore, there appears lead's adverse effects on the kidney or if felt to be due in part to segmental to be a dose-response relationship for some other mechanism is involved. demyelination. 3. Gastrointestinal. Lead may also teratospermia in lead exposed workers. Vascular and electrocardiogarphic Women exposed to lead may changes have been detected but have affect the gastrointestinal system producing abdominal colic or diffuse experience menstrual disturbances including dysmenorrhea, menorrhagia not been well characterized. Lead is thought to impair thyroid function and abdominal pain, constipation, and amenorrhea. Following exposure to interfere with the pituitary-adrenal axis, obstipation, diarrhea, anorexia, nausea lead, women have a higher frequency of but again these effects have not been and vomiting. Lead colic rarely develops sterility, premature births, spontaneous well defined. at blood lead levels below 80 pg/100 g. miscarriages, and stillbirths. 4. Renal. Renal toxicity represents one Germ cells can be affected by lead - III. MedicalEvaluation of the most serious health effects of lead and cause genetic damage in the egg or The most important principle in poisoning. In the early stages of disease sperm cells before conception and result evaluating a worker for any nuclear inclusion bodies can frequently in failure to implant, miscarriage, occupational disease including lead be identified in proximal renal tubular stillbirth, or birth defects. poisoning is a high index of suspicion on cells. Renal function remains normal Infants of mothers with lead poisoning the part of the examining physician. As and the changes in this stage are have a higher mortality during the first discussed in Section 2, lead can affect probably reversible. With more year and suffer from lowered birth numerous organ systems and produce a advanced disease there is progressive weights, slower growth, and nervous wide array of signs and symptoms, most interstitial fibrosis and impaired renal system disorders. of which are non-specific and subtle in Function. Eventually extensive Lead can pass through the placental nature at least in the early stages of interstitial fibrosis ensues with sclerotic barrier and lead levels in the mother's disease. Unless serious concern for lead 1-31-80 fSec. 1910.1025. Appendix C] Published by THE BUREAU OF NATIONAL AFFAIRS, INC., Washington, D.C. 20037 BRF 0306 31:8442 REFERENCE FILE toxicity is present, many of the early exposures should be elicited. Any potential blood loss through the clues to diagnosis may easily be previous histpry.of hematological, gastrointestinal tract, overlooked. neurological, gastrointestinal, renal, A complete neurological examination The crucial initial step in the medical psychological, gyneqotogical, genetic, or should include an adequate mental evaluation is recognizing that a worker's reproductive'problems should be status evaluation including a search for employment can result in exposure to specifically noted. behavioral and psychological lead. The worker will frequently be able A careful and complete review of disturbances, memory testing, to define exposures to lead and lead systems must be'pertormed to assess evaluation for irritability, insomnia, containing materials but often will not both recognized complaints and subtle hallucinations, and mental clouding. volunteer this information unless specifically asked. In other situations the worker may not know of any exposures to lead but the suspicion might be raised on the part of the physician because of the industry or occupation of the worker. Potential occupational exposure to lead and its compounds occur in at least 120 or slowly acquired symptoms which the worker might not.appreciate aft being significant The review of symptoms should include the following: General--weight loss, fatigue, decreased appetite. Head, Eyes, Ears,'Nose, Throat (HEENJJ--headaches, visual disturbances or decreased yisual acuity, Gait and Coordination should be examined along with close observation for tremor*. A detailed evaluation of peripheral nerve function including careful sertsojy and motor function testing'is warranted Strength testing' particularly of extensormuscte groups of all extremities;is of fundamental importdncfe. occupations. Including lead smelting, the hearing deficits or tinnitus, pigmentation, Cranial'nerve evaluation Bhould also manufacture of lead storage batteries, of the oral mucosa, or metallic taste in the manufacture of lead pigments and mouth. products containing pigments, solder Cardio-pulmonary--shortness of manufacture, shipbuilding and ship breath; cough, chest pains, palpitations, repair, auto manufacturing, construction, or orthopnea. and painting. Gastrointestinal--nausea, vomiting, Once the possibility for lead exposure heartburn, abdominal pain, constipation is raised, the focus can then be directed or diarrhea. toward eliciting information from the Neurologic--irritability, insomnia, medical history, physical exam, and weakness (fatigue), dizziness, loss of finally from laboratory data to evaluate memory, confusion, hallucinations, the worker for potential lead toxicity. incoordination, ataxia, decreased A complete and detailed work history strength in hands or feet, disturbances is important in the initial evaluation. A in gait, difficulty in climbing stairs, or listing of all previous employment with seizures. be irtcioded in the routine examination. The abdominal examination should include auscultation for bowel sounds and abddaninal bruits and palpation for organomegaly, massqs, and diffuse abdominal tenderness. Cardiovascular examination should evaluate possible early signs of congestive.heart failure.'Pulmonary status should be addressed particularly if respirator protection is contemplated. As part of the medical evaluation, the lead standard requires the following laboratory studies: information on work processes, Hematologic--pallor, easy fatigability, 1. Blood lead level exposure to fumes or dust, known abnormal blood loss, melena. 2. Hemoglobin and hematocrit exposures to lead or other toxic Reproductive (male and female and determinations, red cell indices, and substances, respiratory protection used, spouse where relevant)--history of examination of the peripheral blood and previous medical surveillance infertility, impotence, loss of libido, smear to evaluate red blood cell should all be Included in the worker's abnormal menstrual periods, history of morphology record. Where exposure to lead is miscarriages, stillbirths, or children with 3. Blood urea nitrogen suspected, information concerning on- birth defects. 4. Serum creatinine the-job personal hygiene, smoking or Musculo-skeletal--muscle and joint 5. Routine urinalysis with microscopic eating habits in work areas, laundry pains. examination. procedures, and use of any protective The physical examination should 6. A zinc protoporphyrin level (This clothing or respiratory protection emphasize the neurological, requirement is currently not in effect equipment should be noted. A complete gastrointestinal, and cardiovascular due to the pending litigation, but is work history is essentia! in the medical systems. The worker's weight and blood recommended nonetheless). evaluation of a worker with suspected pressure should be recorded and the In addition to the above, the physician lead toxicity, especially when long term oral mucosa checked for pigmentation is authorized to order any further effects such as neurotoxicity and characteristic of a possible Burtonian or laboratory or other tests which he or she nephrotoxicity are considered. lead line on the gingiva. It should be deems necessary in accordance with The medical history.ls also_cf noted, however, that the lead line may sound medical practice. The evaluation fundamental importance and:should- not be present even in severe lead include a listing of all past and current poisoning if good oral hygiene is must also include pregnancy testing or laboratory evaluation of male fertility if medical conditions, current medications' practiced. requested by the employee. including proprietary drug intake, The presence of pallor on skin Additional tests which are probably previous surgeries and hospitalizations, examination may indicate an anemia, not warranted on a routine basis but allergies, smoking history, alcohol which if severe might also be associated may be appropriate when blood lead consumption, and also non-occupational with a tachycardia. If an anemia is and ZPP levels are equivocal include lead exposures such as hobbies suspected, an active search for blood delta aminolevulinic acid and (hunting, riflery). Also known chjldhood loss should be undertaken including coproporphyrin concentrations in the Occupational Safety & Health Reporter [Sec. 1910.1025, Appendix Cl BRF 0307 TOXIC SUBSTANCES Sv'lSl 31:8443 urine, and dark-field illumination for total lead is deposited there. A very toxicily than the level of blood lead detection of basophilic-stippling in red important component of the total lead itself. The level of ZPP reflects lead blood cells. body-burden is lead in soft tissue [liver, absorption over the preceding 3 to 4 If an anemia Is detected further kidney, and brain). This fraction of the months, and therefore is a better studies including a oareful examinatlon lead body burden, the biologically active indicator of lead body burden. TTie ZPP of the peripheral smear! reticulocyte lead, is not entirely reflected by-blood requires more time than the blood lead count,, stool for occult blood, serum iron, lead levels since ills a-function'of the to read significantly elevated levels; the total iron binding capacity, bilirubin; dynamics of lead absorption, return to normal after discontinuing lead and, if appropriate, vitamin B12 and distribution, deposition in bone and exposure is also slower. Furthermore, folate may be of value:iti attempting to identify the cause of thb anemia. If a peripheral neuropathy is suspected, nerve conduction studies are warranted both for diagnosis and-as a basis to monitorany therapy. .. If renal disease Is questioned, a.24 hour urine collectionfor creatinine clearance,protein, and electrolytes may be indicated. Elevated uric.add levelp may result from lead-induced renal disease and a.serum ur^c add level excretion. Following discontinuation of the ZPP test is simpler, faster, and less exposure to lead, the excess body expensive to perform and no burden is only slowly mobilized from contamination is possible. Many bone and other relatively stable body investigators believe it is the most stores and excreted. Consequently, a reliable means of monitoring chronic high blood lead level may only represent lead absorption. recent heavy exposure to lead without a significant total body excess and likewise a low blood lead level does not exclude an elevated total body burden of lead. Stine protoporphyrin results from the inhibition of the enzyme ferrochelatase which catalyzes the insertion of an iron molecule into the protoporphyrin molecule, which then becomes heme. If might be performed. Also due to its correlation with recent iron is not inserted into the molecule An electrocardiogram and chest x-ray exposures, the blood lead level may then zinc, having a greater affinity for may be,obtained as.deemed appropriate. vary considerably over short time Sophisticated andhigjily specialize^ intervals. testing' should'not be done routinely and protoporphyrin, takes the place of the iron, forming ZPP. An elevation in the level of circulating where indicated shouldlbe under the To minimize laboratory error and ZPP may occur at blood lead levels as direction of a specialist, erroneous results due to contamination, low as 20-30 /tg/lOQ g in some workers. blood specimens must be carefully Once the blood lead level has reached [Section 1910.1025, Appendix C(III) collected after thorough cleaning of the 40 p.g/100 g there is more marked rise in corrected at 44 FR 68827, November 30, skin with appropriate methods using the ZPP value from its normal range of 1979] lead-free blood containers and analyzed less than 100 p.g/100 ml. Increases in IV. Laboratory Evaluation The blood lead level at present remains the single most important test to. monitor lead exposure altd is tHe test used in the: medical surveillance program under the }ead Standard t6 guide employee medical'removal. The. ZPP which has several Advantages ovfer the blood lead level Is, due to the pending litigation, not required under the standard. Because of its'relatively recent development and the lack of extensive data concerning its interpretation, the ZPP currently remains an ancillary test; This section will discuss the blood lead level and ZPP in detail and will outline their relative advantages and disadvantages. Other blood tests currently available to evaluate lead exposure will also be reviewed. The blood lead level is a good index of current or recent lead absorption when there is no anemia present and when the worker has not taken any chelating agents. However, blood lead levels along with urinary lead levels do not necessarily indicate the total body by-a reliable laboratory, Under.the standard, samples must be analyzed in laboratories which are approved by the Center for Disease Control (CDC) or which have received satisfactory grades in proficiency testing by the CDC in the previous year. Analysis is to be made using atomic absorption spectro photometry, anodic stripping voltam metry, or any method which meets the accuracy requirements set forth by the standard. The determination of lead in urine is generally considered a less reliable monitoring technique than analysis of whole blood primarily due to individual variability in urinary excretion capacity as well as the technical difficulty of obtaining accurate 24 hour urine collections. In addition, workers with renal insufficiency, whether due to lead or some other cause, may have decreased lead clearance and consequently urine lend levels may underestimate the true lead burden. Therefore, urine lead levels should not be used as a routine test. blood lead levels beyond 40 pg/100 g are associated with exponential increases in ZPP. Whereas blood lead levels 'fluctuate over short time spans, ZPP levels ren. : relatively stable. ZPP is measured directly in red blogd cells and is present for the cell's entire 120 day life-span. Therefore, the ZPP level in blood reflects the average ZPP production over the previous 3-4 months and consequently the average lead exposure during that time interval. It is recommended that a hematocrit be determined whenever a confirmed ZPP of 50 /ig/100 ml whole blood is obtained to rule out a significant underlying anemia. If the ZPP is in excess of 100 jig/100 ml and not associated with abnormal elevations in blood lead levels, the laboratory should be checked to be sure that blood leads were determined using atomic absorption spectrophotometry, anodic stripping voltametry, or any method which meets the accuracy re quirements set forth by the standard by a CDC aproved laboratory which is experienced in lead level burden of lead and aro not adequate The zinc protoporphyrin test, unlike determinations. Repeat periodic blood measures of past exposure. One reason the blood lead determination, measures lead studies should be obtained in all for this is that lead has a high affinity an adverse metabolic effect of lead and individuals with elevated ZPP levels to for bone and up to 90% of the body's as such is a better indicator of lead be certain that an associated elevated blood lead level has not been missed 1-31-80 [Sec. 1910,1025, Appendix C] Published by THE BUREAU OF NATIONAL AFFAIRS, INC., Washington, D.C. 20037 35 31:8444 REFERENCE FILE due to transient fluctuations in blood the disadvantages include variability in Even with adequate worker education leads. results, the necessity to collect a ZPP has a characteristic fluorescence complete 24 hour urine Sample which on the adverse health effects of lead and appropriate training in work practices, spectrum with a peak at 594 nm which is has a specific gravity greater than 1.010, personal hygiene and other control detectable with a hematofluorimeter. and also the foot that ALA decomposes measures, the physician has a primary The hematofluorimeter is accurate and in the presence of light responsibility for evaluating potential portable and can provide on-site, The pattern pf porphyrin excretion in lead toxicity in the worker. It is only instantaneous results for workers who the urine can also be helpful in through a careful and detailed medical can be frequently tested via a Anger identifying lead intoxication. With lead and work history, a complete physical prick. poisoning, the urine concentrations of examination and appropriate laboratory However, careful attention must be coproporphyrins I and n, testing that an accurate assessment can given to calibration and quality control porphobilinogen and uroporphyrin 1 rise. be made. Many of the adverse health procedures. Limited data on blood The most important increase, however, effects of lead*toxicity are either lead--ZPP correlations and the ZPP is that of coproporphyrin IH; levels may irreversible or only partially reversible levels which are associated with the exceed 5,000 pg/l in the urine in lead and therefore early detection of disease adverse health effects discussed in poisoned individuals, but its correlation is very Important Section 2 are the major limitations of the with blood lead levels and.ZPP are not test Also it is difficult to correlate ZPP as good as those of ALA. Increases in levels with environmental exposure and urinary porphyrins are not diagnostic of there is some variation of response with lead toxicity and may be seen in age and sex. Nevertheless, the ZPP porphyria, some Aver diseases, and in promises to be an important diagnostic patients with high reticulocyte counts. test for the early detection of lead toxicity and its value will increase as more data is collected regarding its relationship to other manifestations of lead poisoning. Levels of delta-aminolevulinic acid [Section 1910.1025, Appendix C(IV) corrected at 44 FR 68827, November 30, 1979] Summary. The Occupational Safety and Health Administration's standard for inorganic lead places significant (ALA) in the urine are also used as a emphasis on the medical surveillance of measure of lead exposure. Increasing all workers exposed to levels of concentrations of ALA are believed to inorganic lead above the action level of result from the inhibition of the enzyme 30 pg/m1 TWA. The physician has a delta-aminolevulinic acid dehydrase fundamental role in this surveillance (ALA-D). Although the test is relatively program, and in the operation of the easy to perform, inexpensive, and rapid. medical removal protection program. This document outlines the medical monitoring program as defined by the occupational safety and health standard for inorganic lead. It reviews the adverse health effects of lead poisoning and describes the important elements of the history and physical examinations as they relate to these adverse effects. Finally, the appropriate laboratory testing for evaluating lead exposure and toxicity is presented. It is hoped that this review and discussion will give the physician a better understanding of the OSHA standard with the ultimate goal of protecting the health and well-being of ihe worker exposed to lead under his or her care. [The next page is 31:8451] Occupational Safety & Health Reporter (Sec. 1910.1025, Appendix C] 36 BRF 0309