Health Hazards of Solvents slide #1



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Health Hazards of Solvents

SLIDE #1:

Health Hazards of Solvents was developed by James E. Cone, MD, MPH and Karen Packard, RDH, MS.
This presentation is made possible by a grant from the Association of Occupational and Environmental Clinics and the National Institute for Occupational Safety & Health.
SLIDE #2:

Teaching Objectives:

To provide an overview of occupational solvent exposure - Review the problem / impact of solvent exposures on the working population and list the occupations where solvent exposure is most likely to occur.
To review potential health outcomes and public health prevention options - Recognize the acute and chronic health effects of solvent exposure.
To provide step by step approach to diagnostic testing and treatment of solvent-related diseases - learn to evaluate and diagnose solvent exposure using a 10 step clinical process.
To provide background information on specific solvents – and identify prevention and risk reduction strategies for the most common types of solvent exposures
List relevant regulatory provisions and requirements regarding solvents and prevention of worker exposures
To illustrate the diverse effects of solvents through cases involving solvent toxicity
Given a case study, identify relevant clinical issues faced by practitioners.
SLIDE #3:

What is a solvent? A solvent is a liquid at room temperature used to dissolve other substances. Some classes of common organic solvents are listed. Other chemicals may also be used as solvents in some settings, such as acids. Water-based processes are increasingly replacing many of the historic uses of organic solvents due to concerns regarding environmental as well as occupational exposures.


SLIDE #4:

What is the scope of the problem of solvent toxicity? Over 49 million tons of organic hydrocarbon solvent chemicals are produced and used each year in the US alone.

Often exposure in the occupational setting as well as environmental setting involves a mixture of solvents.
SLIDE #5:

What is the scope of the problem of solvent toxicity? Over 49 million tons of organic hydrocarbon solvent chemicals are produced and used each year in the US alone.

Often exposure in the occupational setting as well as environmental setting involves a mixture of solvents.
SLIDE #6:

Workplace solvents may also result in exposures to neighborhood residents if discharged from workplaces without adequate controls.


Other hazards of organic hydrocarbon solvents include:

Risk of fire or explosion with flammable solvents;

Improper storage or disposal may result in groundwater contamination, as has occurred, for example, in Silicon Valley where trichloroethylene and other solvents were found to be leaking from underground storage tanks.
SLIDE #7:

Solvents are present in many commercial processes that may result in environmental as well as occupational exposure. For example, perchloroethylene, a chlorinated hydrocarbon solvent, may be present in freshly dry cleaned clothes. Apartments located in the same building above dry cleaning establishments using perchloroethylene have been found to have measurable levels of this solvent in the air. The International Agency for Research on Cancer (IARC) recently classified perchloroethylene in Group 2A, as a substance considered "probably carcinogenic to humans."


Prevention of exposure: Increasingly, water-based processes or other substitutes are replacing perchloroethylene in dry cleaning. A dry-cleaning shop should have modern dry-to-dry equipment that does not require the transfer of wet solvent-soaked clothing from one machine to another. A closed system should be used to refill solvent tanks. Containers of perchloroethylene should be tightly closed or covered to prevent evaporation.
Reference: Altmann L, Neuhann HF, Kramer U: Neurobehavioral and neurophysiological outcome of chronic low-level tetrachloroethene exposure measured in neighborhoods of dry cleaning shops. Environ Res 1995 May; 69(2): 83-9

SLIDE #8:

Solvents may be classified by their solubility in oil or water, flammability and explosivity, volatility. Metabolism may produce toxic byproducts, such as carbon monoxide produced by the breakdown of methylene chloride in the body. Many solvents are complex mixtures, such as paint thinners (white spirit, naphtha) and Stoddard solvent.



SLIDE #9:

How do solvents get into the body?

Inhalation

Absorption

-skin

-mucous membranes



Ingestion

Injection – this is rare


SLIDE #10:

Health effects of solvents may be seen primarily in the:

Brain – memory loss, confusion, difficulty concentrating, fatigue, headache

Reproductive system – miscarriages, fetal alcohol syndrome

Kidneys - Glomerulonephritis

Skin – Irritant dermatitis, defatting

Liver – Fatty liver, chemical hepatitis

Cardiovascular system – Increased sensitivity to epinephrine, exacerbation of coronary artery disease by CO due to methylene chloride, carbon disulfide


SLIDE #11:

Biological monitoring is the measurement of a toxic chemical (or chemical metabolite) in the body of an exposed person, as opposed to the monitoring of levels in the environment. Advantages of biological monitoring include its ability to detect skin absorption, account for differential absorption of an inhaled dose, effectiveness of personal protective equipment, non-occupational as well as occupational exposure and integrated exposure over time. Disadvantages are that some tests are invasive, involving blood collection, and are more expensive than air monitoring, or are relatively unavailable clinically (e.g., 2,5 hexanedione for n-hexane). The American Conference of Governmental and Industrial Hygienists (ACGIH) has adopted a set of "Biological Exposure Indices" (BEI's) - standard methods for monitoring the blood, urine, or exhaled air of workers exposed to chemical substances. Ethyl benzene, styrene, toluene, trichloroethylene and xylene all have biological monitoring methods that may be useful in evaluation of workers exposed to these solvents.


See Talaska, G. Human Biological Monitoring and Biological Markers (lecture): 

http://www.eh.uc.edu/classes/talaska/BM%20course%20Lecture%201.pdf
SLIDE #12:

Occupations that are often exposed to solvents include:

Painters

Construction workers

Semiconductor workers

Machinists / auto mechanics

Manufacturing workers

Glue, Paint, Chemical, Plastics

Rotogravure Printers, Metal Degreasers

Graffiti removers

Refinery workers

Manicurists

Drycleaners

Many others


SLIDE #13:

Some of the more common solvent-related diseases include:

Acute Intoxication

Chemical Headache

Chemical Hepatitis

Chronic Toxic Encephalopathy

Hematological Effects

Renal Effects

Reproductive Health Effects

Toxic Peripheral Neuropathy - One of the most famous examples is that of Bill Bowerman –former University of Oregon track coach and co-founder of Nike who, developed n-hexane related peripheral neuropathy from glues he used for making prototype running shoes.


SLIDE #14:

The diagnosis of solvent-related disease can be challenging due to its mimicry of other diseases, overlap with alcohol and other toxic drug-induced conditions, and lack of awareness that solvent exposure has occurred among workers. Improving the likelihood of recognition of solvent-related disease depends on increased vigilance among both workers, employers and clinicians, particularly when expected response to treatment for a disease such as peripheral neuropathy does not occur, triggering a search for other causes. Certain conditions should trigger the thought that it might be solvent-related: hepatitis, peripheral neuropathy, chronic headache, cognitive impairment, miscarriage, and asthma.


SLIDE #15:

Step 1 involves obtaining medical and exposure records. These may include Industrial Hygiene data

Labels, Material Safety Data Sheets (MSDS), Chemical Inventory Lists

OSHA reports


SLIDE #16:

Step 2 involves obtaining the history of symptoms, exposure, job duties, exposure monitoring results and frequency of acute solvent intoxication episodes – usually manifested by headache, dizziness, trouble concentrating, numbness, or confusion.


SLIDE #17:

Acute solvent intoxication can be seen in various stages, beginning with narcosis (impaired psychomotor function as measured by reaction time, manual dexterity, coordination, or body balance). This may progress to

Anesthesia

Central nervous system depression

Respiratory arrest

Unconsciousness

and finally death, due to cardiac arrest.

SLIDE #18:

The past medical history may be significant for:

History of asthma

History of Blood Dyscrasias

Hearing loss

History of Psychological Problems

Prior to exposure

After exposure


SLIDE #19:

Physical examination:

Focus on:

Skin – is there evidence of defatting of skin? Nummular eczema?

Eyes – nystagmus, visual acuity loss.

Gastrointestinal – liver size

Neurologic system – cranial nerves, motor and sensory function, deep tendon reflexes

Mental Status – particularly short term memory, mood and attention are useful to test.


SLIDE #20:

Laboratory testing includes:

Screening – depending on the solvent, this may include liver function tests, complete blood count

Biological Indices – as mentioned on previous slide

Pathologic Indices – specific tests of function affected by solvents, including pontogram (nystagmus), Lanthony D-15 Color Vision testing (for acquired color vision loss), neuropsychological testing, sway, or other functional tests.
SLIDE #21:

Nerve condition testing is indicated in those exposed to n-hexane or other peripheral neurotoxins with symptoms of possible peripheral neuropathy (numbness, tingling or dysesthesias of the extremities). Here is shown a patient doing the Lanthony D-15 color vision test. Impairment of hearing acuity has been associated with chronic solvent exposure. Peak flow measurements may be useful in evaluation of asthma that is suspected to be exacerbated by solvent exposures at work.


SLIDE #22:

A site visit to the patient’s worksite is sometimes key to making the diagnosis. Always ask the patient for permission to contact the employer. Most employers will be receptive to the physician who takes the time to investigate the actual working condition and provide objective evidence as well as possible recommendations regarding exposures of concern. Industrial hygiene sampling may be recommended. OSHA or other industrial hygiene sampling results may be available to evaluate suspected exposures. What ventilation systems are in place and operational? What chemicals are present and in what quantities? How is the housekeeping and general upkeep of the equipment. Are there odors or other indicators of exposure detectable? If you do not have the time to visit, perhaps you can enlist the patient to obtain photos of work processes, labels of chemicals used.


SLIDE #23:

What is the relationship of the patient’s symptoms or conditions and likely exposures at work or in the environment? Is the latency period adequate?

Exposure data consistent? The general test for work-relatedness is ‘more likely than not’ or 51% probability, according to most state’s workers’ compensation laws. Is the worker’s asthma exacerbated, if not caused, by solvent exposures at the workplace?
SLIDE #24:

Was the dose of the solvent exposure adequate, in your opinion, to cause the problem? (e.g., is there a history of acute intoxication episodes?)



OR Is patient particularly sensitive to the effects of solvents (e.g. increased individual susceptibility or acquired intolerance)? There is increasing evidence that the range of responsiveness or sensitivity of humans (and animals) is much broader than we previously thought ( R. C. MACPHAIL. Episodic Exposures to Chemicals

What Relevance to Chemical Intolerance? Ann NY Acad Sci Mar. 2001, p 103-111).



SLIDE #25:

Are there other disease conditions that need to be evaluated before a solvent-related diagnosis can be concluded? Or is there a pre-existing condition that may be exacerbated by solvent exposure? Once the diagnosis of work-relatedness has been made, generally a report to the insurance carrier or state agency conducting surveillance of work-related illnesses is necessary.


SLIDE #26:

Disposition – your report should address:

Return to work

Modified duty / preclusions – should the worker avoid some types of exposure in the future that may aggravate the condition?

Factors of disability

Objective/ Subjective. Objective findings include loss of reflexes, motor weakness, results of neuropsychological evaluation. Subjective includes symptoms such as numbness, headache.

Vocational rehabilitation – is there need for retraining.

Apportionment – if there is evidence of some prior degree of disability

Future medical care – what is likely to be needed in terms of future treatment?

SLIDE #27:

Prevention is key to occupational public health: what can you recommend?

Elimination

Substitution

Engineering Controls

Administrative controls – Isolation

Personal Protective Equipment

Education


SLIDE #28:

Effectiveness of personal protective equipment depends heavily on the appropriate selection, training and use of sometimes uncomfortable clothing and respirators. Consider:

Protective Clothing-Impermeable aprons

Gloves – Breakthrough time depends on type of glove, solvent exposure and activity

Chemically resistant gloves: natural rubber, butyl rubber, chloroprene, nitrile, and fluorocarbon; or various plastics: polyvinyl chloride, polyvinyl alcohol, polyethylene
SLIDE #29:

A proper respirator program must include:

Training

Cleaning


Fit testing

Medical Clearance

Change of filters –schedule depends on exposure type and amount – this may be difficult in settings where solvents that have poor warning properties such as methylene chloride may be used, requiring frequent scheduled change of cartridges.
SLIDE #30:

Solvent substitution due to environmental regulation is increasingly a reason for selection of solvents – and may result in unintended consequences that include increased occupational or environmental risk of other solvent exposure – n-hexane substitution for chlorinated hydrocarbons in brake cleaners is one example, and methyl tert butyl ether in gasoline resulting in groundwater contamination.


SLIDE #31:

See Jonathan S Rutchik, MD, MPH, “Organic Solvents” for an excellent review of solvent toxicity. Available at:



(http://www.emedicine.com/neuro/topic285.htm)


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