(continued) Your employer is required to select respirators from the types listed in the respiratory protection subsection of the standard. Any respirator chosen must be approved by the National Institute for Occupational Safety and Health (NIOSH) under the provisions of 42 CFR part 84. The respirator selection table will enable your employer to choose a type of respirator which will give you proper protection based on your airborne lead exposure. Your employer may select a type of respirator that provides greater protection than that required by the standard; that is, one recommended for a higher concentration of lead than that to which you are exposed.
An air purifying respirator is any respirator which has a filter, cartridge or canister which cleans the work room air as you breathe it. The typical air purifying respirator is a negative pressure respirator because it requires the force of your inhalation to draw air through the filtering element. It is less protective than a powered air purifying respirator (PAPR) which also has a filter, cartridge or canister to clean the air, but a power source which continuously blows filtered air into your breathing zone. Your employer might make a PAPR available to you to ease the burden of having to wear a negative pressure air purifying respirator for long periods of time. The standard provides that you can obtain a PAPR upon request.
Supplied-air respirators are also available which, as the name implies, are respirators to which breathing quality air is supplied from a source such as an air compressor, blower or compressed air cylinder. Three types of supplied-air respirators are availabledemand, pressure demand, and continuous flow. The demand-type requires the force of inhalation to open a diaphragm valve thus admitting air from the supply source. As any leakage around the facepiece will permit the concurrent admission of contaminated air, the demand-type only provides protection generally equivalent to that of the typical negative pressure air purifying respirator of the same facepiece type. Greater protection is provided by either the pressure-demand or continuous-flow types as positive air pressure exists within the respirator at all times.
Your employer must also start a Respiratory Protection Program in accordance with General Industry Safety Order 5144. This program must include written procedures for the proper selection, use, cleaning, storage, and maintenance of respirators.
Your employer must assure that your respirator facepiece fits properly. Proper fit of a respirator facepiece is critical and no single facepiece fits all facial configurations equally well. Obtaining a proper fit thus may require your employer to make available two or three different mask types in order that facepiece leakage is minimized for each employee. In order to assure that your respirator fits properly and that facepiece leakage is minimized, your employer must give you either a "quantitative or qualitative fit test" as specified in Appendix A of Section 5144, Respiratory Protection.
You must also receive from your employer proper training in the use of respirators. Your employer is required to teach you how to wear a respirator, to know why it is needed, and to understand its limitations.
The standard provides that if your respirator uses filter elements, you must be given an opportunity to change the filter elements whenever an increase in breathing resistance is detected. You also must be permitted to periodically leave your work area to wash your face and respirator facepiece whenever necessary to prevent skin irritation. If you ever have difficulty in breathing during a fit test or while using a respirator, your employer must make a medical examination available to you to determine whether you can safely wear a respirator. The result of this examination may be to give you a positive pressure respirator (which reduces breathing resistance) or to provide alternative means of protection.
V. Protective Work Clothing and Equipment
If you are exposed to lead above the PEL, or if you are exposed to lead compounds such as lead arsenate or lead azide which can cause skin and eye irritation, your employer must provide you with protective work clothing and equipment appropriate for the hazard. If work clothing is provided, it must be provided in a clean and dry condition at least weekly, and daily if your exposure to airborne lead is greater than 150 m g/M 3. Appropriate protective work clothing and equipment can include coveralls or similar full-body work clothing, gloves, hats, shoes or disposable shoe coverlets, and face shields or vented goggles. Your employer is required to provide all such equipment at no cost to you. He is responsible for providing repairs and replacement as necessary, and also is responsible for the cleaning, laundering or disposal of protective clothing and equipment. Contaminated work clothing or equipment must be removed in change rooms and not worn home or you will extend your exposure and expose your family since lead from your clothing can accumulate in your house, car, etc. Contaminated clothing which is to be cleaned, laundered or disposed of must be placed in closed containers in the change room. At no time may lead be removed from protective clothing or equipment by any means which disperses lead into the workroom air.
VI. Housekeeping
Your employer must establish a housekeeping program sufficient to maintain all surfaces as free as practicable of accumulations of lead dust. Vacuuming is the preferred method of meeting this requirement, and the use of compressed air to clean floors and other surfaces is absolutely prohibited. Dry or wet sweeping, shoveling, or brushing may not be used except where vacuuming or other equally effective methods have been tried and do not work. Vacuums must be used and emptied in a manner which minimizes the reentry of lead into the workplace.
VII. Hygiene Facilities and Practices
The standard requires that change rooms, showers, and lunchrooms be made available to workers exposed to lead above the PEL. When the PEL is exceeded, the employer must assure that food and beverage is not present or consumed, tobacco products are not present or used, and cosmetics are not applied, except in these facilities. Change rooms, showers, and lunchrooms, if available, must be used by workers exposed in excess of the PEL. After showering, no clothing or equipment worn during the shift may be worn home, and this includes shoes and underwear. Your own clothing worn during the shift should be carried home and cleaned carefully so that it does not contaminate your home. Lunchrooms may not be entered with protective clothing or equipment unless surface dust has been removed by vacuuming, downdraft booth, or other cleaning method. Finally, workers exposed above the PEL must wash their hands and faces prior to eating, drinking, smoking or applying cosmetics.
All of the facilities and hygiene practices just discussed are essential to minimize additional sources of lead absorption from inhalation or ingestion of lead that may accumulate on you, your clothes, or your possessions. Strict compliance with these provisions can virtually eliminate several sources of lead exposure which significantly contribute to excessive lead absorption.
VIII. Medical Surveillance
The medical surveillance program is part of the standard's comprehensive approach to the prevention of lead-related disease. Its purpose is to supplement the main thrust of the standard which is aimed at minimizing airborne concentrations of lead and sources of ingestion. Only medical surveillance can determine if the other provisions of the standard have effectively protected you as an individual. Compliance with the standard's provisions will protect most workers from the adverse effects of lead exposure, but may not be satisfactory to protect individual workers (1) who have high body burdens of lead acquired over past years, (2) who have additional uncontrolled sources of non-occupational lead exposure, (3) who exhibit unusual variations in lead absorption rates, or (4) who have specific non-work related medical conditions which could be aggravated by lead exposure (e.g., renal disease, anemia). In addition, control systems may fail, or hygiene and respirator programs may be inadequate. Periodic medical surveillance of individual workers will help detect those failures. Medical surveillance will also be important to protect your reproductive ability regardless of whether you are a man or woman.
All medical surveillance required by the standard must be performed by or under the supervision of a licensed physician. The employer must provide required medical surveillance without cost to the employees and at a reasonable time and place. The standard's medical surveillance program has two parts periodic biological monitoring and medical examinations.
Your employer's obligation to offer medical surveillance is triggered by the results of the air monitoring program. Medical surveillance must be made available to all employees who are exposed in excess of the action level (without regard to the use of respirators) for more than 30 days a year. The initial phase of the medical surveillance program, which includes blood lead level tests and medical examinations, must be completed for all covered employees within 150 days of the effective date of the lead standard. Priority within this first round of medical surveillance must be given to employees whom the employer believes to be at greatest risk from continued exposure (for example, those with the longest prior exposure to lead, or those with the highest current exposure). Thereafter, the employer must periodically make medical surveillance both biological monitoring and medical examinations available to all covered employees.
Biological monitoring under the standard consists of blood lead level (PbB) and zinc protoporphyrin tests at least every 6 months after the initial PbB test. If a worker's PbB exceeds 40 m g/100g the monitoring frequency must be increased from every 6 months to at least every 2 months and not reduced until two consecutive PbBs indicate a blood lead level below 40 m g/100g. Each time your PbB is determined to be over 40 m g/100g, your employer must notify you of this in writing within five working days of his receipt of the test results. The employer must also inform you that the standard requires temporary medical removal with economic protection when your PbB exceeds certain criteria (See Discussion of Medical Removal Protection). During the first year of the standard, this removal criterion is 80 m g/100g. Anytime your PbB exceeds 80 m g/100g your employer must make available to you a prompt follow-up PbB test to ascertain your PbB. If the two tests both exceed 80 m g/100g and you are temporarily removed, then your employer must make successive PbB tests available to you on a monthly basis during the period of your removal.
Medical examinations beyond the initial one must be made available on an annual basis if your blood lead level exceeds 40 m g/100g at any time during the preceding year. The initial examination will provide information to establish a baseline with which subsequent data can be compared. An initial medical examination must also be made available (prior to assignment) for each employee being assigned for the first time to an area where the concentration of airborne lead equals or exceeds the action level. In addition, a medical examination or consultation must be made available as soon as possible if you notify your employer that you are experiencing signs or symptoms commonly associated with lead poisoning or that you have difficulty breathing while wearing a respirator or during a respirator fit test. You must also be provided a medical examination or consultation if you notify your employer that you desire medical advice concerning the effects of current or past exposure to lead on your ability to procreate a healthy child.
Finally, appropriate follow-up medical examinations or consultations may also be provided for employees who have been temporarily removed from exposure under the medical removal protection provisions of the standard (See Part IX, below).
The standard specifies the minimum content of pre-assignment and annual medical examinations. The content of other types of medical examinations and consultations is left up to the sound discretion of the examining physician. Pre-assignment and annual medical examinations must include (1) a detailed work history, (2) a thorough physical examination, and (3) a series of laboratory tests designed to check your blood chemistry and your kidney function. In addition, at any time upon your request, a laboratory evaluation of male fertility will be made (microscopic examination of a sperm sample), or a pregnancy test will be given.
The standard does not require that you participate in any of the medical procedures, tests, etc. which your employer is required to make available to you. Medical surveillance can, however, play a very important role in protecting your health. You are strongly encouraged, therefore, to participate in a meaningful fashion The standard contains a multiple physician review mechanism which provides you with the right to a second medical opinion from a physician of your choice if you are dissatisfied with an examination by a physician chosen by your employer. The standard requires the two physicians to attempt a resolution of any difference in their opinions. If any dispute remains unresolved, the standard provides that a third physician, selected by you and your employer, shall make a final, binding medical determination unless you and your employer reach an agreement which is otherwise consistent with the recommendations of one of the physicians. Generally, your employer will choose the physician who conducts medical surveillance under the lead standard unless you and your employer otherwise agree on the choice of a physician or physicians. Some companies and unions have agreed in advance, for example, to use certain independent medical laboratories or panels of physicians. Any of these arrangements are acceptable so long as required medical surveillance is made available to workers.
The standard requires your employer to provide certain information to a physician to aid in his or her examination of you. This information includes (1) the standard and these appendices, (2) a description of your duties as they relate to lead exposure, (3) your exposure level, (4) a description of personal protective equipment you wear, (5) prior blood lead level results, and (6) prior written medical opinions concerning you that the employer may have. After a medical examination or consultation the physician must prepare a written report which must contain (1) the physician's opinion as to whether you have any medical condition which places you at increased risk of material impairment to health from exposure to lead, (2) any recommended special protective measures to be provided to you, (3) any blood lead level determinations, and (4) any recommended limitation on your use of respirators. This last element must include a determination of whether you can wear a powered air purifying respirator (PAPR) if you are found unable to wear a negative pressure respirator.
The medical surveillance program of the lead standard may at some point in time serve to notify certain workers that they have acquired a disease or other adverse medical condition as a result of occupational lead exposure. If this is true, workers may have legal rights to compensation from public agencies, their employers, firms that supply hazardous products to their employers, or other persons. The results of the medical surveillance program can significantly affect the legal remedies of a worker who has acquired a job-related disease or impairment.
The medical surveillance subsection of the standard also contains provisions dealing with chelation. Chelation is the use of certain drugs (administered in pill form or injected into the body) to reduce the amount of lead absorbed in body tissues. Experience accumulated by the medical and scientific communities has largely confirmed the effectiveness of this type of therapy for the treatment of very severe lead poisoning. On the other hand, it has also been established that there can be a long list of extremely harmful side effects associated with the use of chelating agents. The medical community has balanced the advantages and disadvantages resulting from the use of chelating agents in various circumstances and has established when the use of these agents is acceptable. The standard includes these accepted limitations due to a history of abuse of chelation therapy by some lead companies. The most widely used chelating agents are calcium disodium EDTA, Ca Na 2 EDTA), calcium disodium versenate (Versenate), and d-penicillamine (penicillamine or Cupramine).
The standard prohibits "prophylactic chelation" of any employee by any person the employer retains, supervises or controls. "Prophylactic chelation" is the routine use of chelating or similarly acting drugs to prevent elevated blood levels in workers who are occupationally exposed to lead, or the use of these drugs to routinely lower blood levels to predesignated concentrations believed to be 'safe'. It should be emphasized that where an employer takes a worker who has no symptoms of lead poisoning and has chelation carried out by a physician (either inside or outside of a hospital) solely to reduce the worker's blood lead level, such practice is generally considered prophylactic chelation. The use of a hospital and a physician does not mean that prophylactic chelation is not being performed. Routine chelation to prevent increased or reduce current blood lead levels is unacceptable whatever the setting. The standard allows the use of "therapeutic" or "diagnostic" chelation if administered under the supervision of a licensed physician in a clinical setting with thorough and appropriate medical monitoring. Therapeutic chelation responds to severe lead poisoning where there are marked symptoms. Diagnostic chelation involves giving a patient a dose of the drug then collecting all urine excreted for some period of time as an aid to the diagnosis of lead poisoning.
In cases where the examining physician determines that chelation is appropriate, you must be notified in writing of this fact before such treatment. This will inform you of a potentially harmful treatment and allow you to obtain a second medical opinion if you choose to do so.
IX. Medical Removal Protection
Excessive lead absorption subjects you to increased risk of disease. Medical removal protection (MRP) is a means of protecting you when, for whatever reasons, other methods such as engineering and administrative controls, work practices, and respirators have failed to provide the protection you need. MRP involves the temporary removal of a worker from his or her regular job to a place of significantly lower exposure without any loss of earnings, seniority, or other employment rights or benefits. The purpose of this program is to cease further lead absorption and allow your body to naturally excrete lead which has previously been absorbed. Temporary medical removal can result from an elevated blood lead level, or a medical opinion. Up to eighteen months of protection is provided as a result of either form of removal. The vast majority of removed workers, however, will return to their former jobs long before this eighteen-month period expires. The standard contains special provisions to deal with the extraordinary but possible case where a worker's bloodlead level does not adequately decline during eighteen months of removal.
During the first year of the standard, if your blood lead level is 80 m g/100g or above, you must be removed from any exposure where your air lead level without a respirator would be 100 m g/m 3 or above. If you are removed from your normal job you may not be returned until your blood lead level declines to at least 60 m g/100g. These criteria for removal and return will change according to the following schedule during subsequent years.
Removal blood Air lead Return blood
lead ( m g/100g) ( m g/M 3)lead ( m g/100g)
Second Year.......... 70 and above.... 50 and above.... At or below 50.
Third and
Fourth Years........ 60 and above.... 30 and above.... At or below 40.
Fifth and
Succeeding Years.... 50 and above.... 30 and above.... At or below 40.
averaged over
six months.
You may also be removed from exposure even if your blood lead levels are below these criteria if a medical determination indicates that you temporarily need reduced lead exposure for medical reasons. If the physician who is implementing your employer's medical program makes a written opinion recommending your removal or other special protective measures, your employer must implement the physician's recommendation. If you are removed in this manner, you may only be returned when the doctor indicates that it is safe for you to do so.
The standard does not give specific instructions dealing with what an employer must do with a removed worker. Your job assignment upon removal is a matter for you, your employer and your union (if any) to work out consistent with procedures or agreements for job assignments which may exist in your place of employment. Each removal must be accomplished in a manner consistent with existing collective bargaining relationships. Your employer is given broad discretion to implement temporary removals so long as no attempt is made to override existing agreements. Similarly, a removed worker is provided no right to veto an employer's choice which satisfies the standard.
In most cases, employers will likely transfer removed employees to other jobs with sufficiently low lead exposure. Alternatively, a worker's hours may be reduced so that the time-weighted average exposure is reduced, or he or she may be temporarily laid off if no other alternative is feasible.
In all of these situations, MRP benefits must be provided during the period of removal that is, you continue to receive the same earnings, seniority, and other rights and benefits you would have had if you had not been removed. Earnings include more than just your base wage; they include overtime, shift differentials, incentives, and other compensation you would have earned if you had not been removed. During the period of removal you must also be provided with appropriate follow-up medical surveillance. If you were removed because your blood lead level was too high, you must be provided with a monthly blood test. If a medical opinion caused your removal, you must be provided medical tests or examinations that the doctor believes to be appropriate. If you do not participate in this follow up medical surveillance, you may lose your eligibility for MRP benefits.
When you are medically eligible to return to your former job, your employer must return you to your "former job status." This means that you are entitled to the position, wages, benefits, etc., you would have if you had not been removed. If you would still be in your old job if no removal had occurred, you are to be returned to this job. If you would not be in your old job, the job assignment to which you return must be consistent with the decision which your employer would have been obliged to make had no removal occurred. MRP only seeks to maintain your rights, not expand them or diminish them.
If you are removed under MRP and you are also eligible for worker compensation or other compensation for lost wages, your employer's MRP benefits obligation is reduced by the amount that you actually receive from these other sources. Similarly, if you obtain other employment during the time you are laid off, the benefits you receive under MRP are reduced by the amount you earn in such other employment.
The standard also covers situations where an employer voluntarily removes a worker from exposure to lead due to the effects of lead on the employee's medical condition, even though the standard does not require removal. In these situations MRP benefits must also be provided as though the standard required removal. Finally, it is important to note that in all cases where removal is required, respirators cannot be used as a substitute. Respirators may be used before removal becomes necessary, but not as an alternative to a transfer to a low exposure job or to a lay-off with MRP benefits.
X. Employee Information and Training
Your employer is required to provide an information and training program for all employees exposed to lead at or above the action level or who may suffer skin or eye irritation from lead. This program must inform these employees of the specific hazards associated with their work environment, protective measures which can be taken, the danger of lead to their bodies (including their reproductive systems), and their rights under the standard. In addition your employer must make readily available to all employees, including those exposed below the action level, a copy of the standard and these appendices.
Your employer is required to complete this training program for all employees within 180 days of the effective date of the lead standard. Subsequently, all new employees (who may be exposed to lead at or above the action level or for whom the possibility exists of eye or skin irritation from lead exposure) must be trained prior to initial assignment.
This training program must also be provided at least annually thereafter.
XI. Signs
The following warning sign must be posted in work areas where the exposure to lead exceeds the PEL:
WARNING LEAD WORK AREA POISON NO SMOKING OR EATING
XII. Recordkeeping
Your employer is required to keep all records of exposure monitoring for airborne lead. These records must include the name and job classification of employees measured, details of the sampling and analytic techniques, the result of this sampling, and the type of respiratory protection being worn by the person sampled. Your employer is also required to keep all records of biological monitoring and medical examination results. These must include the names of the employee, the physician's written opinion, and a copy of the results of the examination. All of the above kinds of records must be kept for 40 years or for at least 20 years after your termination of employment, whichever is longer.
Recordkeeping is also required if you are temporarily removed from your job under the medical removal protection program. This record must include your name and social security number, the date of your removal and return, how the removal was or is being accomplished, and whether or not the reason for the removal was an elevated blood lead level. Your employer is required to keep each medical removal record only for the duration of an employee's employment.
The standard requires that if you request to see or copy environmental monitoring, blood lead level (PbB) monitoring, or medical removal records, they must be made available to you or to a representative that you authorize. Your union also has access to these records. Upon your request, your complete medical records must also be provided to you, to your physician or to any other person whom you may specifically designate. Your union does not have access to your personal medical records unless you authorize such access.
XIII. Observation of Monitoring
When air monitoring for lead is performed at your workplace as required by the standard, your employer must allow you or someone you designate to observe the monitoring. The observer is entitled to an explanation of the measurement procedure and to record the results obtained. Since results will not normally be available at the time of the monitoring, the observer is entitled to record or receive the results of the monitoring when returned by the laboratory. Your employer is required to provide the observer with any personal protective devices required to be worn by employees working in the area that is being monitored. The employer must require the observer to wear all such equipment and to comply with all other applicable safety and health procedures.
XIV. Effective Date
The standard's effective date is September 8, 1979, and the employer obligations under the standard begin to come into effect as of that date.
XV. For Additional Information
A. Copies of the Federal lead standard and explanatory materials can be obtained free of charge by calling or writing the OSHA Office of Publications, Room S-1212, United States Department of Labor, Washington, D.C. 20210; Telephone, (202) 523-6138. The following publications are available:
1. The Federal lead standard and summary of the statement of reasons (preamble), Federal Register, Volume 43, pp. 52952-53014, November 14, 1978.
2. The full statement of reasons (preamble), Federal Register, Volume 43, pp. 54354-54509, November 21, 1978.
3. Partial Administrative Stay and Corrections to the Federal lead standard, Federal Register, Volume 44, pp. 5446-5448, January 26, 1979.
4. Notice of the Partial Judicial Stay, Federal Register, Volume 44, pp. 14554- 14555, March 13, 1979.
5. Corrections to the preamble, Federal Register, Volume 44, pp. 20680-20681, April 6, 1979.
6. Additional correction to the preamble concerning the construction industry, Federal Register, Volume 44, p. 50338, August 28, 1979.
7. Appendices A, B and C to the Federal lead standard, Federal Register, Volume 44, pp. 60980-60994, October 23, 1979. Corrections to the appendices, Federal Register, Volume 44, p. 68828, November 30, 1979.
8. Notice of Limited Reopening of Rulemaking Record (and summary of U.S. Court of Appeals decision), Federal Register, Volume 45, pp. 63881-3, September 26, 1980.
9. Supplemental feasibility statement (in response to U.S. Court of Appeal's remand order), Federal Register, Volume 46, pp. 6134-6228, January 21, 1981.
10. Revised supplemental feasibility statement, Federal Register, Volume 46, pp. 60758-60776, December 11, 1981.
11. Revisions of the Federal standard and appendices and new Appendix D. Federal Register, Volume 47, pp. 51110-51119, November 12, 1982.
B. Additional information about the California lead standard, its enforcement, and your employer's compliance can be obtained from the nearest CAL/OSHA Consulting Service Office in Downey, Fresno, Panorama City, Sacramento, San Diego, and San Francisco. The CAL/OSHA Consulting Service is listed in telephone directories under California State Government/Industrial Relations Department.
Appendix C
Medical Surveillance Guidelines
Introduction
The occupational health standard for lead was promulgated to protect workers exposed to lead which, as defined by the standard, includes metallic lead, all inorganic lead compounds and organic lead soaps but excludes all other organic lead compounds. The term "inorganic lead" used throughout this appendix is meant to be synonymous with the definition of lead set forth in the standard.
Under this final standard in effect as of September 8, 1979, occupational exposure to inorganic lead is to be limited to 50 mu g/M 3 (micrograms per cubic meter) based on an 8-hour time-weighted average (TWA). This level of exposure must be achieved through a combination of engineering, work practice, and administrative controls (in periods of time ranging from 1 to 10 years) in primary lead smelting, secondary lead smelting, electronics, gray iron foundries, ink manufacture, paints and coatings manufacture, can manufacture, and printing. In these industries, respirators may be used to meet the 50 mu g/M 3 exposure limit pending the implementation of the prescribed controls. For all other industries, there is no prescribed period during which compliance with the PEL must be achieved by controls other than respiratory protection.
The standard also provides for a program of biological monitoring and medical surveillance for all employees exposed to levels of inorganic lead above the action level of 30 mu g/M 3 (TWA) for more than 30 days per year.
The purpose of this document is to outline the medical surveillance provisions of the standard for inorganic lead and to provide further information to the physician regarding the examination and evaluation of workers exposed to inorganic lead.
Section I provides a detailed description of the monitoring procedure including the required frequency of blood testing for exposed workers, provisions for medical removal protection (MRP), and notification and recordkeeping requirements of the employer. Discussions of respirator use, respirator monitoring, and chelation therapy are also included.
Section II discusses the toxic effects and clinical manifestations of lead poisoning and effects of lead intoxication on enzymatic pathways in heme synthesis. The adverse effects on both male and female reproductive capacity and on the fetus are also discussed.
Section III outlines the recommended medical evaluation of the worker exposed to inorganic lead including details of the medical history, physical examination, and recommended laboratory tests, which are based on the toxic effects of lead as discussed in Section II.
Section IV provides detailed information concerning the laboratory tests available for the monitoring of exposed workers. Also discussed are the relative value of each test and the limitations and precautions which are necessary in the interpretation of laboratory results.
I. Medical surveillance and monitoring requirements for workers exposed to inorganic lead.
Under the occupational health standard for inorganic lead, a program of biological monitoring and medical surveillance is to be made available to all employees exposed to lead above the action level of 30 mu g/M [FN3] TWA for more than 30 days each year. This program consists of periodic blood sampling and medical evaluation to be performed on a schedule which is defined by previous laboratory results, worker complaints or concerns, and the clinical assessment of the examining physician.
Under this program, the blood lead level of all employees who are exposed to lead above the action level of 30 mu g/M [FN3] is to be determined at least every six months. The frequency is increased to every two months for employees whose last blood lead level was between 40 mu g/100g whole blood and the level requiring employee medical removal to be discussed below. For employees who are removed from exposure to lead due to an elevated blood lead, a new blood lead level must be measured monthly. A zinc protoporphyrin (ZPP) measurement is required on each occasion that a blood lead level measurement is made.
An annual medical examination and consultation performed under the guidelines discussed in Section III is to be made available to each employee for whom a blood test conducted at any time during the preceding 12 months indicated a blood lead level at or above 40 mu g/100 g. Also, an examination is to be given to all employees prior to their assignment to an area in which airborne lead concentrations reach or exceed the action level. In addition, a medical examination must be provided as soon as possible after notification by an employee that the employee has developed signs or symptoms commonly associated with lead intoxication, that the employee desires medical advice regarding lead exposure and the ability to procreate a healthy child, or that the employee has demonstrated difficulty in breathing during a respirator fitting test or during respirator use. An examination is also to be made available to each employee removed from exposure to lead due to a risk of sustaining material impairment to health, or otherwise limited or specially protected pursuant to medical recommendations.
Results of biological monitoring or the recommendations of an examining physician may necessitate removal of an employee from further lead exposure pursuant to the standard's medical removal protection (MRP) program. The objective of the MRP program is to provide temporary medical removal to workers either with substantially elevated blood lead levels or otherwise at risk of sustaining material health impairment from continued substantial exposure to lead. The guidelines which are summarized in the following table were created under the standard for the temporary removal of an exposed employee and his or her subsequent return to work in an exposure area.
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Effective Date
---------------------------------------------------------------------
---------------------------------------------------------------------
9/8/79 9/8/80 9/8/81
---------------------------------------------------------------------
A. Blood lead level >=80 >=70 >=60
requiring employee <
>g/100g <>g/100g <>g/100g
medical removal.
(Level must be
confirmed with
second follow-up
blood lead
level within two
weeks of first
report.)
B. Frequency which
employees exposed
to action level of
lead (30
<>g/m<>
TWA) must have
blood lead level
checked (ZPP is
also strongly
recommended in
each occasion that
a blood lead is
obtained):
1. Last blood level Every 6 months Every 6 months Every 6 months
less than 40
<>g/100g
2. Last blood lead Every 2 months Every 2 months Every 2 months
level between 40
<>g/100g
and level requriing
medical removal
(see A above).
3. Employees removed Every 1 month Every 1 month Every 1 month
from exposure
to lead because of
an elevated blood
lead level.
C. Permissible <100 <>g/m <50 <>g/m <30<>g/m
airborne exposure [FN3]8 [FN3]8 [FN3]8
limit for
workers removed from hr. TWA. hr. TWA. hr. TWA.
work due to an
elevated blood lead
level (without
regard
to respirator
protection).
D. Blood lead level <=60<>g/ <=50 <>g/ <=40<>g/
confirmed with a 100g 100 g 100 g
second
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1...+...10....+...20....+...30....+...40....+...50....+...60....+...7
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----------------------------------
9/8/82 9/8/83
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>=60 >=60<>g/100 g
<>g/100g or average of
last
three blood
samples over
previous
6 months
(whichever is
over a
longer time
period) is 50
<>g/100g
or greater unless
last blood
sample
is 40
<>g/100g or
less.
Every 6 months Every 6 months
Every 2 months Every 2 months.
Every 1 month Every 1 month.
<30 <>g/m <30 <>g/m
[FN3]8 [FN3]8
hr.TWA. hr. TWA.
<=40 <>g/ <=40<>g/
100g 100g.
----------------------------------
70..+...80....+...90....+....0....
Note: When medical opinion indicates that an employee is at risk of material impairment from exposure to lead, the physician can remove an employee from exposures exceeding the action level (or less) or recommend special protective measures as deemed appropriate and necessary. Medical monitoring during the medical removal period can be more stringent than noted in the table above if the physician so specifies. Return to work or removal of limitations and special protection is permitted when the physician indicates that the worker is no longer at risk of material impairment.
Under the standard's ultimate worker removal criteria, a worker is to be removed from any work having any eight-hour TWA exposure to lead of 30 mu g/M [FN3] or more (without regard to the use of respirators) whenever either of the following circumstances apply: (1) a blood lead level of 60 mu g/100g or greater is obtained and confirmed by a second follow-up blood lead level performed within two weeks after the employer receives the results of the first blood sampling test, or (2) the average of the previous three blood lead determinations or the average of all blood lead determinations conducted during the previous six months, whichever encompasses the longest time period, equals or exceeds 50 mu g/100g, unless the last blood sample indicates a blood lead level at or below 40 mu g/100g in which case the employee need not be removed. Medical removal is to continue until two consecutive blood lead levels are 40 mu g/100g or less.
During the first two years that the ultimate removal criteria are being phased in, the return criteria have been set to assure that a worker's blood lead level has substantially declined during the period of removal. From September 8, 1979 to September 8, 1980, the blood lead level requiring employee medical removal is 80 m g/100 g. Workers found to have a confirmed blood lead level at or above this value need only be removed from work having a daily 8-hour TWA exposure to lead at or above 100 mu g/M [FN3]. (Respirators are not to be used as a means of achieving this level of exposure.) Workers so removed are to be returned to work when their blood lead levels are at or below 60 mu g/100g of whole blood. From September 8, 1980 to September 8, 1981, the blood lead level requiring medical removal is 70 mu g/100g. During this period workers need only be removed from jobs having a daily 8-hour TWA exposure to lead at or above 50 mu g/M [FN3] (without respirator use) and are to be returned to work when a blood lead level no greater than 50 mu g/100g is achieved. Beginning September 8, 1981, return depends on a worker's blood lead level declining to 40 mu g/100g of whole blood.
As part of the standard, the employer is required to notify in writing each employee whose blood lead level exceeds 40 mu g/100g. In addition each such employee is to be informed that the standard requires medical removal with MRP benefits, discussed below, when an employee's blood lead level exceeds the above defined limits.
In addition to the above blood lead level criteria, temporary worker removal may also take place as a result of medical determinations and recommendations. A written medical opinion must be prepared after each examination pursuant to the standard. If the examining physician includes a medical finding, determination or opinion that the employee has a medical condition which places the employee at increased risk of material health impairment from exposure to lead, then the employee must be removed from exposure to lead at or above the action level. Alternatively, if the examining physician recommends special protective measures for an employee (e.g., use of a powered air purifying respirator) or recommends limitations on an employee's exposure to lead, then the employer must implement these recommendations. Recommendations may be more stringent than the specific provisions of the standard. The examining physician, therefore, is given broad flexibility to tailor special protective procedures to the needs of individual employees. This flexibility extends to the evaluation and management of pregnant workers and male and female workers who are planning to raise children. Based on the history, physical examination, and laboratory studies, the physician might recommend special protective measures or medical removal for an employee who is pregnant or who is planning to conceive a child when, in the physician's judgement, continued exposure to lead at the current job would pose a significant risk. The return of the employee to his or her former job status, or the removal of special protections or limitations, depends upon the examining physician determining that the employee is no longer at increased risk of material impairment or that special measures are no longer needed.
During the period of any form of special protection or removal, the employer must maintain the worker's earnings, seniority, and other employment rights and benefits (as though the worker had not been removed) for a period of up to 18 months. This economic protection will maximize meaningful worker participation in the medical surveillance program, and is appropriate as part of the employer's overall obligation to provide a safe and healthful workplace. The provisions of MRP benefits during the employee's removal period may, however, be conditioned upon participation in medical surveillance.
On rare occasions, an employee's blood lead level may not acceptably decline within 18 months of removal. This situation will arise only in unusual circumstances, thus the standard relies on an individual medical examination to determine how to protect such an employee. This medical determination is to be based on both laboratory values, including lead levels, zinc protoporphyrin levels, blood counts, and other tests felt to be warranted, as well as the physician's judgment that any symptoms or findings on physical examination are a result of lead toxicity. The medical determination may be that the employee is incapable of ever safely returning to his or her former job status. The medical determination may provide additional removal time past 18 months for some employees or specify special protective measures to be implemented.
The lead standard provides for a multiple physician review in cases where the employee wishes a second opinion concerning potential lead poisoning or toxicity. If an employee wishes a second opinion, he or she can make an appointment with a physician of his or her choice. This second physician will review the findings, recommendations or determinations of the first physician and conduct any examinations, consultations or tests deemed necessary in an attempt to make a final medical determination. If the first and second physicians do not agree in their assessment they must try to resolve their differences. If they cannot reach an agreement then they must designate a third physician to resolve the dispute.
The employer must provide examining and consulting physicians with the following specific information: a copy of the lead standard and all appendices, a description of the employee's duties as related to exposure, the exposure level to lead and any other toxic substances (if applicable), a description of personal protective equipment used, blood lead levels, and all prior written medical opinions regarding the employee in the employer's possession or control. The employer must also obtain from the physician and provide the employee with a written medical opinion containing blood lead levels, the physician's opinion as to whether the employee is at risk of material impairment to health, any recommended protective measures for the employee if further exposure is permitted, as well as any recommended limitations upon an employee's use of respirators.
Employers must instruct each physician not to reveal to the employer in writing or in any other way his or her findings, laboratory results, or diagnoses which are felt to be unrelated to occupational lead exposure.
They must also instruct each physician to advise the employee of any occupationally or non-occupationally related medical condition requiring further treatment or evaluation.
Thestandard provides for the use of respirators where engineering and other primary controls have not been fully implemented. However, the use of respirator protection shall not be used in lieu of temporary medical removal due to elevated blood lead levels or findings that an employee is at risk of material health impairment. This is based on the numerous inadequacies of respirators including skin rash where the facepiece makes contact with the skin, unacceptable stress to breathing in some workers with underlying cardiopulmonary impairment, difficulty in providing adequate fit, the tendency for respirators to create additional hazards by interfering with vision, hearing, and mobility, and the difficulties of assuring the maximum effectiveness of a complicated work practice program involving respirators. Respirators do, however, serve a useful function where engineering and work practice controls are inadequate by providing supplementary, interim, or short-term protection, provided they are properly selected for the environment in which the employee will be working, properly fitted to the employee, maintained and cleaned periodically, and worn by the employee when required. (continued)