Health hazard evaluation report, HETA 2001-0381-2932, Smurfit-Stone Container Corporation, Missoula, Montana.
In March 2001, the National Institute for Occupational Safety and Health (NIOSH) received a request for technical assistance (HETA 2001-0209) from the Occupational Safety and Health Administration (OSHA) regarding dermatitis among employees at Smurfit-Stone Container Corporation ("Smurfit"), a paper-production plant in Missoula, Montana. During an OSHA inspection at the plant, the OSHA inspector learned that over 60 employees had experienced a "skin ailment" over the previous two years. A NIOSH site visit was conducted in April 2001 to assist OSHA in determining the role of occupational exposures in the skin diseases. At that time, 14 of 25 employees interviewed and examined had rashes; at least nine of these appeared consistent with occupational contact dermatitis. HETA 2001-0209 was closed with a letter to OSHA (Appendix A) on July 11, 2001, concluding that there was evidence of work-related dermatitis among Smurfit workers. On June 13, 2001, NIOSH received a health hazard evaluation (HHE) request from the Paper, Allied Industrial, Chemical and Energy Workers Local 8-0885 to further evaluate specific exposures at the Smurfit paper mill to determine the source of the dermatitis. To assess workers' exposures, bulk samples of pulp, paper, and white-water were collected from various locations throughout the paper manufacturing process. Samples were analyzed for various chemicals (biocide and naturally occurring compounds), metals, and biological organisms (mold/fungi and bacteria) that could possibly account for the rash. A self-administered questionnaire was used to obtain information on demographics, skin problems, job tasks, work history, and the work environment for all employees. Workers who indicated they had a rash on the day they completed the questionnaire and agreed to have their skin examined were examined by the NIOSH dermatologist. Three hundred fifty-four out of four hundred seven employees (89%) completed the questionnaire. Forty-three workers fit the case definition of having a chronic rash (i.e., having a high recurrence or continual rash). Forty workers fit the case definition of having work-related current rashes which were clinically consistent with either dermatitis and/or folliculitis. The questionnaire and skin examinations did not reveal a single type of skin problem but rather a variety of problems. Analysis of the questionnaire data showed a weak but statistically significant association between chronic rash and not always laundering work clothes (prevalence ratio 2.0 [confidence interval1.1-3.8]) and washing hands more than four times per day (prevalence ratio 1.9 [confidence interval1.1-3.2]). Most areas of the plant had workers with chronic rash, which was not associated with any specific area of the plant. There was a statistically significant association of a previous history of eczema and chronic rash (prevalence ratio 4.4 [confidence interval 2.5 to 7.9]) although the number of workers with previous eczema was relatively small. Chemical and metal analysis of the bulk materials did not identify any single compound in any substantial amount which we suspect would account for the reported dermal ailments. Mostly, trace amounts of typical biocide by-products and natural occurring compounds (e.g., pinene and resin acids) were found. Metals found in the pulp, paper, and white-water samples were found in the source water in similar concentrations and not of concern regarding skin problems. Results of the microbial analyses were unremarkable except in one sample, which contained Pseudomonas aeruginosa a secondary infectious agent of the skin. Coliforms, however, were present in some samples which indicate that pathogens (some are associated with skin ailments) may be present in the pulp even though they were not found in the NIOSH evaluation. In addition, during the initial site visit, a potential heat stress problem was identified in the rewinder area which could lead to excessive sweating and ultimately cause skin damage. Also, glass fibers were found in two bulk samples collected from the same area which is associated with dermatitis. A health hazard was identified at the Smurfit pulp and paper plant in Missoula, Montana. Approximately 11% of the workers had dermatitis or folliculitis. A single definitive etiologic agent was not identified. However, exposure to pulp, white-water, and/or finished paper alone or in combination with resin acids, dust, biocides, glass fibers, and heat may play a role in the skin problems. Based on the information gathered during multiple site visits, we recommend decreasing workers= exposures to the pulp and white-water. Controls such as elimination of potential sources of pathogens, administrative changes, and personal protective equipment are recommended.