07/26/2010

Interim Guidance for Protecting Deepwater Horizon Response Workers and Volunteers

National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services and
Occupational Safety and Health Administration, U.S. Department of Labor

Recommendations contained in the Interim Guidance will be updated as more information about exposures is collected and assessed in relationship to the incidence and prevalence of symptoms, illnesses and injuries.

The recommendations provided in this Interim Guidance focus on issues specific to the Deepwater Horizon Response and do not address issues common to all disaster response work activities. For more information on general disaster response, consult the NIOSH Emergency Response Topic Page at http://www.cdc.gov/niosh/topics/emergency.html .

Contents

1. General Recommendations
2. Health Effects from Crude Oil and Dispersant Exposure
3. Conducting Exposure Assessment
4. Pre-Placement Medical Evaluation
5. Medical Care and Symptoms, Near-Miss, Injury and Illness Reporting and Recording
6. Heat Stress Prevention
7. Fatigue Prevention
8. Traumatic Incident Stress Prevention
9. Use of Personal Protective Equipment
   1. Guidance on Selection of Protective Clothing
      1. Selection of Fabric
      2. Selection of Seams
      3. Selection of Design
   2. Reuse of Personal Protective Equipment
      1. Protective Clothing and Gloves
      2. Respirators
   3. Use of Respiratory Protection
      1. Source Control Activities
      2. Off-Shore Activities
         1. Vessels Involved in Burning Crude Oil
         2. Vessels Not Involved in Source Control or Burning
      3. Shoreline Clean-up Activities
      4. Decontamination Activities
         1. PPE and Other Equipment
         2. Cleaning Wildlife
      5. Waste Stream Management Activities
   4. Resources for Use of Respiratory Protection
   5. Voluntary Use of Respirators

Appendix A: Human Health Effects Studies from Selected Oil Tanker Spill Disasters

References

I. General Recommendations

The National Institute for Occupational Safety and Health (NIOSH) and the Occupational Safety and Health Administration (OSHA) recognize that many important and well-considered efforts to protect the health and safety of Deepwater Horizon Response workers and volunteers are currently being implemented. To ensure a comprehensive approach to safety and health, NIOSH and OSHA recommend that:

1. Exposures to toxic chemical and physical agents, heat, fatigue and psychological stress should be reduced by using engineering and administrative controls (including work-rest cycles, distance, location and barrier protection) and, where necessary, the use of personal protective equipment (PPE);
2. Exposures to toxic chemical and physical agents should be comprehensively and routinely assessed during work activities under varying conditions. Validated methods for area and personal breathing zone sampling should follow an approved, standardized and comprehensive Deepwater Horizon Response air sampling plan coordinated among all relevant government agencies and non-governmental organizations (and their contractors) that are conducting sampling activities;
3. Dermal exposures to crude oil and toxic chemical agents should be minimized and appropriate PPE should be worn for response activities in which the chance for dermal exposure is high;
4. Selection and use of PPE, including the full protective ensemble, should consider and address the potential to increase heat stress problems in workers and volunteers;
5. All workers and volunteers should be educated about hazards associated with response activities¹, encouraged to participate in worker and volunteer rostering², and have a pre-placement medical evaluation;
6. All health symptoms, illnesses, injuries or near-misses related to work activities should be reported by workers and volunteers; should be recorded by employers, contractors and volunteer organizations; and should be evaluated by safety and health or licensed health care professionals with action taken to protect workers;
7. Periodic, systematic reviews and evaluation of health symptoms, illnesses, injuries or near-misses related to work activities should be done and preventive action taken; and
8. Workers and volunteers should be provided training and assistance to prevent psychological stress associated with response activities and to support resiliency. ³, ⁴

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II. Health Effects from Crude Oil and Oil Dispersant Exposure

Crude oil is a complex mixture of chemical constituents including various alkanes (butane, pentane, and hexane); aromatic hydrocarbons (benzene, ethyl benzene, toluene, and xylenes); cycloalkanes; other nitrogen, oxygen, and sulfur compounds (hydrogen sulfide); and trace metals such as iron, nickel, copper and vanadium. Some constituents of crude oil can have significant toxicity. For example, several aromatic hydrocarbons are considered to be human carcinogens.⁵ The International Agency for Research on Cancer (IARC) indicates that for crude oil, there is inadequate evidence for the carcinogenicity in humans, although there is limited evidence for carcinogenicity in experimental animals.⁶

Hydrocarbon exposure from crude oil constituents will vary based on its exposure to the atmosphere, time in the marine aquatic and coastal environment, treatments with dispersants and interaction of the chemicals, wave action and heat. Generally, the more "aged" or "weathered" crude oil is (by mixing with seawater and traveling long distances from the source), the lower are the concentrations of volatile organic compounds (VOCs). Although it generates less VOCs, weathered crude oil still contains harmful chemicals which can cause skin irritation and other irritant reactions. Thus, use of gloves and protective clothing is recommended to minimize skin contact with weathered oil, including oil deposited on the shore (“tarballs” or “tarpatties”). Appropriate hand hygiene facilities should be readily available to clean incidental skin exposures.

Weathered crude oil is unlikely to pose an inhalation risk although a potential risk does exist for it to be aerosolized into respirable airborne droplets or volatilized by activities such as pressure washing. Even though detection of hydrocarbon "odors" is common in areas contaminated by crude oil, odor is not a reliable indication of a health hazard. Some individuals, though, are bothered by odors and can develop symptoms (e.g., may report dizziness, nose and throat irritation, headache and/or nausea). These individuals may need medical evaluation when symptoms occur, especially if severe or persistent. Individuals with severe or persistent symptoms should be relocated to perform tasks where symptoms can be alleviated.

Studies of tanker oil spill responses have reported adverse health effects in response workers. ^{7, 8,9,10,11,12,13,14,15} A summary of studies about the human health effects associated with selected oil tanker disasters can be found in Appendix A. These studies may underestimate the health effects associated with the Deepwater Horizon Response activities since the magnitude and duration of the Response is unprecedented. In addition, there is an incomplete understanding about the human health toxicity associated with the use of large amounts of dispersant, about the toxicity of the mixed exposure to large amounts of crude oil, dispersants and combustion products together and the cumulative effect of such exposures occurring over a long duration.

Since knowledge about potential inhalational exposures to the mixed exposure of crude oil, dispersant and combustion products associated with the Deepwater Horizon Response work is incomplete and still evolving, NIOSH and OSHA believe it is prudent to reduce the potential for adverse health effects by the responsible use of engineering controls, administrative controls and PPE, including respirators when appropriate. In the absence of comprehensive and coordinated health surveillance among workers and volunteers, and the absence of interpretable, quantitative exposure data, NIOSH and OSHA recommend that employers take precautions sufficient to ensure workers are protected from the chemical, physical and psychological hazards posed by the Deepwater Horizon Response.

Note 1: OSHA is currently monitoring worker exposures and looking for levels of airborne exposure shown likely to cause health effects from chemical exposure to fresh crude oil, weathered oil, dispersants, cleaning agents and other materials. Current OSHA monitoring results can be found at http://www.osha.gov/oilspills/oil_directreading_bysite.html . To date, no air sampling by OSHA has detected any hazardous chemical levels of concern.

Note 2: At the request of BP, NIOSH is conducting health hazard evaluations (HHEs) to evaluate worker exposures and health effects from the fresh crude oil, weathered oil, dispersants, cleaning agents, and other chemicals (e.g., diesel emissions) across all response activities. NIOSH is posting updates about HHE activities on the NIOSH website at http://www.cdc.gov/niosh/hhe/ .

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III. Conducting Exposure Assessment

At this time, there is a need for a coordinated, comprehensive and routine air sampling plan for all response worksites among those government agencies and non-governmental organizations (and their contractors) that are conducting sampling activities. A comprehensive exposure assessment of the Deepwater Horizon Response work activities involves evaluation of multiple different work settings, each with its own set of exposure variables. These work settings involve changing weather conditions, various types and amounts of VOCs being released, work tasks resulting in potential skin and inhalational exposures, and exposure to wildlife and physical hazards, such as heat, snakes and insects. In addition, response workers and volunteers are engaging in activities that may be unfamiliar, thus increasing the potential for injury or exposure.

Exposure assessment to hydrocarbons using traditional 8-hour, 40-hour per week, shifts should be adjusted to reflect the greater duration of work shift and work week exposure experienced by Deepwater Horizon Response workers. Most existing occupational exposure limits for determining harmful levels of chemical agents are based on an 8-10 hour workday and a 40-hour work week. ¹⁶ For extended hours, downward adjustment should be made to the exposure limit based on hours worked. Rote application of exposure criteria without adjustment will not provide sufficient protection to workers engaged in long-duration response work. Published methods are available to adjust exposure criteria for extended work shifts.¹⁷

Respiratory protection precautions are necessary for uncharacterized chemical exposures until the need for such precautions has been ruled out by comprehensive assessment of exposures to toxic chemical agents during work activities under a variety of relevant conditions. Quantitative methods for area and personal breathing zone sampling should follow an approved, standardized and representative Deepwater Horizon Response air sampling plan coordinated among all government agencies and non-governmental organizations (and their contractors) which are conducting sampling activities. Routine, ongoing exposure assessment should continue as part of a comprehensive worker safety and health program.

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IV. Pre-Placement Medical Evaluation

NIOSH developed recommendations for pre-placement medical evaluations for workers involved in the Deepwater Horizon Response (

http://www.cdc.gov/niosh/topics/oilspillresponse/preplacement.html ). These recommendations are designed to: (1) provide health care professionals with guidance on the important elements of a pre-placement evaluation; (2) assist health care professionals in identifying (a) workers with health concerns that need to be addressed, (b) workers that may have specific susceptibilities for whom activities may need to be restricted or modified, and (c) workers with medication, immunization or training needs; and (3) provide valuable information to the worker on his/her health status and the potential demands of the work they are undertaking. However, NIOSH recommendations are not intended to replace existing medical evaluation programs.

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V. Medical Care and Symptom, Near-Miss, Injury and Illness Reporting and Recording

Workers are urged to report any symptoms they associate with their response work to their employer, their physician, poison control center, state or local health department or a local health facility. Symptoms reported from excessive exposure to crude oil/dispersants commonly include eye, nose and throat irritation, headache, dizziness, upset stomach, cough or shortness of breath.

Workers are urged to seek medical attention for any symptoms they associate with their response work. Workers should also have immediate access to medical care provided by licensed healthcare professionals with appropriate expertise. All medical conditions should be assessed for work-relatedness of the illness or injury.

Workers should be encouraged to report any occurance of symptoms, near-misses, injuries and illnesses. These reports should be analyzed to assess real-time trends so that actions can be taken to prevent similar incidents. This information is also useful in identifying the potential for long-term health effects. Symptom, near-miss, illness and injury data should be readily available to all partners, including state and local health officials, as well as the general public.

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VI. Heat Stress Prevention

Deepwater Horizon Response workers and volunteers are at very serious risk for developing heat stress. Many heat stress programs already have been implemented in the Deepwater Horizon Response. The following discussion is meant to review the basic elements of a heat stress program. Excessive exposure to hot environments can cause a variety of heat-related problems, including heat stroke, heat exhaustion, heat cramps, and fainting. Heat can also increase the risk of injuries in workers from sweaty palms, fogged-up safety eyewear, and dizziness. Protective clothing and other PPE will increase the risk of heat-related problems. PPE should be selected to minimize heat stress on the wearer.

Workers at greater risk of heat stress include those who are 65 years of age or older, are overweight, have heart disease or high blood pressure, or take medications that may be affected by extreme heat. Heat stroke is the most serious heat-related disorder and occurs when the body becomes unable to control its temperature; the body's temperature rises rapidly, the sweating mechanism fails, and the body is unable to cool down. Heat stroke can cause death or permanent disability if emergency treatment is not given.

Note that requiring or allowing workers to use certain types of PPE, particularly dermal PPE, that is not required for their specific work task, will increase the potential for the development of heat stress.

Prevention of heat stress in workers is important. A heat stress program should include the following elements:

• Information for workers about the effects of heat stress, and how to recognize heat-related illness symptoms and prevent heat-induced illness;
• Acclimatization of new workers or workers returning to work from absences of three or more days ¹⁸
• Specific procedures to be followed for heat-related emergency situations;
• Provisions to administer first aid immediately to workers displaying symptoms of heat-related illness.

Additional elements include the following:

• Addressing and reducing physical demands on workers;
• Using relief workers or assigning extra workers for physically demanding jobs;
• Providing cool water to workers—avoiding drinks with caffeine, alcohol, or large amounts of sugar;
• Establishing specific work-rest regimens based on the physical demands and environmental heat-related conditions;
• Scheduling work cycles to coincide with cooler temperatures in the day or night;
• Providing cool and shady areas for use during rest breaks; and
• Monitoring workers through a buddy system for signs of heat stress.

Several resources about preventing heat stress are available at the following websites:

NIOSH ( http://www.cdc.gov/niosh/topics/heatstress/ )
OSHA ( http://www.osha.gov/SLTC/heatstress/index.html )
Cal/OSHA ( http://www.dir.ca.gov/dosh/healthillnessinfo.html )

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VII. Fatigue Prevention

Disaster response workers often work longer shifts and more consecutive shifts than the typical 40-hour work week. Working longer hours may increase the risk of work injuries and accidents and can contribute to poor health. The scientific literature indicates that working at least 12 hours per day was associated with a 37% increased risk of injury¹⁹ and construction workers working more than 8 hours per day had a 15 % higher injury rate.²⁰ Fatigue and stress from strenuous work schedules can be compounded by heavy physical workloads, unfavorable environmental conditions (e.g., damaged infrastructure, hazardous materials and debris, sparse living conditions), long commutes, and personal demands on workers.

Therefore, disaster response organizations should have management plans in place to minimize fatigue risks, recognize hazards, and provide regular opportunities for worker rest and recovery. The National Response Team, an organization of 15 Federal departments and agencies responsible for coordinating emergency preparedness and disaster response, has prepared guidance and checklists for managing fatigue during disaster recovery operations.
Consider the following general guidelines: ^21,22,23,24

• Regular Rest: Establish at least 10 consecutive hours per day of protected time off-duty in order to obtain 7-8 hours of sleep. Rest and a full complement of daily recovery sleep are the best protections against excessive fatigue in sustained operations. Allowing only shorter off-duty periods (e.g. 4-5 hours) can compound the fatigue of long work hours.

• Rest Breaks: Frequent brief rest breaks (e.g., every 1-2 hours) during demanding work are more effective against fatigue than few longer breaks. Allow longer breaks for meals.

• Shift Lengths: Five 8-hour shifts or four 10-hour shifts per week are usually tolerable. Depending on the workload, twelve-hour days may be tolerable with more frequent interspersed rest days. Shorter shifts (e.g. 8 hours), during the evening and night, are better tolerated than longer shifts. Fatigue is intensified by night work because of nighttime drowsiness and inadequate daytime sleep.

• Workload: Examine work demands with respect to shift length. Twelve-hour shifts are more tolerable for “lighter” tasks (e.g., desk work). Shorter work shifts help counteract fatigue from highly cognitive or emotionally intense work, physical exertion, extreme environments, or exposure to other health or safety hazards.

• Rest Days: Plan one or two full days of rest to follow five consecutive 8-hour shifts or four 10-hour shifts. Consider two rest days after three consecutive 12-hour shifts.

For additional information on working hours, see www.cdc.gov/niosh/topics/workschedules .

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VIII. Traumatic Incident Stress Prevention

Workers and volunteers may experience stress and fatigue when they respond to environmental disasters, both natural and human-caused. Deepwater Horizon response workers and volunteers are at risk of feeling uncomfortable levels of stress from what mental health professionals refer to as a traumatic incident. The term traumatic is used because of an unexpected and troubling change in the natural order of things, such as the untimely death or injury of oil-covered wildlife and the impact on fishing communities and the environment. It is important that responders monitor their health and well-being during their response activity period, and even months after their response work has ended.

Specific recommendations to help manage responder stress and fatigue during and after a response (in addition to tips for parents, teachers, and response workers) can be found on the Substance Abuse & Mental Health Services Administration (SAMSHA) website at http://samhsa.gov/Disaster/ and the NIOSH website at

http://www.cdc.gov/niosh/topics/oilspillresponse/traumatic.html .

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IX. Use of Personal Protective Equipment

A variety of PPE will be needed by Deepwater Horizon Response workers and volunteers. Administrative controls and engineering controls should be utilized first to minimize the need for PPE in any particular job. Where such controls will not effectively minimize the exposures, then PPE will be necessary. Appropriate selection of PPE begins with answering two questions: (1) what are the hazards faced by a worker or volunteer in a particular job? (2) what is the anticipated level of hazard exposure for a worker or volunteer in doing that job?

Crude oil and its constituents, as well as oil dispersants, can cause skin irritation and inflammation. NIOSH and OSHA recommend avoiding all unprotected skin and eye contact to crude oil, dispersants and other chemicals used during response activities. PPE to prevent skin contact must be selected carefully for use in a hot, wet environment. Skin damage due to chaffing from increased sweating, coupled with the mechanical stress of ill-fitting PPE, can compromise the skin’s natural barrier against bacteria. In addition, the use of sunscreen, shaded safety glasses and wide-brimmed hats are recommended.

For many response tasks, gloves, protective clothing and protective footwear will be necessary. Several types of materials are capable of protecting against crude oil, including those made from neoprene, nitrile and butyl rubber, as well as other commercially available products. PPE should be evaluated before purchase and use by contacting the manufacturer to be sure it has barrier performance against the expected exposures. For eye/face protection, safety glasses, safety goggles, or face shields may be required depending on the specific work activity.

A good source for information about eye and face protection, protective clothing, gloves and protective footwear can be found at http://www.osha.gov/oilspills/oil_ppematrix.html .²⁵

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Appendix A: Human Health Effects Studies from Selected Oil Tanker Spill Disasters

Previous reports have associated symptoms and other adverse health effects in clean-up workers and communities with spills of crude and fuel oil from tankers. These studies involve crude oil or refined petroleum products that may not be directly comparable to crude oil in the Deepwater Horizon event. Studies of eight tanker disasters are shown below. More detailed information is available in several recent reviews by Aguilera et al 2010⁸ and Rodriguez-Trigo et al 2007.¹⁵

Spill	Type of Oil	Health Effects	Author
Exxon Valdez (Alaska, 1989)	Crude	Worker comp claims (1811): sprains/strains (506), respiratory (264), cut/laceration (150) & contusion/crushing (144).	Gorman et al, 199111
		Alaskan Native and Euro-American residents found to have depressive symptoms. One year later, PTSD was associated with social disruption.	Palinkas et al, 199235 and 200436
MV Braer (Scotland, 1993)	Crude	Residents affected by the oil spill compared to a control community 95 km away. Subject had significantly more headache, throat irritation, and itchy eyes. Day 1 after the spill was the most frequent day for onset of symptoms; 97% resolved by day 7. Six months later, exposed residents more likely to report their health was poor or had deteriorated.	Campbell et al, 199337; Campbell et al, 199438
Sea Empress (Wales, 1996)	Crude	Residents in exposed areas reported higher rates of physical and psychological symptoms than control areas.	Lyons et al, 199939
Nakhodka (Japan, 1997)	Fuel C oil	Residents had low back pain and leg pain, headache, and symptoms of the eyes and throat despite low measured levels of exposure.	Morita et al, 19999
Erika (France, 1999)	Heavy #6 Fuel Oil	Workers (1465) surveyed: backache (439 ), headache (317), skin irritation (230), eye irritation (126), difficulty breathing (98), nausea & vomiting (91).	Schvoerer et al, 200040
Prestige (Spain, 2002)	Residual fuel oil (“bunker C oil”)	Workers had headaches, itchy eyes, nausea, vomiting, dizziness, throat & respiratory problems. Risk factors for symptoms included working periods longer than 20 days in highly polluted areas, performing three or more activities, and having skin contact with fuel on head/neck or upper limbs. Receiving health and hygiene information prior to starting a clean-up activity was a protective factor.	Suarez et al, 200541
		Cleanup exposure caused increase in genotoxic damage.	Perez-Cadahia et al, 2006 10
		Workers (7000) had significantly higher rates of upper and lower respiratory tract symptoms, with a dose related increase based on number of days, number of hours worked per day and number of activities.	Zock et al, 200777
Tasman Spirit (Pakistan, 2003)	Crude	Workers had acute decline in lung function measured by spirometry in 31 clean-up workers. More weeks of work was associated with greater losses of lung function. One year later, repeat spirometry among 20 workers showed function comparable with controls.	Meo et al, 200842; Meo et al, 200943
Heibei Spirit (South Korea, 2007)	Crude	Workers had increased levels of VOC metabolites in urine. Resident of heavily/moderately oil-soaked areas had higher anxiety and depression. Both groups had increased headache, nausea, dizziness, sore throat, cough, skin rash, and sore eyes.	Lee et al, 201044 Lee et al, 2010b45

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