Current Intelligence Bulletin 60

Interim Guidance for Medical Screening and 

Hazard Surveillance for Workers Potentially 

Exposed to Engineered Nanoparticles

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health

Current Intelligence Bulletin 60

Interim Guidance for Medical Screening and 

Hazard Surveillance for Workers Potentially 

Exposed to Engineered Nanoparticles

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health
ii

This document is in the public domain and may be freely copied or 

reprinted.

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document were accessible as of the publication date.

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DHHS (NIOSH) Publication No. 2009–116

February 2009

Safer • Healthier • PeopleTM
iii

Foreword

“Do occupational exposures to engineered nanoparticles pose an unintended risk 

of adverse health effects?” This is not an abstract or theoretical question that practitioners have the luxury of debating for years before it becomes a reality. Nanotechnology is a reality, with potential for great growth in the 21st Century. Workers are 

already engaged in processes in which they may be exposed to materials that never 

existed before in nature. We do not fully know how these engineered nanoparticles 

may enter the body, where they may travel once inside, or what effects they may have 

on the body’s systems. We do not fully know whether or how effects may differ for 

chemically or structurally different particles at the nanoscale. Diverse stakeholders 

have agreed that research to address these questions is essential for the responsible 

development of nanotechnology.

As research progresses to answer those questions, the National Institute for Occupational Safety and Health (NIOSH) has recommended prudent precautionary 

interim measures for reducing work-related exposures and assessing potential risk. 

In the hierarchy of prevention, it is important to consider where it may be of value 

to provide medical screening of workers who may be exposed to a potential health 

hazard, but who may be asymptomatic—that is, who have no identifiable symptom 

of an occupational disease. On the frontiers of nanotechnology, where as yet little 

data exist for assessing risk with confidence, it is difficult to recommend specific 

screening tests. NIOSH has sought a wide range of opinions on the matter and along 

with its own review of the scientific literature presents this interim guidance for 

medical screening and hazard surveillance. The evidence base on the health effects 

of engineered nanoparticles is rapidly growing and NIOSH will continue to monitor 

and assess it and will update those recommendations as more definitive information 

becomes available.

Christine M. Branche, Ph.D.

Acting Director

National Institute for Occupational

 Safety and Health

Centers for Disease Control

 and Prevention

v

Executive Summary

Concerns have been raised about whether workers exposed to engineered nanoparticles are at increased risk of adverse health effects. The current body of evidence 

about the possible health risks of occupational exposure to engineered nanoparticles is quite small. While there is increasing evidence to indicate that exposure 

to some engineered nanoparticles can cause adverse health effects in laboratory 

animals, no health studies of workers exposed to the few engineered nanoparticles 

tested in animals have been published. The purpose of this document from the National Institute for Occupational Safety and Health (NIOSH) is to provide interim 

guidance about whether specific medical screening, including performing medical 

tests on asymptomatic workers, is appropriate for these workers. 

Medical screening is only one part of what should be considered a complete safety 

and health management program. An ideal safety and health management program 

follows a hierarchy of controls and involves various occupational health surveillance measures. Since specific medical screening of asymptomatic workers exposed 

to engineered nanoparticles has not been extensively discussed in the scientific literature, this document makes recommendations based upon what is known until 

more rigorous research can be performed. 

Currently there is insufficient scientific and medical evidence to recommend the 

specific medical screening of workers potentially exposed to engineered nanoparticles. Nonetheless, this lack of evidence does not preclude specific medical screening by employers interested in taking precautions beyond existing industrial hygiene 

measures. If nanoparticles are composed of a chemical or bulk material for which 

medical screening recommendations exist, these same screening recommendations 

would be applicable for workers exposed to engineered nanoparticles as well.

As research into the hazards of engineered nanoparticles continues, vigilant reassessment of available data is critical to determine whether specific medical screening is warranted for workers. In the interim, the following recommendations are 

provided for workplaces where workers may be exposed to engineered nanoparticles in the course of their work:

• Take prudent measures to control exposures to engineered nanoparticles.

• Conduct hazard surveillance as the basis for implementing controls.

• Continue use of established medical surveillance approaches.

NIOSH will continue to collect and evaluate new research findings and update its recommendations about medical screening programs for workers exposed to nanoparticles. 
vi

NIOSH will also continue to consider the strengths and weaknesses of establishing 

exposure registries for workers potentially exposed to engineered nanoparticles for 

future health surveillance and epidemiological studies.
vii

Contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

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

Background: Brief Review of the Literature. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Effects of Exposure to Ultrafine Particles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Effects of Exposure to Engineered Nanoparticles. . . . . . . . . . . . . . . . . . . . . . . 2

Occupational Health Surveillance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Medical Surveillance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Frequent Uses for Medical Surveillance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Hazard Surveillance and Risk Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Discussion and Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

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

Take Prudent Measures to Control Exposures to

 Engineered Nanoparticles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Conduct Hazard Surveillance as the Basis for Implementing Controls. . . . . 7

Continue use of Established Medical Surveillance Approaches . . . . . . . . . . . 7

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

Appendix A: Critical Aspects of an Occupational Medical Screening

 Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Appendix B: OSHA Standards That Include Requirements for

 Medical Surveillance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Appendix C: Hazards for Which NIOSH Has Recommended the Use of

 Medical Surveillance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Appendix D: Discussion of Occupational Health Surveillance Programs

 with Medical Screening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Appendix E: Examples of Limitations in the Evidence Base for Specific

 Medical Screening of Workers Exposed to Engineered Nanoparticles. . . . . . . 21

Single-Walled Carbon Nanotubes (SWCNTs). . . . . . . . . . . . . . . . . . . . . . . . . . 21

Nanoscale Metal Oxides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Nanoscale Cadmium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Appendix F: Exposure Registries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
viii

Acknowledgements

This Current Intelligence Bulletin (CIB) was developed by the staff of the National Institute for Occupational Safety and Health (NIOSH) who participate in the 

NIOSH Nanotechnology Research Center (NTRC). Special thanks go to Paul S. 

Schulte, Director, Education and Information Division, NIOSH and manager of the 

NTRC, Douglas Trout, and Ralph D. Zumwalde for writing and organizing the report. The NIOSH NTRC also acknowledges the contributions of Vanessa Becks and 

Gino Fazio for desktop publishing and graphic design, and Douglas Platt for editing 

the document.

NIOSH greatly appreciates the time and efforts of expert peer reviewers and NTRC 

staff who provided comments on a draft of this CIB. 

Peer Reviewers

Michael Kosnett, MD, MPH

University of Colorado at Denver and Health Sciences Center

Ken Donaldson, BSc, PhD, DSc, CBiol, FRCPath, FFOM

University of Edinburgh Centre for Inflammation Research, ELEGI Colt

Laboratory 

James Lockey, MD, Professor of Occupational, Environmental and Pulmonary 

Medicine, University of Cincinnati

Attendees and Participants: Workshop on occupational health surveillance 

and nanotechnology workers. April 17–18, 2007, Arlington, VA.

Richard Canady 

FDA

James Collins 

Dow Chemical 

Michael Fischman

Intel

Charles Geraci

NIOSH/EID 

Barbara Gibson

3M

Harold Haase

Lockheed Martin

William Halperin

UMDNJ

Deanna Harkins

U.S. Army CHPPM

John Howard

NIOSH/OD

Matt Hull

Luna Innovations

Jackie Isaacs

NEU, Nano (NSEC)

Amy Jones

Lockheed Martin

Steve Joslin

Luna Innovations

Anthony Klapper

Reed Smith

Michael Kosnett

Am Coll Med Tox

Eileen Kuempel

NIOSH/EID

Tabitha Maher

Altairnano

Robert McCunney

MIT

(Continued)
ix

James Melius

LIUNA

George Mellendick

Pfizer

Michael Muhm

Boeing

Diane Mundt

Environ International Corp

Kenneth Mundt

Environ International Corp

Vladimir Murashov

NIOSH/OD

Michael Nasterlack

BASF

Minda Nieblas

OSHA

Lyn Penniman

OSHA

John Piacentino

NIOSH/OD

Scott Prothero

EPA

Anita Schill

NIOSH/OD

Mary Schubauer-Berigan

NIOSH/DSHEFS

Paul Schulte

NIOSH/EID

John Sestito

NIOSH/DSHEFS

Clifford Strader

DOE

Pat Sullivan

NIOSH/DRDS

Marie Sweeney

NIOSH/DSHEFS

Douglas Trout

NIOSH/DSHEFS

David Warheit

DuPont

Norbert Will

Clariant

Ralph Zumwalde

NIOSH/EID

Attendees and Participants: Workshop on occupational health surveillance 

and nanotechnology workers. April 17–18, 2007, Arlington, VA. (Continued)

1

Interim Guidance for the Medical Screening and 

Hazard Surveillance for Workers Potentially 

Exposed to Engineered Nanoparticles

Introduction

Nanotechnology is a system of innovative 

methods for controlling and manipulating 

matter at the near-atomic scale to produce 

engineered materials, structures, and devices. 

Engineered nanoparticles are generally considered to include a class or subset of these 

manufactured materials with at least one dimension of approximately 1 to 100 nanometers (www.nano.gov/html/facts/whatIsNano.

html). At these scales, materials often exhibit 

unique properties beyond those expected at the 

chemical or bulk level that affect their physical, 

chemical, and biological behavior. The term 

“ultrafine” is also frequently used in the literature to describe particles with dimensions less 

than 100 nanometers that have not been intentionally produced (e.g., manufactured) but are 

the incidental products of processes involving combustion, welding, or diesel engines. It 

is currently unclear whether a distinction in 

particle terminology is justified from a safety 

and health perspective if the particles have the 

same physicochemical characteristics.

The potential occupational health risks associated with the manufacture and use of nanomaterials are not yet clearly understood. Many engineered nanomaterials and devices are formed 

from nanometer-scale particles (i.e., nanoparticles) that are initially produced as aerosols or 

colloidal suspensions. Exposure to these materials during manufacturing and use may occur 

through inhalation, dermal contact, or ingestion; however, inhalation exposure is the main 

route of concern [ASCC 2006]. There is very 

limited information available about dominant 

exposure routes, the potential for exposure, 

and material toxicity. 

At this time, society in general and companies 

in particular are faced with the dilemma of balancing a desire to expand a potentially bountiful technology against the potential hazards 

that may result. The real risks from the technology are not known, and the perceived risks are 

undetermined. In this regard, nanotechnology 

is no different from any other emerging technology. One of the first areas where exposures 

to engineered nanoparticles will occur is in the 

workplace. In the face of uncertainty about the 

hazards of nanoparticles, a corporate or societal response (such as implementing appropriate occupational health surveillance measures) 

may assure the public that appropriate efforts 

are being taken to identify and control potential hazards in a timely fashion.

Concerned individuals from government, industry, labor, and academia, together with occupational health professionals and medical 

personnel, have raised questions about whether 

workers exposed to engineered nanoparticles 

should be provided some type of medical surveillance. The purpose of this document is to 
2 NIOSH CIB 60 • Medical Screening of Workers

provide interim guidance concerning specific 

medical screening for these workers—that is, 

medical tests for asymptomatic workers—until 

additional research either supports or negates 

the need for this type of screening. The type 

and degree of screening recommended here is 

in addition to any medical surveillance taking 

place as part of existing occupational health 

surveillance efforts. 

Background: A Brief Review of 

the Literature

Effects of Exposure to Ultrafine 

Particles

Results from epidemiological studies in the 

general population have shown associations between fine particulate air pollution and increased 

morbidity and mortality from respiratory and 

cardiopulmonary disease [Dockery et al. 1993; 

Ibald-Mulli et al. 2002; Pope et al. 2004]. Other 

studies have investigated specific markers of effect associated with exposure to the ultrafine 

particulate fraction of air pollution [Ruckerl et 

al. 2006]. Studies of workers exposed to ultrafine 

particles (e.g., diesel exhaust and welding fume) 

have reported elevated lung cancer risks [Steenland et al. 1998; Garshick et al. 2004; Antonini 

2003] while results from some animal studies 

have shown that many types of poorly soluble 

ultrafine particles can elicit a greater pulmonary 

inflammatory response than larger particles of 

the same composition on a mass for mass basis 

[Oberdörster et al. 1994; Lison et al 1997; Zhang 

et al. 2000, 2003; Brown et al. 2001; Höhr et al. 

2002; Duffin et al. 2007]. Toxicological studies 

indicate that the chemical and physical properties that influence the toxicity of ultrafine particles may also be relevant to mechanisms that influence the toxicological response to engineered 

nanoparticles [Castranova et al. 2000; Aitken et 

al. 2004; Donaldson et al. 2005, 2006; Maynard 

and Kuempel 2005; Oberdörster et al. 2005a, 

b; Kreyling et al. 2006; Gwinn and Vallyathan 

2006; Borm et al. 2006; Helland et al. 2007]. 

Studies have also shown that physicochemical 

properties such as surface reactivity, chemical 

composition, crystal structure, and shape also 

influence the toxicity of nanoscale particles 

[Zhang et al. 1998; Dick et al. 2003; Warheit 

et al. 2007a, b]. Adverse effects reported from 

exposure to ultrafine particles have raised concerns about workers exposed to engineered 

nanoparticles [Royal Society and Academy 

of Engineering 2004; Maynard and Kuempel 

2005; IRRST 2006; Nel et al. 2006; Schulte and 

Salmanca-Buentello 2007; Maynard 2007; Lam 

et al. 2006; Kuempel et al. 2007; Aitken et al. 

2004; ASCC 2006]

Effects of Exposure to Engineered 

Nanoparticles

Animal studies with some types of engineered 

nanoparticles have caused adverse lung effects 

(e.g., pulmonary inflammation and progressive 

fibrosis) [Lam et al. 2004, 2006; Shvedova et 

al. 2005; Takagi et al. 2008; Poland et al. 2008] 

and cardiovascular effects (e.g., inflammation, 

blood platelet activation, plaque formation, 

and thrombosis) [Radomski et al. 2005; Donaldson et al. 2006; Li et al. 2007]. Other studies 

have demonstrated that discrete nanoparticles 

may enter the bloodstream from the lungs and 

translocate to other organs [Oberdörster et 

al. 2002] while other studies have shown that 

discrete nanoparticles (35-37 nm count median diameter) that deposit in the nasal region 

may be able to enter the brain by translocation 

along the olfactory nerve [Oberdörster et al. 

2005(b); Elder et al. 2006]. A broader review 

of the human and animal data can be found 

in the NIOSH document Approaches to Safe 
NIOSH CIB 60 • Medical Screening of Workers 3

Nanotechnology: An Information Exchange with 

NIOSH [NIOSH 2006a].

Occupational Health 

Surveillance

NIOSH has historically recommended implementing occupational health surveillance programs when workers are exposed to potentially 

hazardous materials. Occupational health surveillance involves the ongoing systematic collection, analysis, and dissemination of exposure and health data on groups of workers for 

the purpose of preventing illness and injury. 

This information is frequently used for establishing and evaluating the hierarchy of preventive actions [Halperin 1996]. The general 

term occupational health surveillance includes 

medical and hazard surveillance. Occupational 

health surveillance is an essential component 

of an effective occupational safety and health 

program [Harber et al. 2003; NIOSH 2006b; 

Wagner and Fine 2008; Baker and Matte 2005]. 

While this document supports that concept, the 

main focus is whether a typical medical surveillance program that includes additional medical 

screening is warranted for workers potentially 

exposed to engineered nanoparticles.

Medical Surveillance

Medical surveillance targets actual health 

events or a change in a biologic function of an 

exposed person or persons. Medical surveillance is a second line of defense behind the 

implementation of engineering, administrative, and work practice controls including the 

use of personal protective equipment. NIOSH 

recommends the medical surveillance of workers when they are exposed to hazardous materials. The elements of a medical surveillance 

program generally include the following: 

1. An initial medical examination and collection of medical and occupational histories.

2. Periodic medical examinations at regularly 

scheduled intervals, including specific medical screening tests when warranted.

3. More frequent and detailed medical examinations as indicated on the basis of findings 

from these examinations.

4. Post-incident examinations and medical 

screening following uncontrolled or nonroutine increases in exposures such as spills.

5. Worker training to recognize symptoms of 

exposure to a given hazard.

6. A written report of medical findings.

7. Employer actions in response to identification of potential hazards.

When the purpose of a medical surveillance 

program is to detect early signs of work-related illness and disease, it is considered a type 

of medical screening, also referred to as medical monitoring and includes medical testing to 

detect preclinical changes in organ function or 

changes before a person would normally seek 

medical care and when intervention is beneficial [Ashford et al. 1990; Baker and Matte 2005; 

Halperin et al. 1986; Harber et al. 2003; ILO 

1998]. The establishment of a medical screening program should follow established criteria 

[Halperin et al. 1986; Borak et al. 2006; Baker 

and Matte 2005; Harber 2003] and that specific 

disease endpoints must be able to be determined by the test selected (see Appendix A). 

Frequent Uses for Medical 

Surveillance 

Medical examinations and tests are used in 

many workplaces to determine whether an 

employee is able to perform the essential 
4 NIOSH CIB 60 • Medical Screening of Workers

functions of the job, with or without reasonable accommodation, without posing a direct 

and imminent threat to the safety or health of 

the worker or others. Workplace medical examinations must be conducted in compliance 

with the Americans with Disabilities Act of 

1990 (ADA) (Public Law No. 101-336). For 

example, this law prohibits making a job offer 

contingent upon the applicant’s submission to 

a medical examination. Still, medical examinations and examinations conducted before placing a worker in a given job could potentially 

provide useful baseline information in a variety of ways. For example, even if there appears 

to be no reason for immediate concern about 

exposure to engineered nanoparticles in a particular workplace setting, this type of baseline 

data may benefit employers and workers alike 

if questions come up later regarding potential 

worker health problems associated with the 

specific engineered nanoparticle. 

Medical surveillance of workers is also required by law when there is exposure to a specific workplace hazard. Although OSHA does 

not have a standard that specifically addresses 

occupational exposure to engineered nanoparticles, OSHA has a number of standards 

that require medical surveillance of workers. 

Workplaces with engineered nanoparticles 

comprised of chemicals addressed by current 

OSHA standards (Appendix B) are subject to 

the requirements of those standards, including 

the requirements for medical surveillance. In 

addition, medical surveillance of workers handling engineered nanoparticles may also be 

triggered when workers are exposed to other 

hazardous substances (e.g., those listed in Appendix B) present in nanoparticle operations. 

In addition to substance-specific standards, 

OSHA has standards with broader applicability. For example, employers must follow the 

medical evaluation requirements of OSHA’s 

respiratory protection standard [29 CFR 

1910.134] when respirators are necessary to 

protect worker health. This standard includes 

elements of medical surveillance. Likewise, the 

OSHA standard for occupational exposure to 

hazardous chemicals in laboratories [29 CFR 

1910.1450] requires medical consultation following the accidental release of hazardous 

chemicals.

NIOSH also recommends medical surveillance 

(including screening) of workers when there is 

exposure to certain occupational hazards (Appendix C). None of the hazards noted in Appendix C are identified as engineered nanoparticles, but medical surveillance would apply to 

workers exposed to nanoparticles comprised 

of chemicals for which NIOSH has a recommendation. The medical surveillance of these 

workers may provide useful information if 

questions arise in the future about the health 

effects of their exposure to nanoparticles. 

Hazard Surveillance and Risk 

Management

Hazard surveillance involves identifying potentially hazardous practices or exposures in the 

workplace and assessing the extent to which 

they can be linked to workers, the effectiveness of controls, and the reliability of exposure 

measures [Sundin and Frazier 1989; Froines et 

al. 1989]. Hazard surveillance for engineered 

nanoparticles is an essential component of 

any occupational health surveillance effort 

and is used for defining the elements of the 

risk management program. One component 

of a risk management program involves taking action to minimize exposure to potential hazards. In 

the case of engineered nanoparticles, even in 

the absence of adequate health information, an 
NIOSH CIB 60 • Medical Screening of Workers 5

understanding of potential worker exposures 

can form the basis for ongoing risk management. Other critical elements of a risk management program include recognizing potential exposures and determining appropriate 

actions to minimize them (e.g., implementing 

engineering controls, employing good work 

practices, and using personal protective equipment) [NIOSH 2006a]. Hazard surveillance 

should include the identification of work tasks 

and processes that involve the production and 

use of engineered nanoparticles, and should be 

viewed as one of the most critical components 

of any risk management program.

Discussion and Conclusions

Assessing the potential toxicity of engineered 

nanoparticles is at an early stage. A body of scientific evidence has accrued from toxicology 

studies on selected engineered nanoparticles 

and from epidemiology studies of individuals exposed to ultrafine nanoparticles suggests that some nanoscale particles may pose 

a health concern [Kuempel et al. 2007; Gwinn 

and Vallyathan 2006; Donaldson et al. 2006]. 

This evidence suggests that safety and health 

professionals should consider precautionary management approaches in workplaces 

where there is exposure to engineered nanoparticles [Schulte and Salamanca-Buentello 

2007; NIOSH 2006a; Royal Society and Royal 

Academy of Engineering 2004; Borm et al. 

2006; Holman et al. 2006; IRSST 2006] such as 

the implementation of occupational risk management programs. Such approaches are described in the NIOSH document Approaches to 

Safe Nanotechnology: An Information Exchange 

with NIOSH [NIOSH 2006a]. 

The current body of evidence about the possible health risks of occupational exposures to 

engineered nanoparticles is not sufficient to 

support the determination of specific medical 

screening to identify preclinical changes associated with exposure to engineered nanoparticles. No substantial link has been established 

between occupational exposure to engineered 

nanoparticles and adverse health effects. In 

addition, the toxicological research to date is 

insufficient to recommend such monitoring, 

the appropriate triggers for it, or components 

of it. As the volume of research on the potential health effects from exposure to engineered 

nanoparticles increases, continual reassessment 

will be needed to determine whether medical 

screening is warranted for workers who are 

producing or using engineered nanoparticles. 

NIOSH will continue to examine new research 

findings and update its recommendations on 

medical screening programs for workers exposed to nanoparticles. Appendix D provides a 

brief discussion concerning occupational health 

programs that include medical screening and 

might serve as a model for future reference for 

one or more engineered nanoparticles. Appendix E provides discussion highlighting details of 

instances where sufficient evidence to support 

recommendations for specific medical screening for workers exposed to engineered nanoparticles is lacking. 

At this time, only a few types of engineered 

nanoparticles have been studied, and a clear 

and consistent picture of the relevant endpoints for workers has not yet emerged. Various physicochemical parameters of nanoparticles (e.g., composition, size, shape, surface 

characteristics, charge, functional groups, 

crystal structure, and solubility) appear to affect toxicity [Oberdörster et al. 2005a; Borm 

et al. 2006; Warheit et al. 2007b; IRSST 2006]. 

It is not known whether size is the overriding 

parameter, though most studies show that size 

appears to be the major factor in enhancing the 
6 NIOSH CIB 60 • Medical Screening of Workers

toxicity of engineered nanoparticles compared 

with the toxicity of larger particles of the same 

composition. Results from a limited number of 

experimental animal studies with engineered 

nanoparticles indicate the potential for respiratory and circulatory effects [Aitken et al. 2004; 

Borm et al. 2006; ASCC 2006; IRRST 2006]; 

however, it is not clear which effects are most 

critical, whether they are dose-dependent, and 

whether these effects are relevant to human 

exposure. Additional studies are needed to 

determine the biological significance of different physicochemical parameters and whether 

these parameters can be used to predict the 

potential toxicity of other untested engineered 

nanoparticles. 

When occupational health surveillance is being 

established, it is necessary to understand the 

relative, absolute, and population-attributable 

risks to workers who are handling engineered 

nanomaterials. This includes understanding 

the hazard as well as the extent of exposure 

and ultimately the risk. Limited information 

is available on these topics, but exposures may 

be generally low relative to the airborne exposures of the same material in larger but respirable particle sizes. The level of risk resulting 

from lower exposures to nanomaterials is unknown. Ultimately, epidemiological studies of 

exposed workers will be needed to help assess 

exposure-response relationships. Although 

such studies are difficult to conduct, they are 

more likely than medical screening to clarify 

the relationship between exposure and adverse 

effects at this time. 

Finally, there is not yet enough research to 

make categorical determinations of the hazards 

based on combinations of physicochemical factors [ASCC 2006; Aitken et al. 2004]. Although 

preliminary studies indicate that while specific 

medical screening may be warranted in the future, insufficient information is now available 

to make any recommendations beyond hazard 

surveillance. NIOSH will continue to assess the 

scientific evidence and periodically update the 

guidance on medical screening. 

Recommendations

Continued in vivo and in vitro toxicological research is needed to identify potential health endpoints related to occupational exposure to engineered nanoparticles. Epidemiological studies 

of exposed workers will be needed to establish 

associations between exposures to engineered 

nanoparticles and adverse health effects and to 

assess other potential exposure-response relationships. Research is needed to assess various 

candidate biological markers that may ultimately be used in medical screening, including molecular markers [Schulte 2005]. This research is 

needed to assess sensitivity, specificity, and predictive value of biomarkers and clinical tests that 

might be developed and used to screen workers’ 

health. Determining sufficient positive predictive value of a screening modality to detect adverse health effects early enough in the course 

of the disease to enable secondary prevention, is 

an important factor when considering medical 

screening efforts.

The following recommendations are provided 

for workplaces where workers may be exposed 

to engineered nanoparticles during the course 

of their work.

Take prudent measures to 

control exposures to engineered 

nanoparticles.

A prudent approach to controlling exposures 

to engineered nanoparticles has been described 

in the NIOSH draft document Approaches to 
NIOSH CIB 60 • Medical Screening of Workers 7

Safe Nanotechnology: An Information Exchange 

with NIOSH [NIOSH 2006a].

Conduct hazard surveillance as the 

basis for implementing controls.

To establish prudent measures for controlling 

exposure to engineered nanoparticles, it is 

important to identify which jobs or processes 

involve the production or use of engineered 

nanoparticles. Employers should identify and 

document the presence of engineered nanoparticles in their workplaces and the work tasks 

associated with them. This information will 

serve as the basis for applying various control 

measures [NIOSH 2006a]. Hazard surveillance 

programs should be designed to address some 

or all of the following questions:

ȣ What exposure agents are found in the 

workplace?

ȣ Are standardized, reliable, and 

practical methods available for 

measuring workers’ exposures to the 

agents?

ȣ What exposure metrics (e.g., mass, 

particle count, particle surface 

area) are most relevant to the most 

important health concerns?

ȣ To what extent can specific exposures 

(e.g., nanoparticles) be linked to 

people?

ȣ What actions have been taken 

to control potentially hazardous 

exposures?

ȣ How effective are the controls (e.g., 

engineering)?

ȣ Which agents affect the most workers?

ȣ What jobs or industries are most likely 

to cause exposures to workers?

ȣ What health effects are most likely 

related to these exposures?

ȣ How are specific occupational 

exposures changing over time?

Continue use of established medical 

surveillance approaches.

Currently, there are many established uses for 

medical surveillance by employers and occupational health practitioners (see Section 3.3). 

These may pertain to workers exposed to engineered nanoparticles, but they are not specifically focused on them. Employers should 

continue using these established approaches to 

collect data that may be informative in the future about whether there is an increase in the 

frequency of adverse health effects related to 

exposure to engineered nanoparticles. NIOSH 

continues to recommend occupational health 

surveillance as an important part of an effective risk management program. Lack of evidence for recommending medical screening 

for workers potentially exposed to engineered 

nanoparticles should not stop employers who 

want to take additional precautions, including 

medical screening, beyond those already established. However, it is important to note that 

nonspecific medical testing can have negative 

consequences such as adverse effects resulting 

from tests (e.g., radiation from chest radiographs), creating unnecessary anxiety in workers and employers from false-positive screening tests, and the economic ramifications of 

additional diagnostic evaluations [Nasterlack 

et al. 2007; Schulte 2005; Marcus et al. 2006]. 

NIOSH will continue to evaluate the usefulness 

of establishing exposure registries in workplaces were there is potential exposure to engineered nanoparticles. As the understanding of 

occupational exposure to engineered nanoparticles increases, the development of exposure 
8 NIOSH CIB 60 • Medical Screening of Workers

registries may be needed to form the basis for 

future epidemiologic research (Appendix F). 

Such registries probably need to cover workers from numerous companies to reflect the 

diversity of exposures, to account for the small 

number of workers exposed at a given site, and 

to assess chronic health effects. 

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NIOSH CIB 60 • Medical Screening of Workers 13

APPENDIX A • Critical Aspects of an 

Occupational Medical Screening Program

Assessment of workplace hazards

Identification of target organ toxicities for each hazard

Selection of test for each “screenable health effect”

Development of action criteria

Standardization of data collection

process

Performance of testing

Interpretation of test results

Test confirmation

Determination of work status

Notification

Diagnostic evaluation

Evaluation and control of exposure

Recordkeeping 

[Baker and Matte 2005].
14 NIOSH CIB 60 • Medical Screening of Workers

APPENDIX B • OSHA Standards That Include 

Requirements for Medical Surveillance

2-acetylaminofluorene ethylene oxide

acrylonitrile ethyleneimine

4-aminodiphenyl formaldehyde

inorganic arsenic hazardous waste

asbestos lead

benzene methyl chloromethyl ether

benzidine alpha-naphthylamine

bis-chloromethyl ether beta-naphthylamine

1,3–butadiene methylene chloride

coke oven emissions 4-nitrobiphenyl

cotton dust n-nitrosodimethylamine

dibromochloropropane beta-propriolactone

3.3’-dichlorobenzidine vinyl chloride

4-dimethylaminoazobenzene methylenedianiline

cadmium bloodborne pathogens

occupational exposure to hazardous chemicals in the 

laboratories

chromium (VI)
NIOSH CIB 60 • Medical Screening of Workers 15

APPENDIX C • Hazards for Which NIOSH Has 

Recommended the Use of Medical Surveillance

NIOSH publication number Title and date NTIS stock number 

76–195 Acetylene (1976) PB 267068 

77–112 Acrylamide (1976) PB 273871 

78–116 Acrylonitrile (1978) PB 81–225617 

77–151 Alkanes (C5-C8) (1977) PB 273817 

76–204 Allyl Chloride (1976) PB 267071 

74–136 Ammonia (1974) PB 246699 

78–216 Antimony (1978) PB 81–226060 

74–110 Arsenic, Inorganic (1974),

(Revised 1975) 

PB 228151 

75–149 Arsenic, Inorganic (1975) PB 246701 

72–10267 Asbestos (1972) PB 209510 

77–169 Asbestos (Revised) (1976) PB 273965 

78–106 Asphalt Fumes (1977) PB 277333 

74–137 Benzene (1974) PB 246700 

* Benzene (Revised) (1976) PB 83–196196 

77–166 Benzoyl Peroxide (1977) PB 273819 

78–182 Benzyl Chloride (1978) PB 81–226698 

72–10268 Beryllium (1972) PB 210806 

* Beryllium (Revised) (1977) PB 83–182378 

2-Butoxyethanol

[See: Ethylene Glycol Monobutyl Ether] 

77–122 Boron Trifluoride (1976) PB 274747 

76–192 Cadmium (1976) PB 274237 

77–107 Carbaryl (1976) PB 273801 

78–204 Carbon Black (1978) PB 81–225625 

76–194 Carbon Dioxide (1976) PB 266597 

(continued)
16 NIOSH CIB 60 • Medical Screening of Workers

NIOSH publication number Title and date NTIS stock number 

77–156 Carbon Disulfide (1977) PB 274199 

73–11000 Carbon Monoxide (1972) PB 212629 

76–133 Carbon Tetrachloride (1975) PB 250424 

* Carbon Tetrachloride (Revised) (1979) PB 83–196436 

76–170 Chlorine (1976) PB 266367 

75–114 Chloroform (1974) PB 246695 

* Chloroform (Revised 1979) PB 83–195856 

77–210 Chloroprene (1977) PB 274777 

73–11021 Chromic Acid (1973) [Revised; see Chromium VI] PB 222221 

760–129 Chromium VI (1975) PB 248595 

78–191 Coal Gasification Plants (1978) PB 80–164874 

95–106 Coal Mine Dust PB 96–191713 

78–107 Coal Tar Products (1977) PB 276917 

82–107 Cobalt (1981) PB 82–182031 

73–11016 Coke Oven Emissions (1973) PB 216167 

80–106 Confined Spaces, Working in

Construction [See: Excavations] (1979)

PB 80–183015

75–118 Cotton Dust (1974) PB 246696 

78–133 Cresol (1978) PB 86–121092 

77–108 Cyanide, Hydrogen and Cyanide Salts (1976) PB 266230 

78–115 Dibromochloropropane (1978)

1,2-Dichloroethane [See: Ethylene Dichloride]

PB 81–228728 

96–104 2-Diethylaminoethanol (1996) PB 96–197371 

78–215 Diisocyanates (1978) PB 81–226615 

78–131 Dinitro-ortho-Cresol (1978) PB 80–175870 

77–226 Dioxane (1977) PB 274810 

76–128 Elevated Work Stations, Emergency Egress from 

(1975)

PB 248594 

76–206 Epichlorohydrin (1976) PB 81–227019 

77–221 Ethylene Dibromide (1977) PB 276621 

76–139 Ethylene Dichloride (1976) PB 85–178275 

78–211 Ethylene Dichloride (1,2- Dichloroethane)

(Revised) (1978) 

PB 80–176092 

(continued)
NIOSH CIB 60 • Medical Screening of Workers 17

NIOSH publication number Title and date NTIS stock number 

90–118 Ethylene Glycol Monobutyl Ether and Ethylene 

Glycol Monobutyl Ether Acetate (1991)

PB 91–173369 

91–119 Ethylene Glycol Monomethyl Ether, Ethylene 

Glycol Monoethyl Ether, and Their Acetates 

PB 92–167147 

83–103 Excavations, Development of Draft Construction 

Safety Standards for, Volume 1 (1983) 

PB 84–100569 

* Excavations, Development of Draft Construction 

Safety Standards for, Volume 2 (1983) 

PB 83–233353 

77–152 Fibrous Glass (1977) PB 274195 

76–103 Fluorides, Inorganic (1975) PB 246692 

77–193 Fluorocarbon Polymers, Decomposition Products 

of (1977) 

PB 274727 

77–126 Formaldehyde (1976) PB 273805 

85–116 Foundries (1985) PB 86–213477 

79–133 Furfuryl Alcohol (1979) PB 80–176050 

78–166 Glycidyl Ethers (1978) PB 81–229700 

83–126 Grain Elevators and Feed Mills (1983) PB 83–138537 

89–106 Hand-Arm Vibration (1989) PB 90–168048 

83–125 Guidelines for Controlling Hazardous Energy 

During Maintenance and Servicing (1983)

PB 84–199934 

72–10269 Hot Environments (1972) PB 210794 

86–113 Hot Environments (Revised 1986) PB 86–219508 

78–172 Hydrazines (1978) PB 81–225690 

Hydrogen Cyanide [See: Cyanide, Hydrogen and 

Cyanide Salts]

76–143 Hydrogen Fluoride (1976) PB 81–226516 

77–158 Hydrogen Sulfide (1977) PB 274196 

78–155 Hydroquinone (1978) PB 81–226508 

75–126 Identification System for Occupationally 

Hazardous Materials (1974)

PB 246698 

76–142 Isopropyl Alcohol (1976) PB 273873 

* Kepone (1976) PB 83–196170 

78–173 Ketones (1978)

Labeling [See: Identification System for 

Occupationally Hazardous Materials]

PB 80–176076 

73–11010 Lead, Inorganic (1972) PB 214265 

78–158 Lead, Inorganic (Revised) (1978) PB 81–225278 

Lockout/Tagout [See: Hazardous Energy]

(continued)
18 NIOSH CIB 60 • Medical Screening of Workers

NIOSH publication number Title and date NTIS stock number 

76–188 Logging from Felling to First Haul (1976) PB 266411 

76–205 Malathion (1976) PB 267070 

73–11024 Mercury, Inorganic (1973) PB 222223 

76–148 Methyl Alcohol (1976)

Methyl Chloroform [See: 1,1,1-Trichloroethane]

PB 273806 

77–106 Methyl Parathion (1976) PB 274191 

76–138 Methylene Chloride (1976) PB 81–227027 

98–102 Metalworking Fluids (1998) PB 99–133910 

77–164 Nickel, Inorganic (1977) PB 274201 

76–141 Nitric Acid (1976) PB 81–227217 

78–212 Nitriles (1978) PB 81–225534 

76–149 Nitrogen, Oxides of (1976) PB 81–226995 

78–167 Nitroglycerin and Ethylene Glycol Dinitrate (1978) PB 81–225526 

73–11001 Noise (1972) PB 213463 

2006–123 Occupational Exposure to Refractory Ceramic 

Fibers

98–126 Occupational Noise Exposure PB 98–173–735 

83–127 Oil and Gas Well Drilling (1983) PB 84–242528 

77–115 Organotin Compounds (1976) PB 274766 

84–115 Paint and Allied Coating Products (1984) PB 85–178978 

76–190 Parathion (1976) PB 274192 

Perchloroethylene [See: Tetrachloroethylene] 

78–174 Pesticides, Manufacture and Formulation PB 81–227001 

76–196 Phenol (1976) PB 266495 

76–137 Phosgene (1976) PB 267514 

77–225 Polychlorinated Biphenyls (1977) PB 276849 

84–103 Precast Concrete Products Industry (1984) PB 85–220051 

88–101 Radon Progeny in Underground Mines (1988) PB 88–173455 

77–192 Refined Petroleum Solvents (1977) PB 85–178267 

2006–123 Refractory Ceramic Fibers (2006) PB 2006–1123003 

75–120 Silica, Crystalline (1974) PB 246697 

76–105 Sodium Hydroxide (1975) PB 246694 

83–119 Styrene (1983) PB 84–148295 

74–111 Sulfur Dioxide (1974) PB 228152 

* Sulfur Dioxide (Revised) (1977) PB 83–182485 

74–128 Sulfuric Acid (1974) PB 233098 

(continued)
NIOSH CIB 60 • Medical Screening of Workers 19

NIOSH publication number Title and date NTIS stock number 

77–121 1,1,2,2-Tetrachloroethane (1976) PB 273802 

76–185 Tetrachloroethylene (Perchloroethylene) (1976) PB 266583 

78–213 Thiols: N-Alkane Mono, Cyclohexane, and 

Benzene (1978) 

PB 81–225609 

78–179 o-Tolidine (1978) PB 81–227084 

73–11023 Toluene (1973) PB 222219 

73–11022 Toluene Diisocyanate (1973) [Revised; See: 

Diisocyanates] 

PB 222220 

76–184 1,1,1-Trichloroethane (Methyl Chloroform) (1976) PB 267069 

73–11025 Trichloroethylene (1973) PB 222222 

77–127 Tungsten and Cemented Tungsten Carbide (1977) PB 275594 

73–11009 Ultraviolet Radiation (1972) PB 214268 

77–222 Vanadium (1977) PB 81–225658 

78–205 Vinyl Acetate (1978) PB 80–176993 

* Vinyl Chloride (1974) PB 246691 

* Vinyl Halides (1979) PB 84–125699 

77–140 Waste Anesthetic Gases and Vapors (1977) PB 274238 

88–110 Welding, Brazing, and Thermal Cutting (1988) PB 88–231774 

75–168 Xylene (1975) PB 246702 

76–104 Zinc Oxide (1975) PB 246693 

*Denotes the absence of a publication number or that recommendations were provided in testimony by NIOSH to 

the U.S. Department of Labor.

NTIS [National Technical Information Service] Web site: http://www.ntis.gov 
20 NIOSH CIB 60 • Medical Screening of Workers

APPENDIX D • Discussion of Occupational 

Health Surveillance Programs with Medical 

Screening 

Occupational health surveillance programs exist that may be useful as models on which to 

base future efforts in the management of occupational exposures to one or more engineered 

nanoparticles together with any potential health 

risk(s) related to those exposures. 

Occupational exposures to metalworking fluids 

(MWF) have been implicated in health problems including a variety of dermatologic and 

respiratory health conditions. In the NIOSH 

Criteria for a Recommended Standard: Occupational Exposure to Metal Working Fluids

[NIOSH 1998], medical monitoring (screening) 

is recommended by NIOSH as part of a complete MWF safety and health program. Similarly, 

in the Safety and Health Best Practices Manual 

for Metalworking Fluids [OSHA, 2008], OSHA 

recommends a model for a medical monitoring 

(screening) program and provides information 

on implementation. These recommended programs provide examples of how appropriate 

occupational health surveillance principles 

may be applied toward prevention and control of occupational exposures and associated 

health risks. Although there are still scientific 

uncertainties related to occupational exposures 

to MWF that require further research, the recommendations for these medical monitoring 

programs are based on evaluation of extensive 

data concerning exposures, health effects, and 

exposure-health effect relationships. As noted 

in the NIOSH Criteria Document for a Recommended Standard, these recommendations 

concerning MWF are made with the expectation that they will prevent or greatly reduce the 

risk of adverse health effects in exposed workers. Gathering exposure and health effect data 

related to occupational exposure to engineered 

nanoparticles will be essential when formulating medical screening programs for workers 

exposed to engineered nanoparticles.
NIOSH CIB 60 • Medical Screening of Workers 21

APPENDIX E • Examples of Limitations in the 

Evidence Base for Specific Medical Screening of 

Workers Exposed to Engineered Nanoparticles

Key among the criteria for recommending specific medical screening of workers exposed to 

engineered nanoparticles include determining 

whether the substance in question is a hazard 

and whether the disease to be averted is sufficiently common in the worker population to 

justify routine screening [Nasterlack et al. 2007; 

Borak et al. 2006; Halperin et al. 1986]. For 

engineered nanoparticles, there is insufficient 

evidence for a definitive hazard determination. 

Only a small number of the myriad types of 

engineered nanoparticles have undergone experimental animal inhalation testing, and no 

broad categories of physicochemical risk factors have been identified to allow for projecting hazards across particle types. No chronic 

inhalation studies of engineered nanoparticles 

have been conducted to date. The existence of 

a few short-term inhalation studies on carbon 

nanotubes and nanoscale metal oxides is not 

adequate to identify what disease endpoints to 

assess in medical screening. There is also insufficient information available regarding the absolute, relative or population-attributable risks 

associated with nanoparticle exposures [Nasterlack et al. 2007]. 

Examples of the issues in determining the rationale for recommending medical screening 

for workers potentially exposed to engineered 

nanoparticles are described as follows. 

Single-Walled Carbon 

Nanotubes (SWCNTs)

Intratracheal (IT) exposure to SWCNTs has 

been associated with interstitial fibrosis in the 

rat (Lam et al. 2004]. Aspiration of purified SWCNTs caused rapid and progressive interstitial 

fibrosis in mice [Shvedova et al. 2005]. NIOSH 

has also shown that inhalation of SWCNTs 

cause interstitial fibrosis [Shvedova et al. 2008]. 

The problem is that purified SWCNTs are not 

redox reactive and the interstitial fibrosis is not 

driven by oxidant generation and inflammation. Therefore, measurement of markers of oxidant stress or inflammation in humans would 

not be predictive. If interstitial lung disease was 

considered the health endpoint of concern, 

monitoring of the carbon monoxide diffusion 

capacity of the lung could be performed noninvasively. A significant decline in diffusion would 

indicate a loss of alveolar-capillary gas exchange 

and suggest early signs of pre-clinical disease. 

Unfortunately, virtually no published data exist on occupational exposure concentrations for 

working in SWCNT operations. Consequently, 

there is too little information available at this 

time to verify disease endpoints. There is also 

too little information available on exposure in 

general and ultimately the risk to workers who 

handle these materials. 
22 NIOSH CIB 60 • Medical Screening of Workers

Nanoscale Metal Oxides

Pulmonary exposure to nanoscale metal oxides such as titanium dioxide (TiO2

) have been 

shown in rat models to cause pulmonary inflammation [Oberdörster et al. 2005] and to 

inhibit the ability of the systemic microvasculature to respond to dilators [Nurkiewicz 

et al.2006; Nurkiewicz et al. in press] after 

IT or inhalation exposures. Ultrafine (nanoscale) TiO2

 has been shown to be more potent 

in causing these effects than fine TiO2 on an 

equivalent mass basis. These effects have been 

associated with oxidant stress and induction of 

inflammatory mediators. Therefore, markers 

of oxidant stress and inflammation could be 

considered as early indicators of human exposure or response. Oxidant stress markers have 

been suggested as markers of toxicity to metal 

oxide nanoparticles as a class [Nel et al. 2006]. 

Examples of such markers would be nitrous 

oxide or isoprostanes in exhaled breath or 

blood markers of oxidant stress. However, the 

utility of these markers for screening workers 

exposed to engineered nanoparticles has not 

been demonstrated. In addition, some research 

shows that nanoscale TiO2 is linked to cancer 

of the lung and the International Agency for 

Research on Cancer (IARC) has categorized titanium dioxide as a possible carcinogen to humans [IARC 2006]. Nonetheless, no evidence 

clearly demonstrates that medical screening 

of asymptomatic workers exposed to lung carcinogens decreases the chance of dying from 

cancer (NCI 2007; Marcus et al. 2006).

Nanoscale Cadmium

Cadmium is a substance that has medical screening recommendations for workers exposed in order to prevent or assess lung and kidney toxicity 

(see Appendices B and C). At a minimum, these 

recommendations should pertain to nanoscale 

cadmium (e.g., such as that used in the production of quantum dots). Medical screening is 

typically triggered by the airborne concentration of the substance in the workplace (e.g., the 

“action level” concentration). An action level is 

some fraction, usually 50%, of an occupational 

exposure limit (OEL). Whether the action level 

concentration recommended for nonnanoscale 

cadmium particles is adequate for nanoscale 

cadmium is unknown. Workplaces with engineered nanoparticles of materials addressed 

by current OSHA standards are subject to the 

requirements of those standards, including the 

requirements for medical surveillance.
NIOSH CIB 60 • Medical Screening of Workers 23

APPENDIX F • Exposure Registries

Exposure registries are useful tools for surveillance of new or perceived hazards. A registry 

provides a structured and orderly approach to 

handling the problem of identifying and maintaining communication with workers exposed to 

hazardous substances [Schulte and Kaye 1988]. 

An exposure registry is the enrollment of persons 

exposed or likely to have been exposed to occupational or environmental hazards; the registry may 

include how these groups are managed with regard to primary or secondary preventive efforts. 

In occupational situations, company employee 

rosters are de facto registries; however, they may 

not address employees who leave a company. 

Moreover, for a new cross-cutting technology 

such as nanotechnology, the registry could enroll 

persons from various companies. Generally, exposure registries are developed and maintained 

by government entities, but there are examples 

of private-sector registries related to exposure to 

commercial products.

The purposes and functions of exposure registries may be summarized as follows:

• Delineate a population at risk

• Follow cohort to ascertain exposure-disease associations

• Follow cohort to ensure the institution of 

appropriate primary and secondary prevention and medical surveillance

• Follow cohort to allow for appropriate social, legal, and economic support

• Demonstrate societal concern for the cohort and provide a base for political action relevant to the exposure

• Notify a cohort of an exposure, preventive measures, or therapeutic advances 

that were not understood or known at the 

time the registry was established

Various issues should be addressed when considering development of exposure registries. 

These include the term of the registry, needs of 

registrants, confidentially of information, cost of 

maintaining the registry, and the potential impact 

of the registry on workers and companies.

Registries are essentially a collection of individual worker information over time with at least 

a preliminary plan for analysis. Data collected 

in registries may be subject to limitations. Exposure registries are not always useful in etiologic research. For diseases with low prevalence following low-level exposures, exposure 

registries are not very effective tools because 

(1) exposure classification is often difficult, 

(2) the statistical power of prospective studies 

is low, and (3) the time period of the study may 

be impractically long. Moreover, changes in 

exposures experienced by registry participants 

over time may complicate the ability to establish clear exposure-disease relationships.

Exposure registries may provide opportunities 

to determine the exposure-disease association 

and risk. Also, when practical prospective studies can be designed, registries can be used to establish hypotheses. Many questions arise when 

considering an exposure registry for etiologic 

research, including: 

• How can exposed persons be adequately 

differentiated from nonexposed persons? 
24 NIOSH CIB 60 • Medical Screening of Workers

• What group could serve as a comparison 

group so that the disease experience of the 

exposed group can be evaluated? 

• How long should the group be followed? 

Although exposure registries are useful tools to 

assist populations potentially at risk, their utility for workers exposed to engineered nanoparticles needs further evaluation. 
NIOSH CIB 60 • Medical Screening of Workers 25

Notes
26 NIOSH CIB 60 • Medical Screening of Workers

Notes

S

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