Take-home exposures can pose threat outside work

Exposed workers can put families at risk

In the world of occupational health, the phrase "taking your work home with you" can take on a different and sometimes frightening meaning. Workers who have been exposed to toxic substances can bring them home on their clothes, their skin, or even their tools, and unwittingly place their families at risk for a wide variety of illnesses.

Just how large a threat this represents remains unclear.

"Some of these risks are well documented — specifically, with asbestos, for example," offers Grace Paranzino, MS, RN, CHES, FAAOHN, president of the Philadelphia/Pennsylvania Association of Occupational Health Nurses and assistant professor at Drexel University College of Medicine in Philadelphia. "A worker may not come down with related lung disease, but someone else in the household may. That could be because the household member may not know what to do to prevent exposure."

"The concern about take-home exposures is a meaningful and important one," says Jonathan Borak, MD, DABT, associate clinical professor of medicine and epidemiology at Yale University in New Haven, CT, director of the Yale University Inter-Disciplinary Risk Assessment Forum, and president of a consulting firm that bears his name. "It is one of the means of exposure that is under-appreciated by the general population."

Interestingly, the chair of the National Institute for Occupational Safety and Health (NIOSH)-sponsored Workers’ Family Protection Task Force, whose recently released report has helped renew interest in this subject, urges a balanced approach. "We don’t want people feeling there is a smoldering epidemic — the exact extent of the problem nowadays is not known," asserts Harvey Checkoway, PhD, a professor in the department of environmental health at the University of Washington in Seattle.

The task force, put together in 1994-95, was asked to review a NIOSH document on take-home exposures, comment on it, critique it and come up with recommendations. Its findings were published in July on the NIOSH web site (www.cdc.gov/niosh) under the title, "Protecting Workers’ Families." (The NIOSH web site also includes a listing of industries that are more prone to take-home exposures.)

"There’s no evidence of people getting sick and dying left and right," Checkoway continues. "We ended our report with a question, not a conclusion: What else is being brought home nowadays, and how much of it?"

An occ-med concern

Experts agree that seeking the answer to that question is an important concern for occupational health professionals — for a number of reasons. "Certainly, preventing disease is the right thing to do," says Checkoway. "There are also liability issues. Besides that, today’s kids are tomorrow’s next generation of workers. Many large companies have facilities all over the world, and things we think are under control here may not be so well controlled elsewhere."

"Over and beyond the moral and ethical issues about trying to do good is the fact that illness in a worker’s family impacts the worker," adds Borak. "Occupational health professionals should see the worker as a person — and not only in the workplace." In addition, Borak notes, most workers are the source of their family’s health insurance, so it has an impact both on them and on their employers.

Third, he notes, "ACOEM [the American College of Occupational and Environmental Medicine] has extended itself beyond the fence line of the plant. Take-home contamination is one of those areas where occupational exposure becomes environmental exposure by going home with the worker."

There are a large number of potential sources for take-home exposures. The NIOSH report cited asbestos, lead, and beryllium as among the most prominent. "We kept talking about those three as classic examples, but we’re not sure these are as much of current-day interest or pose take-home exposures," notes Checkoway.

Certainly, environmental regulations have limited the use of lead, asbestos, and certain pesticides, but that doesn’t mean the danger has been totally eliminated, Checkoway notes. "Are some of the old bad actors still bad actors? Jobs involving asbestos are pretty uncommon, but abatement workers handle it, for example, when it episodically shows up in schools," says Checkoway. "And lead-based paints are used by radiator repair people, bridge painters, some welders, lead smelters, and electricians."

"Personally, I think it’s [still] true because we’ve been able to document exposures," says Paranzino. "Sheet metal workers, construction workers, even people who do home remodeling can be exposed to asbestos. Lead is used in battery reclamation centers, as well as by construction workers and bridge workers."

"I’d be more inclined to say those three substances may be the most salient or memorable," notes Borak. "But asbestos is much more important and illustrative. There are clear cases of spouses of asbestos workers developing mesothelioma [a form of lung cancer], probably because of fibers brought home on a working spouse’s clothes, perhaps even exposing her as she cleans them."

Paranzino’s father died of mesothelioma. "Asbestos has a long latency period — 20 years or more," she says. "My dad worked for 40 years in a naval ship yard as a tool and dye maker. When he was diagnosed in his 70s, we were shocked."

Paranzino conducted an exposure history, not only to determine how her father was exposed, but how other family members might have been. "He didn’t change clothes at work; he sat at the kitchen table on an upholstered chair, and we could surmise he still had fibers on his clothing," she says. "My mom didn’t separate his clothing from the others," she continues, noting possible exposure of others. "I’m 44. When he was exposed, I was a kid. Did he hold me when he came home from work? Ultimately, this issue impacts everyone."

Beryllium, says Borak, is not the threat it once was. A very strong, lightweight metal, it has been used as an alloy to harden many metals and is very important as a neutron mediator and component in control and trigger mechanisms of nuclear weapons. But after links were found to lung disease, it has come under tight federal regulation.

"It used to cause an acute lung disease, pneumonitis. But that wouldn’t happen now unless there’s a catastrophic event; the current occupational exposure levels are too low," Borak says. "Only about 3% to 5% of the population becomes sensitized."

There are, however, other substances that remain of concern. "There was a study of people in a Vermont thermometer factory," he notes. "The kids had mercury poisoning due to a working parent bringing it home. Mercury, which vaporizes slowly, hovers close to ground level, so children who crawl on the floor are at greater risk."

Borak also was co-author of an article published in the April 2002 Journal of Occupational and Environmental Medicine detailing exposure to creosote. "It shows the dermal route is more important than the inhalation route," he explains. "There’s one other area that is enormously important and just breaking into prominence: pesticides," Borak observers. Migrant farm workers, he points out, are an underserved population when it comes to occupational health. "They have found very high levels of pesticide residue in the urine of their children in Oregon and Washington [state]," he says. "Parents work in the field and bring it home with them."

Checkoway notes that some substances may not be as closely tracked as others. "Radiation and biological exposures are outside of NIOSH’s purview," he observes.

Prevention not rocket science

While some of the substances endangering workers are exotic and rare, proper procedures for limiting take-home exposures can be surprisingly simple. "A lot of this can be prevented by good work practices, use of protective equipment, disposable equipment, having workers wash and shower before going home, not bringing tools home — pretty standard common sense," says Checkoway.

Borak agrees that changing clothes and showering at the end of a shift "substantially lowers the level of exposure." Ironically, he continues, this relatively under-recognized concern is amenable to some of the least expensive interventions. "We may be talking about disposable, impermeable — but not airtight — jumpsuits, or wearing a cover, or gloves," he says. Installing showers — even portable canvas showers for agricultural workers — is relatively inexpensive, says Borak. There also are certain soaps that are especially effective, and his consulting firm recently prepared a proposal that includes fingernail brushes. "The cost is akin to that of providing clean sand for cigarette trays," he notes. The cost of not taking such steps can be considerable, he adds. "A worker can’t sue you, but his wife can," he explains. "And the [employer’s] liability exposure for a next of kin is much greater."

Effective health and safety programs in which workers are made aware of potential take-home exposures are very important, adds Paranzino. "Do the workers know what those potential exposures are? Are they provided with appropriate personal protective equipment? If so, do they remove it before they take it home or get on a bus?" One of the other major issues in fighting take-home exposures is a complete exposure history, says Paranzino. "This is generally not done in the workplace — even by occupational health professionals," she asserts.

"Most exposure histories that are done are reactive and limited," she continues. "It’s always a response to something. Therefore, the company is always worried about exposures on that particular job; but for the most part, they don’t ask about past work practices and past exposures." Finally, she says, it’s important to involve occupational health nurses in this process, "Because they play an integral role in facilitating the safety and health of workers." (For further information, visit the American Association of Occupational Health Nurses web site, www.aaohn.org.)

Borak recommends these bottom-line steps to minimize the likelihood of take-home exposures: "Find out systematically what exposures are occurring and what potential there is for their being brought home," he advises. "What protective measures are in place? Are they being used, and are they effective?"

[For more information, contact:

Grace K. Paranzino, MS, RN, CHES, FAAOHN, Assistant Professor, Drexel University College of Medicine, Department of Family, Community & Preventive Medicine, 2900 Queen Lane, Philadelphia, PA 19129. Telephone: (215) 991-8469. Fax: (215) 843-6028.

Jonathan Borak, MD, Associate Clinical Professor of Medicine and Epidemiology, Yale University, 234 Church St., #1100, New Haven, CT 06510. Telephone: (203) 777-6611. Fax: (203) 777-1411.

Harvey Checkoway, PhD, University of Washington, Department of Environmental Health, Box 357234, Seattle, WA 98195. Telephone: (206) 543-2052. E-mail: checko@u.washington.edu.]