# NIOSH Hazard Review: Carbonless Copy Paper/Introduction

1 Introduction
1.1 Background
In 1987, the Occupational Safety and Health Administration (OSHA) requested the National Institute for Occupational Safety and Health (NIOSH) to investigate the validity of reported adverse health effects in workers occupationally exposed to chemicals contained in or released from carbonless copy paper (CCP). OSHA also requested that NIOSH publish its ﬁndings if health effects were confirmed. The OSHA request was based on one worker's concern that skin, respiratory problems, and possible brain damage were due to consistent exposure to CCP [52 Fed. Reg. 22534 (1987)]. In addition, 10 to 12 of the initial complainant's coworkers who were also exposed to CCP were reported to have suffered adverse health effects.
Thus in 1987, NIOSH issued a Federal Register notice soliciting information about possible adverse health effects from CCP exposure [52 Fed. Reg. 22534 (1987)]. On the basis of information available at that time, no strong conclusion could be reached concerning a consistent link between CCP and major health effects. Between 1987 and 1997, a number of additional incidents were identified as involving health problems potentially related to CCP. Therefore, in 1997 NIOSH issued a second Federal Register notice soliciting new information [62 Fed. Reg. 8023 (1997)].
This report contains a review of the published literature on CCP and the submissions from the two Federal Register notices. NIOSH prefers to use the published literature when investigating the relationship between an occupational exposure and adverse health effects, but some unpublished sources were used in this case because the published literature was limited. The unpublished information was found to be of variable quality, validity, and utility.
1.2 Development and Production of CCP
CCP was introduced in 1954 by the National Cash Register Company as no-carbon-required (NCR) paper—an alternative to separate sheets of carbon paper [Sandberg 1955; Green 1955; Miller and Phillips 1972; Calnan 1979; Buring and Hennekens 1991]. NCR was a patented name, but many of the patents have expired, and several companies have licenses in other countries.
The mechanism of CCP involves coating the under surface of the top sheet of CCP with an emulsion of a colorless dye in a solvent (see Chapter 2). The emulsion is held in microscopic capsules (microcapsules) that are ruptured by firm pressure from a writing instrument. The released dye reacts with a reagent on the surface of the paper and changes the dye to a colored product (generally violet, blue, or black). CCP may also be referred to as one of the following:
* Pressure-sensitive paper
* Reaction-copy paper
* Color-reaction paper
* Self-copying paper
CCP comprises an extremely complex grouping of products. A given CCP can vary greatly as to its constituents, weight and types of paper coatings, paper color, dye colors and combination of dyes used on coatings, solvents and solvent mixtures (including variations from different suppliers), physical form (rolls versus sheets), and final form of the product (i.e, bound with adhesives). To improve quality and performance, the "recipes" used in the manufacture of CCP change frequently. No single product can be identified as a typical formulation of CCP since each product may have its own distinct constituents and different manufacturing processes. Thus the product known as CCP is not a single product but includes thousands of different and often unique products [Mead Corporation 1997 (a NIOSH docket submission)].
Production of CCP grew on an enormous scale after its introduction in 1954. By the 1960s, U.S. sales were about 16,000 tons, and production had started in Europe. In 1962, a Japanese company signed a license agreement with the National Cash Register Company, and by 1970, worldwide production rose to 100,000 tons. In 1991, about 1.8 million tons of CCP (the equivalent of nearly 200 billion 8.5- × 11-in. sheets) [Fetters 1997 (a NIOSH docket submission)] were produced and used [Buring and Hennekens 1991; Murray 1991]. Consumption is divided into three principal regions: North America—800,000 tons, Japan and the Far East—300,000 tons, and Europe—600,000 tons [Murray 1991]. The Association of European Manufacturers of Carbonless Papers [AEMCP 1985] indicated that in 1985 there were more than 50 manufacturers of CCP throughout the world.
By 1979, four companies in Great Britain, four in Japan, five in other European countries, and five major companies in the United States were manufacturing this paper [Calnan 1979]. Currently, 12 plants (5 manufacturers) in the United States [Fetters 1997 (a NIOSH docket submission)] and more than 50 plants around the world [AEMCP 1985] manufacture CCP. U.S. production averaged nearly 1 million tons during the period 1987–1996 [Graves and Tardiff 1999]. Annual global sales exceed $5 billion [Finch 1990].
The production industry employs more than 10,000 workers [Fetters 1997 (a NIOSH docket submission)]. Although the total number of workers potentially exposed to CCP in workplaces other than manufacturing (such as offices, laboratories, other businesses, schools, banking, etc.) is unknown [Pedersen 1998], it is likely to be in the millions. Also unknown is the extent to which the general public is potentially exposed to CCP during business transactions, receipt checking, etc.
1.3 Reported Health Effects
About 10 years after the introduction of CCP, medical complaints began to be reported by exposed office workers [North Carolina Medical Journal 1982; Magnusson 1974; Göthe et al. 1981; Buring and Hennekens 1991]. In 1975, OSHA requested information from physicians about any unusual frequency of eye, mucous membrane, or skin irritation associated with CCP similar to the information being reported at that time in Sweden [North Carolina Medical Journal 1982].
Since 1965, various health effects associated with exposure to CCP have been reported in the literature appearing from Denmark, Finland, England, Sweden, Germany, the Netherlands, France, Italy, Belgium, Japan, Norway, and the United States. The National Swedish Board of Occupational Safety and Health ​[1976] gathered information about the components of CCP and came to the following conclusions:
* None of the substances present in CCP at that time had known irritant or allergenic effects.
* The problems of skin and mucous membrane irritation are most common in the winter when the humidity is low.
* None of the substances gave rise to large amounts of dust.
* None of the substances would lead one to expect vapors to be generated at room temperatures.
* The odor reported by some may originate from the solvents in the adhesives or the inks.
Despite these negative conclusions, the Swedish Board noted that further attention to the question was warranted, "since problems with the skin and mucous membranes are still being reported by persons working with carbonless paper." Thus they also issued advice and instructions related to the handling of CCP [National Swedish Board of Occupational Safety and Health 1976].
In February 1980, the Swedish Trade Union called for a ban on CCP [Göthe et al. 1981], which was claimed to be the cause of numerous conditions including the following [Göthe et al. 1981; Kanerva et al. 1993]:
| Itching | Headache |
| Redness of the skin | Joint pain |
| Breathing difficulty | Rapid heart beat |
| Hoarseness and airway obstruction | Burning of the nose, eyes, mouth, and chest |
| Chest tightness and pain | Unpleasant smell and taste |
| Asthma | Contact urticaria |
| Fatigue | Allergic Contact dermatitis |
| Nausea | Irritant contact dermatitis |
Government and public concerns have waxed and waned in response to various reports in the literature as well as anecdotal information. The Danish, French, Swedish, and German governments have offered recommendations for reducing exposure to CCP (summarized in Chapter 6) that rely on simple work practices, personal hygiene, substitution, administrative controls, and increased ventilation as preventive measures. The Danish, French, and German governments have also recognized alleged health effects from CCP exposure as compensable according to the seriousness of the worker's reaction [Norbäck et al. 1983b].
At the first symposium on CCP (which was held in Stockholm and attended by producers, labor, government, and representatives from nine nations), Göthe et al. [1981] commented that strong forces had been mobilized in Sweden 2 years before the meeting to ban CCP or find a substitute for it. They noted that support for such resolutions has "often been anxiousness enhanced by unverified rumors or alarming mass-media reports about dramatic and serious diseases caused by work with carbonless copy papers." On the basis of their field investigations, Göthe et al. [1981] indicated that handling large amounts of CCP might induce dose-related but benign and nonallergic irritative symptoms, particularly in the mucous membranes of the nose and mouth. These authors did not consider these symptoms to be specific for CCP: they could also be elicited by handling large amounts of ordinary paper. But it appeared that a higher percentage of CCP workers might develop these symptoms than workers exposed to ordinary paper. These ​investigators did not consider the phenomenon to indicate any large health risk, but they noted that CCP seems to be somewhat more irritating than ordinary paper in equivalent amounts.
In Canada, Harris [1983] reported that the symptoms directly associated with use of CCP (and shown to decrease outside of work or at other tasks) develop primarily in office workers who use CCP and less in those who make it. He stated that the symptoms (1) appear to be quickly reversible when exposure ceases, (2) are rarely caused by allergic reactions, and (3) vary greatly from office to office (which may depend on combinations of factors including the brand of CCP, the intensity of use, and office conditions such as ventilation and humidity). He further stated that no individual chemicals such as formaldehyde, oils, or paper dust had been identified as causing the related symptoms and that measurements in the office air were generally too low to account for the symptoms. Harris [1983] concluded that the reported health problems were due to the mixture of chemicals used in CCP and to mechanical irritation by the clay coatings on the paper.
To provide a comparison with the information available on CCP, Brissette and Paquette [1987] summarized the known information about the prevalence of health problems associated with carbon paper in Quebec, Canada. They reported that 34 of 390 cases of industrial dermatitis reported in 1929 and 5 of 5,000 cases reported between 1932 and 1936 were related to carbon paper, but the observations were not based on patch testing. They further reported that at the Finsen Institute in Copenhagen, cutaneous toxicity to carbon paper was evaluated in 40,000 people. Only four cases of allergic contact dermatitis were recorded, and the agents responsible were triorthocresyl phosphate, oleic alcohol, nigrosine, and violet methyl. None of these agents are reported to be used in CCP.
On February 13, 1986, the National Swedish Board of Occupational Safety and Health decreed that the CCP Announcement No. 1976:2 [National Swedish Board of Occupational Safety and Health 1976] (which recommended actions to be taken when CCP-exposed workers showed symptoms of irritation) was no longer valid: "The problems which were previously considered to be caused by carbonless paper are now regarded as being of an extremely complex nature and have been linked directly to the paper only in a small number of cases (see Arbete Och Hälsa [Work and Health] 1983:2, Report on Problems Caused by Carbonless Paper).
1.4 Information Sources and Types
This NIOSH report is based on published and unpublished information. The published information includes case studies and case series, cross-sectional epidemiological studies, patent literature, and some reports of human and animal experimental studies. The unpublished materials were submitted to the NIOSH Docket in response to the Federal Register notices in 1987 and 1997 [52 Fed. Reg. 22534 (1987) and 62 Fed. Reg. 8023 (1997)]. These unpublished materials generally include human repeat insult patch test (RIPT) studies, animal exposure studies, and medical records of workers who indicated that they had exposure to CCP.