69 Principles of Toxicology and Epidemiology

Principles of toxicology and
epidemiology
Principles of toxicology and epidemiology
Element B2: Principles of toxicology and epidemiology .............................................................................. 4

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Table Of Contents
1.1 Physical Nature of Airborne Contaminants ............................................................................................... 5
1.0 Classifying hazardous substances ................................................................................................................ 4

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4.8 SUMMARY ............................................................................................................................................................. 76

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4.7 Notification of New Substances Regulations 1993 .............................................................................. 75
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Element B2: Principles of toxicology and epidemiology

Learning outcomes
On completion of this element, candidates should be able to:
Describe the classification of hazardous substances with reference to appropriate

legislation
Describe the main effects and route of attack of hazardous substances on the
human body
Explain the relevance of toxicological data to the identification of work related ill
- health
Explain the principles of epidemiology and its application in health surveillance of

a workforce
Relevant Standards
International Labour Standards, Chemical Safety Convention , C170,

International Labour Organisation, Geneva, 1990
Article 8: Chemical safety data sheets
International Labour Standards, Chemical Safety Recommendation , R177,

International Labour Organisation, Geneva, 1990
Articles 6 & 7: Classification
International Labour Office, Safety in the Use of Chemicals at Work, an ILO Code
of Practice, ILO, 1993. ISBN: 9221080064
Section 2: General obligations

Section 4: Labelling and marking
Section 5: Chemical safety data sheets
The International Programme of Chemical Safety (IPCS), INCHEM Health and

Safety Guides (Series), World Health Organisation, 2005.
Minimum hours of tuition 7 hours.
1.0 Classifying hazardous substances

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In this section we will give definitions of the physical forms - solids, liquids, dusts,
fibres, mists, gases, fumes and vapours.
We will then give an explanation of the following:
-toxic -definition of toxicity; examples of toxic effects of commonly occurring toxic
substances -trichloroethylene, asbestos, carbon monoxide, isocyanates, siliceous dusts,
lead
-corrosive -definition of corrosive; effects on the human body of contact with
corrosive substances; examples of commonly occurring corrosive substances -acids,
ammonia, sodium hydroxide
-irritant -definition of irritant; examples of irritant effects of commonly occurring
substances e.g. cleaning agents, silicates
-harmful -definition of harmful; examples of harmful effects and common substances
causing such effects
-dermatitic -definition of dermatitis; primary/contact and secondary/allergic or
sensitised forms of dermatitis; circumstances likely to lead to dermatitis; typical
workplace examples
-sensitisation -definition of sensitisation; skin, respiratory system; health effects and
typical workplace examples of sensitising agents
-carcinogenic -definition of carcinogen; examples of types of cancer relative to
specific substances (e.g. asbestos, coal tar, chromium, wood dust)
-mutagenic- definition of mutagen; examples of substances found in the workplace.
-asphyxiant - definition of asphyxiant; examples of substances found in the workplace
1.1 Physical Nature of Airborne Contaminants

Airborne contaminants can be grouped under the general term of aerosol. An aerosol is
a scientific term that applies to any disperse system of liquid or solid particles
suspended in air, so it applies to a wide range of particulate systems encountered
occupationally. Aerosols of interest to the occupational hygienist include (Note: 1 m =
1 m/1,000,000):
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Dusts : Solid particles made airborne by mechanical disintegration of bulk solid

material, (i.e. cutting, crushing, grinding). Size 1 m 1000 m
Spray : Large liquid droplets produced by mechanical disruption of bulk liquid,

(i.e. spraying, pouring, stirring). Size 10 m 1000 m
Mist : Finer liquid droplets produced during condensation, (i.e. cooling of hot
vapours). Size 0.01 m 10 m
Fume : Small solid particles produced by condensation of vapours or gaseous

combustion products, (i.e. cooling of combustion products from hot processes).
Size 0.01 m 1 m
Smoke : Very small solid or liquid particles of complex shape arising from
incomplete combustion, (i.e. hot processes involving combustion). Size 0.01 m
1 m
As well as size, particle shape is important in determining the effects of inhalation of

airborne contaminants since this affects the way that particles behave in air and also
how they behave after they have been deposited in the respiratory tract. Particle
shapes include:
Spherical - e.g. mists and sprays
Isometric - (non-spherical but compact particles) e.g. dusts
Platelets - (plate-shaped particles) e.g. certain dusts such as mica
Fibres - (long, thin needle-shaped particles) e.g. asbestos and mineral fibre
Since airborne contaminants occur in a wide range of shapes and dimensions it is
necessary to employ simple indices of size in order to compare the aerodynamic
properties of different aerosols. A commonly used index is the aerodynamic diameter,
which is the diameter of a sphere of water which has the same falling speed in air as
the particle in question. Since we are principally interested in how the aerosol particle
behaves in air and also in the respiratory tract, this comparative index gives a useful
indication of how different types of aerosol particle are likely to behave.
You will remember that in Unit B1 we made reference to the Effective Spherical
Diameter (ESD) (which is a similar index to the aerodynamic diameter in that it
attempts to approximate the shape of the aerosol particle to an equivalent sphere) in
relation to filtration and deposition of airborne particles in the various sections of the
respiratory tract. We can now see from our study of aerosols how the particular
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physical form of the airborne contaminant will affect its ability to penetrate the
respiratory tract and consequently cause harm.
1.2 Risk and safety phrases

Earlier we examined the way in which chemical agents can adversely affect important
target organs and systems of the body. We also considered the defensive systems
which operate to protect against these agents. Here we continue our investigation into
the effects of exposure to chemical agents.
Classification of chemical agents

Before we can begin our study of the risks from exposure to chemical agents we need
to consider how substances are classified in terms of their ill-health effects.
The Chemicals (Hazard Information and Packaging for Supply) (Amendment)
Regulations 2005 , entered into force on 31 October 2005. The regulations are
commonly known as CHIP. The regulations bring into legal effect all the new entries,
revisions, deletions and amendments to the classification and labelling requirements of
hazardous substances set out in the 29th Adaptation to Technical Progress (29th ATP)
to the Dangerous Substances Directive (European Commission Directive
2004/73/2004).
We shall now explore these Regulations in more detail, as well as the use of risk and
safety phrases, and the application of safety data sheets in preventing ill-health arising
from the use of chemicals.
Chemical (Hazard Information and Packaging for Supply) Regulations 2002,
as amended
These Regulations (termed CHIP) apply to any substance or preparation which is
dangerous for supply. Minor amendments to the 1994 Regulations have been made by
the Chemical (Hazard Information and Packaging for Supply) (Amendment)
Regulations 1996, 1998 and 1999 which principally served to extend the Approved
Supply List. In addition CHIP has been referred to as CHIP2, CHIP3 and at the time of
writing the course material it is now been called CHIP 3.1.
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The key provisions of the Regulations are:
All substances or preparations which are dangerous for supply must be classified
under CHIP:
o The Approved Supply List provides classifications for around 2,000 chemicals.
o Substances dangerous for supply which are not given in the Approved Supply List
must be classified under specific categories of danger and assigned risk phrases.
Suppliers of all substances or preparations classified as dangerous for supply

must provide safety data sheets.
Dangerous substances must be supplied in a suitable package providing

adequate containment.
Substances or preparations dangerous for supply must carry an appropriate

label.
These particular requirements are covered in more detail below.
1.3 Categories of Danger

CHIP defines 23 categories of danger. Carcinogens, mutagens and substances toxic for
reproduction are subdivided into categories, with Category 1 representing the most severe hazard.
The list below gives these categories. In addition, Table 1.1 shows the Health Effects Classification
and includes the category of danger, the indication of danger (i.e. very toxic, toxic, harmful,
corrosive, irritant), the appropriate symbol and the symbol letter.
Symbol
Hazard
Description of hazard
explosive
Chemicals that explode.
oxidising
Chemicals that react exothermically with other
(Physicochemical)
chemicals.
F
highly
flammable
Chemicals that may catch fire in contact with air,

only need brief contact with an ignition source,
have a very low flash point or evolve highly
flammable gases in contact with water.
F+
extremely
Chemicals that have an extremely low flash point
flammable
and boiling point, and gases that catch fire in

contact with air.
(Health)
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T+
very toxic
Chemicals that at very low levels cause damage to

health.
toxic
Chemicals that at low levels cause damage to

health.
category 1
carcinogens
category 2
Chemicals that may cause cancer or increase its

incidence.
carcinogens
Xn
category 3
carcinogens
category 1
Chemicals that induce heritable genetic defects or
mutagens
increase their incidence.
category 2
mutagens
Xn
category 3
mutagens
category 1
Chemicals that produce or increase the incidence
reproductive of non-heritable effects in progeny and/or an

toxins
T
impairment in reproductive functions or capacity.
category 2
reproductive
toxins
Xn
category 3
reproductive
toxins
Xn
harmful
Chemicals that may cause damage to health.
corrosive
Chemicals that may destroy living tissue on

contact.
Xi
irritant
Chemicals that may cause inflammation to the skin

or other mucous membranes.
(Environmental)
N
dangerous for Chemicals that may present an immediate or

the
delayed danger to one or more components of the
environment environment
Table 1.1: Health Effects Classification of Hazardous Substances
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Risk Phrases
Risk phrases are an important part of the classification and are assigned according to particular
criteria. The risk phrase gives more information than the category of danger and is more
specific to the particular chemical. The Approved Supply List contains a section which lists 64
individual risk phrases and also gives a further 57 combined risk phrases. The complete list of
risk phrases is given in Table 1.2.
1.4 Safety Data Sheets

Suppliers of substances are required, under CHIP, to provide safety data sheets. The
purpose of the safety data sheet is to give information to users of the substance to
enable them to take the necessary measures to protect health and safety and the
environment.
Safety data sheets must contain the following information:
Identification of the substance
Composition and ingredients
Identification of hazards
First aid measures
Fire-fighting measures
Accidental release measures
Handling and storage
Exposure controls and personal protective equipment
Physical and chemical properties
Stability and reactivity
Toxicological information
Ecological information
Disposal considerations
Transport information
Regulatory information
Suppliers must ensure that safety data sheets are kept up to date and revised
accordingly.
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1.5 Particular Risks

Risk
Number
Severity
Score
Risk Phrase
R1
Explosive when dry
R2
Risk of explosion by shock, friction, fire or other sources of

ignition
R3
Extreme risk of explosion by shock, friction, fire or other

sources of ignition
R4
Forms very sensitive explosive metallic compounds
R5
Heating may cause an explosion
R6
Explosive with or without contact with air
R7
May cause fire
R8
Contact with combustible material may cause fire
R9
Explosive when mixed with combustible material
R10
Flammable
R11
Highly flammable
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Risk
Severity
Number
Score
Risk Phrase
R12
Extremely flammable
R14
Reacts violently with water
R14/15
Reacts violently with water, liberating extremely flammable

gases
R15
Contact with water liberates extremely flammable gases
R15/29
Contact with water liberates toxic, extremely flammable gases
R16
Explosive when mixed with oxidising substances
R17
Spontaneously flammable in air
R18
In use, may form flammable/explosive vapour-air mixture
R19
May form explosive peroxides
R20
Harmful by inhalation
R20/21
Harmful by inhalation and in contact with skin
R20/21/22
Harmful by inhalation, in contact with skin and if swallowed
R20/22
Harmful by inhalation and if swallowed
R21
Harmful in contact with skin
R21/22
Harmful in contact with skin and if swallowed
R22
Harmful if swallowed
R23
Toxic by inhalation
R23/24
Toxic by inhalation and in contact with skin
R23/24/25
Toxic by inhalation, in contact with skin and if swallowed
R23/25
Toxic by inhalation and if swallowed
R24
Toxic in contact with skin
R24/25
Toxic in contact with skin and if swallowed
R25
Toxic if swallowed
R26
Very toxic by inhalation
R26/27
Very toxic by inhalation and in contact with skin
R26/27/28
Very toxic by inhalation, in contact with skin and if swallowed
R26/28
Very toxic by inhalation and if swallowed
R27
Very toxic in contact with skin
R27/28
Very toxic in contact with skin and if swallowed
R28
Very toxic if swallowed
R30
Can become highly flammable in use
R31
Contact with acids liberates toxic gas
R32
Contact with acids liberates very toxic gas
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Risk
Severity
Number
Score
Risk Phrase
R33
Danger of cumulative effects
R34
Causes burns
R35
Causes severe burns
R36
Irritating to eyes
R36/37
Irritating to eyes and respiratory system
R36/37/38
Irritating to eyes, respiratory system and skin
R36/38
Irritating to eyes and skin
R37
Irritating to respiratory system
R37/38
Irritating to respiratory system and skin
R38
Irritating to skin
R39
Danger of very serious irreversible effects
R39/23
Toxic: danger of very serious irreversible effects through

inhalation
R39/23/24

inhalation and in contact with skin
R39/23/24/25

inhalation, in contact with skin and if swallowed
R39/23/25

inhalation and if swallowed
R39/24
Toxic: danger of very serious irreversible effects in contact

with skin
R39/24/25
1.5.1 Notes:
Extremely Flammable F+ and Highly Flammable F
For the purposes of CHIP, a Flammable Liquid is one with a flash point of less
than 37.8 C.
A Highly Flammable Liquid (F) is one with a flash point of less than 21 C
A Highly Flammable solid is one that is spontaneously combustible in air at

ambient temperature, readily ignites after brief contact with a flame or evolves
highly flammable gases in contact with water or moist air.
An Extremely Flammable Liquid (F+) is one with a flash point less than 0 C and
a boiling point of 35 C or less
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Carcinogens
Category 1 - substances known to be carcinogenic to humans
Category 2 - substances that should be regarded as if they are carcinogenic to
humans, for which there is sufficient evidence, based on long-term animal studies and
other relevant information, to provide a strong presumption that human exposure may
result in the development of cancer.
Category 3 - substances that cause concern owing to possible carcinogenic effects but
for which available information is not adequate to make satisfactory assessments.
Categories 1 and 2 carry the "toxic" (T) symbol and the Risk Phrase R45 (may cause
cancer) or R49 (may cause cancer by inhalation).
Category 3 carries the "harmful" (Xn) symbol and the Risk Phrase R40 (possible risk
of irreversible effects).
Very Toxic (T+) and Toxic (T)
LCnThis abbreviation is used for the exposure concentration of a toxicant lethal

to n% of a test population e.g. LC 50
LDnThis abbreviation is used for the dose of a toxicant lethal to n% of a test

population.
Evident Toxicity- this concept is used to designate toxic effects after exposure to
a substance tested, which are so severe that exposure to the next highest fixed
dose would probably lead to death.
Very Toxic (T+)

Acute lethal effects:
R28 "Very Toxic if swallowed" : LD 50 oral, rat < or = 25mg/kg : less than
100% survival at 5mg/kg oral, rat.
R27 "Very Toxic in contact with skin" : LD 50 dermal, rat or rabbit: < or =
50mg/kg.
R26 "Very Toxic by inhalation" ; LC 50 inhalation, rat, for aerosols or

particulates < or = 0.25mg/litre/4h
Non-lethal irreversible effects after a single exposure:
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R39 "Danger of very serious irreversible effects": Irreversible damage is

likely to be caused by a single exposure by an appropriate route, generally in the
above dose ranges. In order to indicate the route of exposure, combinations of
Risk Phrases may be used e.g. R39/23 i.e. 'Dangerof very serious irreversible
effects by inhalation'.
Toxic (T)
Acute lethal effects:
R25 "Toxic if swallowed" : LD 50 oral, rat 25 < LD 50 < or = 200mg/kg: At

5mg/kg, oral, rat less than 100% survival but evident toxicity.
R24 "Toxic in contact with skin" : LD 50 dermal, rat or rabbit: 50 < LD 50 < or
= 400mg/kg.
R23 "Toxic by inhalation" ; LC 50 inhalation, rat, for aerosols or particulates:

0.25 < LD50< or = 1mg/litre/4hr
Non-lethal irreversible effects after a single exposure:

R39 "Danger of very serious irreversible effects": Irreversible damage is likely to
be caused by a single exposure by an appropriate route, generally in the above dose
ranges. In order to indicate the route of exposure, combinations of Risk Phrases may
be used e.g. R39/23 i.e. 'Dangerof very serious irreversible effects by inhalation'.
Severe effects after repeated or prolonged exposure:
R48 "Danger of serious damage to health by prolonged exposure": Serious
damage is likely to be caused by repeated or prolonged exposure by an appropriate
route. "Toxic with R48" is used when effects are observed at levels of the order of:
Oral, rat < or = 5mg/kg(bodyweight)/day
Dermal, rat or rabbit < or = 10mg/kg(bodyweight)/day
Inhalation, rat < or = 0.025mg/l, 6hr/day
In order to indicate the route of exposure, combinations of Risk Phrases may be used
e.g. R48/23 i.e. "Dangerof serious damage to health by prolonged exposure by
inhalation"
1.5.2 What is the GHS?

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What is the GHS?

The GHS is an acronym for The Globally Harmonized System of Classification and
Labelling of Chemicals. The GHS is a system for standardizing and harmonizing the
classification and labelling of chemicals. It is a logical and comprehensive approach to:
Defining health, physical and environmental hazards of chemicals;
Creating classification processes that use available data on chemicals for

comparison with the defined hazard criteria; and
Communicating hazard information, as well as protective measures, on labels

and Safety Data Sheets (SDS).
GHS Document ("Purple Book") <- Click image to visit website.
Many countries already have regulatory systems in place for these types of
requirements. These systems may be similar in content and approach, but their
differences are significant enough to require multiple classifications, labels and safety
data sheets for the same product when marketed in different countries or even in the
same country when parts of the life cycle are covered by different regulatory
authorities. This leads to inconsistent protection for those potentially exposed to the
chemicals, as well as creating extensive regulatory burdens on companies producing
chemicals. For example, in the United States (U.S.) there are requirements for
classification and labelling of chemicals for the Consumer Product Safety Commission,
the Department of Transportation, the Environmental Protection Agency, and the
Occupational Safety and Health Administration.
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The GHS itself is not a regulation or a standard. The GHS Document (referred to as
"The Purple Book") establishes agreed hazard classification and communication
provisions with explanatory information on how to apply the system. The elements in
the GHS supply a mechanism to meet the basic requirement of any hazard
communication system, which is to decide if the chemical product produced and/or
supplied is hazardous and to prepare a label and/or Safety Data Sheet as appropriate.
Regulatory authorities in countries adopting the GHS will thus take the agreed criteria
and provisions, and implement them through their own regulatory process and
procedures rather than simply incorporating the text of the GHS into their national
requirements. The GHS Document thus provides countries with the regulatory building
blocks to develop or modify existing national programs that address classification of
hazards and transmittal of information about those hazards and associated protective
measures. This helps to ensure the safe use of chemicals as they move through the
product life cycle from "cradle to grave."
1.6 Labelling
Substances dangerous for supply must carry a label on their receptacle and on any
other packaging to ensure clear visibility of the following information:
Details of supplier (name, address, telephone number)
Name of substance (as given in Approved Supply List)
For preparations the name of the constituents that make it dangerous for supply
The indications of danger and corresponding symbols
Risk and safety phrases
EEC number where applicable
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Note that the safety phrase, although not part of the classification, is an essential
element of compliance with CHIP. The safety phrase indicates the principal
precaution(s) that need to be taken with the substance and will normally be selected
when the substance is classified. The Approved Supply List contains a section which
lists 52 individual safety phrases and also gives a further 17 combined safety phrases.
The complete list of safety phrases is given in Table 1.3.
The physical characteristics of the label must include:
Secure fixing
Clear and indelible printing
Indication of danger symbols printed in black on an orange background and

readily noticeable from the rest of the label
A minimum dimension that depends on the capacity of the package being

labelled, i.e.
<3 litres 52 mm by 74 mm >500 litres 148 mm by 210 mm

The aim is to ensure the packaging of chemical products is appropriate, secure and
provides the necessary information to safeguard the user.
1.7 Particular Safety Precautions
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Safety
Number
Safety Phrase
S1
Keep locked up
S(1/2)
Keep locked up and out of the reach of children
S2
Keep out of the reach of children
S3
Keep in a cool place
S3/7
Keep container tightly closed in a cool place
S3/7/9
Keep container tightly closed in a cool, well-ventilated place
S3/9/14
Keep in a cool, well-ventilated place away from ... (incompatible

materials to be indicated by the manufacturer)
S3/9/14/49
Keep only in the original container in a cool, well-ventilated place away

from ... (incompatible materials to be indicated by the manufacturer)
S3/9/49
Keep only in the original container in a cool, well-ventilated place
S3/14
Keep in a cool place away from ... (incompatible materials to be indicated

by the manufacturer)
S4
Keep away from living quarters
S5
Keep contents under ... (appropriate liquid to be specified by the

manufacturer)
S6
Keep under ... (inert gas to be specified by the manufacturer)
S7
Keep container tightly closed
S7/8
Keep container tightly closed and dry
S7/9
Keep container tightly closed and in a well-ventilated place
S7/47
Keep container tightly closed and at temperature not exceeding ... OC (to
be specified by the manufacturer)
S8
Keep container dry
S9
Keep container in a well-ventilated place
S12
Do not keep the container sealed
S13
Keep away from food, drink and animal feeding stuffs
S14
Keep away from ... (incompatible materials to be indicated by the

manufacturer)
S15
Keep away from heat
S16
Keep away from sources of ignition - No smoking
S17
Keep away from combustible material
S18
Handle and open container with care
S20
When using do not eat or drink
S20/21
When using do not eat, drink or smoke
S21
When using do not smoke
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Safety
Number
Safety Phrase
S22
Do not breathe dust
S23
Do not breathe gas/fumes/vapour/spray (appropriate wording to be

specified by the manufacturer)
S24
Avoid contact with skin
S24/25
Avoid contact with skin and eyes
S25
Avoid contact with eyes
S26
In case of contact with eyes, rinse immediately with plenty of water and
seek medical advice
S27
Take off immediately all contaminated clothing
S27/28
After contact with skin, take off immediately all contaminated clothing,
and wash immediately with plenty of ... (to be specified by the
manufacturer)
S28
After contact with skin, wash immediately with plenty of ... (to be
specified by the manufacturer)
S29
Do not empty into drains
S29/35
Do not empty into drains; dispose of this material and its container in a
safe way
S29/56
Do not empty into drains, dispose of this material and its container at
hazardous or special waste collection point
S30
Never add water to this product
S33
Take precautionary measures against static discharges
S35
This material and its container must be disposed of in a safe way
S36
Wear suitable protective clothing
S36/37
Wear suitable protective clothing and gloves
S36/37/39
Wear suitable protective clothing, gloves and eye/face protection
S36/39
Wear suitable protective clothing and eye/face protection
S37
Wear suitable gloves
S37/39
Wear suitable gloves and eye/face protection
S38
In case of insufficient ventilation wear suitable respiratory equipment
S39
Wear eye/face protection
S40
To clean the floor and all objects contaminated by this material use ... (to
be specified by the manufacturer)
S41
In case of fire and/or explosion do not breathe fumes
S42
During fumigation/spraying wear suitable respiratory equipment

(appropriate wording to be specified by the manufacturer)
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Safety
Number
S43
Safety Phrase
In case of fire use ... (indicate in the space the precise type of firefighting equipment. If water increases the risk add - Never use water)
S45
In case of accident or if you feel unwell seek medical advice immediately

(show the label where possible)
S46
If swallowed, seek medical advice immediately and show this container or

label
S47
Keep at temperature not exceeding ... OC (to be specified by the

manufacturer)
S47/49
Keep only in the original container at temperature not exceeding ... OC

(to be specified by the manufacturer)
S48
Keep wet with ... (appropriate material to be specified by the

manufacturer)
S49
Keep only in the original container
S50
Do not mix with ... (to be specified by the manufacturer)
S51
Use only in well-ventilated areas
S52
Not recommended for interior use on large surface areas
S53
Avoid exposure - obtain special instructions before use
S56
Dispose of this material and its container at hazardous or special waste

collection point
S57
Use appropriate containment to avoid environmental contamination
S59
Refer to manufacturer/supplier for information on recovery/recycling
S60
This material and its container must be disposed of as hazardous waste
S61
Avoid release to the environment. Refer to special instructions/safety

data sheet
S62
If swallowed, do not induce vomiting: seek medical advice immediately

and show this container or label
S63
In case of accident by inhalation: remove casualty to fresh air and keep

at rest
S64
If swallowed, rinse mouth with water (only if the person is conscious)
Table 1.3: (Note that certain Safety Phrases, e.g. 10, 11, 19, etc. are no longer
in use.)
1.8 Summary of what you need to do -CHIP
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1.9 Factors affecting the risks to health of chemical agents

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We have just examined the CHIP Regulations and established three broad categories of
harm under which we categorise dangerous health effects:
Toxic hazards (i.e. very toxic, toxic, harmful, carcinogenic, mutagenic, toxic for
reproduction)
Corrosive/irritant hazards
Dermatitic hazards (i.e. irritant, sensitising)
We shall now explore these categories of chemical agent in more detail, examining
particular examples and their specific harmful effects.
However, before we look at specific examples of the principal types of chemical agent
you will find it helpful to consider some of the factors that can affect the overall risk to
health of an individual following exposure.
Concentration
The concentration of a particular chemical agent is an important parameter in
determining the likelihood of harm occurring and also how much damage may be done.
Chemical reactions usually proceed faster if the concentration is higher and therefore a
toxic substance is likely to poison faster, or a corrosive one to burn quicker if the
concentration is higher. Also the higher the concentration, the more per unit volume of
substance we have to deliver a toxic dose or inflict a chemical burn. It is therefore a
fair generalisation (although there may be rare exceptions) that the higher the
concentration of a chemical agent we are handling, the greater the risk of harm.
The health and safety practitioner is likely to encounter chemical concentrations
expressed in two ways:
By volume:
A solutions concentration may be expressed as 5% by volume, i.e. 5 parts of acid

diluted in 100 parts of solution
A gass concentration may be expressed as 500 ppm, i.e. 500 volume units of gas
per million volume units of atmosphere
By weight:
A solutions concentration may be expressed as 5 gms per 1, i.e. 5 grams of sodium

cyanide diluted in 1 litre of solution
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A gass concentration may be expressed as 500 mg/m3 i.e. 500 milligrams of dust in
1 cubic metre of atmosphere
Often the classification of the chemical agent itself depends on the concentration of the
substance, so in the Approved Supply List (and consequently under CHIP) an acid may
be classified as corrosive if supplied at 20% concentration, but only irritant if supplied
at 5%. This is because the corrosive properties of the acid depend on concentration
and are significantly reduced with dilution, until at very low concentrations (high
dilutions) the acid shows no corrosive properties at all.
It also follows from our knowledge of dose/response relationships that a very dilute
solution of a toxic agent is unlikely to contain enough of the substance to exceed the
threshold dose for a harmful effect. Thus knowledge of the concentrations at which
chemical agents are handled and used will enable us to estimate the likely effects of
exposure.
Similarly the effects of airborne contaminants are concentration dependent and this
information is published in EH40 in the form of Workplace Exposure Limits which are
used as control standards for airborne contaminants. We will be studying this in more
detail in the next unit Unit B3.
1.10 Other sources of information

Internet
CAS Number
Substance Name
Project supervisors
Molecular formula
Do
EC Number
not
forget
to
consult
those
carrying out the work they are
Chemical Safety (CS) Series
often the experts!
Environmental Hygiene (EH) Series

General (GS) Series
Medical (MS) Series
Chemical Safety (CS) Series
Chemical Safety (CS) SeriesEH1 Cadmium - health
and safety precautions.
EH16 Isocyanates - health hazards and
precautionary measures.
Page 24 of 79
MS12 Mercury medical guidance notes.

MS13 Asbestos medical guidance notes.
Health & Safety Executive
Health & Safety Services
World Health Organisation
Unions
Text books
Internet resources
As you will be aware you can find absolutely everything on the internet
e.g. Toxline is a database that covers literature on all aspects toxicology including
chemicals pharmaceuticals, pesticides, environmental pollutants and mutagens.
http://toxnet.nlm.nih.gov/
Should you be surfing and find other useful resources please post them in the forums.
2.0 Main routes of attack on the human body
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Previousley we have already looked at the main routes of entry of harmful substances
into the human body i.e. inhalation, ingestion, skin pervasion and injection. We also
identified target organs and target systems.
We will now add a little further to this by discussing the distinctions between inhalable
and respirable dust as this information will be needed in unit B5 (monitoring). In
addition we will further look at the body's defensive responses.
2.1 Inhalable and Respirable Dust
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Dust is generally understood to be an aerosol of solid particles, mechanically produced,

with individual particle diameters of 0.1m upwards and can be a problem in almost
any industry, from bakeries to building sites. The hazards of dusts like lead, silica and
cotton are well known, but there are many other substances which may be present in
dust and are hazardous to health.
Particle size is critical in determining where particulates will settle in the lung. Larger
particles will settle in the bronchi and the bronchioles, and will not tend to penetrate to
the smaller airways found in the alveolar region. These are termed inspirable particles.
Those smaller sized particles that can penetrate the gas exchange region of the lungs,
the alveolus, are termed respirable particles
Inspirable Particulate: Only part of the total quantity of dust that is present in the
worker's breathing zone is inhaled. This part is designated as the `inspirable
fraction' of dust and is governed by the flow rates in the nose and mouth areas, as
well as the airflow around the head.
Respirable Particulates: Dust particles having a 50% cut point of 4 m m (ACGIH) or
5 m m (BMRC). These particles may be hazardous when deposited in the gas
exchange region of the lungs.
Figure 2.1 Basic Structure of the Respiratory System

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Particle size is expressed as 'equivalent' or 'aerodynamic' diameter. This is equal to the

diameter of spherical particles of unit density that have the same falling velocity in air as
the particle in question. Amongst inhaled particles, those with an equivalent diameter
greater than approximately 20 microns (m m), will be trapped in the nose and upper
airways. Inhalable Dust is a new term used to describe dust that is hazardous when
deposited anywhere in the respiratory tree including the nose and mouth. It has a 50%
cut-point of 100 m m and includes the big and the small particles. Particles in the region
of 7 - 20 microns will penetrate to the bronchioles and are inspirable, while particles in
the size range 0.5 - 7 microns are respirable. Particles smaller than this will not settle
out as their terminal velocity is so small that there is insufficient time for them to be
deposited in the alveolus and they are exhaled out again. This is shown on the BMRC
penetration curve below.
Figure 2.2. British Medical Research Council penetration curve for respirable
particles showing 50% cut point at 5mm.
Key Point:Inhalable dust is dust that is hazardous when

deposited anywhere in the respiratory tree. Particles in the
region of 7 - 20 microns will penetrate to the bronchioles and
are inspirable, while particles in the size range 0.5 - 7
microns are respirable.
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Cut Point: Describes the performance of cyclones and other

particle size selective devices. For personal sampling, the 50%
cut point is the size of the dust that the device collects with 50%
efficiency.
Airborne dust concentration

The concentration of dust to which a person is exposed is also critical to the impact on
the health of the person exposed. This is measured in the breathing zone of the worker,
which is an imaginary hemisphere of approximately 30 cm, extending in front of their
face and measured from the midpoint of an imaginary line joining the ears (see diagram
below).
Figure 2.3. The Breathing Zone

As previously stated we will discuss air sampling within unit B5.
2.2 THE BODY'S DEFENCE MECHANISMS

Inhalation and Respiratory Defences
Respiration not only facilitates the transport of oxygen into and carbon dioxide out of
the lungs, but it also allows the ingress of harmful agents such as chemicals, physically
Page 29 of 79
damaging dusts and fibres, air of excessive temperature or dryness, and biological
agents such as bacteria or viruses. Some of the defence processes are readily
identified:
Coughing results in the forceful ejection of inhaled substances.
Goblet cells in the conducting airways secrete mucus which, forming sputum, is
expectorated or swallowed; and the nose itself filters out the largest particles.
Before we attempt to study the respiratory defence mechanisms in detail, we need to

return for a moment to the respiratory tract (Figures 1.1 and 1.3).
Those parts of the respiratory pathway down to and including the terminal bronchioles
are the conducting airways; those beyond constitute the respiratory units, where gas
exchange occurs.
Initial filtration of particles larger than 10 m takes place in the hairs in the
nasal cavity.
Smaller particles and aerosols between 7 and 10 m are trapped in the mucus
secreted by goblet cells lining the conducting airways and then transported
upwards by the ciliary escalator to the pharynx where they can be either
swallowed or expectorated (see Figure 2.4).
Figure 2.4
Smaller particles and aerosols between 0.5 and 7 m pass into the respiratory
units where deposition takes place in the respiratory bronchioles and alveoli.
Here they may be ingested as foreign bodies by macrophages, large cells
normally found in tissues which produce blood cells. Macrophages may migrate
back along the respiratory pathways to the ciliary escalators, ultimately to be
swallowed or expectorated. It is also thought that some transport occurs through
the alveolar membrane and into the circulatory system.
2.2 THE BODY'S DEFENCE MECHANISMS (Cont.)

We can summarise the deposition of aerosols and particles in the respiratory system as follows:
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Deposition Site
Particle Size
Above 10 m
Nasal cavity
7-10 m
Ciliary escalator
0.5-7 m
Respiratory bronchioles and alveoli
Below 0.5 m
Most remain airborne and are exhaled.

Some diffuse and come into contact with the
airway
or alveolar membrane
Table 1.2:Deposition of Aerosols and Particles in the Respiratory System
Once in the bloodstream, the toxic substance (e.g. benzene) may act upon the blood itself or be
carried around until it affects another organ, such as the liver, kidneys or bladder. Materials
swallowed may be excreted unchanged in the faeces.Others may be acted upon by enzymes,
acids, and other processes in the gut, or be absorbed and pass via the portal vein to the
liver.Here they may be further acted upon and metabolised or conjugated into a variety of
soluble by products to be excreted in the urine.
Some toxic materials, such as lead, are initially stored in the bones of the skeleton so the toxic
effects can be minimised by slowly allowing it to leach back into the bloodstream.
The various pathways which may be taken by toxic materials deposited in the conducting airways
and respiratory units are shown in Figure 2.5.
Substances which pass through the alveolar membrane enter directly into the pulmonary
capillaries or find their way into the tissue spaces of the lungs from which they are drained by the
lymphatic system.Substances reaching the interstitial spaces are sometimes stored harmlessly
prior to draining into the lymphatic system (e.g. tin and iron compounds), or may result in
damage or set up disease processes (e.g. fibrosis or pneumoconiosis).Because the lymph glands
act as filters for substances or micro-predators (such as phagocytes) which are being carried away
by the lymphatic system, they are often involved in lung disease.Many cancers of the lung, for
example, start in the lungs lymph glands.
Figure 2.5
Table 2.1 shows nine examples of input substances, their sites of contact in the respiratory
pathways, together with their principal effects.
Input Substance
Site of Contact
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Effect
1 Soluble irritant gases

(e.g. NH3)
2
Low solubility irritant

gases (NO2)
3 Sensitising metals (Cd)
Upper conducting
airways
Lower conducting
Inflammation
airways and respiratory

units
Conducting airways
(depending on particle
size)
4 Di-isocyanates (TDI)
Inflammation
Conducting airways
Immuno-pathological
reaction
Immuno-pathological
reaction (e.g. asthma)
5 Cotton dust
Conducting airways
Immuno-pathological
reaction (e.g. byssinosis)
6 Fibrogenic dusts:
Silica
Asbestos
7 Radio-isotopes
Conducting airways and
Collagenous
respiratory units
pneumoconiosis (silicosis)
Lower conducting
Collagenous
airways and respiratory
pneumoconiosis
units
(asbestosis)
Neoplasia (cancers)
respiratory units
8 Hardwood dusts
Upper conducting
Neoplasia (cancers)
airways and sinuses

9 Cigarette smoke
Metaplasia of bronchial
respiratory units
lining (lung cancer)
Table 2.1:Substances, Site of Contact and Effect

Defensive Cells
Defensive cells are very important in protecting the body against harmful inputs of all
kinds. Those associated with work and occupational illnesses make up only a small
proportion of such damaging inputs with which the body has to contend. Two examples
will serve to illustrate the types of defence cell which are important in occupational
health and hygiene:
(a) Phagocytes, which play a central role in the prevention of lung diseases;
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(b) Blood-borne defensive cells, which give rise to the immune response and the
inflammatory response.
Phagocytosis
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Figure 2.6
Stage 1 : Chemotaxis - proximity of foreign body stimulates movement of phagocyte
towards intruder.
Stage 2 : Adhesion of foreign body to phagocyte. It is thought the immune response
(qv) is the basis for adhesion.
Stage 3 : Ingestion of foreign body into the phagocytic cell, and
Stage 4 : inclusion of the foreign body attracts a lysosome which discharges enzymes
into the phagosome, i.e. the mixture of enzymes and the foreign body.
Stage 5 : Nitric oxide synthesising enzymes chemically digest the foreign body which
may remain in the phagocyte's cytoplasm; or the phagosome may be deposited in the
surrounding tissue or fluids and thence into the lymphatic system. Alternatively, the
foreign body may remain as an indigestible inclusion while the phagocyte migrates to
other tissue.
Harmful particles, micropredators and other foreign bodies engulfed by phagocytes
may thus be rendered harmless.

Sometimes phagocytes may be killed by toxic action. This results in the formation of
pus, which is then discharged leaving a void subsequently made good by the formation
of scar tissue. In the lungs it causes fibrosis, whereby the tissues lose their elasticity
and breathing becomes progressively laboured.
Inflammatory Response
Inflammation is the reaction of tissue to a harmful agent which is insufficient to kill the
tissue. It can follow when a foreign body enters the body by way of inhalation,
ingestion, absorption, pervasion, implantation, surface penetration, trauma, or energy
transformation. Although inflammation is a defensive process of great importance, if
called upon to act for too long it can sometimes result in disease.
Acute Inflammation
Acute inflammation is the immediate defensive reaction of tissue to any injury and is
typified by the following sequence of events:
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(i) Initially the capillary vessels in the area of tissue affected briefly constrict.
(ii) Then the same blood vessels dilate and the capillary walls become more permeable.
(iii) Protein-rich fluid (plasma) exudes from the capillaries into the surrounding tissue,
causing swelling (oedema).
(iv) Phagocytes migrate through the capillary walls towards the harmful input, where
they ingest it together with any damaged tissue.
(v) Tissue-dwelling macrophages join with the phagocytes and scavenge the affected
area, which is sometimes additionally bonded by fibrinogen (a protein associated with
blood clotting).
Healing Process
Towards the end of the inflammatory phase, cells called fibroblasts appear and secrete
collagen. This is a fibrous protein which cross-links with polysaccharides (sugars) to
form a meshwork of scar tissue which steadily builds up to repair the affected area.
While this is going on, if the affected area is close to the skin, epidermal cells remove
any final debris in the area and begin to dismantle the scar tissue.
Chronic Inflammation
Sometimes excessive amounts of collagen are formed and in certain chronic
inflammatory responses, macrophages die and other macrophages phagocytose their
dead. The combination of living and dead macrophages forms structures known as
giant cells. Scarring is a repair process by which gaps in tissue are made good. In
some types of chronic inflammation, however, this repair process becomes disordered.
The overgrowth of scar tissue, brought about by over-production of collagen, shrinks
and contracts, tearing and distorting the surrounding tissues. In the lungs, this results
in the condition known as emphysema and some types of pneumoconiosis result in
extensive scarring and fibrosis.
Immune Response
This term describes the mechanisms concerned with defence and preservation of
normal body integrity. In its classical form a wide range of chemicals and
micropredators provoke an immune response which involves the production of
antibodies within the space of a few days. Whenever next the antigen enters the body,
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it reacts with the residual antibody and the combination of antigen and antibody can be
phagocytosed as detailed above.
In addition to the classical disposal of antigens, two other types of immune response
are recognised:
(i) Surveillance
Sometimes dividing cells give rise to mutant forms and any excess could result in the
growth of abnormal tissue (benign or malignant). Surveillance by immune response
results in these mutants being recognised as alien and destroyed.
(ii) Self-disposal
Redundant blood and tissue cells need to be phagocytosed from the body and the
immune response ensures that redundant cells are recognised as distinct from
functioning cells.

It is important to link the immune response with inflammatory responses, since the
two can be regarded as complementary stages in a continuous process. The immune
response can be regarded as the mechanism concerned with identifying and preparing
any harmful inputs or the resulting damaged tissues for the inflammatory process.
Harmful inputs which can provoke an immune response include:
Micropredators and chemicals
Energies which cause tissue damage
Psycho-social climates (to produce, for example, asthma)
Respiratory Inflammation
The respiratory pathway is vulnerable to attack by many irritants and corrosives or any
other substances which attack the skin. The terminology of the inflammatory processes
follows the pathway of air into the lungs, via:
Rhinitis
Laryngitis
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Tracheitis
Bronchitis
Pneumonia In extreme cases the effects of inflammation lead to swelling and exudation
of fluids resulting in narrowing or even total blocking of the small conducting airways.
Exudation in the alveoli leads to interference with respiratory gas exchange, even to a
fatal degree. Gases of low solubility will penetrate the respiratory pathway deep into
the alveoli. Such gases include sulphur dioxide, ozone, phosgene and oxides of
nitrogen. The inflammation caused results in fluid accumulating in the respiratory units
(oedema). Other irritants include metal fumes (metal fume fever) and polymer fumes
(polymer fume fever).
Inflammation of the Skin
Inflammation of the skin is much the same as for any other body organ; there are
blood capillary changes, there is increased permeability and there is migration of cells.
Inflamed skin is painful, sometimes itchy, often red and fissured, sometimes
accompanied by exudate and shedding of scales.
Chemicals attack the skin by pervasion or implantation, resulting in contact dermatitis,
which may take a number of forms:
Irritant Dermatitis
This is caused by corrosive irritants such as acids, alkalis, detergents, oils, metallic
particles, solvents, oxidising and reducing agents and some biological agents (e.g.
giant hogweed). If the irritant is particularly aggressive, it can result in destruction of
the skin.
Acute Irritant Dermatitis
This is brought about by contact with acids and alkalis, for example, which result in
acute inflammation.
Cumulative Insult Dermatitis
This typically develops after repeated exposure to weak irritants over a long period of
time.
Allergic Contact Dermatitis
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Also known as Contact Sensitisation Dermatitis, it is associated with a wide range of

substances. Some metals, such as cobalt and nickel, produce allergic reactions. With
nickel, for example, contact with its alloys or salts can result in a form of contact
dermatitis which may also affect skin on other parts of the body not directly exposed to
the agent. Once this sensitivity (to very small amounts) has developed, it is usually
permanent.
It is almost impossible to give a list of materials known to cause sensitisation
dermatitis.
Certainly it would be very long, but would include coal-tar products, explosives,
photographic chemicals, dyestuffs and intermediates, insecticides, oils, resins, alkyd
resins and plasticisers.
2.3 CARCINOGENESIS
Background
A cancer is a growing mass of non-productive tissue that is relentlessly progressive,
ending in the death of the individual. This tissue growth is termed a malignant tumour
and can spread within the body via the bloodstream or the lymphatic system. This
process, termed metastasis, leads to the formation of other small tumours scattered
widely throughout the body. These new tumours can grow into nearby tissues and
destroy them as a consequence by a process termed invasion. Metastasis and invasion
are the two characteristics that distinguish malignant tumours from those classified as
benign.
Descriptions of the important terms associated with carcinogenesis are as follows:
Tumour : a swelling related to the growth of diseased cells, which grows at the
expense of other healthy cells in its vicinity. There are basically two kinds:
benign and malignant.
Benign tumours usually grow very slowly, remain localised and their cell structure
is often similar to the cells of origin.
Malignant tumours grow rapidly without restraint, spread into surrounding tissue
and have their own cell structure, unlike the cells of origin. The term cancer is used to
describe the formation of malignant tumours.
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Carcinogen : an agent (either physical, chemical or viral) which has the ability
to produce malignant tumours. In terms of occupational cancer, the carcinogenic
agent will be physical and chemical.
Occupational carcinogen : a carcinogen which induces cancer in a person as a

result of their occupation. This is a definition given by the World Health
Organisation and appears to be clear and simple. Unfortunately, in practice the
classification of a cancerous condition arising from occupation is far from simple.
Formation of Cancerous Cells

It is generally accepted that cancerous cells are formed by the carcinogen attacking the
mechanism which controls the reproduction of normal cells. The toxic action of
carcinogens differs from 'ordinary' toxic action:
They upset the fundamental cell reactions within the cell structure, whereas
ordinary toxic substances mainly upset the general metabolic processes which
prevent cells from functioning normally.
They evoke irreversible effects which continue after exposure to the carcinogen
has ceased. The action of ordinary toxic agents usually stops when the exposure
ceases and recovery generally follows.
The effects of a carcinogenic agent will not appear for many years after
exposure. The period of time is its latency period. Periods between 5 and 50
years are given for different agents. During this time, there is little or no
warning of the eventual tragic outcome. 'Ordinary' toxic agents can evoke an
acute response and also a chronic response.
The particular point made above highlights the importance of strict control in the use of
carcinogenic substances. Once the symptoms have been diagnosed, the problem will
often have reached the point of no return.
2.3.1 Mode of Action of Chemical Carcinogens

Carcinogens interact with the genetic material of the cell, the DNA, causing structural
and functional alterations which cause the cell to grow in an uncontrolled manner. This
damage to the DNA may be repaired by enzymes that exist within the cell nucleus.
However, in cases where this repair is not carried out effectively the cell is significantly
altered and acquires properties which were absent prior to the damage. In some
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instances these new properties may be passed on to daughter cells during cell division.
This hereditary transmission of new characteristics is an indication that the cell has
been mutated and the event that brings about this change is termed a 'mutation'. The
process of mutagenesis, therefore, is considered the first step in the process of
carcinogenesis and many short-term tests for carcinogenicity are based on the ability
of a chemical to induce mutations.
Generally, carcinogens and mutagens are categorised as such on the basis of human
or, more likely, animal data. The International Agency for Research on Cancer (IARC)
classifies substances as:
'Carcinogenic to humans' (human evidence)
'Probably carcinogenic to humans' (good animal evidence)
'Possibly carcinogenic to humans' (less good animal evidence)
No-threshold Concepts
Later in this unit we will consider dose-response relationships which are based on the
concept of a minimum level of toxin exposure below which no harmful effect can be
detected. The assumption is that below this specific level, the degree of harm inflicted
by the toxin is insignificant and will cause lasting damage. This threshold level for
acute toxic effects can therefore be used to define occupational exposure limits.
In the case of carcinogenic toxins the situation is much more complex. Theoretically, a
single 'hit' or reaction of a compound or its metabolite on the crucial part of one DNA
molecule might be sufficient to initiate a cancerous change. Hence there is no threshold
of harm and any level of exposure to a carcinogen has the potential to cause cancer. In
practice, however, the chances of one molecule reaching the target site are probably
small for most compounds and depend on a number of factors including potency,
absorption, distribution, and metabolism. The capacity of the particular cell to repair
such damage will also be important. You should therefore appreciate how the concept
of a no-threshold level of harm for carcinogenic substances differs significantly from
the approach to exposure limits applied to other toxins and thus affects the assessment
of risk and the setting of appropriate control standards.
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Setting and Justifying Control Strategies for New Suspected Carcinogens

In practice there must be a threshold dose for a particular carcinogen, but is it difficult
to determine in mammals in vivo because the critical biochemical changes at cellular
level are impossible to detect. The results from animal carcinogenicity testing studies
are particularly hard to assess. It is difficult to show an increased frequency of tumours
in a small population, such as those used in animal cancer studies in which there may
already be a significant incidence of some types of tumour. There is also a practical
statistical limit which determines the frequency of occurrence of a cancer which can be
detected. Hence assessing cancer risk from carcinogenicity studies is very difficult. As a
result those conducting and assessing the tests tend to err on the side of caution.
Another problem is the need to use high doses close to the maximum tolerated dose in
carcinogenicity testing. This approach is contentious since carcinogens may show dosedependent metabolism which can distort interpretation of the carcinogenicity data for
weak carcinogens tested at dose levels much higher than occupationally expected.
Consequently a compound may only be carcinogenic under the extreme dosing
conditions of the test.
Extrapolation between species is also a problem in risk assessment and the
interpretation of toxicological data. The species or strain used in a particular
carcinogenicity study may have a high incidence of a specific type of tumour. The
assessment of the significance of an increase in the incidence of this tumour and its
relevance to man can pose particular problems.
Therefore risk assessment for carcinogenicity tends to be much more difficult than for
any other type of toxic effect. The incidence of a toxic effect may be measured under
precise laboratory conditions, but extrapolation to a real-life situation to give an
estimate of risk involves many assumptions and gives rise to uncertainties. The setting
of control standards from these risk assessments is therefore often based on obscure
data which may be without precise scientific foundation.
In practice there is little alternative to extrapolation from scientific studies, since for
new chemical substances human data is not available and toxic effects in man cannot
be verified by direct experimentation. Thus evaluation of human exposure from the
limited data available tends to lead to a worst-case estimation, which by definition will
tend to exaggerate the risk to human health.
2.3.2 Environmental and Non-occupational Cancers
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Another problem in setting standards for exposure to carcinogenic substances is the

fact that the long latent period between exposure to particular agents and the
development of tumours in man makes it difficult to establish in retrospect what has
actually caused the cancer. Also it is often not possible to distinguish occupational and
non-occupational cancers. Chemicals are often thought to be a major factor in the
causation of human cancer. However, carcinogenic chemicals can be identified in food,
the air, and the environment generally and are not just confined to the workplace.
We shall look at the principal occupational carcinogens such as asbestos, arsenic,
benzene, chromium, nickel, and mineral oils in a later study unit. Remember that
exposure to several chemicals can occur in one person's working lifetime, with possible
carcinogenesis of a number of tumours (e.g. lung, mesothelioma, head and neck).
However, there are also more important sources of non-occupational cancers.
The main offender in this category is the habit of cigarette smoking, the carcinogenic
effects of which are well known. An estimate of the risk of cancer attributable to
various agents suggests that the largest contribution comes from the effects of tobacco
and from dietary habits. There is no support for the common belief that most cancers
could be prevented by controlling chemical pollution of the air, food and water, or
occupational exposure.
The incidence of most cancers is either steady or declining, with the exception of
cancers which are directly linked to smoking. If the increased use of chemicals either
occupationally or environmentally is causing cancer, it is doing so to an extent that is
not measurable in the overall statistics.
There is certainly no evidence of an epidemic of cancer caused by the increased use of
synthetic chemicals. Nevertheless, while cancers probably originate from a whole
variety of circumstances, exposure to chemicals does contribute to the generation of at
least some cancers.
The effect of environmental and non-occupational cancers, therefore, is to provide a
background level against which any suspected occupational cancer must be
distinguished and measured. This adds a further complication to the difficulty of
assessing the actual risk of occupational carcinogens and setting meaningful control
standards in relation to the inherent cancer risk of the population as a whole.
2.4 SUMMARY
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Class of Toxin
Target
Some Symptoms
Example
Jaundice, liver
Carbon tetrachloride
Organ/System
damaged
Hepatotoxins
Liver
enlargement
Nephrotoxins
Kidney
oedema, Proteinuria Halogenated

hydrocarbons
Neurotoxins
Nervous system
Narcosis,
Mercury and
behavioural changes compounds,
Chloroform, ether
Hematopoietic
Blood or hemato-
Cyanosis, loss of
Carbon monoxide,
agents
poietic system
consciousness
cyanides
Lung toxins
Lungs
Cough, difficulty
breathing
Asbestos, siliceous
dust
Reproductive toxins Reproductive organs, Sterility, birth

Cutaneous agents
Eye toxins
Lead and
developing foetus
defects,
compounds
Skin
Defatting, rashes,
Ketones, chlorinated
irritation
organic solvents
Conjunctivitis,
Acids, organic
corneal damage
solvents
Eye
3.0 Toxicology INTRODUCTION

Here we begin with a comprehensive review of the principles of toxicological
investigation and their use and limitation in recognising health hazards.
METHODS OF TOXICOLOGICAL TESTING
Legal Requirements
Regulations relating to the use of new substances in the UK require a range of physicochemical, toxicological and ecotoxicological studies. The level of testing depends on the
quantity of substance that is intended to be produced but the types of toxicological
studies that are required are given below (and described in more detail later):
Acute toxicity: Oral Inhalation Cutaneous (skin)
Skin and eye irritancy
Skin sensitisation: Positive result indicates potential for contact dermatitis
Subacute toxicity (28 days)
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Mutagenicity (bacterial and non-bacterial):
To determine if the substance has the ability to cause genetic damage and the
potential to induce cancer
Carcinogenicity:
-If mutagenicity tests prove positive the animal is subjected to lifetime exposure to the
substance and at post-mortem an examination is carried out to detect tumours
Teratogenicity:
To examine the effect of the substance on the development of the embryo and foetus
to identify gross anatomical abnormalities
In addition to these tests it may be necessary to repeat the studies using other species
of animals and/or alternative routes of exposure.
Dose/Response Relationships
Toxic substances have very different effects on organisms, including the minimum level
at which an effect is detectable; the sensitivity of the organism to small increases in
dose; and the level at which the harmful effect (most significantly, death!) occurs.
Such factors are indicated in the dose-response relationship, which is a key concept in
toxicology:
Dose is the amount per unit body mass of toxic substance to which the
organism is exposed.
Response is the resultant effect.
In order to define a dose-response relationship we must specify the particular effect,

i.e. death, and also the conditions under which the effect is obtained, i.e. length of
time of administration of the dose.
If we consider a specific example we can see that:
At low doses no organisms will show a response, i.e. they all live.
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At higher doses all organisms show a response, i.e. they all die.
In between there is a range of doses over which some organisms respond and
others do not. This is shown in Figure 3.1.
The dose-response curve is S-shaped and the mid-point represents the dose which
would cause an effect (in this case death) in 50% of the organisms. It is designated as
the LD50.
You should appreciate that LD50 is not an exact value and in recent years there has
been much discussion as to its usefulness and necessity in toxicology. The LD50 values
may vary for the same compound between different groups of the same species of
animal.
However, the value is of use in comparing how toxic a substance is in relation to other
substances. Table 3.1 gives examples of LD50 values for a variety of chemical
substances.
Compound
LD50 (mg/kg)
Ethanol
10,000
DDT
100
Nicotine
Tetrodotoxin
0.1
Dioxin
0.001
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Botulinus toxin
0.00001
Table 3.1
ED50 (effective dose for 50%) and TD50 (toxic dose for 50%) are related parameters
which indicate the dose at which a biological response is likely. Comparison of ED50
with LD50 gives an indication of the margin of safety between the dose which causes
the first identifiable effect and that which is fatal.
Testing for carcinogenic potential is more complex since there is no simple doseresponse relationship. The toxicology of carcinogens is approached in a different way
but still involves exposing laboratory animals (usually rats and mice) to the chemical
by oral, inhalation or skin contact techniques.
There are also short-term predictive tests available which are considered to simulate
potential carcinogenicity in man. They are called short term, in contrast to the usual
lifetime studies in rodents which can take three to four years before a result is
available.
Short term tests include:
Those for mutation (Ames test)
Tests for DNA damage
Test for chromosomal damage
Tests for cell transformation
We will consider some of these tests in more detail later in this study unit.
Once a dose-response relationship has been demonstrated there are a number of
parameters that can be derived from it.
If exposure is oral and lethality is used as the end point, LD50 can be determined as
we have seen previously. LD50 is defined as 'a statistically derived expression of a
single dose of a material that can be expected to kill 50% of the animals'.
However, the S-shaped dose-response curve can be further analysed mathematically to
determine doses that have a higher or lower probability of fatality. The determination
of LD90 from the dose response curve, for example (see Figure 3.1) enables estimation
of the dose that will kill the majority (i.e. 90%) of a sample of animals.
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When the route of exposure is inhalation and lethality is used as the end point it is the
concentration of the airborne toxin that is of concern. Since the amount of toxin
inhaled depends on the duration of exposure there are two ways to express this data:
The lethal concentration can be determined for a specified duration of exposure.

If the median lethal concentration is determined this is designated as LC50,
which is defined as the statistically derived expression of the concentration of
airborne toxin that can be expected to kill 50% of exposed animals in a specified
time. As indicated above the resulting dose-response relationship can be used to
estimate other corresponding parameters such as LC90.
The lethal time can be determined for exposure to a given concentration of

airborne toxin. If the median lethal time is determined this is designated as
LT50, which is defined as the statistically derived expression of the exposure
time necessary that can be expected to kill 50% of exposed animals at a
specified concentration of airborne substance.
With all these parameters it is important to remember that they simply represent
statistically determined doses, concentrations or times, derived experimentally in the
manner described above. Their use in comparing the 'toxicity' of different substances
and consequently their potential to cause occupational ill-health must be qualified by a
clear understanding of the limitations of the method by which this statistical data is
derived.
We made reference earlier to the concept of a dose below which no effect or response
is measurable. This is termed the threshold dose and can be clearly demonstrated with
responses such as lethality. This concept of a threshold dose for the toxic effect is an
important one and implies that there will be a dose at which the response does not
occur in any member of the population.
This is shown in Figure 3.1 where the dose response curve shows no deviation from the
x-axis (% effect = 0) until log dose reaches a value of 5 units. The term for this is the
'no observed adverse effect level' or NOAEL. We have already discussed the converse
of this with carcinogens where a threshold dose cannot be established and therefore it
must be assumed that any exposure to carcinogenic substances has the possibility of
an adverse effect.
The NOAEL is important for setting exposure limits such as occupational exposure
standards which are designed to represent a level of exposure at which there is no
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evidence of harm. We will discuss the application of this type of toxicity data in
establishing criteria for occupational exposure limits in Unit B3.
3.1 Types of Toxicity Test

Toxicity tests tend to share certain basic principles. They usually involve exposing
experimental animals to the test substance under controlled conditions.
For existing chemicals, toxicological information may also be obtained from
epidemiological data such as human exposure in the workplace or humans and animals
exposed in the general environment. So, for example, workplace exposure may be
determined from the measurement of potentially toxic substances or their metabolites
in human body fluids.
Similarly environmental exposure to pesticides may be determined in the field by
measurement of pesticide levels in wild birds.
The main types of toxicity tests are described below.
Acute Toxicity Tests
These are designed to determine the effects which occur within a short period after
dosing.
These tests can determine a dose-response relationship and the LD50 value.
The initial tests will involve increasing the dose to a sample of animals by successive
orders of magnitude (factors of 10) in order to establish the range of toxic effects.
Once this has been established a study similar to that outlined in Table 3.2 can be
carried out in order to classify the substance. Note that the criterion used is 90%
survival.
Test Dosage
5 mg/kg
Result
Action/Classification
< 90% survival > 90%

survival but toxicity >
Very toxic Toxic Retest
90% survival no toxicity
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at 50 mg/kg
50 mg/kg
500 mg/kg
< 90% survival > 90%
Toxic, retest at 5 mg/kg
survival but toxicity >
Harmful Retest at 500
90% survival no toxicity
mg/kg
< 90% survival or toxicity

> 90% survival no
toxicity
Harmful, retest at 50
mg/kg Unclassified
Table 3.2: Investigation of Acute Oral Toxicity

If a large enough sample of animals is used at each dosage level the LD50 value can
be determined from analysis of the data.
Subacute Toxicity Tests
These involve exposing animals to a substance for a prolonged period of one or three
months, which enables toxic effects which have a slow onset to be detected.
This type of exposure provides information on the target organs affected by the
substance and the major toxic effects. Such tests also allow measurement of the
substance in blood and tissues to be made.
The information gained can be used in the design of the next type of test, the chronic
toxicity test.
Chronic Toxicity Tests
These tests involve lifetime exposure of animals to the substance under study.
Similar measurements to those described for subacute toxicity tests can be made
throughout the study to identify the development of pathological changes which can
then be detected in a post-mortem.
Other long-term changes in measurements such as food and water intake, body
weight, and behavioural changes can serve to indicate harmful effects.
These types of study are important in determining possible effects of long-term
occupational exposure or environmental exposure to low levels of chemicals.
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For all three types of toxicity test the following parameters should also be considered:
Type of chemical under study (novel compound or in use for some time)
Selection of doses (quantity; single dose or repeated doses)
Species and strain of animal (extrapolation to human exposure)
Exposure route (comparable with likely occupational exposure route)
Method of exposure (physical and/or chemical properties of substance)
Experimental observations and measurements to be made (similarities with

other compounds of known toxicity)
3.2 Uses and limitations of toxicological testing

So far we have made general reference to various types of toxicity test designed to
identify acute or chronic effects. We now develop this further and examine three very
different methods used to examine substances for toxic effects.
(a) Mutagenicity testing aims to identify the potential to cause damage to genetic
material. This, in turn, indicates the possibility that the substance in question could
possess mutagenic or carcinogenic properties.
(b) Long-term toxicity tests involve lifetime studies on animals exposed to potentially
toxic substances and are able to provide a wealth of information on mode of action,
dose effect relationships and target organs.
(c) Chemical analogy tests enable predictions to be made on possible mode of toxic
activity based on the chemical structure and properties of substances.
We shall examine each of these different test methods in turn to determine the
methodology and also the possible limitations in their use.
Mutagenicity Testing
Mutagenesis occurs as a result of interaction between mutagenic agents (agents able
to cause mutations) and the genetic materials of organisms. Evolution of living species
is based on spontaneous mutation followed by natural selection.
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Mutations that give a natural advantage to a species survive to be promoted by natural

selection, whereas those that reduce the chances of survival are eliminated. However,
in recent years a growing number of toxic substances have been shown to possess
mutagenic properties and the concern is the inability to predict the eventual effects of
human exposure to these substances. In addition, tests for mutagenicity are now more
widely used because of their use as a rapid screening method for carcinogenicity,
because most mutagens have been found to be carcinogens. Furthermore,
mutagenicity tests are useful in establishing the mode of action of carcinogens since
human tumours often display chromosomal abnormalities.
Gene Mutation
DNA (deoxyribonucleic acid) consists of a long double helical chemical strand of

ordered nucleic acid bases. The order and combination of the four different types of
base provide a genetic code which contains unique information (in 'packets' called
genes) to enable the synthesis of proteins and the construction of living matter. As well
as holding the information necessary for the growth of organisms, this genetic
information can also be transmitted from one generation of cells to the next through
self-replication. In this way species of organisms survive through reproduction.
Gene mutations involve additions or deletions of bases in the DNA molecules. In
addition a mutagenic chemical, or part of it, may be incorporated into the DNA
molecule. In either case these changes to the DNA molecule may cause the
substitution of a new amino acid or a different amino acid sequence in the synthesised
protein molecule, thus leading to a modification (possibly damaging) to the biological
properties of the protein.
The most common test to detect genetic mutation is the Ames test. The basis of this
test is to expose bacteria to the suspected mutagen and observe for detectable
mutation. This is done by using a special type of Salmonella typhimurium bacteria
which has been genetically modified to grow only in a medium containing histidine (a
type of amino acid).
Normal bacteria, however, will multiply in a histidine-deficient medium. Consequently
the test bacteria are incubated in a medium which contains insufficient histidine and
therefore no growth takes place. If a mutagen is now added to the medium it will cause
genetic changes which reverse the original genetic modification and now enables
affected bacteria to multiply as normal in the histidine-deficient environment. Hence
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the observation of appreciable growth indicates that reverse mutation has taken place
and the substance in question does have mutagenic properties.
Since this test only involves the exposure of bacteria to the mutagen it is termed an 'in
vitro' test. However, gene mutation tests can also be carried out 'in vivo' (in a host
animal, usually a mouse) by injecting the host with the mutagen and directly
examining either microorganisms or host cells for evidence of genetic damage.
Chromosomal Effects
The effect of a mutagen on a chromosome (an assembly of genes) may be great

enough to be visible microscopically, either as structural aberrations or changes in
numbers.
Heritable Effects
At present there is no direct correlation between laboratory tests for heritable

mutations and human experience. Nevertheless, if a substance has been shown to be
mutagenic in a variety of test systems, including heritable mutations in mammals, it
must be considered as a mutagen in humans unless there is convincing evidence to the
contrary.
Long-term Animal Toxicity Studies
Humans are more often exposed to chemicals at levels much lower than those that are
acutely fatal, but they are exposed over longer periods of time. To assess the nature of
these toxic effects under these more realistic situations long-term toxicity studies on
animals are conducted. The key elements of such studies are outlined below.
Experimental Design
Species and number:
Generally two or more species should be used that metabolise the chemical in a way
similar to humans (often rats and dogs are used due to size, availability and the
amount of toxicological data already available on these animals).
Equal numbers of male and female animals should be used, with from 10 to 50
animals in each dose group.
Route of administration:
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The chemical should be administered by the likely route of exposure.

For most chemicals the route will be oral, so the chemical will be incorporated into
the diet or drinking water.
For special circumstances such as industrial products, agricultural products and
drugs, dermal application or inhalation may be used.
Dose and duration:
-Dosage will be set at three levels:

High enough to show signs of toxicity but not to kill
Low enough to show no toxic effect
Intermediate
Duration is generally two years for rats and seven years or more for dogs.
Observations and Examinations
Body weight and food consumption:
Decreased body weight gain is a simple but sensitive indicator of toxic effects.
Food consumption is also a useful indicator.
Appearance and behaviour: Both of these parameters, along with development

of any abnormalities, should be noted.
Laboratory tests: These include blood and urine sampling and testing.
Post-mortem examination:
All dead animals should be subjected to a full pathological examination, including

weight and analysis of major organs.
Correlation between general observations, clinical laboratory tests and post-mortem
examination for major organs and systems can provide valuable information on the
effects and mechanism of action of the chemical in question.
Evaluation:
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The parameters of observations and examinations described above will provide

information on the toxicity of the chemical under test with respect to the target organs,
the effects on these organs, and the dose-effect and dose-response relationships.
In addition the NOAEL from long-term studies can be used to determine exposure
limits or 'acceptable daily intakes' for humans, as we have discussed previously.
3.3 Chemical Analogy Studies

One of the methods used to attempt to predict the possible toxic properties of a
substance is to assume that chemically related substances will show similarities in toxic
properties. Whether this is a true assumption will depend on the mechanism of action
of the known toxicant and whether the chemical analogue is able to act in a similar
way.
The principal mechanisms of action, along with examples of the process or site of
action and types of toxicant, are outlined below.
Interference with receptors that transmit physical or chemical signals to cells:
Neurotransmitters (organophosphate pesticides)

Hormone receptors (halogenated aromatic hydrocarbons)
Enzymes (cyanides)
Transport proteins (carbon monoxide)
Interference with membrane function:
Membrane fluidity (organic solvents)

Mitochondrial membranes (organo-tin compounds)
Interference with cellular energy production:
Haemoglobin (carbon monoxide)

Electron transport inhibition (cyanides)
Covalent binding to biomolecules:
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Lipids peroxidation (carbon tetrachloride)

Nucleic acids (mutagens)
You can see that some of the examples given above include ranges of chemically
related toxic substances that possess a similar mechanism of action due to their closely
related chemical structure. It also follows from this that by understanding the
mechanism of action, it may be possible to predict other types of substance, of
different structure but similar mechanism of action that could interact with metabolic
processes in the same way as a particular toxicant.
Predictive studies of this type usually start by examining the physicochemical
properties of the substance to determine its vapour pressure, water and lipid solubility.
This information gives clues as to likely routes of exposure (inhalation, skin, or oral),
likelihood of absorption and possible routes of excretion of absorbed material. Then
further predictive information can be obtained from the structure of the substance
(including structures of impurities), through the use of structure activity relationships
and data on analogous substances referred to above.
Preliminary assessments of chemical carcinogens often begin with a close examination
of chemical structure. Whilst chemicals that have structures similar to known
carcinogens or mutagens are not necessarily carcinogenic themselves, they will be
assigned a high priority in any carcinogen testing programme. In addition, there is
evidence to show that certain chemical structures have been shown to be correlated
with carcenogenicity.
3.4 SUMMARY
In this study unit we have seen that there are legal requirements as to the toxicological
testing of new substances - the level of testing depends on the quantity of substance
to be produced.
A key concept in toxicology is the dose-response relationship, 'dose' being the amount
per unit body mass of toxic substance to which the organ is exposed, and 'response'
being the resultant effect. The mid-point of the S-shaped dose-response curve
represents the dose which would cause death in 50% of the organisms - LD50. LD90
enables estimation of the dose that will kill the majority (i.e. 90% of a sample of
animals). Lethal concentration (LC) can be determined for a specified duration of
exposure.
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There are three types of toxicity test - acute (to determine the effects which occur
within a short period after dosing); subacute (to provide information on the target
organs affected by the substance and the major toxic effects); and chronic (lifetime
exposure of animals to the substance under study).
Mutagenicity occurs as a result of interaction between mutagenic agents and the
genetic materials of organisms. The Ames test is the most common test for gene
mutation. Long-term animal toxicity studies, often with rats and dogs, are carried out
to assess the effects of human exposure to chemicals over long periods.
Chemical analogy studies assume that chemically related substances will show
similarities in toxic properties.
A collection of resources and online video lectures to supplement this element
can be found at http://www.agls.uidaho.edu/etoxweb/lectures/lectures.htm
4.0 Epidemiology
In this final section of study unit B5 we are going to look at epidemiology (determining
the cause having first observed the effects) by examining the main methodologies of
epidemiology, the sources of information available, their application and limitations and
also the use of epidemiological techniques in the workplace.
HISTORICAL PERSPECTIVE
You will remember that occupational health and hygiene are concerned with
recognition, measurement, evaluation and control. Epidemiology is the science which
forms the basis of the four stages. At its crudest, epidemiology may be said to be the
elucidation of the cause having first observed the effects. For example, if a number of
workers on a particular process are suddenly affected by dermatitis, i.e. the effect, it is
likely that the cause is of occupational origin, possibly a new raw material. However,
the cause can often only be established in the light of current knowledge and
understanding. John Snow (1813-1858) flew in the face of conventional wisdom when
he suggested that cholera was due to contaminated water rather than airborne
miasmas.
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A semblance of the cause-effect relationship in occupational disease has been

recognised since early times. Hippocrates, the father of medicine (born 460 BC), was
probably among the first to recognise lead as a cause of colic; and Pliny (23-79 AD)
describes mercurialism in writing of the diseases of slaves.
One of the greatest technical manuals ever written is De Re Metallica by Agricola
(Georg Bauer), first published in Basle in 1556. He described and illustrated in detail
the techniques and methods used by German mining engineers to win metallic ores
and also covered aspects of occupational diseases (he was a medical doctor by
profession). On miners in the Carpathian mountains he comments:
On ventilation: 'If a shaft is very deep and no tunnel reaches to it, or no drift
from another shaft connects to it, or when a tunnel is of great length and no
shaft reaches to it, then the air does not replenish itself. In such a case it (the
air) weighs heavily upon them (the miners), causing them to breathe with
difficulty and extinguishing lamps. It is therefore necessary to install machines
to enable the air to be renewed and for the miners to carry on their work.' (See
Figure 4.1.)
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Figure 4.1.
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On accidents: 'The Burgomeister gives no one permission to enter the mines

after blasting until the poisonous vapours are cleared.'
On diseases of the lung: 'If the dust has corrosive qualities, it eats away the
lungs and implants consumption in the body. In the mines of the Carpathian
mountains, women are found who have married seven husbands, all of whom
this terrible consumption has carried off to a premature death.'
To protect miners against the effects of the dust, Agricola advised purification of the air
by ventilation and the use of loose veils over their faces.
Paracelsus (1493-1541) published the first monograph devoted entirely to the
occupational diseases of mine and smelter workers (Von der Bergsucht und Anderen
Bergkrankheiten, 1567). Although he makes correct clinical observations, he then turns
to alchemical theories to explain them:
'The lung sickness comes through the power of the stars, in that their peculiar
characteristics are boiled out, which settle on the lungs in three different ways: in a
mercurial manner like a sublimated smoke that coagulates, like a salt spirit, which
passes from resolution to coagulation, and thirdly, like a sulphur, which is precipitated
on the walls by roasting.'
If Hippocrates is the father of medicine, then Bernardino Ramazzini (1633-1714) is the
father of occupational medicine. His De Morbis Artificum Diatriba (1700) contains
accounts of the occupational diseases suffered by miners of metals, healers by
inunction, chemists, potters, tinsmiths, glass-workers, painters, sulphur-workers,
blacksmiths, workers with gypsum and lime, apothecaries, cleaners of privies and
cesspits, fullers, oil pressers, tanners, cheese-makers, tobacco-workers, corpsecarriers, midwives, wetnurses, vintners and brewers, bakers and millers, starchmakers, sifters and measurers of grain, stone-cutters, launderers, workers handling
flax, jute and silk, bathmen, salt-makers, workers who stand for long periods,
sedentary workers, grooms, porters, athletes, runners, singers, preachers, farmers,
fishermen, soldiers, learner men, priests and nuns, printers, scribes and notaries,
confectioners, weavers, coppersmiths, carpenters, grinders of metals, brick-makers,
well-diggers, sailors and rowers, hunters, and soap-makers.
In short, most of the important occupations of the day. As a result of his investigations
he added an important question to the Hippocratic art, urging physicians to ask of their
patients, 'What is your occupation?' He also 'urged physicians to leave their
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apothecaries shop, which is redolent with cinnamon, and to visit the latrines where
they may see the cause of ill health.'
4.1 STATISTICS AND EPIDEMIOLOGY

Importance of Statistics
Few early writers produced statistics to support their accounts of occupational diseases and it
was not until after the publication of his famous Essay on the Principle of Population (1798) that
Malthus emphasised the importance of statistical techniques when he claimed that food supply
and birth rate increase in arithmetical and geometrical ratios respectively, so that poverty
(through lack of food) is the inevitable result of increased population.
William Farr was appointed as compiler of statistics at the newly formed General Register Office
(of births, marriages and deaths) in 1839 and by 1866 he was able to state, on the basis of
statistical analysis, that the curve of an epidemic (such as smallpox, typhoid or cholera) at first
ascends rapidly then slopes more slowly to a maximum, to fall more rapidly than it climbed
(Farrs Law). The General Record Office has published occupational mortality data every ten
years since introduced by Farr in 1851.
Cholera
Endemic in India for centuries, cholera became pandemic in Asia between 1816-1830 and reached
England in 1831. In the summer of 1854 cholera broke out in London, being particularly severe in
the poorly drained slums around St. Giles and Soho, giving the opportunity for John Snow to carry
out the first truly epidemiological investigation into the relationship between cause and effect of
a disease. The effect was obvious. After an incubation lasting about three days, victims suffer
from severe diarrhoea and vomiting, accompanied by cramps in the legs and abdomen. The skin
loses its elasticity due to dehydration, becoming cold and clammy, the heartbeat becomes
weakened and the pulse and voice very feeble. Before treatment with modern antibiotics,
patients would die after a few days and mortality rates were very high.
During the course of the epidemic Snow plotted the household of every death in the area and his
On the Mode of Communication of Cholera, 1855, includes the figures of his most famous field
study around the Broad Street pump. By plotting the incidence of deaths onto a map (Figure 4.2)
he was able to demonstrate that the nodal point was the Broad Street pump. This led to his initial
conclusion that it was the water from this pump which had been responsible for the outbreak.
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Further investigation revealed that shortly before the epidemic the Lambeth Water Company had
removed their waterworks to Thames Ditton, well above the tidal reaches of the Thames, and
hence the water was uncontaminated by London sewage. The Southwark and Vauxhall Water
Company, however, continued to supply water from the Thames at London Bridge. He found there
were 14 times more fatalities from cholera in people drinking the Southwark supply than in those
drinking the Thames Ditton supply. He became absolutely convinced when he learned of the
death of a Hampstead woman who sent a carrier daily to collect water from the Broad Street
pump and died of cholera as a result. Her niece, who had visited her for a day, also became the
only victim of the disease in her district. As Snow was proclaiming that dirty water was
responsible for the epidemic, so a Parliamentary enquiry was establishing the cause as stale air
from the closely packed tenements in the area, thus proving that Miasmatic Theory was still
prevalent amongst most eminent medical men of the day.
b2image036.jpg
Figure 4.2: Cholera Deaths Between 19 Aug and 30 Sept, 1854, as Plotted by John Snow
Plotting the Incidence of Legionnaires Disease
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Environmental Health Officers investigating two outbreaks of Legionnaires Disease around the
BBCs Bush House in 1987 and Leicester Square in 1988 used Snows method of plotting the
incidence onto maps in an effort to identify the source of the infection.
The technique has also been used in the investigation of complaints arising from the use of
pesticides and other agricultural chemicals. Some studies may take several years of intensive
investigation to complete, consuming thousands of man-hours of work.
4.2 SOURCES OF EPIDEMIOLOGICAL DATA

The first data used for the investigation of occupational causes of disease were population census
figures and death registrations, the only information available for such purposes at the time.
These days there is much more data available for the epidemiologist to use for studies and the
principal sources are given below.
National Records
The main national records available for study are:
Death Certificates
These provide a reasonably accurate and quantifiable measure of serious illness. However,
problems occur with:
The accuracy of the cause of death (this relies on the physicians decision as to the ultimate
The occupation of the deceased (this may be the occupation at the time of death but not
necessarily the one that caused the death).
Birth Certificates
These can be used in conjunction with data on congenital malformations and pregnancy
complications to study the effect of parents occupations on these conditions.
Morbidity
The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR)
requires the reporting and central recording of industrial accidents and diseases, whilst industrial
injury benefit claims and prescribed diseases are reported to the Department of Social Security.
However, problems with these sources of data include:
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Failure to report accidents and injury despite the legal requirement;

Errors in diagnosis or identification of occupational disease.
Local Records
Depending on the study in question, hospital records, data from family doctors, information
collected by professional associations (e.g. the Royal Society of Chemists morbidity and mortality
study) or trade union records may provide useful data for epidemiological studies.
In addition some large employers maintain continued surveillance on high risk workers as they
move within the company and also when they leave or retire.
If a specific study is being undertaken this type of local data may provide valuable information to
enable a fuller picture to be built up of particular employees health and employment history.
4.3 CRITERIA FOR CAUSE AND EFFECT

A number of important criteria must be satisfied in order to establish a definite
relationship between a diseases cause and effect:
Strength: the relative incidence of the disease in exposed and unexposed

groups.
Consistency: observing the disease in different places and at different times by

different observers.
Specificity: where the association (between cause and effect) is limited to

specific workers and to a particular type of disease there is a strong argument in
favour of causation.
Biological gradient: if an increase in dose or exposure brings about an increase

in incidence then there is strong evidence of causation.
Biologically plausible: the relationship should not conflict with known facts of the
natural history and aetiology of the disease.
Analogy: similar chemicals, biological agents and physical inputs being likely to
have similar effects.
Preventive action: if the preventive action works, i.e. there is a reduction in the
effect, then it is likely the cause was correctly identified, e.g. a reduction in an
atmospheric contaminant affecting the frequency or severity of the disease or
other associated event. It is perhaps this final criterion which may be said to be
the proof of the pudding.
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In the case of the original 1976 American Legionella outbreak, health investigators
identified the following causal factors:
Strength: early on it had been established that the victims were mainly
convention delegates.
Consistency: a similar outbreak had occurred in Pontiac in 1968 and shortly after
other outbreaks were identified in Vermont (1977), Indiana (1978) and Oxford,
England (1979).
Specificity: air conditioning plant was soon implicated as an indirect cause.
Biological gradient: eventually it was established that potential victims had to

inhale an aerosol containing a high concentration of Legionella pneumophilia.
Biological plausibility: A suggestion that an anti-military madman had murdered

the legionnaires smacked of hysteria rather than accounting for the known
biological facts.
Analogy: all the evidence pointed to a biological cause (bacterium, virus, etc.)
Preventive action: cleaning and sterilising possible water sources eliminated the
bacterium from water tanks and other water supplies.
The success of preventative action is proof that the epidemiologists had correctly
identified the cause of the disease, together with the events and circumstances
necessary to link cause with effect.
PROBLEMS IN ACHIEVING CONTROL

It is fortunate that the measures implemented for the control of Legionnaires Disease
and elimination of the bacterium from water systems proved simple and effective. This
is not always the case and sometimes the interval between implementation of control
measures and an observed decline in the incidence of a disease may cover many years.
In these circumstances it is inevitable that doubts will arise as to the effectiveness of
the control measures and consequently as to the actual cause. Some examples will
serve to illustrate the point.
Example 1: Lead Poisoning
Lead poisoning became notifiable in the potteries in 1896, when there were 351 cases
out of some 5,000 at risk. Although the overall rate began to fall almost immediately,
the number of deaths remained fairly constant for a number of years afterwards. Lead
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poisoning became notifiable in all factories in 1899 and the cases of poisoning fell from
more than a thousand in 1900 to 55 in 1960; but again the death rate did not follow a
similar pattern. Indeed, it increased in some years (see Figures 4.3 and 4.4). In the
electric accumulator industry the incidence of lead poisoning rose from 1900 until the
passing of the Lead Accumulator Regulations in 1924, after which there was a decline
in the incidence of poisonings (see Figure 4.5). Once again the death rate remained
relatively constant. It would have been comparatively easy in this period to suggest
that it was not lead which was responsible for the disease; but we now know that the
time lag is largely due to the long-term effects of lead poisoning and because the
bones store large amounts of lead, releasing it slowly over a number of years.
Figure 4.3: Lead Poisoning in the Potteries
Figure 19.4: Notified Cases of Lead Poisoning
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Figure 4.5: Notified Cases of Lead Poisoning in the Electric Accumulator

Industry
Example 2: Mesothelioma
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Diseases such as mesothelioma may have a latency period of as much as 40 years

between exposure and manifestation, so we must expect to diagnose causes of the
disease well into the next century, even though asbestos has been subject to tight
controls since the 1970s.
Example 3: Dermatitis
With diseases such as dermatitis, where the victim may become sensitised, the disease
may flare up again following only very small exposure to the harmful agent or to
another agent which is chemically analogous.
4.4 EPIDEMIOLOGICAL INVESTIGATIONS

An essential feature of epidemiological investigation is a count of the incidence of the
disease and a comparison of affected and unaffected populations. Nowadays is it more
usual to resort to more advanced statistical techniques rather than simple counting.
In 1664 King Charles II ordered that 'Bills of Mortality' be kept for each parish of
London so the extent of the Great Plague could be established accurately. The first
victim was in November 1664 and each week the number of victims gradually
increased, such that by April 1665 twenty-five died in one week. By late summer the
parishes of Clerkenwell, Shoreditch, Bishopsgate, Moorgate, Whitechapel and Stepney
had all been affected. A page from the Bills of Mortality makes interesting reading
(Figure 4.6).
Page 68 of 79
Figure 4.6: Page Copied From the Bills of Mortality
Page 69 of 79
From the data contained in these weekly reports we can calculate the relative incidence
of each cause of death and, from successive weeks, it was possible to tell whether the
plague was increasing or decreasing. We also have a record in this instance of two
industrial accidents - a drowning and a fall! You may be surprised by some of the data;
for example, the number who died from 'teeth'. In fact this was a combination of blood
poisoning and infection as a consequence of poor dental care. A number died from food
poisoning or other digestive disorders (collick, griping in the guts, rising of the lights,
scowring, surfeit and winde) as a result of poor hygiene. One died 'suddenly'!
Modern epidemiological investigations are far more sophisticated than this, as you will
see below.
4.5 Types of Epidemiological Study

We have already acknowledged that epidemiology is concerned with the distribution of
a particular occupational disease and the search to identify the occupational factors
that may be involved. We can therefore see that a representation of the workplace
situation involves individuals of different age, sex, occupation, race and duration of
employment experiencing continually varying exposures to workplace agents.
Within this changing workplace population, occupational ill-health may occur either
during employment, during future employment or after retirement. From this
complicated picture, which is changing with time, the epidemiologist must try and
design studies which will establish a cause and effect relationship between workplace
agents and occupational disease.
If we wish to investigate this process and/or the population there are two basic studies
that we can make.
Cross-sectional Studies
The cross-sectional study involves a 'snapshot in time' of the relevant workforce. A
section of workforce are examined over a short period of time. The advantage of this
type of study is that it is a quick and cheap opportunity to study the problem in hand,
but the disadvantage is that the population at risk is assessed over a narrow time
frame. This means that the investigators cannot look at exposure and the resulting
outcome over a period of time. The cross-sectional study therefore tends to be:
Outcome-selective: the study examines the prevalence of a particular

occupational condition within the population.
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Exposure-selective: the study examines a particular population that has been

exposed to a specified occupational condition.
For this reason cross-sectional studies are also known as prevalence studies. The
design of a cross-sectional study involves the following main stages:
(a) Establishing precise aims
(b) Defining the study population
(c) Determining the sample size - important for statistical purposes
(d) Recruitment of all relevant cases in the sample
(e) Analysis - prevalence rates in relation to sample groups
Longitudinal Studies
The longitudinal study involves investigation of the workforce over a significant period
of time. This type of investigation takes longer to carry out and is more expensive, but,
because it takes place over a period of time rather than at a specific point in time, it
provides the opportunity to study exposure and its outcome as a time-related chain of
events. Two types of longitudinal studies are commonly employed:
The Case-control Study
This type of study is retrospective, beginning with a definition of a group of cases and
relating these (along with non-cases or controls) to the past exposure history. The
main drawback of this type of study is obtaining accurate exposure history which may
need to go back as far as 40 years.
With the case-control study the investigation compares a group of individuals who have
the disease or condition with another group who do not. The comparison is made with
respect to past characteristics of both groups and, unlike the follow-up study (see
below) the outcome is known.
The case-control method may be used, for example, to investigate the frequency of
asbestos workers who have respiratory problems or lung disease against a control
group drawn from the general population. It is quicker and less expensive than a
cohort study (see below) and is often used as the first step to see if there may be an
association between a suspected cause and a known effect. It is also useful in
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investigating a disease of low prevalence. Unfortunately, however, case-controlled

studies are generally less informative than cohort studies and spurious associations are
likely to occur.
The Follow-up Study
This study takes a group of exposed (and possibly non-exposed control) persons where
the exposure is defined and accurately known. The group is then followed up over an
appropriate period of time to assess the eventual outcome of the exposure. This
method is prospective (following the group forward in time) and avoids the problem of
tracing exposure history retrospectively, as with the case-control study.
Follow-up studies are useful for:
Special exposure (e.g. Japanese atomic bomb survivors)
Ease of follow up (e.g. hospital patients, professional groups)
Geographical groupings (e.g. migrant studies)
A cohort study is a specific type of follow-up study where a population is defined in
advance for exposure characteristics, followed for a period of time and then the
outcome measured. Follow-up studies are designed to observe incidence of
occupational ill-health and should, naturally, extend over a period of time longer than
that required for the outcome to develop.
Such retrospective studies are used to determine whether there is an association, for
example, between exposure to asbestos (the cause) and the incidence of lung cancer
(the effect) and uses two groups (cohorts) of subjects:
Exposed
Unexposed (the control group).
The incidence of lung cancer is then calculated for each group and if significantly more
people suffer in the exposed group then there is strong evidence for cause and effect.
In cases where there is not sufficient past data to work on it will be necessary to set up
a prospective study.
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Cohort studies are concerned with the relationship between the cause, as evidenced by
the history and nature of the exposure, and the effect, i.e. the presence of the disease.
The advantages of cohort studies are that they provide:
A more accurate account of exposure related to deaths or disease and a direct
estimate of the risk associated with the causal factors;
Information on secular trends which reveal changes in the degree of risk.
Against this must be set the following disadvantages:
It may be necessary to wait many years for the development of the disease
(mesothelioma might take as long as 40 years to manifest itself);
Some of the cohort may be lost over the period of study.
4.6 USES AND LIMITATIONS OF EPIDEMIOLOGICAL STUDIES

There are five main uses of epidemiology in occupational health and hygiene:
Primary monitoring to identify hazards. Population studies are frequently the

only way of identifying an occupational risk of disease such as lung cancer,
coronary heart disease, varicose veins, or rheumatic disorders, because they are
common in the general population.
Secondary monitoring to keep known hazards under control. Surveillance of a

group of workers exposed to recognised hazards identifies any susceptible
individuals and assesses the value of preventive measures and the effectiveness
of control measures.
Determining causes helps to establish health standards. Studying groups of

workers may lead to a determination of the association with the exposure to a
contaminant such as a dust or vapour; leading to the establishment of the cause
and occupational hygiene standards such as workplace exposure limits (WELs).
Community studies reveal how many people are affected and how seriously.
Priorities can then be established enabling preventive action to be taken when
and where it is needed.
Evaluating health services to find out how they are used, their success in
reaching certain standards and the value attached to them by the population
they serve.
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In terms of the practical application of epidemiological methods to occupational health

and hygiene, secondary monitoring is particularly important and is now implemented
through the Control of Substances Hazardous to Health (COSHH) Regulations.
Primary monitoring, the recognition of hazards, may be said to be a consequence of
good primary procedures. Thus, if some workers begin to exhibit symptoms of
dermatitis where no previous incidence has been recognised, there is a strong
possibility that it has been caused by a change either in the process or in work
patterns, or by the introduction of a new or replacement raw material. Having observed
the effect it should be possible to determine the cause by studying work patterns and
raw materials.
As we have seen the purpose of the epidemiological study is to establish the
distribution of health-related events or states in a specified population and also the
factors responsible. This information can then be applied in the control of the particular
health problem.
Practical Application of Epidemiological Methods
In order to plan and implement an epidemiological study the following broad steps
need to be followed:
Establish the objectives of the study and what hypotheses need to be tested. (Is
disease A caused by agent B?)
Define the study population bearing in mind statistical limitations of study and
control group size.
Prepare a protocol and also any questionnaires needed.
Undertake a pilot study to test methodology.
Collect and analyse data.
Test hypotheses and record and report conclusions.
The exact detail of the study will depend on the type of epidemiological investigation
that is being performed.
Limitations of Epidemiology
The main problems of epidemiological studies, which have been touched on in the
previous sections, include:
Page 74 of 79
The 'healthy worker' effect, whereby the control group has a different health
status compared with the cases (pre-employment health screening has the effect
of excluding less healthy individuals and consequently raising the general health
of employed persons in comparison to those not in work).
A poor response rate which reduces the sample size and its statistical
significance.
A high turnover of study populations.
The latency period between exposure and effect is longer than the study period.
Poor quality of health effects data and/or exposure data.
No effect of exposure noted which may be a consequence of a poor or small

study population.
For an epidemiological study to be effective the following factors should be addressed:
Clearly formulated hypothesis and study objective
Appropriate study design
Collection of good quality health effects and exposure data
Valid population choice for case study and control
High response rate and good sampling strategy
Population size large enough and correct statistical techniques used
No-effect study result investigated for validity and or statistical significance
In this way the cause-association hypothesis that aims to relate occupational exposure
to incidences of ill-health should be able to be validated, either positively or negatively.
4.7 Notification of New Substances Regulations 1993

The Notification of New Substances Regulations 1993 are more commonly referred to
as NONS.
It is a European wide system that requires chemicals suppliers to get information on
substances that are new to the European market. This information is used to decide
whether or not the substance is dangerous. HSE together with the Environment Agency
are responsible for running the scheme in Great Britain.
If you make chemicals and supply them to others within the EU or if you import
chemicals then it is possible that these regulations apply to you. You may not even be
aware that you are supplying a new substance as it may be contained within a product.
For example, it could be the colorant in an ink-jet cartridge or part of a cleaning
product. Remember that these regulations only apply to new chemicals.
Page 75 of 79
New substance is anything which does not appear on the European Inventory of
Existing Commercial Chemical Substances (EINECS) an inventory which was
closed to new entries in 1981. Note, some chemicals which are not specifically listed
are deemed to be included (e.g. hydrates like copper sulphate pentahydrate is not
listed but is deemed to be included in the entry for the anhydrous). Even if something
is technically a new substance, it may be exempt from notification and testing e.g.
certain polymers and also chemicals below certain thresholds. The regulations place
duties on each manufacturer or importer (not downstream users/suppliers) who
manufactures in the EU or who imports into the EU. Notified chemicals will eventually
appear in the European LIst of Notified Commercial Chemical Substances (ELINCS).
Such an entry may then also make it to the Approved Supply List (UK implementation
of Annex I to the Dangerous Substances Directive 67/548/EEC) once the European
Chemicals Bureau have assessed the data and decided on a satisfactory EU-wide
classification.
This whole regime will be replaced with the Registration, Evaluation and Authorisation
of Chemicals (REACh) regulations (a directly enforceable European regulation) which
will remove the distinction between new and existing and require all chemicals
above certain thresholds to be registered and, if insufficient data available, tested too.
Some more hazardous chemicals will be subject to authorisation by the competent
authority to allow continued use. This will effectively extend the current system for new
substances to existing substances too (with some changes).
4.8 SUMMARY
Epidemiology is the determination of the cause having first observed the effects.
Sources of epidemiological data include national records, such as birth and death
certificates and morbidity records, and local medical and trade union records and
surveillance of high risk workers.
Important criteria that must be satisfied in order to establish a definite relationship
between a diseases cause and effect include: strength; consistency; specificity;
biological gradient; biologically plausible; analogy; and preventive action.
There are two main types of epidemiological study.
Cross-sectional studies (prevalence studies) are outcome-selective (examines the
prevalence of a particular occupational condition within the population) or exposureselective (examines a particular population that has been exposed to a specified
occupational condition). The design of a cross-sectional study involves establishing
Page 76 of 79
precise aims; defining the study population; determining the sample size; recruitment
of all the relevant cases in the sample; and analysis.
Longitudinal studies investigate the workforce over a significant period of time. The
case-control study (retrospective) begins with a definition of a group of causes and
relates these (along with controls) to the past exposure history.
The follow-up study (prospective) takes a group of exposed persons (and possibly nonexposed controls) and follows them up over an appropriate time period to assess the
eventual outcome of the exposure. Cohort studies are a specific type of follow-up
study.
There are, of course, limitations to epidemiology including the healthy worker effect; a
poor response rate; a high turnover of the study population; latency period between
exposure and effect longer than the study period; poor quality of data; and no effect of
exposure noted, perhaps due to a poor or small study population.
For an epidemiological study to be effective there should be: a clear hypothesis and
study objective; appropriate study design; collection of good quality data; valid
population choice; high response rate and good sampling strategy; large enough
population; and a no effect study result investigated for validity.
Weblink http://pmep.cce.cornell.edu/profiles/extoxnet/TIB/epidemiology.html
discusses the link between cigarette smoking and lung cancer.
Types of toxic effects caused by industrial chemicals
Toxic
Part of body
property
affected
Time scale
of
Effect
Example
appearence
Ammonia,
Irritant or
Any, but usually the
A few
Inflammation,
corrosive
eyes, lungs and skin
minutes to
burns and blisters sulphuric
several days of exposed area.
acid, nitrogen
Frequently healed oxides,

after acute
exposure. Chronic
exposure may
lead to permanent
damage.
Page 77 of 79
caustic soda
Fibrogenic
Generally lungs
Years
Gradual
Bauxite dust,
cumulative loss of asbestos,

lung function
bagasse
leading to
disability and
death if there is
chronic exposure.
Allergic
Any, but frequently
Days to
In lungs may lead Toluene, di-
lungs and skin
years
to chronic asthma- isocyanate

like disease and
(TDI), amine
permanent
hardeners for
disability. In skin
epoxy resins.
may produce
industrial
dermatitis.
Dermatitic
Skin
Days to
Inflamed, peeling
Strong acids,
years
skin rashes. May
alkalis,
result from chronic detergents,

exposure to
carbon
irritants, allergenic tetrachloride,

agents, solvents or trichloroethyl
detergents.
Carcinogenic
ene.
Any organs, bu
10 to 40
Cancer in affected 2-
frequently skin,
years
organ or tissue.
Naphthylamin
Ultimately this
e, certain tars
may cause
and oils,
premature death.
benzidine,
lungs, bladder
asbestos
Poisonous
Any organs but
A few
Death of cells in
Carbon
frequently liver,
minutes to
vital organis with
tetrachloride,
brain, kidney
many years eventula failure of mercury,

organ to carry out cadmium,
important
carbon
biological
monoxide,
functions.
hydrogen
Ultimately can
cyanide.
cause death.
Page 78 of 79
Asphyxiants
Lungs
Minutes
Page 79 of 79
Gases replace
Acetylene,
normal oxygen
carbon
content of air
dioxide

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Principles of toxicology and

Principles of toxicology and epidemiology

Element B2: Principles of toxicology and epidemiology .............................................................................. 4

1.1 Physical Nature of Airborne Contaminants ............................................................................................... 5

1.0 Classifying hazardous substances ................................................................................................................ 4

Principles of toxicology and epidemiology

4.8 SUMMARY ............................................................................................................................................................. 76

4.7 Notification of New Substances Regulations 1993 .............................................................................. 75

Principles of toxicology and epidemiology

Element B2: Principles of toxicology and epidemiology

Describe the classification of hazardous substances with reference to appropriate

Explain the principles of epidemiology and its application in health surveillance of

International Labour Standards, Chemical Safety Convention , C170,

Article 8: Chemical safety data sheets

International Labour Standards, Chemical Safety Recommendation , R177,

Articles 6 & 7: Classification

Section 2: General obligations

The International Programme of Chemical Safety (IPCS), INCHEM Health and

Minimum hours of tuition 7 hours.

1.0 Classifying hazardous substances

Principles of toxicology and epidemiology

1.1 Physical Nature of Airborne Contaminants

Principles of toxicology and epidemiology

Dusts : Solid particles made airborne by mechanical disintegration of bulk solid

Spray : Large liquid droplets produced by mechanical disruption of bulk liquid,

Fume : Small solid particles produced by condensation of vapours or gaseous

As well as size, particle shape is important in determining the effects of inhalation of

Principles of toxicology and epidemiology

1.2 Risk and safety phrases

Classification of chemical agents

Principles of toxicology and epidemiology

The key provisions of the Regulations are:

Suppliers of all substances or preparations classified as dangerous for supply

Dangerous substances must be supplied in a suitable package providing

Substances or preparations dangerous for supply must carry an appropriate

These particular requirements are covered in more detail below.

1.3 Categories of Danger

Chemicals that explode.

Chemicals that react exothermically with other

Chemicals that may catch fire in contact with air,

Chemicals that have an extremely low flash point

and boiling point, and gases that catch fire in

Principles of toxicology and epidemiology

Chemicals that at very low levels cause damage to

Chemicals that at low levels cause damage to

Chemicals that may cause cancer or increase its

Chemicals that induce heritable genetic defects or

increase their incidence.

Chemicals that produce or increase the incidence

reproductive of non-heritable effects in progeny and/or an

impairment in reproductive functions or capacity.

Chemicals that may cause damage to health.

Chemicals that may destroy living tissue on

Chemicals that may cause inflammation to the skin

dangerous for Chemicals that may present an immediate or

Table 1.1: Health Effects Classification of Hazardous Substances

Principles of toxicology and epidemiology

1.4 Safety Data Sheets

Identification of the substance

Composition and ingredients

First aid measures

Accidental release measures

Handling and storage

Exposure controls and personal protective equipment