California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4 - Division of Industrial Safety › Subchapter 7 - General Industry Safety Orders › Group 16 - Control of Hazardous Substances › Article 110 - Regulated Carcinogens › Appendix C - Medical Surveillance Guidelines

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
I. General
Medical examinations are to be provided for all
						  employees exposed to levels of inorganic arsenic above the action level
						  (0.005mg/m3) for at least 30 days per year (which
						  would include, among others, all employees who work in regulated areas).
						  Examinations are also to be provided to all employees who have had 10 years or
						  more exposure above the action level for more than 30 days per year while
						  working for the present or predecessor employer though they may no longer be
						  exposed above the level.
An initial medical examination is to be provided to all
						  such employees within 4 months of the effective date of the standard. In
						  addition, an initial medical examination is to be provided to all employees who
						  are first assigned to areas in which worker exposure will probably exceed
						  0.005mg/m3 at the time of initial assignment. In
						  addition to its immediate-diagnostic usefulness, the initial examination will
						  provide a baseline for comparing future test results. The initial examination
						  must include as a minimum the following elements:
(1) A work and medical history, including a smoking
						  history;
(2) A physical examination with special attention to
						  skin, nose, respiratory tract, lymph nodes, nervous system, and liver;
(3) Posterior-anterior chest X-ray (14-inch x
						  17-inch);
(4) A sputum cytology examination; and
(5) Other examinations which the physician believes
						  appropriate because of the employee's exposure to inorganic arsenic or because
						  of required respirator use.
Periodic examinations are also to be provided to the
						  employees listed above. The periodic examinations shall be given annually for
						  those covered employees 45 years of age or less with fewer than 10 years
						  employment in areas where employee exposure exceeds the action level
						  (0.005mg/m3). Periodic examinations need not include
						  sputum cytology and only an updated medical history is required.
Periodic examinations for other covered employees,
						  shall be provided every six (6) months. These examinations shall include an
						  updated medical history and all tests required in the initial examination,
						  except for the chest X-ray, and that the medical history need only be
						  updated.
The examination contents are minimum requirements.
						  Additional tests such as pulmonary function tests may be useful.
II. Noncarcinogenic Effects
The standard is based on minimizing risk of exposed
						  workers dying of lung cancer from exposure to inorganic arsenic. It will also
						  minimize skin cancer from such exposure.
The following three sections quoted from "Occupational
						  Diseases: A Guide to Their Recognition," Revised Edition, June 1977, National
						  Institute for Occupational Safety and Health is included to provide information
						  on the nonneoplastic effects of exposure to inorganic arsenic. Such effects
						  should not occur if the OSHA standards are followed.
A. Local--Trivalent arsenic compounds are corrosive to
						  the skin. Brief contact has no effect but prolonged contact results in a local
						  hyperemia and later vesicular or pustular eruption. The moist mucous membranes
						  are most sensitive to the irritant action. Conjunctiva, moist ad macerated
						  areas of skin, the eyelids, the angles of the ears, nose, mouth, and
						  respiratory mucosa are also vulnerable to the irritant effects. The wrists are
						  common sites of dermatitis, as are the genitalia if personal hygiene is poor.
						  Perforations of the nasal septum may occur. Arsenic trioxide and pentoxide are
						  capable of producing skin sensitization and contact dermatitis. Arsenic is also
						  capable of producing keratoses, especially of the palms and soles.
B. Systemic--The acute toxic effects of arsenic are
						  generally seen following ingestion of inorganic arsenical compounds. This
						  rarely occurs in an industrial setting. Symptoms develop within ½ to 4
						  hours following ingestion and are usually characterized by constriction of the
						  throat followed by dysphagia, epigastric pain, vomiting, and watery diarrhea.
						  Blood may appear in vomitus and stools. If the amount ingested is sufficiently
						  high, shock may develop due to severe fluid loss, and death may ensue in 24
						  hours. If the acute effects are survived, exfoliative dermatitis and peripheral
						  neuritis may develop.
Cases of acute arsenical poisoning due to inhalation
						  are exceedingly rare in industry. When it does occur, respiratory tract
						  symptoms--cough, chest pain, dyspnea-giddiness, headache, and extreme general
						  weakness precede gastrointestinal symptoms. The acute toxic symptoms of
						  trivalent arsenical poisoning are due to severe inflammation of the mucous
						  membranes and greatly increased permeability of the blood capillaries.
Chronic arsenical poisoning due to ingestion is rare
						  and generally confined to patients taking prescribed medications. However, it
						  can be a concomitant of inhaled inorganic arsenic, from swallowed sputum, and
						  improper eating habits. Symptoms are weight loss, nausea and diarrhea
						  alternating with constipation, pigmentation and eruption of the skin, loss of
						  hair, and peripheral neuritis. Chronic hepatitis and cirrhosis have been
						  described. Polyneuritis may be the salient feature, but more frequently there
						  are numbness and parasthenias of "glove and stocking" distribution. The skin
						  lesions are usually melanotic and keratotic and may occasionally take the form
						  of an intradermal cancer of the squamous cell type, but without infiltrative
						  properties. Horizontal white lines (striations) on the fingernails and toenails
						  are commonly seen in chronic arsenical poisoning and are considered to be a
						  diagnostic accompaniment of arsenical polyneuritis.
Inhalation of inorganic arsenic compounds is the most
						  common cause of chronic poisoning in the industrial situation. This condition
						  is divided into three phases based on signs and symptoms.
First Phase: The worker complains of weakness, loss of
						  appetite, some nausea, occasional vomiting, a sense of heaviness in the
						  stomach, and some diarrhea.
Second Phase: The worker complains of conjunctivitis, a
						  catarrhal state of the mucous membranes of the nose, larynx, and respiratory
						  passage. Coryza, hoarseness, and mild tracheobronchitis may occur. Perforation
						  of the nasal septum is common, and is probably the most typical lesion of the
						  upper respiratory tract in occupational exposure to arsenical dust. Skin
						  lesions, eczematoid and allergic in type, are common.
Third Phase: The worker complains of symptoms of
						  peripheral neuritis, initially of hands and feet, which is essentially sensory.
						  In more severe cases, motor paralyses occur; the first muscles affected are
						  usually the toe extensors and the peronei. In only the most severe cases will
						  paralysis of flexor muscles of the feet or of the extensor muscles of hands
						  occur.
Liver damage from chronic arsenical poisoning is still
						  debated, and as yet the question is unanswered. In cases of chronic and acute
						  arsenical poisoning, toxic effects to the myocardium have been reported based
						  on EKG changes. These findings, however, are now largely discounted and the EKG
						  changes are ascribed to electrolyte disturbances concomitant with arsenicalism.
						  Inhalation of arsenic trioxide and other inorganic arsenical dusts does not
						  give rise to radiological evidence or pneumoconiosis. Arsenic does have a
						  depressant effect upon the bone marrow, with disturbances of both
						  erythropoiesis and myelopoiesis.
III. SPUTUM CYTOLOGY
Sputum can be collected by aerosol inhalation during
						  the medical exam or by spontaneous early morning cough at home. Sputum is
						  induced by transoral inhalation of an aerosolized solution of eight per cent (8
						  percent) sodium chloride in water. After inhaling as few as three to five
						  breaths the subject usually yields an adequate sputum. All sputum should be
						  collected directly into sixty percent (60 percent) alcohol.
1.
						  Editorial correction moving NOTE and HISTORIES 1-10 to precede Appendix A of
						  section 5214 (Register 99, No. 28). For
						  prior history of Appendices, see section
						  5214.