Health Hazard Evaluation Report 2012-0135-3184 Page 1

Evaluation of Potential Employee Exposures 

at a Medical Examiner’s Office 

Report No. 2012-0135-3184

June 2013

Bradley S. King, MPH, CIH

Elena Page, MD, MPH

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health
Page 2 Health Hazard Evaluation Report 2012-0135-3184

Contents

Highlights...............................................i

Abbreviations ..................................... iv

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

Methods ............................................... 3

Results .................................................. 5

Discussion ............................................ 8

Conclusions........................................ 11

Recommendations............................. 11

Appendix A ........................................ 14

Appendix B......................................... 18

Appendix C......................................... 20

References.......................................... 25

Acknowledgements........................... 31

The employer is required to post a copy of this report for 30 days at or near the 

workplace(s) of affected employees. The employer must take steps to ensure 

that the posted report is not altered, defaced, or covered by other material.

The cover photo is a close-up image of sorbent tubes, which are used by the HHE 

Program to measure airborne exposures. This photo is an artistic representation that may 

not be related to this Health Hazard Evaluation.
Health Hazard Evaluation Report 2012-0135-3184 Page i

We evaluated exposures to 

volatile organic compounds, 

mold, airborne particles, 

and formaldehyde in the 

autopsy suite, histology 

laboratory, and toxicology 

laboratory of a medical 

examiner’s office. Exposures 

to formaldehyde and 

volatile organic compounds 

were below occupational 

exposure limits. However, 

poor indoor environmental 

quality conditions (e.g., mold 

growth, water incursion) were 

present and may be related 

to respiratory problems 

reported by employees. 

Recommendations were made 

to address the causes of the 

poor indoor environmental 

quality conditions. 

Highlights of this Evaluation

The Health Hazard Evaluation Program received a request from employer representatives at 

a medical examiner’s office. The request was submitted because of concerns that employee 

health problems such as hives, acquired angioedema, itchy eyes, mouth sores, asthma, 

and gastrointestinal symptoms, among others, may have been related to the environmental 

conditions at the facility. 

What We Did

● We evaluated the facility in May 2012.

● We interviewed employees about their work 

and health.

● We observed work practices and procedures 

in the autopsy suite, histology laboratory, and 

toxicology laboratory.

● We sampled the air for formaldehyde and particles 

during five autopsies.

● We sampled the air for formaldehyde and volatile 

organic compounds during tissue prepping and 

processing in the histology laboratory and for volatile 

organic compounds in the toxicology laboratory.

● We collected surface samples for mold throughout 

the building, including inside the ventilation system.

● We collected surface samples for fiberglass 

throughout the building.

● We measured temperature and relative humidity in 

several areas.

What We Found

● Some employees reported respiratory problems 

that may be related to exposures in the workplace.

● Other health problems such as kidney stones, acne, 

hives, and bladder infections were not related to the building.

● Temperatures and relative humidity varied by building area and some levels fell outside 

of recommended ranges.

● Employees used powdered latex gloves. Airborne latex particles could contribute to 

allergic symptoms.

● Formaldehyde exposures in the autopsy suite were below occupational exposure limits.

● Air change rates in the autopsy suite exceeded national guidelines. Air flowed into the 

autopsy suite from the adjacent room as recommended.
Page ii Health Hazard Evaluation Report 2012-0135-3184

 What We Found (continued)

● Exposures to volatile organic compounds in the histology and toxicology laboratories 

were very low.

● Chronic water damage was found throughout the building.

● Mold growth and deteriorating duct lining were found in the ductwork that served 

floors 1–3.

● Disintegrated fiberglass was found in surface samples but few intact fiberglass fibers 

were present.

 What the Employer Can Do

● Purchase local exhaust ventilation units for cranial autopsy saws.

● Identify and repair all leaks from the building’s pipes, windows, roof, and façade.

● Maintain consistent and comfortable temperatures and airflow throughout the building.

● Remove mold safely from the ductwork to prevent spreading mold spores through the 

building’s ventilation system.

● Provide nitrile gloves instead of powdered latex gloves. 

● Evaluate the potential for entrainment of morgue exhaust into rooftop air intakes.

● Tell employees about steps being taken to address indoor environmental quality problems.

What Employees Can Do

● Use local exhaust ventilation during cranial autopsies when available.

● Stop using powdered latex gloves. Use nitrile gloves instead.

● Keep containers of formaldehyde closed except when needed during autopsies.

● Report any health and safety concerns to your supervisor and to your doctor. 

● Become active in the health and safety committee. Attend meetings and take any training 

related to your job. 
Health Hazard Evaluation Report 2012-0135-3184 Page iii

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 of this report.
Page iv Health Hazard Evaluation Report 2012-0135-3184

Abbreviations

°F Degrees Fahrenheit

ACGIH® American Conference of Governmental Industrial Hygienists

ANSI American National Standards Institute

ASHRAE American Society of Heating, Refrigerating, and Air-Conditioning 

Engineers

C Ceiling limit

CFR Code of Federal Regulations

EPA Environmental Protection Agency

HHE Health hazard evaluation

HVAC Heating, ventilating, and air-conditioning

IEQ Indoor environmental quality

MDC Minimum detectable concentration

MQC Minimum quantifiable concentration

NIOSH National Institute for Occupational Safety and Health

OEL Occupational exposure limit

OSHA Occupational Safety and Health Administration

PEL Permissible exposure limit

ppm Parts per million

REL Recommended exposure limit

sp. Species

STEL Short-term exposure limit

TWA Time-weighted average

VOC Volatile organic compound

WHO World Health Organization
Health Hazard Evaluation Report 2012-0135-3184 Page 1

Introduction 

The Health Hazard Evaluation Program received a request from a manager at a medical 

examiner’s office. The request concerned possible health hazards associated with work 

practices and workplace conditions in several areas including the autopsy suite, the 

toxicology and histology laboratories, and offices. Specific exposures of concern included 

volatile organic compounds (VOCs), fiberglass, mold, particulates, and formalin (a 

preservative containing formaldehyde). Concerns of poor indoor environmental quality (IEQ) 

and insufficient ventilation were also reported. We evaluated the building in May 2012.

Facility Description

The medical examiner’s office provided a variety of forensic services for death investigations 

involving criminal violence, suicide, or accidents as well as deaths that occurred in a 

correctional facility or in a suspicious or unusual manner. The headquarters building 

where these services were performed opened in 1960. It had six floors above ground, and 

a basement and cellar below ground; it included an autopsy suite, mortuary, toxicology 

and histology laboratories, and offices. The medical examiner’s office also occupied a 

second facility nearby; many of the employees working there had previously worked at the 

headquarters building.

The autopsy suite was located in the basement. Several rooms in the cellar below the 

basement were used to store files, stock jars holding tissue and formalin, and other items. 

The autopsy suite was supplied with 100% outdoor air filtered through a prefilter and a high 

efficiency particulate air filter that was ducted from an intake off the second floor. From 

the second floor heating, ventilating, and air-conditioning (HVAC) unit, air moved through 

ductwork to supply storage rooms in the cellar, including the stock jar storage room. These 

areas in the cellar acted as plenums before the air was transferred to the basement-level 

autopsy suite and other areas by transfer fans. Within the autopsy suite were eight downdraft 

autopsy tables and a ducted lab hood that provided additional exhaust for the autopsy suite. 

Additionally, three air recirculating units were used in the autopsy suite to supplement the 

main ventilation system. Exhaust from the basement-level autopsy suite and morgue was 

ducted to exhaust vents on the roof.

Offices took up most of the first, second, and third floors. The original HVAC design used 

two fans on the second floor to provide supply air to these three floors. One fan had been 

decommissioned, leaving the other fan to supply the three floors with a mixture of fresh 

and recirculated air. The facility’s engineers were unable to provide information about 

the amount of outdoor air being provided by the operating fan or why the second fan was 

decommissioned. Return air from these floors mixed with fresh air, passed through the fan 

and heating/cooling coils in the air handling unit, and was divided into separate “hot deck” or 

“cold deck” ductwork. The ductwork directed the air into mixing boxes in individual offices 

on the three floors. Some of these mixing boxes had thermostats controlling a plunger that 

determined the amount of hot or cold air entering the room. However, not all thermostats 
Page 2 Health Hazard Evaluation Report 2012-0135-3184

in offices were functioning, and the parts to fix them reportedly were difficult to find or no 

longer available.

Personnel in the fourth floor histology laboratory worked with tissues collected during 

autopsies, processing them for microscopic examination of the tissue cells. Personnel in the 

toxicology laboratory on the fifth and sixth floors evaluated drugs, poisons, and other toxic 

compounds in body fluids and tissues. Floors four, five, and six were supplied with 100% 

outdoor air by two supply fans on the roof; the air was ducted directly to ceiling vents on 

each floor. The air supplied to the rooms on these floors was then exhausted directly outside. 

The supply air was heated by a hot water system that used reheat coils. Electric thermostats 

controlled these coils by regulating hot water supplied to the reheat coils. An actuator in the 

thermostat opened a valve; it was reported that the valves and the actuators were failing. New 

valves had been located to replace those that were malfunctioning or had failed. Replacement 

actuators reportedly were unavailable. 

In addition to the main ventilation systems, several rooms on multiple floors had independent 

perimeter air supply units. Each perimeter unit had a heating and cooling coil and a selfcontained fan unit that pulled air from the space between the inner and outer façade walls of 

the building into the room. Pleated paper filters were present in some units. Some of these 

filters reportedly had not been replaced in years. Following past renovation work, access to 

the internal equipment for several of the perimeter units was obstructed.

Work Process Descriptions

The autopsy suite had the capacity for eight simultaneous autopsies, each performed by 

a medical examiner with medical residents and mortuary technicians assisting as needed. 

Activities during autopsies could expose the autopsy team to chemical and biological 

hazards. For example, when the autopsy team opened the chest cavity to remove and examine 

the internal organs, organ tissue samples were removed and placed in open containers of a 

10% neutral buffered formalin solution. This solution was used to fix and preserve tissue 

specimens for histologic examination. To access brain tissue, the skull cap was removed 

with a hand-held oscillating autopsy saw. No local exhaust ventilation was used. Four or 

five autopsies typically were performed per day, with ten autopsies performed on a busy day. 

Approximately 30 employees worked in the autopsy suite. 

Investigations of drugs and poisons in body fluids and tissues occurred in the toxicology 

laboratory on the fifth and sixth floors. Laboratorians used techniques such as gas 

chromatography/mass spectrometry to analyze blood, urine, body tissues, stomach contents, 

and other specimens for chemicals. Twenty employees worked in this laboratory. 

The histology laboratory received tissue specimens collected during autopsies. The tissues, 

maintained in small cassettes, were removed from the formalin solution held in the containers 

and loaded into a tray for further processing. This work typically was done within a chemical 

fume hood. Further processing removed the tissue fluids and replaced them with alcohol 

and paraffin to fix the tissue in a block of paraffin. Chemicals used in the tissue processing 
Health Hazard Evaluation Report 2012-0135-3184 Page 3

included dehydrants such as ethyl, isopropyl, and methyl alcohol, and aliphatic hydrocarbons. 

After processing, the block was sliced and the tissue slices were mounted on a slide, dyed, 

and viewed under a microscope. Twelve employees worked in this area. 

Methods

Interviews 

The director of employee health and safety provided a roster of all 160 employees at the 

headquarters building and a list of seven employees who worked at the second facility 

nearby and had reported medical issues they felt were related to work at the headquarters 

building. We serially selected every third employee from the headquarters building roster 

for confidential in-person medical interviews. All employees at the headquarters building 

received an e-mail to notify them that we would be available if they wished to be interviewed 

but had not been selected. We also interviewed employees from the second facility and one 

retired employee by phone or in person. We asked about work location, job duties, health 

issues they felt were related to work, medical history, smoking history, and potential stressors 

at work. In addition, a complete medical history was taken to determine if any medical issues 

employees had but did not relate to their work could be unrecognized occupational illnesses. 

Medical records were obtained and reviewed for employees who reported work-related health 

issues for which they had received medical evaluation. 

Autopsy Suite Exposures 

On May 22, 2012, we observed work practices and procedures during five autopsies in the 

basement autopsy suite. We sampled the air for formaldehyde on eight employees over a full 

shift according to the National Institute for Occupational Safety and Health (NIOSH) Method 

2016, with modifications [NIOSH 2010]. A medical examiner and a medical resident also 

wore a second sampler to collect 15-minute breathing zone air samples. A 15-minute area air 

sample was also collected between the first and second round of autopsies near one of the 

autopsy tables to document background concentrations of formaldehyde. For the 15-minute 

formaldehyde samples, the minimum detectable concentration (MDC) was 0.008 ppm (parts 

per million) and the minimum quantifiable concentration (MQC) was 0.025 ppm for an air 

volume of 3 liters. For the full shift formaldehyde samples, the MDC was 0.001 ppm and the 

MQC was 0.004 ppm for an air volume of 19.5 liters.

Because the oscillating saw creates airborne particulate matter, two Hach Ultra Analytics 

Met One HHPC-6 Handheld Airborne Particle Counters were placed near autopsy tables 

to measure the concentration of airborne particles. We measured air velocity with a TSI 

Q-TrakTM model 9565-P Indoor Air Quality Meter and probe model 966 for calculation 

of the number of air changes per hour. We used Nextteq smoke tubes to visualize air flow 

patterns and assess pressure differentials. We used a TSI Q-TrakTM model 9565-P Indoor Air 

Quality Meter with probe model 982 for environmental temperature and relative humidity 

measurements. 
Page 4 Health Hazard Evaluation Report 2012-0135-3184

Toxicology Laboratory Exposures

On May 23, 2012, we assessed exposures in the toxicology laboratories. We observed 

employees doing blood extractions, preparing working solutions, handling buffers and other 

chemicals, screening urine, and working on the gas chromatography/mass spectrometry 

instruments. We collected air samples on thermal desorption tubes to screen for VOCs 

according to NIOSH Method 2549 [NIOSH 2010]. We collected full-shift air samples 

on three employees and area air samples for analysis of specific VOCs according to 

NIOSH Method 1501 [NIOSH 2010]. Environmental temperature and relative humidity 

measurements were made using Q-TrakTM models 7565-X and 9565-P Indoor Air Quality 

Meters with probe model 982.

Histology Laboratory Exposures

On May 23 and 24, 2012, we assessed exposures in the histology laboratory. We observed 

a laboratory associate preparing autopsy tissues and took full-shift air samples for 

formaldehyde and VOCs. Additionally, we collected seven 15-minute, short-term breathing 

zone air samples for formaldehyde on the lab associate. During the 2 days of sampling 

she spent most of her time removing tissue cassettes from formalin-holding jars and 

placing them in a metal tray for processing. We also observed other laboratory employees 

sectioning paraffin blocks. Three full-shift air samples for VOCs were collected, one each 

on a laboratory helper, a microbiologist, and the laboratory director. Area air samples 

were taken for VOCs around the laboratory. Two full-shift air samples for formaldehyde 

were also collected on the laboratory helper and microbiologist. Sampling and analysis of 

formaldehyde was done according to NIOSH Method 2016, with modifications; sampling 

and analysis for VOCs was done according to NIOSH Methods 2549 and 1501 [NIOSH 

2010]. Environmental temperature and relative humidity measurements were made using a 

Q-TrakTM model 7565-X Indoor Air Quality Meter.

Indoor Environmental Quality

On May 24, 2012, we collected 10 surface samples for mold from locations throughout the 

building, including the second floor HVAC unit and on ductwork, window ledges, carpet, 

and walls of second, third, fourth, and sixth floor rooms. We collected six samples for 

fiberglass from surfaces such as desks and window sills in rooms 125, 311, 333, and 613 

and in hallways on the third and sixth floors. Stick-to-it clear plastic microscope slides were 

used to collect the surface mold and fiberglass samples. Immediately prior to use, the slide 

was removed from the slide mailer, and its protective liner was peeled off to expose the 

adhesive. The slide was placed adhesive side down, gently pressing down to ensure contact 

was made between the slide and the surface. The slide was then removed from the surface, 

with the adhesive side of the slide pulling mold spore structures, hyphae, and fiberglass from 

the sampled surface. The slides were packed in individual mailers, shipped to the analytical 

laboratory, and analyzed microscopically.
Health Hazard Evaluation Report 2012-0135-3184 Page 5

We collected temperature and relative humidity measurements on the first, third, and sixth 

floors with Q-TrakTM models 7565-X and 9565-P Indoor Air Quality Meters to determine if 

these parameters fell within established guidelines. 

Results

Interviews

We interviewed 53 employees. Of these, 40 were serially selected from the roster (none 

refused to be interviewed), six asked for interviews, six were from the second facility, and 

one was retired. Of the 53, 33 reported they had no health issues they related to their work at 

the headquarters building. One reported sarcoidosis, but did not feel it was related to work. 

Twenty employees reported health concerns they related to work at the headquarters building. 

The most common symptoms were eye irritation (five); nose irritation, congestion, and 

sneezing (six); exacerbation of allergies (four); and sinus problems (three). Four individuals 

reported having been diagnosed with asthma since beginning work at the headquarters 

building. Other symptoms reported were headache, cough, hives and angioedema (two each); 

and wheeze, skin problems, stress due to odors from the morgue, dental problems, leg and 

arm cramps, acne, and kidney stones (one each). Medical records were reviewed for five 

employees. One record showed a diagnosis of occupational asthma due to mold exposure. 

The other records did not show sufficient evidence to document a work-related condition. 

Autopsy Suite Exposures

During the five autopsies observed, air samples were taken for formaldehyde on three 

medical examiners, two medical residents, and three mortuary technicians. Results of 

these samples are presented in Appendix A, Table A1. No short-term concentrations of 

formaldehyde exceeded applicable ceiling or short-term occupational exposure limits (OELs) 

set by the Occupational Safety and Health Administration (OSHA), NIOSH, or the American 

Conference of Governmental Industrial Hygienists (ACGIH). Full-shift, time-weighted 

average (TWA) concentrations ranged from 0.01–0.03 ppm and were well below the OSHA 

permissible exposure limit (PEL) of 0.75 ppm. Some full-shift TWA concentrations were 

above the NIOSH recommended exposure limit (REL) of 0.016 ppm.

Aerosol measurements were taken using direct-reading instruments mounted at the feet of 

autopsy tables 4 and 7. Results are shown in Figures B1 and B2 in Appendix B. Background 

aerosol concentrations (measured in particles/liter of air) are shown beginning at 9:14 a.m., 

before autopsy procedures started. Most background particles measured were in the size 

range of 0.3–0.5 micrometers in diameter. A source of additional aerosols produced during 

the autopsies was using the oscillating saw to cut through the cranial bone to remove the skull 

cap. No local exhaust ventilation was used during this procedure. Aerosol concentrations 

showed small peaks when the oscillating saw was used. Typically, bone cutting with the saw 

lasted no longer than 5 minutes. While small peaks were observed when the saws were in 

use, aerosol levels returned to background levels fairly rapidly after the saws stopped. 
Page 6 Health Hazard Evaluation Report 2012-0135-3184

Ventilation measurements were taken at the eight downdraft tables and one fume hood. 

On the basis of these exhaust measurements and the measured dimensions of the room, 

the calculated air changes per hour for the room was 20. This is above the minimum 

recommended of 12 air changes per hour for autopsy rooms [Facility Guidelines Institute 

2010; ASHRAE 2011]. Smoke tube testing identified a negative pressure differential between 

the autopsy room and the adjacent rooms as recommended to minimize the spread of 

contamination. 

During autopsies, we observed employees using face shields, nitrile or latex gloves, aprons, scrubs, 

booties, and head covers. N95 filtering facepiece respirators, appropriate for autopsy procedures, 

were used correctly and in accordance with the OSHA respiratory protection standard. 

Toxicology Laboratory Exposures

We collected two area air samples to screen for VOCs. Compounds identified near two gas 

chromatography/mass spectrometry instruments included ethyl benzene and xylene isomers, 

toluene, and heptane. Compounds identified in the extraction room included ethyl benzene 

and xylene isomers, toluene, heptane, butyl chloride, and ethyl acetate. On the basis of these 

screening samples, ethyl benzene, xylenes, toluene, ethyl acetate, benzene, and heptane 

were quantified from three full-shift air samples and one area air sample. All concentrations 

measured were at or below 0.14 ppm, the highest concentration, which was for ethyl acetate. 

The breathing zone concentrations of VOCs were below 1/100 of the most conservative OEL. 

Laboratory personnel wore nitrile gloves, a laboratory coat, and safety glasses.

Histology Laboratory Exposures

We collected one full-shift and seven 15-minute short-term air samples for formaldehyde 

on a laboratory associate while she prepared, processed, and fixed tissue samples. We also 

collected two full-shift air samples, one each on a laboratory helper and a microbiologist. 

Results of these samples are presented in Appendix A, Table A2. No short-term personal 

breathing zone air sample results for formaldehyde exceeded ceiling or short-term OELs set 

by OSHA, NIOSH, or ACGIH. Results of full-shift TWA concentrations were well below the 

OSHA PEL; one of the full-shift TWA concentrations was slightly above the NIOSH REL. 

VOCs were used in the tissue processor. Screening air samples showed low levels of ethyl 

benzene and xylene isomers, toluene, ethyl acetate, and isopropanol. Other compounds 

identified included ethanol, benzene, and heptane. On the basis of these screening samples, 

ethyl benzene and xylene isomers, toluene, ethyl acetate, benzene, and heptane were 

quantified from three full-shift air samples and one area air sample. All concentrations 

measured were at or below 0.11 ppm, the highest concentration recorded for one of the 

compounds (xylenes). The breathing zone concentrations of every compound for which we 

sampled were below 1/100 of the most conservative OEL.
Health Hazard Evaluation Report 2012-0135-3184 Page 7

Employees preparing, processing, and fixing tissue samples wore nitrile inner gloves and 

powder-free latex outer gloves, a laboratory coat, and an apron. Employees slicing paraffin 

blocks and mounting the slices on slides wore gloves and a laboratory coat. 

Indoor Environmental Quality 

Ten surface samples were collected at locations on the second, third, fourth, and sixth 

floors for the presence of mold growth. The ductwork immediately beyond the second-floor 

HVAC unit that serves the building’s first three floors appeared to have a large amount of 

deteriorating material contaminated with mold (Appendix B, Figure B3). Other locations 

sampled included those where water incursions had been reported. Results of the microscopic 

analysis of the tape samples are detailed in Appendix A, Table A3. Concentrations of fungal 

structures are semi-quantitative (i.e., rare, few, moderate, and many). Identification was 

facilitated by the observation of spores, hyphae, and conidia. Predominant fungi identified 

included Alternaria species (sp.), Aureobasidium/Hormonema sp., Aspergillus/Penicillium 

sp., Cladosporium sp., Engyodontium/Tritirachium sp., Myxomycete/Periconia-like sp., 

Penicillium sp., Scytalidum-like sp., and Ustilago/Ustilaginoid sp.

Examinations of the slides from six surface samples from rooms on the first, third, and sixth 

floors showed trace amounts of intact fiberglass on each sample. However, each sample 

contained material that appeared to be rough-edged glass slag, perhaps a result of fiberglass 

breakage. Cellulose fibers were also prominent along with various plant fibers and pieces. 

We measured temperature and relative humidity in several areas. Results are shown in 

Appendix A, Table A4. The indoor temperatures ranged from 65 degrees Fahrenheit (°F) 

in the autopsy suite to 78°F in the toxicology laboratory. The recommended temperatures 

ranges are 68°F–75°F for autopsy rooms and 70°F–75°F for laboratories (including general 

and histology laboratories) [ANSI/ASHRAE/ASHE 2008]. The relative humidity ranged 

from 53% in an office on the third floor to 71% in an office on the sixth floor, above the 

65% level recommended by the American National Standards Institute/American Society of 

Heating, Refrigerating, and Air-Conditioning Engineers (ANSI/ASHRAE) [ANSI/ASHRAE 

2010a]. 

We also observed the following problems at the headquarters building:

● Possible short circuiting of air because supply diffusers and exhaust grilles were close 

to one another

● Long runs of ductwork to a single supply diffuser at the end of the ductwork resulting 

in low airflow

● Locations in the building with multiple supply diffusers but few exhaust grilles

● Inability to access certain perimeter air supply units for maintenance and repairs
Page 8 Health Hazard Evaluation Report 2012-0135-3184

We received reports of inconsistent airflow throughout the building and the inability of the 

HVAC system to remove heat produced by the laboratory equipment, particularly on the 

fifth and sixth floors. The buildings’ engineers reported difficulty in locating parts to replace 

old, malfunctioning HVAC system components. Additionally, employees reported the 

presence of body decomposition odors on the upper floors of the building. Air intakes for 

these floors and the morgue exhaust were on the roof making it possible for exhaust air to be 

entrained into the outdoor air intakes. 

Discussion 

We identified several occupational health and safety-related problems in the headquarters 

building including use of powdered latex gloves, chronic water intrusion or excessive 

moisture throughout the building, inadequate housekeeping, and the poor condition of 

the HVAC system. Some employees reported work-related health problems shown to 

be associated with occupancy in damp or moldy buildings, including upper and lower 

respiratory symptoms and asthma. Respiratory irritation, allergies, asthma, and nasal 

congestion could be related to airborne latex particles from the use of powdered latex 

gloves, microbial contamination from chronic water damage, ventilation problems related 

to issues in the system’s design and control, inadequate housekeeping and building 

maintenance, or temperature and relative humidity levels outside of established IEQ 

guidelines. Some evidence in the medical literature shows that sarcoidosis may be related 

to damp or moldy buildings [Newman et al. 2004; Rossman et al. 2008; Newman and 

Newman 2012]. Some health problems reported by employees are not related to exposure in 

the building, such as kidney stones, acne, and bladder infections.

Cornstarch is used to powder sterile and non-sterile natural rubber latex gloves to aid in 

glove donning. Natural rubber latex proteins alone or glove powder containing such proteins 

can become airborne and represent a health hazard. Glove powder in environmental dusts 

also can pose a hazard. The three main types of reactions to latex-containing objects include 

irritant contact dermatitis, allergic contact dermatitis, and immediate hypersensitivity 

[NIOSH 1997a]. Additional information on the occupational hazards associated with these 

exposures can be found in the NIOSH Alert, “Preventing Allergic Reactions to Natural 

Rubber Latex in the Workplace” at http://www.cdc.gov/niosh/docs/97-135/ [NIOSH 1997a]. 

Allergic responses are the most common type of health problem associated with exposure 

to molds. These may include sneezing; itching of the nose, eyes, mouth, or throat; nasal 

stuffiness and runny nose; and red, itchy eyes. These were the most commons symptoms 

reported by employees. In 2009, the World Health Organization (WHO) published 

guidelines for protection of public health from mold and other exposures in damp buildings 

[WHO 2009]. On the basis of its review of the scientific literature for this report, WHO 

concluded that there was sufficient epidemiologic evidence that occupants of damp 

buildings are at risk of developing upper and lower respiratory tract symptoms (including 

cough, wheeze, and dyspnea), respiratory infections, asthma, and exacerbation of asthma. 

At least one employee had a documented diagnosis of occupational asthma due to mold 
Health Hazard Evaluation Report 2012-0135-3184 Page 9

in the workplace, and three others reported having been diagnosed with asthma since 

beginning work at the headquarters building. WHO also concluded that limited evidence 

suggests associations between bronchitis and allergic rhinitis and damp buildings. They 

noted clinical evidence that exposure to mold and other microbial agents in damp buildings 

is associated with hypersensitivity pneumonitis. Mold is not the only exposure that may be 

present in damp buildings, and it is still unclear exactly what exposures in damp buildings 

are responsible for health effects [WHO 2009]. In addition to mold, dust mites, bacteria, and 

chemical emissions can be present [NIOSH 2012].

No exposure guidelines for mold in air exist, so it is not possible to distinguish between 

“safe” and “unsafe” levels of exposure. Nevertheless, the potential for health problems 

is an important reason to prevent indoor mold growth and to remediate indoor mold 

contamination. Moisture intrusion, along with nutrient sources such as building materials 

or furnishings such as carpet and upholstered furniture, allows mold to grow indoors, so 

it is important to keep the building interior and furnishings dry. NIOSH concurs with U.S. 

Environmental Protection Agency (EPA) recommendations to remediate mold contamination 

in indoor environments found at http://www.epa.gov/mold/mold_remediation.html [EPA 

2001; Redd 2002]. 

The location that had the most mold was the ductwork immediately after the second floor 

HVAC unit. All four samples collected in this location had a variety of mold species at levels 

described as “moderate” to “many.” The ductwork provided a pathway for dissemination of 

mold spores to other locations in the building. Samples collected at other locations showed 

less mold contamination. Additional information on health effects and mold remediation 

can be found in the Centers for Disease Control and Prevention document “Mold Prevention 

Strategies and Possible Health Effects in the Aftermath of Hurricanes and Major Floods” at 

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5508a1.htm [Brandt et al. 2006].

One of the most common deficiencies in the indoor environment is the improper operation 

and maintenance of ventilation systems and other building components [Rosenstock 

1996]. The combination of heat-producing equipment and poor HVAC performance can 

affect occupant comfort through increased environmental temperatures. In addition to 

reported water incursion directly into the building, high relative humidity can create a 

damp environment capable of supporting mold growth. Measured temperature and relative 

humidity fell outside recommended ranges for specific areas of the facility. Improved HVAC 

operation and maintenance, higher ventilation rates, and comfortable temperature and relative 

humidity can potentially improve occupant symptoms even when a specific cause-effect 

relationship is not identified.

Employees in the autopsy suite faced a number of potential occupational hazards inherent 

in their work, including exposures to infectious agents [CDC 2012]. All autopsies involve 

potential exposures to blood and other body fluids, a risk of being splashed or splattered 

upon, and a risk of percutaneous injury [Nolte et al. 2002]. Exposure to sharp objects within 

the body and bone fragments may also result in cuts, and the manipulation of large organs 

may result in body splashes [CDC 2012]. During these procedures, autopsy suite employees 
Page 10 Health Hazard Evaluation Report 2012-0135-3184

may be at risk of exposure to infectious agents such as Mycobacterium tuberculosis and 

bloodborne pathogens such as Hepatitis B and C, and human immunodeficiency virus [Nolte 

et al. 2002]. 

Procedures that involve the use of mechanical devices (e.g., oscillating saws) may create 

airborne particles that contain infectious pathogens such as Mycobacterium tuberculosis

as well as those not normally transmitted by the inhalation route; such particles can also 

contaminate inanimate surfaces [Nolte et al. 2002]. Skull cap removal potentially generates 

high concentrations of infectious aerosols [Green and Yoshida 1990]. Droplets of blood and 

cerebrospinal fluid as well as the interstices of bone matrix may contain these infectious 

agents, but they could also be carried on the surface of particles formed by the combination 

of bone dust particles with fluid droplets [Green and Yoshida 1990]. The median diameter of 

bone dust particles in the breathing zone of a saw operator generated during a cranial autopsy 

has been reported to be 0.37 micrometers, which can easily penetrate the alveolar region 

of the lung and can remain airborne for long periods [Green and Yoshida 1990]. Our data 

show the majority of particles measured were in the size range of 0.3–0.5 micrometers in 

diameter and that peaks in aerosol concentrations were produced during use of the oscillating 

saw. No local exhaust ventilation was used in conjunction with the oscillating saw. NIOSH 

evaluations of cranial autopsies done with and without the aid of local exhaust ventilation 

indicate that using local exhaust ventilation significantly reduced exposure to aerosols 

produced by the saws [NIOSH 1997b]. 

Formaldehyde in formalin solution is the most common chemical to which autopsy 

employees are exposed [CDC 2012]. Common health complaints due to exposure to low 

concentrations of formaldehyde include irritation of the eyes, nose, and throat; nasal 

congestion; headaches; skin rash; and asthma [NRC 1981]. It often is difficult to attribute 

specific health effects to particular concentrations of formaldehyde because some people may 

have symptoms at levels where others may experience no symptoms [NRC 1981]. 

Formaldehyde concentrations during 15-minute short-term sampling periods in the autopsy 

suite and histology laboratory were below short-term or ceiling limits. All full-shift exposures 

were below the OSHA PEL; several results in the autopsy suite were slightly above the 

NIOSH REL. However, this REL was established in 1981 when NIOSH first recognized 

formaldehyde as a potential occupational carcinogen. On the basis of the carcinogen policy at 

the time, NIOSH set the REL to the “lowest feasible concentration,” which for formaldehyde 

was defined as the analytical limit of quantification of 0.016 ppm for up to a 10-hour TWA 

and a ceiling limit of 0.10 ppm that should not be exceeded [NIOSH 1981]. Research has 

shown, however, that concentrations of formaldehyde in ambient air often can approach 

or exceed this level [Lemen 1987]. Additionally, a revision of the NIOSH carcinogen 

policy [NIOSH 1995], combined with better exposure characterization and advances in 

risk assessment and management strategies, support the need for NIOSH to reassess the 

formaldehyde REL. Nevertheless, the continued use of exposure controls in the autopsy 

suite, such as downdraft tables, and efforts to reduce the amount of time during which 

formaldehyde-containing jars are open are important in minimizing these exposures. The use 

of a chemical fume hood for tissue preparation appears to be useful in limiting the quantity of 

formaldehyde exposures.
Health Hazard Evaluation Report 2012-0135-3184 Page 11

Conclusions 

Water incursion, mold growth, high relative humidity, HVAC system deficiencies, use of latex 

gloves, and poor maintenance and housekeeping practices may be contributing to some of the 

health problems reported by employees. These include respiratory irritation, allergies, asthma, 

and nasal congestion. Implementing the recommendations below will address such deficiencies 

and may reduce the quantity and severity of symptoms experienced by employees. 

Recommendations 

On the basis of our findings, we recommend the actions listed below. We encourage the 

medical examiner’s office to use a labor-management health and safety committee or 

working group to discuss our recommendations and develop an action plan. Those involved 

in the work can best set priorities and assess the feasibility of our recommendations for the 

specific situation at the headquarters building of the medical examiner’s office. 

Our recommendations are based on an approach known as the hierarchy of controls 

(Appendix C: Occupational Exposure Limits and Health Effects). 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. 

Engineering Controls

Engineering controls reduce employees’ exposures by removing the hazard from the process 

or by placing a barrier between the hazard and the employee. Engineering controls protect 

employees effectively without placing primary responsibility of implementation on the 

employee. 

1. Provide local exhaust ventilation when using cranial autopsy saws during autopsies. 

Mobile bone dust collection systems that attach to a variety of cranial autopsy saws 

and provide high efficiency particulate air filtration are commercially available. 

Administrative Controls

The term administrative controls refers to employer-dictated work practices and policies 

to reduce or prevent hazardous exposures. Their effectiveness depends on employer 

commitment and employee acceptance. Regular monitoring and reinforcement are necessary 

to ensure that policies and procedures are followed consistently.

1. Identify and repair all points of water incursion in the building, including leaks 

originating from the building’s pipes, windows, roof, and façade. 
Page 12 Health Hazard Evaluation Report 2012-0135-3184

2. Remove mold contamination in the ventilation ductwork in a manner that would 

prevent aerosolization and distribution of mold spores through the ventilation system.

3. Improve the operation and maintenance of the HVAC systems to provide appropriate 

ventilation rates and temperatures. This includes providing resources to replace or 

renovate aspects of the building’s HVAC systems determined to be past their useful 

working life including failing or non-functioning thermostats and other temperaturesetting equipment. The inability to find replacement parts for necessary components is 

a problem that needs to be addressed. 

4. Ensure the temperature and relative humidity in the building follow current guidelines 

for office, autopsy suites, and laboratory spaces [ANSI/ASHRAE/ASHE 2008; ANSI/

ASHRAE 2010a].

5. Evaluate the appropriateness of the ductwork design, including the locations of supply 

and exhaust registers, to ensure that proper supply and exhaust of conditioned air 

meets the needs of the specific areas of the building.

6. Improve housekeeping and maintenance practices. In particular, we observed stained 

and dirty carpet, upholstery, and air supply registers. Remove and replace soiled carpet 

if it cannot be adequately cleaned and provide more resources to maintain a greater 

level of housekeeping throughout the building.

7. Replace lids on containers of formalin as soon as possible after using.

8. Evaluate the potential that exhaust from the morgue is being entrained into air intakes 

on the roof. If necessary, take corrective action such as relocating exhaust or air supply 

vents.

9. Start an IEQ management program. An IEQ manager or administrator with clearly defined 

responsibilities, authority, and resources should be selected. This individual should have 

a good understanding of the buildings’ structure and function, and should be able to 

communicate effectively with employees. Although no comprehensive regulatory standards 

specific to IEQ have been established, guidelines have been developed by organizations 

and agencies, including ASHRAE, NIOSH, and the U.S. EPA.

10.Include an employee representative in the IEQ management program to assist with 

communication. The NIOSH/U.S. EPA document, “Building Air Quality: A Guide for 

Building Owners and Facility Managers” may be helpful. A companion NIOSH/U.S. 

EPA guide, “Building Air Quality Action Plan,” discusses how to develop and assess 

an IEQ management program. 

11.Encourage employees with potential work-related health concerns to report their 

concerns to their supervisors and to seek evaluation and care from a healthcare 

provider who is knowledgeable in occupational medicine and IEQ issues.

12.Inform building occupants of the actions taken to address IEQ problems and the 

rationale for decisions made to address these problems.
Health Hazard Evaluation Report 2012-0135-3184 Page 13

Personal Protective Equipment

Personal protective equipment is the least effective means for controlling hazardous 

exposures. Proper use of personal protective equipment requires a comprehensive program 

and a high level of employee involvement and commitment. The right personal protective 

equipment must be chosen for each hazard. Supporting programs such as training, changeout schedules, and medical assessment may be needed. Personal protective equipment should 

not be the sole method for controlling hazardous exposures. Rather, personal protective 

equipment should be used until effective engineering and administrative controls are in place.

1. Use nitrile gloves for dermal protection during work activities in lieu of powdered 

latex gloves.
Page 14 Health Hazard Evaluation Report 2012-0135-3184

Appendix A: Tables

Table A1. Air sampling results for formaldehyde in the autopsy suite, May 22, 2012

Sample location PBZ/Area Sampling period

(minutes)

Short-term TWA 

concentration

(ppm)

Full-shift TWA

concentration 

(ppm)

Medical examiner #1 PBZ 412 NA 0.02

Medical examiner #2 PBZ 402 NA 0.03

Medical examiner #3 PBZ 424 NA 0.02

PBZ 15 [0.02] NA

PBZ 15 [0.01] NA

PBZ 15 0.04 NA

PBZ 15 0.02 NA

PBZ 15 ND NA

Medical resident #1 PBZ 430 NA 0.03

Medical resident #2 PBZ 16 [0.01] NA

PBZ 15 0.03 NA

PBZ 15 0.04 NA

PBZ 15 [0.02] NA

PBZ 15 [0.02] NA

PBZ 15 [0.02] NA

Mortuary technician #1 PBZ 413 NA 0.01

Mortuary technician #2 PBZ 400 NA 0.01

Mortuary technician #3 PBZ 246* NA 0.02

Autopsy table Area 16 ND NA

NIOSH REL [NIOSH 2010] C 0.1 0.016

OSHA PEL [NIOSH 2010] STEL 2.0 0.75

ACGIH TLV [ACGIH 2012] C 0.3 —

Values in brackets indicate levels between the MDC and the MQC.

C = Ceiling

NA = Not applicable

ND = Not detected

PBZ = Personal breathing zone

STEL = Short-term exposure limit

*Represents less time than a typical full-shift period due to the employee finishing the shift early
Health Hazard Evaluation Report 2012-0135-3184 Page 15

Table A2. Personal breathing zone air sampling results for formaldehyde in the histology laboratory, 

May 23–24, 2012

Sample location Sampling period

(minutes)

TWA concentration for 

15-minute samples

(ppm)

TWA concentration

(ppm)

Laboratory helper 413 NA 0.01

Microbiologist 376 NA 0.02

Laboratory associate 351 NA 0.01

16 ND NA

15 [0.01] NA

15 ND NA

15 0.04 NA

15 0.06 NA

15 0.03 NA

15 0.03 NA

NIOSH REL [NIOSH 2010] C 0.1 0.016

OSHA PEL [NIOSH 2010] STEL 2.0 0.75

ACGIH TLV [ACGIH 2012] C 0.3 —

Values in brackets indicate levels between the MDC and the MQC.

For the 15-minute samples, the MDC was 0.008 ppm, and the MQC was 0.025 ppm on the basis of 

an air volume of 3 liters.

For the full-shift samples, the MDC was 0.001 ppm, and the MQC was 0.004 ppm on the basis of an 

air volume of 19.5 liters.

C = Ceiling

NA = Not applicable

ND = Not detected

STEL = Short-term exposure limit
Page 16 Health Hazard Evaluation Report 2012-0135-3184

Table A3. Surface sampling results for mold, May 24, 2012

Sample location Rare Few Moderate Many

Ductwork after 

2nd floor HVAC 

unit

Pollen Cladosporium Aureobasidium/

Hormonema

Engyodontium/

Tritirachium

Ductwork after 

2nd floor HVAC 

unit

— — Scytalidum

Hyaline hyphae

Cladosporium

Alternaria

Ustilago

Dematiaceous hyphae

Dematiaceous conidia/

spores

Hyaline

conidia/spores

Ductwork after 

2nd floor HVAC 

unit

— — — Hyaline hyphae

Hyaline

conidia/spores

Ductwork after 

2nd floor HVAC 

unit

— Hyaline hyphae

Hyaline

conidia/spores

Dematiaceous

hyphae

Dematiaceous

conidia/spores

Room 218 

ductwork 

in women’s 

restroom

— Hyaline hyphae

Hyaline

conidia/spores

Dematiaceous 

condia/spores

Cladosporium

Room 309 

window ledge

Epicoccum Myxomycete/

Periconia

Dematiaceous

conidia/spores

Plant hairs

Pollen —

Room 324 

window ledge

Pithomyces/

Ulocladium

Epicoccum

Ascospores

Cladosporium

Hyaline

conidia/spores

Dematiaceous 

conidia/spores

Myxomycete/

Periconia

Pollen

—

Room 404 carpet 

on floor

— — — Bacterial cocci

Room 405 near 

wall replacement

Alternaria/

Pithomyces

Polythrincium

Aspergillus/

Penicillium

Hyaline

conidia/spores

— —

6th floor 

toxicology lab 

wall baseboard

Hyaline 

conidia/

spores

Dematiaceous

conidia/

spores

Pollen

Aspergillus/

Penicillium

Myxomycete/

Periconia

Algae

Yeast —
Health Hazard Evaluation Report 2012-0135-3184 Page 17

Table A4. Temperature and relative humidity measurements, May 22–24, 2012

Sample location Date Sampling period Temperature 

(°F) range and 

[average]

Relative humidity 

(%) range and 

[average]

Autopsy suite 05/22 8:30 a.m. – 2:26 p.m. 65–68 [67] 59–62 [59]

Room 335 05/22 8:35 a.m. – 4:03 p.m. 74–77 [75] 53–57 [55]

Anthropology room 324 05/22 8:40 a.m. – 4:10 p.m. 73–75 [74] 54–59 [57]

Histology laboratory 

room 415

05/23 8:15 a.m. – 12:59 p.m. 74–75 [75] 62–67 [65]

Toxicology laboratory 

near room 503

05/23 8:17 a.m. – 2:28 p.m. 76–76 [76] 59–62 [60]

Toxicology laboratory 

room 508

05/23 8:24 a.m. – 12:48 p.m. 77–78 [77] 57–60 [58]

Room 125 05/24 9:27 a.m. – 12:16 p.m. 73–75 [74] 54–59 [56]

Anthropology room 324 05/24 9:35 a.m. – 12:07 p.m. 69–69 [69] 63–67 [65]

Room 613 05/24 9:33 a.m. – 12:03 p.m. 70–71 [71] 68–71 [69]
Page 18 Health Hazard Evaluation Report 2012-0135-3184

Appendix B: Figures

Figure B1. Concentration of aerosols at the foot of table 4 in the autopsy suite during five autopsies. Figure 

B1 shows two solid-line boxes, labeled 4, which represent the time when the oscillating saw was used at 

autopsy table 4 where the first particle counter was mounted at its foot. Figure B1 also shows three dashedline boxes, labeled 7 or 2, which represent the times when an oscillating saw was used at other autopsy 

tables (table 7 for the first dashed-line box and table 2 for the second and third dashed-line boxes) in the 

autopsy suite. 

Figure B2. Concentration of aerosols at the foot of table 7 in the autopsy suite during five autopsies. Figure 

B2 shows one solid-line box, which represents the time when the saw was used at autopsy table 7 where the 

second particle counter was mounted at its foot. Figure B2 also shows four dashed-line boxes, labeled 2 or 

4, which represent the times when the saw was used at other autopsy tables (table 2 for the first and fourth 

dashed-line boxes and table 4 for the second and third dashed-line boxes). 
Health Hazard Evaluation Report 2012-0135-3184 Page 19

Figure B3. Deteriorating material and mold growth in the 2nd floor HVAC unit ductwork. 
Page 20 Health Hazard Evaluation Report 2012-0135-3184

Appendix C: Occupational Exposure Limits and 

Health Effects

NIOSH investigators refer to mandatory (legally enforceable) and recommended OELs for 

chemical, physical, and biological agents when evaluating workplace hazards. OELs have 

been developed by federal agencies and safety and health organizations to prevent adverse 

health effects from workplace exposures. Generally, OELs suggest levels of exposure that 

most employees may be exposed to for up to 10 hours per day, 40 hours per week, for a 

working lifetime, without experiencing adverse health effects. However, not all employees 

will be protected if their exposures are maintained below these levels. Some may have 

adverse health effects because of individual susceptibility, a pre-existing medical condition, 

or a hypersensitivity (allergy). In addition, some hazardous substances act in combination 

with other exposures, with the general environment, or with medications or personal habits of 

the employee to produce adverse health effects. Most OELs address airborne exposures, but 

some substances can be absorbed directly through the skin and mucous membranes.

Most OELs are expressed as a TWA exposure. A TWA refers to the average exposure during 

a normal 8- to 10-hour workday. Some chemical substances and physical agents have 

recommended short-term exposure limits (STELs) or ceiling values. Unless otherwise noted, 

the STEL is a 15-minute TWA exposure. It should not be exceeded at any time during a 

workday. The ceiling limit should not be exceeded at any time.

In the United States, OELs have been established by federal agencies, professional 

organizations, state and local governments, and other entities. Some OELs are legally 

enforceable limits; others are recommendations. 

● The U.S. Department of Labor OSHA PELs (29 CFR 1910 [general industry]; 29 CFR 

1926 [construction industry]; and 29 CFR 1917 [maritime industry]) are legal limits. 

These limits are enforceable in workplaces covered under the Occupational Safety and 

Health Act of 1970. 

● NIOSH RELs are recommendations based on a critical review of the scientific and 

technical information and the adequacy of methods to identify and control the hazard. 

NIOSH RELs are published in the NIOSH Pocket Guide to Chemical Hazards [NIOSH 

2010]. NIOSH also recommends risk management practices (e.g., engineering controls, 

safe work practices, employee education/training, personal protective equipment, and 

exposure and medical monitoring) to minimize the risk of exposure and adverse health 

effects.

● Other OELs commonly used and cited in the United States include the TLVs, which 

are recommended by ACGIH, a professional organization, and the WEELs, which are 

recommended by the American Industrial Hygiene Association, another professional 

organization. The TLVs and WEELs are developed by committee members of these 

associations from a review of the published, peer-reviewed literature. These OELs are 

not consensus standards. TLVs are considered voluntary exposure guidelines for use 
Health Hazard Evaluation Report 2012-0135-3184 Page 21

by industrial hygienists and others trained in this discipline “to assist in the control of 

health hazards” [ACGIH 2013]. WEELs have been established for some chemicals 

“when no other legal or authoritative limits exist” [AIHA 2012].

Outside the United States, OELs have been established by various agencies and organizations 

and include legal and recommended limits. The Institut für Arbeitsschutz der Deutschen 

Gesetzlichen Unfallversicherung (Institute for Occupational Safety and Health of the German 

Social Accident Insurance) maintains a database of international OELs from European Union 

member states, Canada (Québec), Japan, Switzerland, and the United States. The database, 

available at http://www.dguv.de/ifa/en/gestis/limit_values/index.jsp, contains international 

limits for more than 1,500 hazardous substances and is updated periodically. 

OSHA requires an employer to furnish employees a place of employment free from 

recognized hazards that cause or are likely to cause death or serious physical harm 

[Occupational Safety and Health Act of 1970 (Public Law 91–596, sec. 5(a)(1))]. This is 

true in the absence of a specific OEL. It also is important to keep in mind that OELs may not 

reflect current health-based information.

When multiple OELs exist for a substance or agent, NIOSH investigators generally 

encourage employers to use the lowest OEL when making risk assessment and risk 

management decisions. NIOSH investigators also encourage use of the hierarchy of controls 

approach to eliminate or minimize workplace hazards. This includes, in order of preference, 

the use of (1) substitution or elimination of the hazardous agent, (2) engineering controls 

(e.g., local exhaust ventilation, process enclosure, dilution ventilation), (3) administrative 

controls (e.g., limiting time of exposure, employee training, work practice changes, medical 

surveillance), and (4) personal protective equipment (e.g., respiratory protection, gloves, 

eye protection, hearing protection). Control banding, a qualitative risk assessment and risk 

management tool, is a complementary approach to protecting employee health. Control 

banding focuses on how broad categories of risk should be managed. Information on control 

banding is available at http://www.cdc.gov/niosh/topics/ctrlbanding/. This approach can be 

applied in situations where OELs have not been established or can be used to supplement 

existing OELs.

Below we provide the OELs and surface contamination limits for the compounds we measured, 

as well as a discussion of the potential health effects from exposure to these compounds.

Formaldehyde

Under the OSHA general industry standard for airborne exposure to formaldehyde [29 CFR 

1910.1048], the PEL is 0.75 ppm for an 8-hour TWA, the action level is 0.5 ppm for an 

8-hour TWA, and the STEL is 2 ppm for a 15-minute TWA. The standard requires medical 

surveillance for employees exposed to formaldehyde at or above the action level or STEL.

The NIOSH REL for formaldehyde is 0.016 ppm for up to an 8-hour TWA. NIOSH also has 

a 15-minute ceiling limit of 0.1 ppm that is not to be exceeded during a work shift [NIOSH 
Page 22 Health Hazard Evaluation Report 2012-0135-3184

2010]. NIOSH recognized formaldehyde as a potential occupational carcinogen in 1981 

and, following the NIOSH carcinogen policy at the time, set the REL to the “lowest feasible 

concentration,” which for formaldehyde was defined as the analytical limit of quantification 

of 0.016 ppm for up to 8 hours [NIOSH 1981]. Since then, experience has shown that this 

REL is actually not the “lowest feasible concentration” because formaldehyde in the ambient 

air can exceed 0.016 ppm, a fact later acknowledged by NIOSH [Lemen 1987]. Additionally, 

a revision of the NIOSH carcinogen policy [NIOSH 1995], combined with better exposure 

characterization and advances in risk assessment and management strategies, support the 

need for NIOSH to reassess the formaldehyde REL. This effort is in progress.

The ACGIH lists formaldehyde as a sensitizer with a ceiling limit of 0.3 ppm [ACGIH 2013]. 

An ACGIH ceiling limit is an exposure that should not be exceeded at any time during the 

work shift.

The International Agency for Research on Cancer classifies formaldehyde as a human 

carcinogen (group 1) on the basis of associations between formaldehyde exposure and 

nasopharyngeal cancer and leukemia [Baan et al. 2009]. NIOSH considers formaldehyde 

as a potential occupational carcinogen; ACGIH lists formaldehyde as a suspected human 

carcinogen; and the U.S. Department of Health and Human Services lists formaldehyde as 

reasonably anticipated to be a human carcinogen in its 11th report on carcinogens [NIOSH 

1981; DHHS 2011; ACGIH 2013].

Volatile Organic Compounds

VOCs are a large class of low molecular weight chemicals that are organic (i.e., containing 

carbon) and have a sufficiently high vapor pressure to allow some of the compounds to exist 

in the gaseous state at room temperature. The health effects associated with VOCs depend on 

the toxicity of the specific VOC, the level of exposure, and the duration of the exposure [EPA 

2012]. Symptoms from exposure to VOCs may include eye and respiratory tract irritation, 

headaches, dizziness, visual disorders, and memory impairment [NIOSH 2010]. The most 

common route of exposure to VOCs is through inhalation, but some solvents may contribute 

to systemic health effects through skin absorption [LaDou 1990; Klaassen 2008]. The rate of 

systemic elimination of solvents depends on how volatile and lipophilic the chemicals are. 

Some subpopulations may be more susceptible to health effects from solvents on the basis 

of age, sex, and genetics [Klaassen 2008]. VOCs are emitted in varying concentrations from 

numerous indoor sources including, but not limited to, carpeting, fabrics, adhesives, solvents, 

paints, cleaners, waxes, cigarettes, and combustion sources. Heating, burning, or chemical 

reactions may cause materials to emit VOCs. NIOSH and ACGIH have recommended 

occupational exposure limits for many VOCs [NIOSH 2010; ACGIH 2013]. OSHA also has 

standards or PELs for many VOCs [29 CFR 1910.1000].

Mold and Microbial Contamination

Exposure to microbes is not unique to the indoor environment. No environment, indoors 

or out, is completely free from microbes, even a surgical operating room. Remediation of 
Health Hazard Evaluation Report 2012-0135-3184 Page 23

microbial contamination may improve IEQ conditions even though a specific cause-effect 

relationship is not determined. NIOSH investigators routinely recommend the remediation 

of observed microbial contamination and the correction of situations that are favorable for 

microbial growth and bioaerosol dissemination. 

The types and severity of symptoms related to exposure to mold in the indoor environment 

depend in part on the extent of the mold present, the extent of the individual’s exposure, and 

the susceptibility of the individuals (for example, whether they have pre-existing allergies 

or asthma). In general, excessive exposure to fungi may produce health problems by several 

primary mechanisms, including allergy or hypersensitivity, infection, and toxic effects. Molds 

can trigger asthma symptoms (shortness of breath, wheezing, cough) in persons who are 

allergic to mold. Repeated or single exposure to mold or mold spores may cause previously 

nonsensitized individuals to become sensitized. Additionally, molds produce a variety of 

VOCs, the most common of which is ethanol, that have been postulated to cause upper 

airway irritation. However, potential irritant effects of VOCs from exposure to mold in the 

indoor environment are not well understood. Evidence also shows that exposure to fungal 

fragments that can contain allergens, toxins, and (1→3)-β-D-glucan may occur [Górny et al. 

2002; Brasel et al. 2005; Reponen et al. 2006].

In 2004, the Institute of Medicine (IOM) of the National Academies published a detailed 

review of previous scientific studies evaluating health effects of damp buildings [IOM 2004]. 

In 2009, the WHO published an updated review of this literature [WHO 2009]. These two 

documents highlight the respiratory health risks of exposure to damp indoor environments. 

The WHO report explains that: “the presence of many biological agents in the indoor 

environment is due to dampness and inadequate ventilation. Excess moisture on almost 

all indoor materials leads to growth of microbes, such as mold, fungi and bacteria, which 

subsequently emit spores, cells, fragments and volatile organic compounds into indoor air. 

Moreover, dampness initiates chemical or biological degradation of materials, which also 

pollutes indoor air.” With respect to health effects from indoor dampness, the WHO report 

explains that there is sufficient epidemiologic evidence to conclude that occupants of damp 

buildings are at risk of developing upper and lower respiratory tract symptoms including 

cough, wheeze, respiratory infections, asthma, and exacerbation of asthma. The WHO 

report also stated limited evidence suggests an association between damp buildings and 

bronchitis and allergic rhinitis, and that there is clinical evidence that exposure to mold and 

other microbial agents in damp buildings increases the risk of hypersensitivity pneumonitis, 

chronic rhinosinusitis, and allergic fungal sinusitis. Additional evidence from a more recent 

epidemiologic review reported that bronchitis, shortness of breath and eczema should be 

added to the list of health outcomes with sufficient evidence of an association to dampness 

and dampness-related agents [Mendell et al. 2011].

People with weakened immune systems (immune-compromised or immune-suppressed 

individuals) may be more vulnerable to infections by molds. For example, Aspergillus 

fumigatus is a fungal species that has been found almost everywhere on every conceivable 

type of substrate. It has been known to infect the lungs of immune-compromised individuals 
Page 24 Health Hazard Evaluation Report 2012-0135-3184

who inhale the airborne spores [Wald and Stave 1994; Brandt et al. 2006]. Healthy 

individuals are usually not vulnerable to infections from airborne mold exposure.

No standards specific to the nonindustrial indoor environment exist. Measurement of 

indoor environmental contaminants has seldom proved helpful in determining the cause 

of symptoms except where there are unusual sources or a proven relationship between 

specific exposures and disease. With few exceptions, concentrations of frequently measured 

chemical substances in the indoor work environment fall well below the recommended OELs 

published by NIOSH [NIOSH 2010], ACGIH [ACGIH 2013], and the American Industrial 

Hygiene Association [AIHA 2012], and the mandatory PELs set by OSHA [29 CFR 1910 

(general industry)]. ANSI/ASHRAE has published recommended building thermal comfort 

and ventilation guidelines [ANSI/ASHRAE/ASHE 2008; ANSI/ASHRAE 2010a,b]. ACGIH 

and American Industrial Hygiene Association have also developed a manual of guidelines for 

approaching investigations of building-related symptoms that might be caused by airborne 

living organisms or their effluents [ACGIH 1999; AIHA 2008]. Other resources that provide 

guidance for establishing acceptable IEQ are available through U.S. EPA at http://www.epa.

gov/iaq/, especially the joint U.S. EPA/NIOSH document, Building Air Quality, A Guide for 

Building Owners and Facility Managers at http://www.epa.gov/iaq/largebldgs/baqtoc.html.

Temperature and Relative Humidity 

Temperature and relative humidity measurements are often collected as part of an 

IEQ evaluation because these parameters affect the perception of comfort in an indoor 

environment. The perception of thermal comfort is related to one’s metabolic heat 

production, the transfer of heat to the environment, physiological adjustments, and body 

temperature [NIOSH 1986]. Heat transfer from the body to the environment is influenced 

by factors such as temperature, humidity, air movement, personal activities, and clothing. 

The ANSI/ASHRAE Standard 55-2010, Thermal Environmental Conditions for Human 

Occupancy, specifies conditions in which 80% or more of the occupants would be expected 

to find the environment thermally acceptable [ANSI/ASHRAE 2010a]. Assuming slow air 

movement and 50% relative humidity, the operative temperatures recommended by ANSI/

ASHRAE range from 68.5°F–76°F in the winter, and from 75°F–80.5°F in the summer. The 

difference between the two is largely due to seasonal clothing selection. ANSI/ASHRAE also 

recommends that relative humidity be maintained at or below 65% [ANSI/ASHRAE 2010a]. 

Excessive humidity can promote the excessive growth of microorganisms and dust mites. 

The ASHRAE/ASHE Standard 170-2008, Ventilation in Health Care Facilities, specifies 

ventilation design parameters that provide control of environmental comfort, asepsis, and 

odor for spaces commonly found in health care facilities. For general laboratories and 

histology laboratories, ventilation systems should be capable of maintaining a range of 

70°F–75°F during normal operations. For autopsy rooms, the recommended temperature 

range is 68°F–75°F. No relative humidity range recommendations are provided for these 

areas [ANSI/ASHRAE/ASHE 2008]. 
Health Hazard Evaluation Report 2012-0135-3184 Page 25

References

ACGIH [1999]. Bioaerosols: assessment and control. Cincinnati, OH: American Conference 

of Governmental Industrial Hygienists.

ACGIH [2013]. 2013 TLVs® and BEIs®: threshold limit values for chemical substances and 

physical agents and biological exposure indices. Cincinnati, OH: American Conference of 

Governmental Industrial Hygienists.

AIHA [2008]. Recognition, evaluation, and control of indoor mold. Prezant B, Weekes DM, 

Miller JD, eds. Fairfax, VA: American Industrial Hygiene Association.

AIHA [2012]. AIHA 2012 Emergency response planning guidelines (ERPG) & workplace 

environmental exposure levels (WEEL) handbook. Fairfax, VA: American Industrial 

Hygiene Association.

ANSI/ASHRAE [2010a]. Thermal environmental conditions for human occupancy. American 

National Standards Institute/ASHRAE standard 55-2010. Atlanta, GA: American Society for 

Heating, Refrigerating, and Air-Conditioning Engineers, Inc.

ANSI/ASHRAE [2010b]. Ventilation for acceptable indoor air quality. American National 

Standards Institute/ASHRAE standard 62.1-2010. Atlanta, GA: American Society of Heating, 

Refrigerating, and Air-Conditioning Engineers, Inc.

ANSI/ASHRAE/ASHE [2008]. Ventilation of health care facilities. American National 

Standards Institute/ASHRAE/American Society of Healthcare Engineering standard 170-

2008. Atlanta, GA: American Society of Heating, Refrigerating, and Air-Conditioning 

Engineers, Inc.

ASHRAE [2011]. 2011 ASHRAE handbook: HVAC applications. Health-care facilities. Atlanta, 

GA: American Society for Heating, Refrigerating, and Air-Conditioning Engineers, Inc. 

Baan R, Grosse Y, Straif K, Secretan B, El Ghissassi F, Bouvard V, Benbrahim-Tallaa L, 

Guha N, Freeman C, Galichet L, Cogliano V, on the behalf of the WHO International Agency 

for Research on Cancer Monograph Working Group [2009]. A review of human carcinogensPart F: chemical agents and related occupations. Lancet Oncol 10(12):1143–1144.

Brandt M, Brown C, Burkhart J, Burton N, Cox-Ganser J, Damon S, Falk H, Fridkin S, 

Garbe P, McGeehin M, Morgan J, Page E, Rao C, Redd S, Sinks T, Trout D, Wallingford K, 

Warnock D, Weissman D [2006]. Mold prevention strategies and possible health effects in 

the aftermath of hurricanes and major floods. MMWR 55(RR-8):1–27.

Brasel TL, Martin JM, Carriker CG, Wilson SC, Straus DC [2005]. Detection of airborne 

Stachybotrys chartarum macrocyclic trichothecene mycotoxins in the indoor environment. 

Appl Environ Microbiol 71(11):7376–7388.
Page 26 Health Hazard Evaluation Report 2012-0135-3184

CDC [2012]. Guidelines for safe work practices in human and animal medical diagnostic 

laboratories. MMWR 61(1):38–46.

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

Office of the Federal Register.

DHHS [2011]. Addendum to the 12th report on carcinogens. U.S. Department of Health and 

Human Services, National Toxicology Program. [http://ntp.niehs.nih.gov/ntp/roc/twelfth/

Addendum.pdf]. Date accessed: June 2013.

EPA [2001]. Mold remediation in schools and commercial buildings. Washington, DC: 

United States Environmental Protection Agency, Office of Air and Radiation, Indoor 

Environments Division. EPA Publication No. 402–K–01–001.

EPA [2012]. An introduction to indoor air quality: organic gases (volatile organic compounds 

– VOCs). [http://www.epa.gov/iaq/voc.html]. Date accessed: June 2013.

Facility Guidelines Institute [2010]. Guidelines for design and construction of health care 

facilities, 2010 edition. Chicago, IL: American Society of Healthcare Engineering of the 

American Hospital Association.

Górny RL, Reponen T, Willeke K, Schmechel D, Robine E, Boissier M, Grinshpun 

SA [2002]. Fungal fragments as indoor air biocontaminants. Appl Environ Microbiol 

68(7):3522–3531.

Green F, Yoshida K [1990]. Characteristics of aerosols generated during autopsy procedures 

and their potential role as carriers of infectious agents. Occup Environ Hyg 5(12):853–858.

IOM [2004]. Damp indoor spaces and health. Washington, DC: Institute of Medicine, 

National Academy Press.

Klaassen CD, ed. [2008]. Casarett and Doull’s toxicology: the basic science of poisons. 7th 

ed. New York: McGraw-Hill Companies, Inc. pp. 931–997.

LaDou J [1990]. Occupational medicine. Norwalk, CT: Appleton & Lange, pp. 297–326.

Lemen RA [1987]. Official letter from R.A. Lemen, Director, Division of Standards 

Development and Technology Transfer, National Institute for Occupational Safety and 

Health, U.S. Department of Health and Human Services, Cincinnati, OH to Tom Hall, Docket 

Office, Department of Labor, Washington, DC, February 9.

Mendell MJ, Mirer AG, Cheung K, Tong M, Douwes J [2011]. Respiratory and allergic 

health effects of dampness, mold and dampness-related agents: a review of the epidemiologic 

evidence. Environ Health Perspect 119(6):748–756.
Health Hazard Evaluation Report 2012-0135-3184 Page 27

Newman LS, Rose CS, Bresnitz EA, Rossman MD, Barnard J, Frederick M, Terrin ML, 

Weinberger SE, Moller DR, McLennan G, Hunninghake G, DePalo L, Baughman RP, 

Iannuzzi MC, Judson MA, Knatterud GL, Thompson BW, Teirstein AS, Yeager H Jr, Johns 

CJ, Rabin DL, Rybicki BA, Cherniack R, ACCESS Research Group [2004]. A case control 

etiologic study of sarcoidosis: environmental and occupational risk factors. Am J Respir Crit 

Care Med 170(12):1324–1330. 

Newman KL, Newman LS [2012]. Occupational causes of sarcoidosis. Opin Allergy Clin 

Immunol 12(2):145–150.

NIOSH [1981]. Current intelligence bulletin 34 – formaldehyde: evidence of carcinogenicity. 

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

Control, National Institute for Occupational Safety and Health. DHHS (NIOSH) Publication 

No. DHHS (NIOSH) 81-111 (1981, updated 1997).

NIOSH [1986]. Criteria for a recommended standard: occupational exposure to hot 

environments, revised criteria. Cincinnati, OH: U.S. Department of Health and Human 

Services, Centers for Disease Control, National Institute for Occupational Safety and Health, 

DHHS (NIOSH) Publication No. 86-13.

NIOSH [1995]. NIOSH recommended exposure limit policy. September 1995. In: NIOSH 

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

for Disease Control and Prevention, National Institute for Occupational Safety and Health.

NIOSH [1997a]. NIOSH Alert: Preventing allergic reactions to natural rubber latex in the 

workplace. 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) Report No. 97-135.

NIOSH [1997b]. Hazard evaluation and technical assistance report: Los Angeles County 

Department of Coroner – Los Angeles, California. By Martinez K and Tubbs R. 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. 1996-

0019-2666.

NIOSH [2010]. NIOSH pocket guide to chemical hazards. 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. 2010-168c. 

[http://www.cdc.gov/niosh/npg/]. Date accessed: June 2013.

NIOSH [2012]. NIOSH alert: preventing occupational respiratory disease from exposures 

caused by dampness in office buildings, schools, and other nonindustrial buildings. By 

Martin M, Cox-Ganser J, Kreiss K, Kanwal R, and Sahakian N. Cincinnati, OH: U.S. 

Department of Health and Human Services, Centers for Disease Control and Prevention, 
Page 28 Health Hazard Evaluation Report 2012-0135-3184

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

2013-102.

Nolte K, Taylor D, Richmond J [2002]. Biosafety consideration for autopsy. Am J Forensic 

Med Pathol 23(2):107–122.

NRC [1981]. Formaldehyde and other aldehydes. Washington, DC: National Research 

Council (National Academy Press).

Redd SC [2002]. State of the science on molds and human health. Statement for the Record 

Before the Subcommittee on Oversight and Investigations and Housing and Community 

Opportunity, Committee on Financial Services, United States House of Representatives. 

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

and Prevention.

Reponen T, Seo S-C, Iossifova Y, Adhikari A, Grinshpun SA [2006]. New field-compatible 

method for collection and analysis of β-glucan in fungal fragments. Abstracts of the 

International Aerosol Conference, St. Paul, Minnesota, p. 955.

Rosenstock L [1996]. NIOSH Testimony to the U.S. Department of Labor on indoor air 

quality. Appl Occup Environ Hyg 11(12):1365–1370.

Rossman MD, Thompson B, Frederick M, Iannuzzi MC, Rybicki BA, Pander JP, Newman 

LS, Rose C, Magira E, Monos D, ACCESS Group [2008]. HLA and environmental 

interactions in sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 25(2):125–132.

Wald P, Stave G [1994]. Fungi. In: Physical and biological hazards of the workplace. New 

York: Van Nostrand Reinhold, p. 394.

WHO [2009]. WHO guidelines for indoor air quality: dampness and mould. Geneva, 

Switzerland: World Health Organization. [http://www.euro.who.int/document/e92645.pdf]. 

Date accessed: June 2013.
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Keywords: NAICS 923120 (Administration of Public Health Programs), coroner, medical 

examiner, autopsies, histology, formaldehyde, IEQ, mold, chemical, ventilation, fiberglass, latex gloves
Health Hazard Evaluation Report 2012-0135-3184 Page 31

The Health Hazard Evaluation Program investigates possible health hazards in the 

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

Health Act of 1970, 29 U.S.C. 669(a)(6). The Health Hazard Evaluation Program also 

provides, upon request, technical assistance to federal, state, and local agencies to control 

occupational health hazards and to prevent occupational illness and disease. Regulations 

guiding the Program can be found in Title 42, Code of Federal Regulations, Part 85; 

Requests for Health Hazard Evaluations (42 CFR 85).

Acknowledgments 

Analytical Support: Jennifer Roberts, Bureau Veritas North America, and Microbiology 

Specialists Incorporated

Desktop Publishers: Mary Winfree 

Editor: Ellen Galloway 

Health Communicator: Stefanie Brown 

Industrial Hygiene Field Assistance: Chad Dowell

Logistics: Donnie Booher and Karl Feldmann

Availability of Report

Copies of this report have been sent to the employer, employees, and union at the 

facility. The state and local health department and the Occupational Safety and Health 

Administration Regional Office have also received a copy. This report is not copyrighted 

and may be freely reproduced. 

This report is available at http://www.cdc.gov/niosh/hhe/reports/pdfs/2012-0135-3184.pdf.

Recommended citation for this report:

NIOSH [2013]. Health hazard evaluation report: evaluation of potential 

employee exposures at a medical examiner’s office. By King B, Page E. 

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. 2012-0135-3184.
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