Evaluation of Methicillinresistant Staphylococcus 

aureus (MRSA) Cases among 

Employees at a Workholding 

Manufacturing Facility

John Gibbins, DVM, MPH

Todd Niemeier, MS, CIH

Health Hazard Evaluation Report

HETA 2009-0098-3103

Positrol Inc.

Cincinnati, Ohio

March 2010

Department of Health and Human Services

Centers for Disease Control and Prevention

Workplace

Safety and Health

 National Institute for Occupational 

Safety and Health

This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific

facility evaluated and may not be universally applicable. Any recommendations made are not to be 

considered as final statements of NIOSH policy or of any agency or individual involved. Additional HHE 

reports are available at http://www.cdc.gov/niosh/hhe/
The employer shall post a copy of this report 

for a period of 30 calendar days at or near 

the workplace(s) of affected employees. The 

employer shall take steps to insure that the 

posted determinations are not altered, defaced, 

or covered by other material during such 

period. [37 FR 23640, November 7, 1972, as 

amended at 45 FR 2653, January 14, 1980].
Health Hazard Evaluation Report 2009-0098-3103 Page i

Appendix A

Report Abbreviations.......................................................................ii

Highlights of the NIOSH Health Hazard Evaluation............ iii

Summary .............................................................................v

Introduction..........................................................................1

Assessment.........................................................................1

Results.................................................................................3

Discussion ...........................................................................4

Conclusions.........................................................................6

Recommendations...............................................................6

References ..........................................................................8

Contents

Acknowledgments and Availability of Report.....................19

Metalworking Fluids...........................................................10

Prevention of Skin Problems when Working with Metal 

Working Fluids...................................................................15

Acknowledgments

Appendix B
Page ii Health Hazard Evaluation Report 2009-0098-3103

°C Degrees celsius

CFU Colony forming unit

cm Centimeter

cm2 Square centimeter

EPA Environmental Protection Agency

HEPA High efficiency particulate air

HHE Health hazard evaluation

HP Hypersensitivity pneumonitis

HSE Health and Safety Executive

IARC International Agency for Research on Cancer

MWF Metalworking fluid

mg/m3 Milligrams per cubic meter

mL Milliliter

MRSA Methicillin-resistant Staphylococcus aureus

NAICS North American Industry Classification System

NIOSH National Institute for Occupational Safety and Health

OSHA Occupational Safety and Health Administration

PAH Polycyclic aromatic hydrocarbon

PEL Permissible exposure limit

PPE Personal protective equipment

REL Recommended exposure limit

STEL Short-term exposure limit

TWA Time-weighted average

Abbreviations
Health Hazard Evaluation Report 2009-0098-3103 Page iii

Highlights of the

NIOSH Health

Hazard Evaluation

In February 2009, the 

National Institute for 

Occupational Safety and 

Health (NIOSH) received 

a management request 

for a health hazard 

evaluation at Positrol Inc. 

in Cincinnati, Ohio. The 

company submitted the 

request because several 

employees had reported 

methicillin-resistant 

Staphylococcus aureus

(MRSA) skin infections, 

and management wanted 

to determine if these 

infections were related to 

workplace exposures.

What NIOSH Did

● We visited the facility in March and May 2009.

● We talked with management and employees about their 

concerns.

● We toured the facility and observed employees at work.

● We spoke with employees confidentially about their health 

and asked if they had ever been diagnosed with MRSA.

● We discussed safety and health training at the facility and 

personal protective equipment use.

● We reviewed medical records of employees who reported 

current or past MRSA infections.

● We provided management and employees copies of the 

NIOSH Safety and Health Topic webpage MRSA and the 

Workplace.

● We reviewed the results of chemical and microbiological tests 

for metalworking fluids (MWFs) that were conducted from 

April 2005 to March 2009 by a third party.

● We collected bulk MWF from machine reservoirs and swab 

samples from machine and bathroom surfaces and tested 

them for the presence of MRSA.

What NIOSH Found

● Three employees reported MRSA skin infections that were 

confirmed through laboratory testing conducted by their 

healthcare provider. We determined these infections were 

unlikely to be related to the workplace.

● The third party chemical and microbiological testing results 

from several MWF samples indicated that total bacteria levels 

are highly variable and poorly controlled.

● MRSA was not found in the bulk MWF or surface samples 

taken at the facility by NIOSH investigators.

● Many machines were not fitted with engineering controls or 

enclosures to keep MWF from splashing or misting.

What Managers Can Do

● Ensure custodial staff keeps restrooms and hand-washing 

facilities clean.

● Encourage employees to report injuries to their supervisor in 

a timely manner.
Page iv Health Hazard Evaluation Report 2009-0098-3103

Highlights of the

NIOSH Health

Hazard Evaluation

(continued)

● Urge employees to keep cuts or wounds covered with dry 

bandages to prevent the spread of MRSA infections while at 

work or home.

● Establish a comprehensive MWF maintenance program with 

designated supervision.

● Evaluate employee exposures to MWFs and evaluate the 

need for engineering controls and enclosures to machines to 

reduce exposure.

● Train employees on MWF health hazards, use of personal 

protective equipment, proper hygiene, and how to report 

health concerns.

● Include all employees exposed to MWF in a medical 

monitoring program.

What Employees Can Do

● Tell management about any workplace injuries or health 

concerns that you think may be related to the workplace.

● Seek prompt medical care for any skin infections.

● Follow wound care instructions provided in the NIOSH 

guidance MRSA and the Workplace and as provided by your 

healthcare provider.

● Participate in training when provided.

● Use appropriate personal protective equipment such as 

gloves, sleeves, and aprons to reduce skin contact with 

MWFs.

● Wash MWFs off skin as soon as possible.

● Maintain good skin health through proper hygiene and use 

of moisturizers.

● Use a high efficiency particulate air (HEPA) filtered vacuum 

to remove dust, and use rags or cloths to wipe up excess 

MWF from parts and machines instead of using compressed 

air. 
Health Hazard Evaluation Report 2009-0098-3103 Page v

Summary

It is unlikely that the three 

cases of MRSA among 

workers at the facility 

were related to workplace 

exposures. Although we 

did not isolate MRSA from 

the MWF in this facility, 

this route of exposure is 

plausible and warrants 

additional evaluation. 

We recommend 

that management 

assess the need for 

engineering controls 

to reduce exposure to 

MWF, and institute a 

comprehensive MWF 

maintenance program 

to reduce the potential 

for microbiological 

contamination. 

In February 2009, NIOSH received an HHE request from 

management at Positrol Inc. in Cincinnati, Ohio. The company 

was concerned because several workers had previously reported 

MRSA skin infections, and management wanted to determine if 

these infections were related to workplace exposures. 

In March 2009, we visited Positrol and observed work processes. 

During the visit we held an opening conference, interviewed 

employees, and reviewed records. In May 2009, we collected bulk 

MWF samples and swab samples from machines and bathroom 

surfaces to test for the presence of MRSA bacteria. 

Our investigation determined that three employees had previously 

been diagnosed with MRSA; however, these infections did not 

appear to be related to each other or to workplace exposures. The 

analysis of the bulk MWF and surface samples did not show the 

presence of MRSA. Our analysis of microbiological and pH tests 

conducted by a third party from April 2005 to March 2009 found 

that total bacterial levels in the MWF were highly variable and 

poorly controlled. 

Many of the machines at the facility were not fitted with 

engineering controls or enclosures to prevent splashing or 

misting of MWF. We recommend that management evaluate 

employee exposures to MWF and, based on guidance outlined 

in this report, evaluate the need for engineering controls and 

enclosures to reduce exposure. We also recommend implementing 

a comprehensive MWF maintenance program to control bacteria, 

and encouraging employees to use appropriate PPE and practice 

good hygiene and wound management.

Keywords: NAICS 33515 (Cutting Tool and Machine Tool 

Accessory Manufacturing), metalworking fluid, methicillin-resistant 

Staphylococcus aureus, machine shop, MRSA
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Health Hazard Evaluation Report 2009-0098-3103 Page 1

Introduction

In February 2009, NIOSH received a management request for an 

HHE at Positrol Inc. in Cincinnati, Ohio. The company submitted 

the HHE request because several employees had reported probable 

MRSA skin infections, and management wanted to determine if 

these infections were related to workplace exposures. 

Background

Positrol Inc. machines and produces a wide variety of workholding 

devices for industrial applications. Initial discussions with 

management upon receipt of the HHE request did not identify 

typical environmental risk factors for MRSA transmission such 

as shared shower facilities, towels, or locker rooms. We sent 

management the NIOSH document MRSA and the Workplace to 

provide background on MRSA infection and prevention strategies. 

The facility, a one-story building, consists of office space and 

a shop floor. The various types of machining tools in the shop 

area include computer-numeric controlled, drilling, grinding, 

and lathing machines. Most machines use commercially available 

synthetic MWFs. Each machine has its own MWF reservoir. 

Biocides are not added to the MWFs to control the growth of 

microorganisms. The frequency of MWF addition or replacement 

varies at the discretion of the machine operator.

In response to the HHE request, we visited the facility on March 

12 and May 14, 2009. On March 12, 2009, we held an opening 

meeting with management and employee representatives, followed 

by a tour of the facility. We talked with employees who agreed to 

confidential interviews, observed work procedures, and obtained 

medical records for three employees who self-reported current or 

prior infection with MRSA to confirm their diagnosis.

Management provided bacteria and pH testing results of MWFs 

conducted by a third party, dating from April 2005 to March 

2009. To determine the amount of bacteria in the MWF, the third 

party company submerged a Sani Check® BF paddle (Biosan 

Laboratories, Inc., Warren, Michigan) in a sample of MWF. The 

paddle was incubated at 25°C–30°C for 24–36 hours. Bacterial 

growth on the paddle was then compared to a picture conversion 

chart to estimate the bacterial load in the MWF. From these 

results, it appeared that testing was conducted every 2–5 months 

on the machines. 

Assessment
Page 2 Health Hazard Evaluation Report 2009-0098-3103

Assessment (continued) On May 14, 2009, we returned to the facility and collected bulk 

MWF and swab surface samples in various locations for analysis 

of MRSA. We wore nitrile gloves while collecting samples and 

changed them out between samples to minimize the risk of crosscontamination. Bulk MWF samples were collected at the fluid 

nozzle of five machines by directing approximately 40 mL of MWF 

into a sterile polypropylene conical tube (Becton, Dickinson and 

Company, Franklin Lakes, New Jersey). Eleven swab samples 

were collected from the surfaces of five machines, men’s shop 

bathroom, office area bathroom, lunchroom, and office area. Dry 

sterile foam-tipped applicator swabs (Puritan Medical Products 

Company, Guilford, Maine) were used to collect these samples. 

Samples were collected in a 100 cm2 area using disposable 10 cm 

x 10 cm templates. After collection, swabs were placed in sterile 

polypropylene conical tubes. Table 1 provides a description of the 

samples collected. 

Table 1. Bulk and swab samples collected on May 14, 2009

Sample 

Type Sample Location

Machine 

Serial 

Number

Comments

Bulk Milwaukee K&T horizontal mill 533-59 Coolant rarely changed 

Bulk ROM 1 M20 milling machine 533-92 Coolant changed approximately 3 weeks 

 before sampling 

 Bulk OD grinder 533-86 Coolant rarely changed

 Bulk OD grinder 533-50 Coolant rarely changed

Bulk LV 15 lathe 533-78 Coolant changed approximately 4 weeks 

 before sampling 

Swab AVS lathe - flat surface above handle 533-04 Coolant rarely changed

Swab Automatic grinder - flat surface next 

to handle 

533-15 Coolant changed 3–5 days before sampling 

Swab Lathe - flat surface near handles 533-88 Coolant change unknown

Swab Men’s shop bathroom - large 

 communal sink 

— —

Swab Men’s shop bathroom - next to stall 

 one door handle 

— —

Swab Women’s bathroom adjacent to 

 breakroom - sink 

— —

Swab Breakroom - counter in front of 

 microwave 

— —

Swab Office area - desktop surface — —

Swab ROM 1 M20 milling machine - 

 surface next to handle on top 

 cover 

— —

Swab LV 15 Lathe - flat surface next to 

 handle 

— —

Swab Field blank — —
Health Hazard Evaluation Report 2009-0098-3103 Page 3

Assessment (continued) All samples (bulk and swab) were placed in a cooler with ice and 

shipped overnight to Microbiology Specialists, Inc.® in Houston, 

Texas. The samples were swabbed onto BBLTM CHROMagarTM 

MRSA (BD-Diagnostic Systems, Sparks, Maryland), a selective and 

differential medium for the detection of MRSA. The media were 

held at 35°C in ambient conditions for 48 hours, but were read 

at 24-hour intervals. MRSA is identified on these media by the 

growth of mauve-colored colonies. 

Industrial Hygiene 

The microbiological test results we reviewed indicated that bacterial 

CFUs ranged from <102 to 107 CFU/mL from 2005 to 2009. The 

pH of the MWFs ranged from 7.8 to 9.5. No obvious pattern was 

observed in these results over time.

No mauve-colored colonies were noted on the BBL CHROMagar 

media at 24 or 48 hours, indicating that MRSA was not isolated 

from any of the bulk and swab samples we collected.

Interviews and Records Review 

Of the 15 employees who worked on the machine shop floor, 

five participated in confidential interviews. Three employees 

reported being told by their physician that they had been infected 

with MRSA; two of these employees reported multiple infections 

and infections among family members over months to years. A 

review of their medical records determined that all three had been 

diagnosed with MRSA in the past by culture and sensitivity testing 

conducted at a clinical laboratory. Other issues raised included 

recurring sinus infections, lack of timely injury reporting, and 

concerns about using compressed air to clean off machines and 

parts, which generates dust and aerosols.

Results
Page 4 Health Hazard Evaluation Report 2009-0098-3103

MRSA refers to types of Staphylococcus aureus (S. aureus) bacteria 

that are resistant to several antibiotics, including methicillin. 

Approximately 25%–35% of the U.S. population is colonized 

(a person who carries a bacteria on his or her body but does not 

exhibit signs of disease) by S. aureus, while an estimated 1.5% is 

colonized by MRSA [Gorwitz et al. 2008]. Community-acquired 

MRSA infections usually occur as skin and/or soft tissue infections 

in otherwise healthy people. Historically, outbreaks have been 

reported in schools, correctional facilities, and military barracks 

[Lindenmayer et al. 1998; CDC 2003a,b; Zinderman et al. 2004; 

Cohen 2005]. Factors that have been associated with the spread 

of MRSA skin infections include close skin-to-skin contact, 

contamination of skin whose integrity has been compromised 

through cuts or abrasions, contact with contaminated items 

and surfaces such as soiled bandages or towels, crowded living 

conditions, and poor hygiene. 

MRSA was not detected in any of the swab or bulk samples that we 

collected. As part of our investigation, we collected bulk and swab 

samples on machines where MRSA-infected employees worked 

as well as on machines where employees did not report MRSA 

infections. In a review of the scientific literature, we identified no 

publications that linked exposure to MWFs with MRSA infections; 

however, it is plausible that this type of bacteria could grow in a 

water-based synthetic MWF environment [Weissfeld 2009].

Our review of prior test results for bacteria in Positrol MWFs 

found that concentrations of bacteria were very high at times (up 

to 107 CFU/mL). Although NIOSH has no RELs for bacteria and 

fungi in MWFs, the HSE in the United Kingdom has provided 

guidance on this issue. The HSE recommends keeping bacteria 

levels in MWF below 103 CFU/mL. If bacteria levels are between 

103 and 106 CFU/mL in the MWF, the HSE recommends cleaning 

the system or changing the biocide regimen. If bacteria levels are 

greater than 106 CFU/mL, they recommend that the employer 

immediately drain the MWFs and clean the machine [HSE 2006]. 

Additional guidance from the HSE on MWFs can be found at

http://www.hse.gov.uk/metalworking/ecoshh.htm. The HSE 

recommends testing bacteria at least once a week [HSE 2006].

Although we did not monitor the air for MWFs during our 

evaluation, we observed some conditions that may lead to 

employee airborne MWF exposures. Specifically, many tooling 

machines that use MWFs were neither enclosed nor fitted with 

Discussion
Health Hazard Evaluation Report 2009-0098-3103 Page 5

Discussion (continued) engineering controls that would help reduce concentrations of 

MWF mists. Additionally, we observed that many employees did 

not wear gloves when working with MWFs. 

Substantial scientific evidence indicates that employees currently 

exposed to MWF aerosols have an increased risk of respiratory 

(lung) and skin diseases. These health effects vary based on the 

type of MWF, route of exposure, concentration, and length of 

exposure [NIOSH 1998b]. The NIOSH REL for MWF aerosols 

is 0.5 mg/m3 for total MWF particulates and 0.4 mg/m3 for the 

thoracic particulate mass, as a TWA concentration for up to 10 

hours per day during a 40-hour workweek. The NIOSH REL 

is intended to prevent or greatly reduce respiratory disorders 

associated with MWF exposure. Some employees have developed 

work-related asthma, HP, or other adverse respiratory effects when 

exposed to MWFs at concentrations below the NIOSH REL 

[NIOSH 1998a,b]. In addition, limiting dermal (skin) exposure is 

critical to preventing allergic and irritant disorders related to MWF 

exposure. In most metalworking operations, it is technologically 

feasible to limit MWF aerosol exposures to 0.4 mg/m3 or less by 

using engineering controls. NIOSH also recommends medical 

monitoring for employees exposed to MWF. Medical monitoring 

is needed for the early identification of employees who develop 

symptoms of MWF-related conditions such as HP, asthma, and 

dermatitis [NIOSH 1998a,b]. If all employees cannot be included 

in a medical monitoring program, priority should be given to 

those at high risk; for example, those exposed to MWF aerosol 

concentrations above a designated level such as half the REL 

[NIOSH 1998a,b]. Medical monitoring consists of preplacement 

and periodic examinations under the medical direction and 

supervision of a qualified physician or other qualified health care 

provider as determined by appropriate state regulations. These 

examinations should be provided to employees at no cost.

More detailed information on administering a medical monitoring 

program for MWF exposure is provided in Appendix A as 

well as information on health effects associated with MWFs, 

microbiological contaminants, and occupational exposure limits. 

Appendix B is a copy of the State of Washington Department of 

Labor and Industries Technical Report 55-7-2001, “Prevention of 

Skin Problems when Working with Metal Working Fluids.” This 

document provides some information on how MWFs may cause 

dermatitis and how to prevent it. The NIOSH criteria document 

for MWFs provides information about respiratory and dermal 
Page 6 Health Hazard Evaluation Report 2009-0098-3103

Discussion (continued) health effects of MWFs [NIOSH 1998a]. Links to both of these 

documents and other useful websites that provide guidelines for 

controlling employee exposures to MWFs and MWF maintenance 

are available on the NIOSH Metalworking Fluids topic page at 

http://www.cdc.gov/niosh/topics/metalworking.

Based on the absence of risk factors commonly associated 

with occupational outbreaks of MRSA infection (contact with 

contaminated bandages or towels, crowding living conditions, 

shared shower facilities, and poor hygiene), negative MRSA results 

in MWF bulk samples and environmental swab sampling, and 

evidence of household transmission among two of three infected 

employees, we conclude that the cases of MRSA reported at the 

facility were likely not related to occupational exposure. However, 

NIOSH investigators identified many machines used at the facility 

that are not enclosed or fitted with local exhaust ventilation to 

control employee exposures to MWFs. Additionally, our review of 

past environmental sampling results revealed inadequate control of 

biological growth in the MWFs at the facility.

Based on our findings, we recommend the actions listed below 

to create a more healthful workplace. We encourage Positrol Inc. 

to use these recommendations to develop an action plan based, 

if possible, on the hierarchy of controls approach. This approach 

groups actions by their likely effectiveness in reducing or removing 

hazards. In most cases, the preferred approach is to eliminate 

hazardous materials or processes and install engineering controls 

to reduce exposure or shield employees. Until such controls are 

in place, or if they are not effective or feasible, administrative 

measures and/or personal protective equipment may be needed. 

Administrative Controls 

Administrative controls are management-dictated work practices 

and policies to reduce or prevent exposures to workplace hazards. 

The effectiveness of administrative changes in work practices 

for controlling workplace hazards is dependent on management 

commitment and employee acceptance. Regular monitoring and 

reinforcement are necessary to ensure that control policies and 

procedures are not circumvented in the name of convenience or 

production.

Conclusions

Recommendations
Health Hazard Evaluation Report 2009-0098-3103 Page 7

Recommendations

(continued) 1. Because MRSA transmission in the community will 

continue to occur, the following recommendations are 

offered to help prevent further MRSA skin infections. 

Additional information about MRSA in the workplace can 

be found at http://www.cdc.gov/niosh/topics/mrsa/.

a. Employees should report injuries and infections that are 

potentially related to work to their supervisor.

b. Employees should keep draining wounds covered with 

clean, dry bandages. If wounds are covered, isolation of 

infected employees is not necessary. 

c. Employees should wash their hands regularly with soap 

and water or alcohol-based hand gel. This is the singlemost important measure to help prevent a wide variety of 

infections. 

d. Employees should maintain good personal hygiene with 

regular bathing. 

e. Employees should not share items that may become 

contaminated with wound drainage, such as towels, 

clothing, or razors. 

f. The company should clean equipment, surfaces, and 

restroom and hand-washing facilities with detergentbased cleaners or EPA-registered disinfectants that 

are labeled as effective in removing bacteria from the 

environment. It is important to read label directions 

thoroughly and ensure all products are used safely and 

appropriately. A list of EPA-registered products effective 

against MRSA is located at http://www.epa.gov/

oppad001/list_h_mrsa_vre.pdf. 

2. Develop a comprehensive MWF program. NIOSH and 

OSHA provide examples of comprehensive MWF programs 

[NIOSH 1998a; OSHA 1999]. Both of these programs 

outline aspects of MWF management including safety and 

health training, employee participation, environmental 

monitoring, hazard prevention and control, and medical 

monitoring. 

a. Include all employees exposed to MWF in a medical 

monitoring program [NIOSH 1998a,b]. This is 

necessary because maintaining MWF concentrations 

below the NIOSH REL does not remove all risk for 

skin or respiratory disease among exposed employees. 
Page 8 Health Hazard Evaluation Report 2009-0098-3103

Recommendations

(continued) Primary prevention efforts to control inhalation and skin 

exposure to MWFs should be done in addition to the 

medical monitoring program. NIOSH publication 98-

116, What You Need to Know about Occupational Exposure 

to MWFs at http://www.cdc.gov/niosh/pdfs/98-116.

pdf provides guidelines for administering a medical 

monitoring program [NIOSH 1998b].

b. Train employees in the health hazards associated with 

MWFs, use of PPE, proper hygiene, and procedures for 

reporting adverse health effects. Additional information 

on these topics can be found in the NIOSH publications 

on MWFs [NIOSH 1998a,b].

c. Follow your MWF supplier’s and the HSE’s 

recommendations for MWF maintenance [HSE 2006]. 

•	 Keep microbial growth under control by adding the 

proper amount of biocides before problems develop. 

•	 Keep MWF pH at 8.8–9.2 or as recommended by 

your supplier. 

•	 Maintain bacterial concentrations below 103 CFU/

mL and fungal levels at <100 CFU/mL [HSE 2006]. 

d. To lessen respiratory exposure, do not use compressed 

air to clean dust and excess MWF off machines or parts. 

Alternatives include the use of a HEPA filtered vacuum 

for dust and rags or cloths to wipe up excess MWF.

CDC (Centers for Disease Control and Prevention) [2003a]. 

Methicillin-resistant Staphylococcus aureus infections in correctional 

facilities--Georgia, California, and Texas, 2001–2003. MMWR 

52(41):992–996.

CDC (Centers for Disease Control and Prevention) [2003b]. 

Outbreaks of community-associated methicillin-resistant 

Staphylococcus aureus skin infections--Los Angeles County, 

California, 2002–2003. MMWR 52(5):88.

Cohen PR [2005]. Cutaneous community-acquired methicillinresistant Staphylococcus aureus infection in participants of athletic 

activities. South Med J 98(6):596–602.

References
Health Hazard Evaluation Report 2009-0098-3103 Page 9

References (continued) Gorwitz RJ, Kruszon-Moran D, McAllister SK, McQuillan G, 

McDougal LK, Fosheim GE, Jensen BJ, Killgore G, Tenover 

FC, Kuehnert MJ [2008]. Changes in the prevalence of nasal 

colonization with Staphylococcus aureus in the United States, 2001–

2004. J Infect Dis 197(9):1226–1234.

HSE [2006]. Managing sumps and bacterial contamination–control 

approach 4. COSHH essentials for machining with metalworking 

fluids. [http://www.hse.gov.uk/pubns/guidance/mw05.pdf]. Date 

accessed: December 2009.

Lindenmayer JM, Schoenfeld S, O’Grady R, Carney JK 1998]. 

Methicillin-resistant Staphylococcus aureus in a high school 

wrestling team and the surrounding community. Arch Intern Med 

58(8):895–899.

NIOSH [1998a]. Criteria for a recommended standard: 

occupational exposure to metalworking fluids. Cincinnati, 

OH: U.S. Department of Health and Human Services, Centers 

for Disease Control and Prevention, National Institute for 

Occupational Safety and Health, DHHS (NIOSH) Publication No. 

98-102.

NIOSH [1998b]. What you need to know about occupational 

exposure to metalworking fluids. Cincinnati, OH: U.S. 

Department of Health and Human Services, Centers for Disease 

Control and Prevention, National Institute for Occupational Safety 

and Health, DHHS (NIOSH) Publication No. 98-116.

OSHA [1999]. Metalworking Fluids: Safety and Health 

Best Practices Manual. [http://www.osha.gov/SLTC/

metalworkingfluids/metalworkingfluids_manual.html]. Date 

accessed: January 2010.

Weissfeld A [2009]. Telephone conversation on April 29, 2009, 

between A. Weissfeld, Microbiology Specialists Inc., and T. 

Niemeier, Division of Surveillance, Hazard Evaluations and Field 

Studies, National Institute for Occupational Safety and Health, 

Centers for Disease Control and Prevention, U.S. Department of 

Health and Human Services. 

Zinderman CE, Conner B, Malakooti MA [2004]. Communityacquired methicillin-resistant Staphylococcus aureus among military 

recruits. Emerg Infect Dis 10(5):941–944.
Page 10 Health Hazard Evaluation Report 2009-0098-3103

Metalworking fluids are complex mixtures used to cool, lubricate, and remove metal chips from tools 

and metal parts during machining of metal stock. Machining processes may include grinding, cutting, 

or boring operations. The four types of MWFs include straight oils, soluble oils, semisynthetics, and 

synthetics [NIOSH 1998a,b; OSHA 1999]. Most straight oils are highly refined products of petroleum 

stocks or animal, marine, and vegetable oils. Straight oils do not contain nor are they diluted with water. 

Other types of MWFs are water-based mixtures that may require dilution. Both soluble oils (oil-based, 

with emulsifiers) and semisynthetic fluids (oil emulsion, with large amounts of water) contain some oil, 

while synthetic fluids are totally water-based products. MWFs often contain a mixture of other substances 

including biocides, corrosion inhibitors, metal fines, tramp oils, and biological contaminants [NIOSH 

1998a]. Selection of a specific MWF is based on the requirements of the task. For example, straight oils 

are cutting oils and prevent rusting of the metal, while water soluble oils cool and lubricate the metal parts 

[OSHA 1999]. 

The term MWF aerosol refers to the mist generated during machining, which may contain a variety of 

substances including any component of the MWF, additives to the MWF, contaminants of the MWF 

such as tramp oils or metals, and biological contaminants such as bacteria and fungi, as well as their 

byproducts such as endotoxin, exotoxins, and mycotoxins. Exposure to MWFs can result from inhaling 

aerosols or from skin contact due to touching contaminated surfaces, handling parts and equipment, 

splashing of fluids, and settling of MWF aerosol on the skin [NIOSH 1998a,b]. Inhalation of MWF 

aerosols may irritate the throat (e.g., sore, burning throat), nose (e.g., runny nose, congestion, and 

nosebleeds), and lungs (e.g., cough, wheezing, increased phlegm production, and shortness of breath). 

MWF aerosol exposure has been associated with chronic bronchitis, asthma, HP, and worsening of preexisting respiratory problems. HP is a spectrum of granulomatous, interstitial lung diseases that occurs 

after repeated inhalation and sensitization to a wide variety of microbial agents (i.e., bacteria, fungi, 

amoebae), animal proteins, and low-molecular weight chemical antigens [CDC 1996; Kreiss and CoxGanser 1997; Zacharisen et al. 1998]. Skin contact with MWFs may cause allergic contact dermatitis and/

or irritant contact dermatitis depending on the chemical composition of the fluid, types of additives and 

contaminants contained in the MWFs, type of metal being machined (e.g., nickel or chromium), and the 

exposed individual’s tendency for developing allergies. Petroleum-based products may cause occupational 

acne [WISHA 2001]. Certain chemical additives, such as those with a low or high pH, irritate the skin 

upon direct contact. Strong detergents and hand cleansers may also cause dermatitis or aggravate an 

existing condition. 

Mineral Oils 

Mineral oils are major components of many MWFs and can contain a complex mixture of aromatic, 

naphthenic, and straight- or branched-chain paraffinic hydrocarbons, as well as various additives and 

impurities. In addition to the general exposure criteria for MWFs cited above, there are criteria specifically 

for the mineral oil components of MWFs. Occupational exposure to mineral oil concentrations in air 

(often called mineral oil mists) is limited by the OSHA PEL and NIOSH REL to 5 mg/m3; NIOSH also 

recommends a STEL of 10 mg/m3 [29 CFR 1910.1000; NIOSH 2005]. 

Appendix A: Metalworking Fluids
Health Hazard Evaluation Report 2009-0098-3103 Page 11

Appendix A: Metalworking Fluids (continued)

Inhalation of mineral oil mist in high concentrations may cause pulmonary effects (e.g., lipoid 

pneumonitis), although few cases have been reported [Proudfit and Van Orstrand 1950]. Prolonged 

exposure to mineral oil mist may also cause dermatitis. Persons with pre-existing skin disorders may be 

more susceptible to these effects. Early epidemiological studies linked cancers of the skin and scrotum 

with exposure to mineral oils [IARC 1982]. It is thought that the presence of PAHs and/or additives with 

carcinogenic properties was responsible for cancer causation in the older MWFs. Modern mineral oils are 

highly refined, which has reduced the concentrations of PAHs found in older, poorly refined mineral oils. 

For uncharacterized mineral oils containing additives and impurities, the IARC determined that there 

is sufficient evidence for carcinogenicity to humans, based on epidemiologic studies; however, IARC has 

determined that for highly refined mineral oils, there is inadequate evidence for carcinogenicity to humans 

[IARC 1987]. 

Microbial Contaminants 

Synthetic, semisynthetic, and soluble oil MWFs are diluted with water. Hence, they can provide a breeding 

ground for bacteria if an inadequate amount of biocide is added. High temperature and low pH and the 

presence of metals can favor bacterial growth. Levels of microbial contamination indicate the cleanliness 

or degree of maintenance of the MWF. However, adding too much biocide may result in biocide-resistant 

strains of bacteria. Inhaling MWF aerosols containing bacteria may result in respiratory problems. 

Employees with broken skin may develop skin infections if they have contact with MWF contaminated 

with bacteria. The outer cell walls of Gram-negative bacteria in MWFs may release lipopolysaccharide 

compounds called endotoxin when the bacteria die or multiply [Olenchock 1997]. Endotoxin are believed 

to cause adverse respiratory effects such as chronic bronchitis and asthma. Adding biocides to water 

contaminated with bacteria may result in the release of endotoxin by dead organisms. 

Insufficient data exist to determine what constitutes a safe level of microbial contamination in MWF – 

either in terms of species present, absolute number of colony forming units, or microbial components. 

Rylander and Jacobs have suggested an occupational threshold concentration equivalent to 100 endotoxin 

units/m3 of air to prevent airway inflammation [Rylander and Jacobs 1997]. However, the concentration 

of endotoxin in bulk samples of MWF cannot be extrapolated to an airborne concentration because 

the airborne concentration depends on how much of the MWF is aerosolized. Contaminated water in 

MWF may also contain fungi. Fungi may infect susceptible hosts such as immunocompromised persons. 

Cephalosporium, a genus commonly isolated from MWFs, has reportedly caused HP. Fungi may also 

produce toxic metabolites called mycotoxins. When contaminated MWF is replaced, some of the bacteria 

may remain and proliferate within a short period if the system is not adequately cleaned. At this time there 

is insufficient health data to recommend a specific limit for bacterial or fungal contamination in MWF.

Some researchers have suggested that well-maintained MWFs should have bacterial concentrations below 

106 CFU/mL of fluid [Rossmore and Rossmore1994]. In a study of 19 small machine shops, Korean 

and Canadian occupational health professionals found that a pH >8.5 (a pH of 9.0–9.5 was found to be 

preferable for controlling the growth of microorganisms) and avoiding contamination of the MWFs with 
Page 12 Health Hazard Evaluation Report 2009-0098-3103

Appendix A: Metalworking Fluids (continued)

tramp oils and foreign substances would help maintain lower endotoxin levels in MWF sumps [Park et 

al. 2001]. The HSE in the United Kingdom has also provided guidance on control of bacteria in MWFs. 

The HSE recommends keeping bacteria levels in MWF below 103 CFU/mL. If bacteria levels are between 

103 and 106 CFU/mL in the MWF, the HSE recommends cleaning the system or changing the biocide. If 

bacteria levels are greater than 106 CFU/mL, they recommend that the employer immediately drain the 

MWFs and clean the machine [HSE 2006]. Additional guidance from HSE on MWFs can be found at 

http://www.hse.gov.uk/metalworking/ecoshh.htm. The HSE recommends testing bacteria once a week 

[HSE 2006]. 

Occupational Exposure Limits

NIOSH recommends limiting exposures to MWF aerosols to 0.4 mg/m3 for the thoracic particulate mass, 

as a TWA concentration for up to 10 hours per day during a 40-hour workweek [NIOSH 1998a]. The 

NIOSH REL is intended to prevent or greatly reduce respiratory disorders associated with MWF exposure. 

Some employees have developed work-related asthma, HP, or other adverse respiratory effects when 

exposed to MWFs at concentrations below the NIOSH REL. Limiting exposure to MWF aerosols is also 

prudent because certain MWF exposures have been associated with various cancers. In addition, limiting 

dermal (skin) exposure is critical to preventing allergic and irritant disorders related to MWF exposure. 

In most metalworking operations, it is technologically feasible to limit MWF aerosol exposures to 0.4 

mg/m3 or less. NIOSH also recommends medical monitoring for employees exposed to MWF. Medical 

monitoring is needed for the early identification of employees who develop symptoms of MWF-related 

conditions such as HP, asthma, and dermatitis. NIOSH recommends that all employees exposed to MWFs 

at over half the REL receive medical monitoring. 

Medical Monitoring 

Medical monitoring is secondary prevention. Primary preventive measures such as engineering controls 

are the most effective and important methods of preventing illness. However, medical monitoring does 

have a place in identifying employees who develop symptoms of MWF-related conditions such as asthma 

or dermatitis. All employees exposed to MWF above half of the NIOSH REL should be included in the 

medical monitoring, and all employees with exposure may benefit from medical monitoring. 

Supervision of the program should be done by a physician or other health professional who is 

knowledgeable about the respiratory protection program and the identification and management of MWFrelated respiratory conditions and skin diseases. The employer should provide the health professional 

current and previous job descriptions, hazardous exposures and their measurements, the type of PPE used, 

relevant material safety data sheets, and applicable safety and health standards.

Medical monitoring should be provided at no cost to the employees, and the physician’s recommended 

restrictions and accommodations should be adhered to. A monitoring program should include the 

following components:
Health Hazard Evaluation Report 2009-0098-3103 Page 13

Appendix A: Metalworking Fluids (continued)

1. Initial or preplacement exams that consist of a standardized symptom questionnaire, medical 

history, and skin exam, at a minimum. Spirometry would be useful to establish baseline lung 

function for future comparison.

2. Periodic exams that include a brief standardized symptom questionnaire. Skin exam and 

spirometry may also be useful. The frequency of exams should be based on the frequency and 

severity of health effects. Employees who do experience health effects possibly related to MWF 

exposure should be given more detailed exams.

3. A written report from the physician that includes the results of any tests performed, the 

physician’s opinion about any medical condition that may increase the risk of disease 

from exposures in the workplace, any recommended restrictions or accommodations, and 

recommendations for further evaluation or treatment. The physician should provide the employer 

with a written report that includes any recommended restrictions and a statement that the 

employee was informed of the results of the exam and of any medical condition that requires 

further evaluation or treatment. No information regarding specific findings or diagnoses should 

be released to the employer without a signed information release from the employee.

References

CDC (Centers for Disease Control and Prevention) [1996]. Biopsy-confirmed hypersensitivity 

pneumonitis in automobile production workers exposed to metalworking fluids -- Michigan. MMWR 

45(28):606–610.

CFR. Code of Federal Regulations. Washington, DC: U.S. Government Printing Office, Office of the 

Federal Register.

HSE [2006]. Managing sumps and bacterial contamination – control approach 4. COSHH essentials 

for machining with metalworking fluids. [http://www.hse.gov.uk/pubns/guidance/mw05.pdf]. Date 

accessed: December 2009.

IARC [1982]. Monographs on the evaluation of the carcinogenic risk of chemicals to humans: chemicals, 

industrial processes and industries associated with cancer in humans. Suppl. 4. Lyon, France: World 

Health Organization, International Agency for Research on Cancer, pp. 227–228.

IARC [1987]. Monographs on the evaluation of the carcinogenic risk of chemicals to humans, overall 

evaluations of carcinogenicity: an updating of IARC monographs vols. 1 to 42. Suppl. 7. Lyon, France: 

World Health Organization, International Agency for Research on Cancer, pp. 252–254.

Kreiss K, Cox-Ganser J [1997]. Metalworking fluid associated hypersensitivity pneumonitis: a workshop 

summary. Am J Ind Med 32(4):423–432.
Page 14 Health Hazard Evaluation Report 2009-0098-3103

Appendix A: Metalworking Fluids (continued)

NIOSH [1998a]. Criteria for a recommended standard: Occupational exposure to metalworking fluids. 

Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and 

Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 98-

102. 

NIOSH [1998b]. What you need to know about occupational exposure to metalworking fluids. 

Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and 

Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 98-

116.

NIOSH [2005]. NIOSH pocket guide to chemical hazards. Barsan ME, ed. Cincinnati, OH: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2005-149.

Olenchock S [1997]. Airborne endotoxin. In: Hurst CJ, Knudsen GR, McInerney MJ, Stetzenbach 

LD, Walter MV, eds. Manual of Environmental Microbiology. Washington, DC: American Society for 

Microbiology Press, pp. 661–665.

OSHA [1999]. Metalworking fluids safety and health best practices manual. [http://www.osha.gov/SLTC/

metalworkingfluids/metalworkingfluids_manual.html]. Date accessed: December 2009.

Park D, Teschke K, Bartlett K [2001]. A model for predicting endotoxin concentrations in

metalworking fluid sumps in small machine shops. Ann Occup Hyg 45(7):569–576.

Proudfit JP, Van Ordstrand HS [1950]. Chronic lipid pneumonia following occupational exposure. AMA 

Arch Ind Hyg Occup Med 1(1):105–111.

Rossmoore LA, Rossmoore HW [1994]. Metalworking fluid microbiology. In: Metalworking Fluids. Byers J 

ed. New York, NY: Marcel Dekker, Inc. pp. 247–271.

Rylander R, Jacobs RR [1997]. Endotoxin in the environment. Intl J Occup Environ Health 3(1):S1-S31.

WISHA [2001]. Preventing occupational dermatitis. Olympia, WA: Washington State Department of 

Labor and Industries, Safety & Health Assessment & Research for Prevention (SHARP) Publication No. 

56-01-1999. 

Zacharisen MC, Kadambi AR, Schlueter DP, Kurup VP, Shack JB, Fox JL, Anderson HA, Fink JN [1998]. 

The spectrum of respiratory disease associated with exposure to metal working fluids. J Occup Environ 

Med 40(7):640–647.
Health Hazard Evaluation Report 2009-0098-3103 Page 15

Introduction

*

Prevention of Skin Problems when Working with Metal Working Fluids

Metal working fluids are industrial coolants and lubricants used to reduce friction and heat generated 

with the machining, grinding and fabrication operations of metal products and to lubricate during 

metalworking operations. The fluids prolong the life of machines, carry away metal chips and protect the 

surfaces of the metal being processed. 

There are three main types of MWFs:

● insoluble fluids (straight or neat oils),

● soluble oils (oil in water emulsions) and

● synthetic fluids.

These fluids can have additives that are corrosion inhibitors, emulsifiers, anti- foaming agents, 

preservatives and biocides. The formula of oil used depends on the raw material or cutting operation to be 

carried out. Straight or neat oils are not commonly found in machine shops as they once were.

Skin Problems

MWFs can be irritating to the skin. Skin problems include mechanical trauma to the skin,

infections, oil acne, folliculitis and irritant and allergic dermatitis.

Mechanical Trauma

Small cuts to the skin from metal shavings (swarf) are a common injury. These cuts can become infected as 

a result from contact with MWFs fluids contaminated with microbial organisms.

Folliculitis and Oil Acne

Exposure to straight oils can result in folliculitis (inflammation of the hair follicles) after having direct 

contact of oil with the skin. Exposed skin or skin under clothing heavily contaminated with oil results in 

blocked skin follicles. Blocked follicles can range in appearance from red irritation around hair follicles, 

small black plugged pores to large pustules. This problem can be found on the neck, hands, arms and 

thighs. If a employees has acne when starting a job working around MWFs, the fluids on the skin may 

make the acne worse.

* Safety and Health Assessment and Research for Prevention Technical Report: 55-7-2001. 

Washington State Department of Labor and Industries. 1-888-66-SHARP. [www.lni.wa.gov/sharp/derm].

Appendix B: Prevention of Skin Problems when Working with

Metal Working Fluids*
Page 16 Health Hazard Evaluation Report 2009-0098-3103

Appendix B: Prevention of Skin Problems when Working with 

 Metal Working Fluids (continued)

Irritant Dermatitis

This is the most common type of skin problem due to exposure to MWFs. Soluble and synthetic metal 

working fluids are strong alkaline solutions (pH of approximately 9 - very basic) containing numerous 

additives and solvents. These solutions remove protective oils in the skin and damage proteins in its outer 

layer. The result is damage to the natural skin barrier, which causes a decrease in the water content of 

the skin. This can cause dry, thickened, fissured and inflamed skin, especially on the palms of the hands. 

The hands and forearms can develop dry, scaly and inflamed patches. Infrequently, very small fluid- filled 

blisters can also develop on the hands and fingers. Small cuts in the skin from metal pieces allow more 

penetration n of irritant fluids and contribute to irritant dermatitis. The type and concentration of fluid 

used, duration of exposure during the work period, and the presence of pre-existing skin disease (eczema 

or severe dry skin) all contribute to the development of dermatitis.

Allergic Dermatitis

This is less common than irritant dermatitis. The additives in MWFs such as biocides, preservatives, 

corrosion inhibitors, amines and the impurities from metal (chrome, nickel), act as allergens and can cause 

an allergic reaction in some susceptible individuals. When skin is irritated, these allergens can penetrate 

more easily through the damaged skin barrier. A person who has developed an allergy to additives or 

impurities can have lesions that resemble irritant dermatitis, usually on the fingers and hands, but the 

lesions do not clear when the person is away from the job (vacation) or with treatment. This person needs 

to be evaluated with patch testing to the components of MWFs (additives and metal impurities) to see if 

there is an allergen responsible for the persistent skin reaction.

Prevention of Dermatitis

A primary method for the prevention of skin problems is to avoid contact with MWFs. Although it is 

impossible to avoid all contact with the fluids, the contact can be minimized and the irritancy of the fluids 

can be controlled.

Environment

Here are some ways to decrease contact with the fluids:

● keep the work area clean, including the machines, from machining fluids and grime, and

● have functioning splashguards on the machines.

The irritancy of the fluids can be minimized by:

● changing to a less irritating MWF if feasible,

● correct dilution of the additives in the fluids,
Health Hazard Evaluation Report 2009-0098-3103 Page 17

Appendix B: Prevention of Skin Problems when Working with 

 Metal Working Fluids (continued)

● maintaining MWFs at the manufacturer-specified concentration and pH,

● ensuring the cleanliness of the fluids by recirculating and filtering/straining them to remove swarf 

and other solid contaminants, and

● avoiding the use of fluids that have become contaminated with excessive microbial organisms.

Employees

Those working with MWFs can also help prevent developing dermatitis by:

● wearing clean clothes while on the job,

● laundering clothing that becomes contaminated with MWFs,

● avoiding placing MWF-soaked rags in pockets,

● wearing protective aprons, and

● wearing protective nitrile gloves (avoid latex because of the potential of developing an allergic 

reaction). Because of the nature of some jobs (fast rotating parts on a machine), wearing gloves may 

not be possible. 

Personal cleanliness is necessary to remove irritating fluids before skin problems develop. This can be 

accomplished by the following measures:

● Washing hands with mild, nonabrasive soaps to remove fluids. Soiled skin areas should be washed at 

least twice during the workday.

● Never use cleaning solvents to wash the skin to remove fluids. These solvents increase the damage 

caused by irritating MWFs by removing even more protective oils in the skin.

● Wiping off hands during the day with towels that are not contaminated with fluids or swarf. 

Disposable paper towels should be considered.

Protecting the skin from the irritant effects of MWFs also requires keeping the skin in good shape.

● Use moisturizers before and after work. Products that are thick creams or ointments work best. 

These products may seem greasy but can heal the skin faster and offer more protection than thinner, 

water-based formulations. Working the moisturizer cream into the skin and wearing clean, thin 

cotton gloves for a couple of hours or wearing the gloves to bed can also speed the recovery of dry, 

fissured, irritated skin. Inexpensive 100% petroleum jelly works as a good moisturizing agent and has 

no added fragrance or preservatives. There are products on the market that are creamy petroleum 

jelly formulations and are easier to apply to the skin.
Page 18 Health Hazard Evaluation Report 2009-0098-3103

Appendix B: Prevention of Skin Problems when Working with 

 Metal Working Fluids (continued)

● Skin barrier creams have not shown to be as effective as claimed in preventing penetration of 

irritants and avoiding hand dermatitis. Silicone-based barrier creams are available but require vigilant 

use every few hours to help decrease contact of irritants with the skin.

● Using a mild soap at home can protect the skin from further damage.

Treatment of Skin Problems from Metal Working Fluids

Prevention is the key to avoiding skin problems. However, despite all efforts, skin problems from MWFs 

may develop. The longer the skin problem has been present, the harder it is treat and to clear. Therefore, 

it is important to seek medical evaluation early if problems develop. The following skin problems may 

require the evaluation by a dermatologist or occupational medicine physician:

● severe oil acne or folliculitis,

● skin infections,

● severe irritated or fissured skin,

● persistent eczema or blisters, which may be irritant or allergic dermatitis. Occasionally, a person may 

require patch testing to determine if there is an allergic component to the skin problem. This usually 

is required when the skin problem does not respond to treatment.
Health Hazard Evaluation Report 2009-0098-3103 Page 19

Acknowledgments and

Availability of Report

The Hazard Evaluations and Technical Assistance Branch 

(HETAB) of the National Institute for Occupational Safety and 

Health (NIOSH) conducts field investigations of possible health 

hazards in the workplace. These investigations are conducted 

under the authority of Section 20(a)(6) of the Occupational Safety 

and Health Act of 1970, 29 U.S.C. 669(a)(6) which authorizes 

the Secretary of Health and Human Services, following a written 

request from any employer or authorized representative of 

employees, to determine whether any substance normally found 

in the place of employment has potentially toxic effects in such 

concentrations as used or found. HETAB also provides, upon 

request, technical and consultative assistance to federal, state, and 

local agencies; labor; industry; and other groups or individuals to 

control occupational health hazards and to prevent related trauma 

and disease.

The findings and conclusions in this report are those of the 

authors and do not necessarily represent the views of NIOSH. 

Mention of any company or product does not constitute 

endorsement by NIOSH. In addition, citations to websites 

external to NIOSH do not constitute NIOSH endorsement of 

the sponsoring organizations or their programs or products. 

Furthermore, NIOSH is not responsible for the content of these 

websites. All Web addresses referenced in this document were 

accessible as of the publication date.

This report was prepared by John Gibbins and Todd Niemeier of 

HETAB, Division of Surveillance, Hazard Evaluations and Field 

Studies. Medical field assistance was provided by Marie de Perio. 

Health communication assistance was provided by Stefanie Evans. 

Editorial assistance was provided by Ellen Galloway. Desktop 

publishing was performed by Robin Smith.

Copies of this report have been sent to employee and management 

representatives at Positrol Inc., the state health department, and 

the Occupational Safety and Health Administration Regional 

Office. This report is not copyrighted and may be freely 

reproduced. The report may be viewed and printed at

http://www.cdc.gov/niosh/hhe/. Copies may be purchased from 

the National Technical Information Service at 5825 Port Royal 

Road, Springfield, Virginia 22161.
Below is a recommended citation for this report:

NIOSH [2009]. Health hazard evaluation report: evaluation of Methicillin-resistant 

Staphylococcus aureus (MRSA) cases among employees at a workholding 

manufacturing facility, Cincinnati, OH. By Gibbins J, Niemeier T. Cincinnati, OH: 

U.S. Department of Health and Human Services, Centers for Disease Control and 

Prevention, National Institute for Occupational Safety and Health, NIOSH HETA

No. 2009-0098-3103

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