Effective Date of Rule: June 1, 2007.

     Purpose: The purpose of this rule making is to clarify the arsenic and benzene appendices from chapter 296-62 WAC and move them into their appropriate chapters.

     Citation of Existing Rules Affected by this Order: Amending WAC 296-848-30005 Training, 296-848-30030 Medical evaluations, 296-849-11050 Training and 296-849-12030 Medical evaluations; and repealing WAC 296-62-07525 Appendix A substance safety data sheet, 296-62-07527 Appendix B substance technical guidelines, 296-62-07529 Appendix C medical surveillance guidelines, and 296-62-07354 Appendices -- Inorganic arsenic.

     Statutory Authority for Adoption: RCW 49.17.010, 49.17.040, 49.17.050, 49.17.060.

      Adopted under notice filed as WSR 06-23-126 on November 21, 2006.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 4, Amended 4, Repealed 4.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 4, Amended 4, Repealed 4.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 0, Repealed 0.

     Date Adopted: January 23, 2007.

Judy Schurke

Acting Director

OTS-9313.1

REPEALER

     The following sections of the Washington Administrative Code are repealed:

WAC 296-62-07354	Appendices -- Inorganic arsenic.
WAC 296-62-07525	Appendix A substance safety data sheet -- Benzene.
WAC 296-62-07527	Appendix B substance technical guidelines -- Benzene.
WAC 296-62-07529	Appendix C medical surveillance guidelines for benzene.

OTS-9314.2

AMENDATORY SECTION(Amending WSR 05-01-173, filed 12/21/04, effective 5/1/05)

WAC 296-848-30005   Training.  

     You must:

     • Train employees:

     – Who are exposed above the action level (AL) of 5 micrograms per cubic meter (΅g/m³) of air;

     OR

     – Who could experience eye or skin irritation from exposure.

     • Provide training:

     – At the time of initial assignment;

     AND

     – At least every twelve months after initial training.

     • Make sure training and information includes all of the following:

     – A review of ((this chapter)) WAC 296-848-100 through 296-848-40045, and 296-848-500.

     ((– The information found in another chapter:

     &sqbul; Go to the General occupational health standards, chapter 296-62 WAC;

     AND

     &sqbul; Find Appendix A-Inorganic Arsenic Substance Information Sheet, WAC 296-62-07354(1).)) – The following health information about inorganic arsenic:

     • Inorganic arsenic is a poison and can affect your body if it's swallowed or inhaled.

     • Exposure to airborne concentrations of inorganic arsenic may cause lung cancer and can be a skin irritant.

     • Arsenic trichloride can be absorbed readily through your skin and is especially dangerous.

     • Wash hands thoroughly before eating or smoking to help minimize your risk for swallowing inorganic arsenic.

     – The purpose for medical evaluations and a description of how you are fulfilling the medical evaluation requirements of this chapter found in Medical evaluations, WAC 296-848-30030.

     • Make a copy of ((each of the following)) this chapter readily available to all employees required to be trained under this section((:

     – This chapter;

     AND

     – These appendices found in another chapter, the General occupational health standards, chapter 296-62 WAC:

     &sqbul; Appendix A-Inorganic Arsenic Substance Information Sheet, WAC 296-62-07354(1).

     &sqbul; Appendix B-Substance Technical Guidelines, WAC 296-62-07354(2).

     &sqbul; Appendix C-Medical Surveillance Guidelines, WAC 296-62-07354(3))).

Reference:	• To see additional training and information requirements in other chapters, go to the:
	– Respirators rule, chapter 296-842 WAC.
	– Safety and health core rules, chapter 296-800 WAC, and find the section titled, Inform and train your employees about hazardous chemicals in your workplace, WAC 296-800-17030.
	• When following these requirements, include specific information about potential exposures to inorganic arsenic, such as the types of operations, locations, quantities, exposure sources, exposure controls, inorganic arsenic use, and storage.

[Statutory Authority: RCW 49.17.010, 49.17.040, 49.17.050, 49.17.060. 05-01-173, § 296-848-30005, filed 12/21/04, effective 5/1/05.]

     IMPORTANT:

     • Medical evaluations conducted under this section will satisfy the medical evaluation requirement found in another chapter, Respirators, chapter 296-842 WAC.

     You must:

     • Make medical evaluations available to current employees who have been, are, or will be exposed to inorganic arsenic concentrations above the AL:

     – At least thirty days in any twelve-month period;

     OR

     – A total of ten years or more of combined employment with you or previous employers with at least thirty days of exposure per year.

     • Make medical evaluations available at no cost to employees.

     – Pay all costs, including travel costs and wages associated with any time spent outside of the employee's normal work hours.

     • Make medical evaluations available at reasonable times and places.

     • Make medical evaluations available by completing Steps 1 through 6 of the Medical Evaluation Process for each employee covered.

Note:	• Employees who wear respirators need to be medically evaluated to make sure the respirator will not harm them, before they are assigned work in areas requiring respirators. Employees who decline to receive medical examination and testing to monitor for health effects caused by inorganic arsenic are not excluded from receiving a separate medical evaluation for a respirator use.
	• If employers discourage participation in medical monitoring for health effects caused by inorganic arsenic, or in any way interfere with an employee's decision to continue with this program, this interference may represent unlawful discrimination under RCW 49.17.160, Discrimination against employee filing, instituting proceeding, or testifying prohibited -- Procedure -- Remedy.

     Helpful tool:

     Declination form for nonemergency related medical evaluations.

     You may use this optional form to document employee decisions to decline participation in the medical evaluation process for exposure to inorganic arsenic. To see this form, go to the Resources section within this chapter.

     Medical Evaluation Process

     Step 1: Identify employees who qualify, as stated above, for medical evaluations.

     Step 2a: Make medical evaluations available for employees identified in Step 1 at the following times:

     • Initially, when employees are assigned to work in an area where exposure monitoring results are, or will likely be, above the action level for at least thirty days in a twelve-month period.

     • Periodically as specified in Table 3.

     • When employment with exposure ends, if the employee has not had an evaluation within the six-month period before exposure ends. Include in these evaluations the same content as specified in Table 4 for initial evaluations, excluding a chest X ray.

Table 3
     Frequencies for Periodic Medical Evaluations

For:	Provide periodic medical evaluations every:
Employees less than forty-five years old with less than ten years of exposure above the AL	Twelve months;
Employees forty-five or older;	Six months;
AND	AND
Employees with more than ten years of exposure above the AL	Twelve months to obtain a fourteen by seventeen-inch posterior-anterior chest X ray for monitoring purposes, unless the LHCP has determined a different frequency for periodic X rays.

     Step 2b: Provide appropriate medical examination and emergency treatment when an employee identified in Step 1 develops signs or symptoms commonly associated with inorganic arsenic exposure.

     Step 3: Select a licensed health care professional (LHCP) who will conduct or supervise examinations and procedures.

     Step 4: Make sure the LHCP receives all of the following before the medical evaluation is performed:

     • A copy of((:

     –)) this chapter((;

     AND

     – The following information found in the General occupational health standards, chapter 296-62 WAC:

     &sqbul; Appendix A-Inorganic Arsenic Substance Information Sheet, WAC 296-62-07354(1).

     &sqbul; Appendix B-Substance Technical Guidelines, WAC 296-62-07354(2).

     &sqbul; Appendix C-Medical Surveillance Guidelines, WAC 296-62-07354(3))).

     • A description of the duties of the employee being evaluated and how these duties relate to inorganic arsenic exposure.

     • The anticipated or representative exposure monitoring results for the employee being evaluated.

     • A description of the personal protective equipment (PPE) each employee being evaluated uses or will use.

     • Information from previous employment-related examinations when this information is not available to the examining LHCP.

     • Instructions that the written opinions the LHCP provides you be limited to the following information:

     – Results from examinations and tests.

     – The LHCP's opinion about whether or not medical conditions were found that would increase the employee's risk for impairment from exposure to inorganic arsenic.

     – Any recommended limitations for:

     &sqbul; Inorganic arsenic exposure;

     AND

     &sqbul; Use of respirators or other PPE.

     – A statement that the employee has been informed of medical results and medical conditions caused by inorganic arsenic exposure requiring further examination or treatment.

     Step 5: Make the medical evaluation available to the employee. Make sure it includes the content listed in Table 4, Content of Medical Evaluations.

     Step 6: Obtain the LHCP's written opinion for the employee's medical evaluation and give a copy to the employee.

     • Make sure the written opinion is limited to the information specified for written opinions in Step 4.

Note:

If the written opinion contains specific findings or diagnoses unrelated to occupational exposure, send it back and obtain a revised version without the additional information.

Table 4
     Content of Medical Evaluations

When conducting:	Include:
An initial evaluation	• A work history and medical history including:
	– Smoking history.
	– The presence and degree of respiratory symptoms such as breathlessness, cough, sputum production, and wheezing.
	• A physical examination that includes:
	– A fourteen by seventeen-inch posterior-anterior chest X ray and the International Labor Office UICC/Cincinnati (ILO U/C) rating.
	– A nasal and skin examination.
	• Additional examinations the licensed healthcare professional (LHCP) believes appropriate based on the employee's exposure to inorganic arsenic or respirator use.
Periodic evaluations for employees less than forty-five years old with less than ten years of exposure above the action level (AL)	• The same content as specified for initial evaluations repeated every twelve months.
Periodic evaluations for employees:	• The following content repeated every six months:
• Forty-five or older;	– A work history and medical history including:
OR	&sqbul; Smoking history.
• With more than ten years of exposure above the AL	&sqbul; The presence and degree of respiratory symptoms such as breathlessness, cough, sputum production, and wheezing.
	– A physical examination that includes a nasal and skin examination.
	– Additional examinations the LHCP believes appropriate based on the employee's exposure to inorganic arsenic or respirator use.
	• A physical examination, repeated every twelve months, that obtains a fourteen by seventeen-inch posterior-anterior chest X ray and the International Labor Office UICC/Cincinnati (ILO U/C) rating.

[Statutory Authority: RCW 49.17.010, 49.17.040, 49.17.050, 49.17.060. 05-01-173, § 296-848-30030, filed 12/21/04, effective 5/1/05.]

     • Make this section readily available to employees as required in Training, WAC 296-848-30005.

     • Provide this section to the licensed health care professional (LHCP) as required in Step 4 of the medical evaluation process found in Medical evaluations, WAC 296-848-30030.

Table 5
General Health Information About Inorganic Arsenic

What is inorganic arsenic?
In this chapter, "inorganic arsenic" means:
–	The element arsenic;
–	Arsenic-containing compounds that don't contain the element carbon;
–	Copper aceto-arsenite.
Arsine is a gaseous inorganic arsenic compound not addressed by requirements in this chapter. It's addressed in a separate chapter, Respiratory hazards, chapter 296-841 WAC.
How does inorganic arsenic get into my body?
Inorganic arsenic enters your body when you:
–	Breath in (inhale) airborne particles such as dusts, fume, sprays, or other aerosols that contain inorganic arsenic. You will also inhale inorganic arsenic particles when you smoke tobacco products that have become contaminated from contact with inorganic arsenic at work. Some compounds, including arsenic trichloride, can be inhaled as a vapor;
–	Swallow (ingest) food, drink, cosmetics such as lip balm, sweat and other substances that become contaminated from contact with inorganic arsenic at work.
Inorganic arsenic particles brought home on your clothes, shoes, or body can be inhaled or ingested by household members.
Some inorganic arsenic compounds enter your body when eye or skin contact occurs. Arsenic trichloride is one example of a compound that is readily absorbed through the eyes and skin.
What happens after inorganic arsenic enters my body?
Once inorganic arsenic enters your body, some of it is changed into a less harmful organic form by the liver. Both the organic and inorganic forms leave your body in urine.
Most of the arsenic will be gone within several days, although some will remain in your body for several months and even longer.
Why is medical monitoring necessary?
Although exposure to inorganic arsenic is associated with various health effects, the most serious health effects are lung and skin cancer. The medical monitoring requirements in this chapter are established to minimize your risk for these diseases.
To learn more about the medical monitoring process, see Medical evaluation, WAC 296-848-30030.
What health effects and symptoms are linked with exposure to inorganic arsenic?
Exposure to inorganic arsenic is associated with various health effects ranging from temporary local effects such as skin irritation to lasting systematic effects due to gradual (chronic) or sudden (acute) poisoning. Such effects should not occur if the requirements in this chapter are followed.
Skin Health Effects:
Arsenic trioxide, arsenic trichloride, and other trivalent compounds can cause skin irritation from direct contact.
–	The following moist mucous membranes are most sensitive to irritation:
	&sqbul;	Eye and inner eyelid (conjunctiva);
	&sqbul;	Linings inside the nose, mouth, and respiratory system.
–	Other sites most vulnerable irritation also include:
	&sqbul;	Eyelids;
	&sqbul;	Angles (the space between 2 planes) of the ears, nose, and mouth;
	&sqbul;	Moist and macerated (softened by moisture) areas of skin;
	&sqbul;	Wrists;
	&sqbul;	Genitalia, if personal hygiene is poor.
Inorganic arsenic is also capable of causing keratoses (small corns or warts), especially on palms and soles.
Trivalent arsenic compounds are corrosive to skin:
–	Brief contact won't cause irritation, but prolonged contact causes localized engorgement (hyperemia) which later forms vesicular (blister-like) or pustular (pimple-like) eruptions.
–	Exposure can create perforations (holes) in the nasal septum (the tissue dividing the nasal cavity in half).
Arsenic trioxide and arsenic pentoxide exposure have been linked to skin sensitization (acquired sensitivity or allergy) and contact dermatitis (inflammation due to allergic or irritant reaction).
Acute Poisoning Effects:
Acute poisoning is usually linked to ingestion, not inhalation, of inorganic arsenic. Cases of acute poisoning rarely occur in occupational settings and inhalation-related cases are exceedingly rare.
When acute poisoning is due to ingestion, the following gastrointestinal symptoms develop within 1/2 to 4 hours:
–	Tightening (constriction) of the throat followed by difficulty or inability to swallow (dysphagia), pain in the region above the belly button (epigastric pain), vomiting, and watery diarrhea. Blood may appear in vomit and stools;
–	Shock may develop due to severe fluid loss when the amount of inorganic arsenic swallowed is sufficiently high. Death can occur in 24 hours.
When acute poisoning is due to inhalation:
–	The following symptoms develop first:
	&sqbul;	Cough;
	&sqbul;	Chest pain;
	&sqbul;	Shortness of breath (dyspnea);
	&sqbul;	Giddiness;
	&sqbul;	Headache;
	&sqbul;	Extreme general weakness.
–	Gastrointestinal symptoms will follow.
Chronic Poisoning Effects:
Cases of chronic poisoning caused by ingestion are also rare. Symptoms are:
–	Weight loss;
–	Nausea and diarrhea alternating with constipation;
–	Skin pigmentation and eruptions;
–	Hair loss;
–	Numbness in hands and feet, "pins and needles" sensation, muscle weakness, and other symptoms resulting from peripheral neuritis;
–	Horizontal white lines (striations) on fingernails and toenails.
Inhalation of inorganic arsenic is the most common cause of chronic poisoning in occupational settings. Symptoms associated with this condition are divided into 3 phases.
–	1st phase, earliest symptoms:
	&sqbul;	Weakness;
	&sqbul;	Loss of appetite;
	&sqbul;	Some nausea;
	&sqbul;	Occasional vomiting;
	&sqbul;	Sense of heaviness in the stomach;
	&sqbul;	Some diarrhea.
–	2nd phase symptoms:
	&sqbul;	Inflammation of the eyes and inner eyelid (conjunctivitis);
	&sqbul;	Inflammation, accompanied by an abundant discharge from mucous membranes (a catarrhal state) of the nose, larynx, and respiratory passage;
	&sqbul;	Symptoms associated with the common cold (Coryza), hoarseness, and mild tracheobronchitis may occur;
	&sqbul;	Skin lesions are common (eczematoid and allergic in type). Perforations (holes) in the nasal septum (the tissue dividing the nasal cavity in half) are the most typical lesions of the upper respiratory tract.
–	3rd phase symptoms (related to peripheral neuritis):
	&sqbul;	Numbness in hands and feet, "pins and needles" sensation, muscle weakness.
	&sqbul;	In severe cases, motor paralyses occur: Initially affecting the toe extensors and the peronei (outer portion of the lower leg).
	&sqbul;	"Wrist drop" or "foot drop" (resulting from paralysis of flexor muscles of feet and hands) only occurs in the most severe cases.

[]

     • Make this section readily available to employees as required in Training, WAC 296-848-30005.

     • Provide this section to the licensed health care professional (LHCP) as required in Step 4 of the medical evaluation process found in Medical evaluations, WAC 296-848-30030.

Table 6
Medical Guidelines
For Evaluating Employees With Exposure

Part 1: DOSH's Requirements
In addition to requiring employers to train employees and protect them from inorganic arsenic exposure, this chapter (the Arsenic rule) requires employers to monitor their employees' health with assistance from licensed health care professionals (LHCPs).
•	For employees who will use respirators, the LHCP will also need to provide the employer with a written medical opinion clearing the employee for workplace respirator use.
These guidelines were designed to support an informed partnership between the LHCP and the employer when monitoring the health of employees exposed to inorganic arsenic.
The employer initiates this partnership by providing the LHCP with a copy of the chapter and other supporting information about the employee and job conditions. The LHCP can then become familiar with the medical monitoring requirements found in WAC 296-848-30030 and 296-848-30080, which address:
•	Frequency and content for routine (initial and periodic) medical examinations and consultations;
•	Emergency and other unplanned medical follow-up;
•	Medical opinions;
•	Medical records retention and content.
Part 2: Inorganic Arsenic Toxicology
Health information about inorganic arsenic, WAC 296-848-50020 provides basic information about the health effects and symptoms associated with inorganic arsenic exposure.
In addition, consider the following information:
Acute Poisoning
Exfoliative dermatitis and peripheral neuritis may develop in patients who survive health effects due to acute poisoning (by ingestion).
Acute toxic symptoms of trivalent arsenical poisoning are caused by severe inflammation of the mucous membranes and greatly increased permeability of the blood capillaries.
Acute and Chronic Poisoning
In cases of acute and chronic poisoning, toxic effects to the myocardium (the middle layer of the heart) reported on EKG changes are now largely discounted and are attributed to electrolyte disturbances concomitant with arsenicalism.
Arsenic has a depressant effect upon bone marrow, with disturbances of both red blood cell production (erythropoiesis) and myclopoiesis.
Chronic Poisoning
Cases of chronic poisoning caused by ingestion are generally linked to patients taking prescribed medications. However, sputum from inhaled inorganic arsenic can be swallowed in addition to other ingested inorganic arsenic due to hand-to-mouth transfer.
Skin lesions are usually melanotic and keratotic and may occasionally take the form of an intradermal cancer of the squamous cell type, but without infiltrative properties.
Chronic hepatitis and cirrhosis have been described. Liver damage is still debated and as yet the question is unanswered.
Polyneuritis may be the prominant feature, but more frequently there are numbness and parasthenias of "glove and stocking" distribution. Horizontal white lines (striations) on the fingernails and toenails are commonly seen and are considered a diagnostic accompaniment of arsenical polyneuritis.
References:
•	Other sources for toxicology information include:
	–	ToxFAQs™ and the Toxicological Profile for Arsenic. Both of these free documents are available from the Agency for Toxic Substances and Disease Registry (ATSDR) and can be obtained by:
		&sqbul;	Visiting http://www.atsdr.cdc.gov/toxprofiles
			OR
		&sqbul;	Calling 1-888-422-8737.
	–	A variety of technical resources on arsenic, available from the National Institutes for Occupational Safety and Health (NIOSH) by visiting http://www.cdc.niosh/topics/chemicals.html
Part 3: Clinical Evaluation of Employees Exposed to Inorganic Arsenic
IMPORTANT:
•	When an employee will use a respirator during work, the LHCP will need to determine whether the employee can safely wear a respirator and what limitations, if any, apply.
Guidance for Physical Examinations
In addition to its immediate diagnostic usefulness, a patient's initial examination will provide a baseline for comparing future test results.
This chapter establishes the minimum content for medical examinations. Additional tests such as lateral and oblique X rays or pulmonary function test may be useful.
You should also include palpation of superficial lymph nodes and a complete blood count when employees are exposed to any of the following compounds:
	–	Copper aceto-arsenite;
	–	Potassium arsenite;
	–	Sodium arsenite;
	–	Other arsenicals associated with lymphatic cancer.
Arsenic trioxide and other inorganic arsenical dusts don't give rise to radiological evidence or pneumoconiosis.

[]

OTS-9315.2

AMENDATORY SECTION(Amending WSR 05-01-172, filed 12/21/04, effective 3/1/05)

WAC 296-849-11050   Training.  

     You must:

     • Provide training and information to employees:

     – At the time of initial assignment to a work area where benzene is present;

     AND

     – At least every twelve months after initial training for employees exposed to airborne concentrations at or above the action level (AL) of 0.5 parts per million (ppm).

     • Make sure training and information includes all of the following:

     – Specific information on benzene for each hazard communication training topic. For the list of hazard communication training tropics, go to the Safety and health core rules, chapter 296-800 WAC, and find Inform and train your employees about hazardous chemicals in your workplace, WAC 296-800-17030;

     AND

     – An explanation of the contents of ((each of the following)) this chapter and guidance about where to find a copy((:

     &sqbul; This chapter.

     &sqbul; The following found in another chapter, the General occupational health standards, chapter 296-62 WAC:

     ♦ The substance safety data sheet -- benzene, found in WAC 296-62-07525, Appendix A.

     ♦ The substance technical guidelines -- benzene, found in WAC 296-62-07527, Appendix B.

     ♦ The medical surveillance guidelines for benzene, found in WAC 296-62-07529, Appendix C)) of it;

     AND

     – A description of the medical evaluation requirements of this chapter found in:

     &sqbul; Medical evaluations, WAC 296-849-12030;

     AND

     &sqbul; Medical removal, WAC 296-849-12050.

Reference:	To see additional training and information requirements in other chapters, go to the:
	• Respirators rule, chapter 296-842 WAC, and find the Training section, WAC 296-842-16005.
	• Safety and health core rules, chapter 296-800 WAC, and find the section titled, Inform and train your employees about hazardous chemicals in your workplace, WAC 296-800-17030.

[Statutory Authority: RCW 49.17.010, 49.17.040, 49.17.050, 49.17.060. 05-01-172, § 296-849-11050, filed 12/21/04, effective 3/1/05.]

     IMPORTANT:

     Medical evaluations conducted under this section will satisfy the medical evaluation requirement found in Respirators, chapter 296-842 WAC.

     You must:

     • Provide the relevant medical follow-up specified in Tables 4 and 5 to any employee exposed to benzene during an emergency.

     • Make medical evaluations available to current employees who meet the following criteria:

     – Potential or actual exposure to benzene at or above the action level (AL) for at least thirty days in any twelve-month period.

     – Potential or actual exposure to benzene at or above either permissible exposure limit (PEL) for at least ten days in a twelve-month period.

     – Past exposure to concentrations above 10 ppm benzene for at least thirty days in a twelve-month period before November 11, 1988.

     – Current or past work as a tire building machine operator using solvents containing more than 0.1% benzene during tire building operations.

     You must:

     • Make medical evaluations available at no cost to employees.

     – Pay all costs, including travel costs and wages associated with any time spent outside of the employee's normal work hours;

     • Make medical evaluations available at reasonable times and places;

     • Make medical evaluations available by completing Steps 1 through 6 of the medical evaluation process for each employee covered.

Note:	• Employees who wear respirators need to be medically evaluated to make sure the respirator will not harm them, before they are assigned work in areas requiring respirators. Employees who decline to receive medical examination and testing to monitor for health effects caused by benzene are not excluded from receiving a separate medical evaluation for a respirator use.
	• If employers discourage participation in medical monitoring for health effects caused by benzene, or in any way interfere with an employee's decision to continue with this program, this interference may represent unlawful discrimination under RCW 49.17.160, Discrimination against employee filing, instituting proceeding, or testifying prohibited -- Procedure -- Remedy.

     Helpful tool:

     Declination form for nonemergency related medical evaluations.

     • You may use this optional form to document employee decisions to decline participation in the medical evaluation process for exposure to benzene.

     Medical evaluation process:

     Step 1: Identify employees who qualify, as stated above, for medical evaluations.

     Step 2: Make medical evaluations available for employees identified in Step 1 at the following times:

     • Initially, before the employee starts a job or task assignment where benzene exposure will occur.

     • Every twelve months from the initial medical evaluation.

     • Whenever the employee develops signs or symptoms commonly associated with toxic benzene exposure.

     • After benzene exposure from an emergency.

     Step 3: Select a licensed health care professional (LHCP) who will conduct or supervise medical evaluations and make sure:

     • Individuals who conduct pulmonary function tests have completed a training course in spirometry sponsored by an appropriate governmental, academic, or professional institution, if they are not licensed physicians;

     AND

     • Your LHCP uses an accredited laboratory, such as one accredited by a nationally or state-recognized organization, to conduct laboratory tests.

     Step 4: Make sure the LHCP receives all of the following before the medical evaluation is performed:

     • A copy of((:

     –)) this chapter.

     ((– The following information found in the General occupational health standards, chapter 296-62 WAC:

     &sqbul; Appendix A, the substance safety data sheet -- benzene, found in WAC 296-62-07525.

     &sqbul; Appendix B, the substance technical guidelines -- benzene, found in WAC 296-62-07527.

     &sqbul; Appendix C, the medical surveillance guidelines for benzene, found in WAC 296-62-07529.))

     • A description of the duties of the employee being evaluated and how these duties relate to benzene exposure.

     • The anticipated or representative exposure monitoring results for the employee being evaluated.

     • A description of the personal protective equipment (PPE) each employee being evaluated uses or will use.

     • Information from previous employment-related examinations when this information is not available to the examining LHCP.

     • Instructions that the written opinions the LHCP provides, be limited to the following information:

     – Specific records, findings, or diagnosis relevant to the employee's ability to work around benzene.

     – The occupationally relevant results from examinations and tests.

     – A statement about whether or not medical conditions were found that would increase the employee's risk for impairment from exposure to benzene.

     – Any recommended limitations for benzene exposure.

     – Whether or not the employee can use respirators and any recommended limitations for respirator or other PPE use.

     – A statement that the employee has been informed of medical results and medical conditions caused by benzene exposure requiring further explanation or treatment.

     Step 5: Provide the medical evaluation to the employee. Make sure it includes the content listed in Table 4, Content of medical evaluations, and Table 5, Medical follow-up requirements.

     Step 6: Obtain the LHCP's written opinion for each employee's medical evaluation and give a copy to the employee within fifteen days of the evaluation date.

     • Make sure the written opinion is limited to the information specified for written opinions in Step 4.

Note:

If the written opinion contains specific findings or diagnoses unrelated to occupational exposure, send it back and obtain a revised version without the additional information.

     IMPORTANT:

     These tables apply when conducting medical evaluations, including medical follow-up for employees exposed to benzene during emergencies.

Table 4
     Content of Medical Evaluations

Table 5
     Medical Follow-up Requirements

[Statutory Authority: RCW 49.17.010, 49.17.040, 49.17.050, 49.17.060. 05-13-152, § 296-849-12030, filed 6/21/05, effective 8/1/05; 05-01-172, § 296-849-12030, filed 12/21/04, effective 3/1/05.]

     • Include an explanation of the contents of this section to employees as required in Training, WAC 296-849-11050.

     • Provide a copy of this section to the licensed health care professional (LHCP) as required in Step 4 of the medical evaluation process found in Medical evaluations, WAC 296-849-12030.

Table 7
General Health Information About Benzene

What is benzene?
Benzene is a clear, colorless liquid with a pleasant, sweet odor. It evaporates into air very quickly. The odor of benzene does not provide adequate warning of its hazard.
In this chapter, "benzene " means:
–	Liquid benzene, benzene vapor, and benzene in liquid mixtures and the vapor released by these liquids. The CAS Registry Number that identifies benzene is 71-43-2.
Synonyms for benzene include: Benzol, benzole, coal naphtha, cyclohexatriene, phenyl hydride, pyrobenzol.
Benzin, petroleum benzin, and benzine are chemicals that do not contain benzene.
How am I exposed to benzene?
Benzene exposure occurs when you:
–	Breath in (inhale) vapor or liquid particles (from actions such as spraying or splashing) containing benzene;
–	Have skin or eye contact with liquid or vapor containing benzene. Benzene is absorbed through the skin. Absorption occurs more rapidly with abraded skin or when benzene is present in solvents (as an ingredient or contaminant) which are readily absorbed;
–	Swallow (ingest) benzene.
What happens after I'm exposed to benzene?
Some benzene that enters your body will be absorbed into the bloodstream. Once in the bloodstream, benzene travels throughout your body and can be temporarily stored in the bone marrow and fat.
Benzene is converted to products, called metabolites, in the liver and bone marrow. Some of the harmful effects of benzene exposure are caused by these metabolites.
Most of the metabolites of benzene leave the body in the urine within 48 hours after exposure.
Why is medical monitoring necessary?
Medical monitoring is necessary to detect changes in your body's blood-forming system, including the bone marrow. These changes can occur due to repeated or prolonged, unprotected exposure to benzene, even at relatively low concentrations. Such changes can lead to various blood disorders, ranging from anemia to leukemia, an irreversible, fatal disease. Many of these disorders may occur without symptoms.
Benzene is classified as a confirmed human carcinogen (Group 1) by the International Agency for Research on Cancer (IARC).
To learn more about the medical monitoring process, see Medical evaluation, WAC 296-849-12030.
What health effects are linked to benzene exposure?
Unprotected exposure to benzene is associated with various health effects including symptoms and diseases associated with either short-term (acute) exposure or long-term exposure (chronic).
Acute effects from inhaling high vapor concentrations:
An initial stimulatory effect on the central nervous system (brain and spinal cord) can occur, characterized by exhilaration, nervous excitation (irritability), and/or giddiness. This may be followed by a period of depression, drowsiness, or fatigue.
Headache, dizziness, nausea, or a feeling of intoxication may develop.
A sensation of tightness in the chest may occur, accompanied by breathlessness. Ultimately the victim may lose consciousness.
In severe inhalation cases, tremors, convulsions, and death may follow due to respiratory paralysis or circulatory collapse in a few minutes to several hours.
Acute effects from inhaling liquid benzene:
Aspiration of small amounts of liquid benzene immediately causes pulmonary edema (excessive accumulation of fluid in lung tissues) and hemorrhage of pulmonary tissue.
Skin contact:
Direct contact may cause redness (erythema).
Benzene has a defatting action on skin. Repeated or prolonged contact may result in any of the following:
–	Primary irritation;
–	Dry skin;
–	Scaling dermatitis (inflammation);
–	Development of secondary skin infections.
Effects on the eyes and mucous membranes:
Localized effects from vapor or liquid contact on the eye are slight. High concentrations of benzene are irritating to eyes (causing a stinging sensation) and mucous membranes of the nose and respiratory tract.
Effects due to prolonged exposure:
The blood forming (hematopoietic) system is the main target for benzene's toxic effects. These effects can vary from anemia to leukemia, an irreversible, fatal disease. Many of the toxic effects may occur without symptoms.
Most importantly, prolonged exposure to small quantities of benzene vapor is damaging to the blood forming system. This damage has occurred at concentrations of benzene that may not cause irritation of mucous membranes or unpleasant sensory effects.
Early signs and symptoms are varied and often not readily noticed and nonspecific. These include:
–	Subjective complaints of headache, dizziness, and loss of appetite may precede or follow clinical signs;
–	Rapid pulse and low blood pressure, in addition to a physical appearance of anemia, may accompany a subjective complaint of shortness of breath and excessive tiredness.
Other symptoms may occur as the condition progresses:
–	Bleeding from the nose, gums, or mucous membranes;
	AND
–	Development of purpuric spots (small bruises).

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     • Include an explanation of the contents of this section to employees as required in Training, WAC 296-849-11050.

     • Provide a copy of this section to the licensed health care professional (LHCP) as required in Step 4 of the medical evaluation process found in Medical evaluations, WAC 296-849-12030.

Table 8
Medical Guidelines For Evaluating Employees Exposed to Benzene

Part 1: Becoming familiar with medical requirements in this chapter
In addition to requiring employers to train employees and protect them from exposure to benzene, this chapter (the Benzene rule) requires employers to monitor their employees' health with assistance from licensed health care professionals (LHCPs).
•	For employees who will use respirators, the LHCP will also need to provide the employer with a written medical opinion clearing the employee for workplace respirator use.
These guidelines were designed to support an informed partnership between the LHCP and the employer when monitoring the health of employees exposed to benzene.
The employer initiates this partnership by providing the LHCP with a copy of the chapter and other supporting information about the employee and job conditions. The LHCP can then become familiar with the medical monitoring requirements found in WAC 296-849-12030 through 296-849-12080, which address:
•	Frequency and content for routine (initial and periodic) medical examinations and consultations;
•	Emergency and other unplanned medical follow-up;
•	Medical opinions;
•	Employee medical removal;
•	Medical records retention and content.
Part 2: Benzene toxicology
Benzene is primarily an inhalation hazard. Systematic absorption may cause depression of the hematopoietic system, pancytopenia, aplastic anemia, and leukemia. Clinical evidence of leukopenia, anemia, and thrombocytopenia, singly or in combination, has been frequently reported among the first signs.
Health information about benzene, WAC 296-848-50010, provides basic information about the health effects and symptoms associated with benzene exposure.
Reference:
•	Other sources for toxicology information include:
	–	ToxFAQs™ and the Toxicological Profile for Benzene. This free document is available from the Agency for Toxic Substances and Disease Registry (ATSDR) and can be obtained by:
		&sqbul;	Visiting http://www.atsdr.cdc.gov/toxprofiles
		OR
		&sqbul;	Calling 1-888-422-8737
	–	A variety of technical resources on benzene from the National Institutes for Occupational Safety and Health (NIOSH) by visiting http://www.cdc.niosh/topics/chemicals.html
Part 3: Treatment of acute toxic effects
When providing assistance to someone contaminated with benzene, make sure you are adequately protected and do not risk being overcome by benzene vapor.
Remove the patient from exposure immediately.
Give oxygen or artificial resuscitation, if indicated.
Flush eyes, wash skin if contaminated and remove all contaminated clothing.
Recovery from mild exposures is usually rapid and complete. Symptoms of intoxication may persist following severe exposures.
Part 4: Preventive considerations
The principal effects of benzene exposure which form the basis for the requirements in this chapter are pathological changes in the hematopoietic system, reflected by changes in the peripheral blood and manifesting clinically as pancytopenia, aplastic anemia, and leukemia.
Consequently, the medical monitoring program is designed to observe, on a regular basis, blood indices for early signs of these effects, and although early signs of leukemia are not usually available, emerging diagnostic technology and innovative regimes make consistent surveillance for leukemia, as well as other hematopoietic effects, essential.
Symptoms and signs of benzene toxicity can be nonspecific. Only a detailed history and appropriate investigative procedure will enable a physician to rule out or confirm conditions that place the employee at increased risk.
Bone marrow may appear normal, aplastic, or hyperplastic, and may not, in all situations, correlate with peripheral blood forming tissues. Because of variations in the susceptibility to benzene morbidity, there is no "typical" blood picture.
The onset of effects of prolonged benzene exposure may be delayed for many months or years after the actual exposure has ceased and identification or correlation with benzene exposure must be sought out in the occupational history.
There are special provisions for medical tests in the event of hematologic abnormalities or for emergency situations.
	–	This chapter specifies that blood abnormalities that persist must be referred "unless the physician has good reason to believe such referral is unnecessary." Examples of conditions that could make a referral unnecessary despite abnormal blood limits are iron or folate deficiency, menorrhagia, or blood loss due to some unrelated medical abnormality.
	–	Blood values that require referral to a hematologist or internist are noted under Part 5: Hematology guidelines.
Part 5: Hematology guidelines
The following guidelines are established to assist the examining LHCP with regard to which laboratory tests are necessary and when to refer an employee to the specialist. A minimum battery of tests is to be performed using strictly standardized methods.
Basic tests
•	The following must be determined by an accredited laboratory:
	–	Red and white cell counts;
	–	Platelet counts;
	–	White blood cell differential;
	–	Hematocrit;
	–	Red cell indices.
•	The normal ranges for the red cell and white cell counts are influenced by altitude, race, and sex, and therefore should be determined by the accredited laboratory in the specific area where the tests are performed.
•	Either a decline from an absolute normal or an individual's baseline to a subnormal value or a rise to a supra-normal value, are indicative of potential toxicity, particularly if all blood parameters decline.
	–	The normal total white blood count is approximately 7,200/mm3 plus or minus 3,000;
	–	For cigarette smokers the white count may be higher and the upper range may be 2,000 cells higher than normal for the laboratory;
	–	In addition, infection, allergies and some drugs may raise the white cell count;
	–	The normal platelet count is approximately 250,000 with a range of 140,000 to 400,000. Counts outside this range should be regarded as possible evidence of benzene toxicity.
•	Certain abnormalities found through routine screening are of greater significance in the benzene-exposed worker and require prompt consultation with a specialist, namely:
	–	Thrombocytopenia;
	–	A trend of decreasing white cell, red cell, or platelet indices in an individual over time is more worrisome than an isolated abnormal finding at one test time. The importance of trend highlights the need to compare an individual's test results to baseline and/or previous periodic tests;
	–	A constellation or pattern of abnormalities in the different blood indices is of more significance than a single abnormality. A low white count not associated with any abnormalities in other cell indices may be a normal statistical variation, whereas if the low white count is accompanied by decreases in the platelet and/or red cell indices, such a pattern is more likely to be associated with benzene toxicity and merits thorough investigation;
		&sqbul;	Anemia, leukopenia, macrocytosis or an abnormal differential white blood cell count should alert the physician to further investigate and/or refer the patient if repeat tests confirm the abnormalities. If routine screening detects an abnormality, follow-up tests which may be helpful in establishing the etiology of the abnormality are the peripheral blood smear and the reticulocyte count;
		&sqbul;	The extreme range of normal for reticulocytes is 0.4 to 2.5 percent of the red cells, the usual range being 0.5 to 1.2 percent of the red cells, but the typical value is in the range of 0.8 to 1.0 percent;
		&sqbul;	A decline in reticulocytes to levels of less than 0.4 percent is to be regarded as possible evidence (unless another specific cause is found) of benzene toxicity requiring accelerated surveillance. An increase in reticulocyte levels to about 2.5 percent may also be consistent with (but is not as characteristic of) benzene toxicity.
Additional tests
1. Peripheral blood smears:
•	Collecting the sample: As with reticulocyte count, the smear should be with fresh uncoagulated blood obtained from a needle tip following venipuncture or from a drop of earlobe blood (capillary blood). If necessary, the smear may, under certain limited conditions, be made from a blood sample anticoagulated with EDTA (but never with oxalate or heparin).
•	Prepping the smear: When the smear is to be prepared from a specimen of venous blood which has been collected by a commercial Vacutainer type tube containing neutral EDTA, the smear should be made as soon as possible after the venesection. A delay of up to twelve hours is permissible between the drawing of the blood specimen into EDTA and the preparation of the smear if the blood is stored at refrigerator (not freezing) temperature.
•	Minimum mandatory observations:
	–	The differential white blood cell count;
	–	Description of abnormalities in the appearance of red cells;
	–	Description of any abnormalities in the platelets;
	–	A careful search must be made throughout of every blood smear for immature white cells such as band forms (in more than normal proportion, i.e., over 10 percent of the total differential count), any number of metamyelocytes, myelocytes, or myeloblasts. Any nucleate or multinucleated red blood cells should be reported. Large "giant" platelets or fragments of megakaryocytes must be recognized;
		&sqbul;	An increase in the proportion of band forms among the neutrophilic granulocytes is an abnormality deserving special mention, for it may represent a change which should be considered as an early warning of benzene toxicity in the absence of other causative factors (most commonly infection). Likewise, the appearance of metamyelocytes, in the absence of another probable cause, is to be considered a possible indication of benzene-induced toxicity;
		&sqbul;	An upward trend in the number of basophils, which normally do not exceed about 2.0 percent of the total white cells, is to be regarded as possible evidence of benzene toxicity. A rise in the eosinophil count is less specific but also may be suspicious of toxicity if it rises above 6.0 percent of the total white count;
		&sqbul;	The normal range of monocytes is from 2.0 to 8.0 percent of the total white count with an average of about 5.0 percent. About 20 percent of individuals reported to have mild but persisting abnormalities caused by exposure to benzene show a persistent monocytosis. The findings of a monocyte count which persists at more than 10 to 12 percent of the normal white cell count (when the total count is normal) or persistence of an absolute monocyte count in excess of 800/mm3 should be regarded as a possible sign of benzene-induced toxicity;
		&sqbul;	A less frequent but more serious indication of benzene toxicity is the finding in the peripheral blood of the so-called "pseudo" (or acquired) Pelger-Huet anomaly. In this anomaly many, or sometimes the majority, of the neutrophilic granulocytes possess two round nuclear segments - less often one or three round segments - rather than three normally elongated segments. When this anomaly is not hereditary, it is often but not invariably predictive of subsequent leukemia. However, only about two percent of patients who ultimately develop acute myelogenous leukemia show the acquired Pelger-Huet anomaly. Other tests that can be administered to investigate blood abnormalities are discussed below; however, such procedures should be undertaken by the hematologist.
2. Sucrose water test and Ham test:
•	An uncommon sign, which cannot be detected from the smear, but can be elicited by a "sucrose water test" of peripheral blood, is transient paroxysmal nocturnal hemoglobinuria (PNH), which may first occur insidiously during a period of established aplastic anemia, and may be followed within one to a few years by the appearance of rapidly fatal acute myelogenous leukemia. Clinical detection of PNH, which occurs in only one or two percent of those destined to have acute myelogenous leukemia, may be difficult; if the "sucrose water test" is positive, the somewhat more definitive Ham test, also known as the acid-serum hemolysis test, may provide confirmation.
Important clinical findings
1. Individuals documented to have developed acute myelogenous leukemia years after initial exposure to benzene may have progressed through a preliminary phase of hematologic abnormality. In some instances pancytopenia (i.e., a lowering in the counts of all circulating blood cells of bone marrow origin, but not to the extent implied by the term "aplastic anemia") preceded leukemia for many years.
•	Depression of a single blood cell type or platelets may represent a harbinger of aplasia or leukemia. The finding of two or more cytopenias, or pancytopenia in a benzene-exposed individual, must be regarded as highly suspicious of more advanced although still reversible, toxicity.
•	"Pancytopenia" coupled with the appearance of immature cells (myelocytes, myeloblasts, erythroblasts, etc.), with abnormal cells (pseudo Pelger-Huet anomaly, atypical nuclear heterochromatin, etc.), or unexplained elevations of white blood cells must be regarded as evidence of benzene overexposure unless proved otherwise.
•	Many severely aplastic patients manifested the ominous findings of:
	–	5 to 10 % myeloblasts in the marrow;
	–	Occasional myeloblasts and myelocytes in the blood;
	–	20 to 30 monocytes.
•	It is evident that isolated cytopenias, pancytopenias, and even aplastic anemias induced by benzene may be reversible and complete recovery has been reported on cessation of exposure. However, since any of these abnormalities is serious, the employee must immediately be removed from any possible exposure to benzene vapor.
	–	Certain tests may substantiate the employee's prospects for progression or regression. One such test would be an examination of the bone marrow, but the decision to perform a bone marrow aspiration or needle biopsy is made by the hematologist.
2. The findings of basophilic stippling in circulating red blood cells (usually found in one to five percent of red cells following marrow injury), and detection in the bone marrow of what are termed "ringed sideroblasts" must be taken seriously, as they have been noted in recent years to be premonitory signs of subsequent leukemia.
3. Recently peroxidase-staining of circulating or marrow neutrophil granulocytes, employing benzidine dihydrochloride, have revealed the disappearance of, or diminution in, peroxidase in a sizable proportion of the granulocytes, and this has been reported as an early sign of leukemia. However, relatively few patients have been studied to date. Granulocyte granules are normally strongly peroxidase positive. A steady decline in leukocyte alkaline phosphatase has also been reported as suggestive of early acute leukemia.
	–	Peroxidase and alkaline phosphatase staining are usually undertaken when the index of suspicion for leukemia is high.
4. Exposure to benzene may cause an early rise in serum iron, often but not always associated with a fall in the reticulocyte count. Thus, serial measurements of serum iron levels may provide a means of determining whether or not there is a trend representing sustained suppression of erythropoiesis.
5. Measurement of serum iron, determination of peroxidase and of alkaline phosphatase activity in peripheral granulocytes can be performed in most pathology laboratories.

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