Medical surveillance guidelines

Yes — Under 1910.1018 App C, medical examinations must be provided to all employees exposed to inorganic arsenic at or above the action level of 5 µg/m3 for at least 30 days per year (this includes employees who work in regulated areas).

• Employers must also provide examinations to employees who have accumulated 10 years or more of exposure above the action level for more than 30 days per year while working for the present or predecessor employer, even if they are no longer currently exposed above the action level.
• Employees first assigned to areas where exposure will probably exceed 5 µg/m3 must receive an initial exam at the time of assignment.

Cited requirement: 1910.1018 App C.

Provide a baseline — Under 1910.1018 App C, the initial medical examination must, at minimum, include a work and medical history (including smoking history and respiratory symptoms), a 14" by 17" (or reasonably-sized equivalent) posterior-anterior chest X-ray, a nasal and skin examination, and any other exams the physician deems appropriate because of inorganic arsenic exposure or required respirator use.

• History should document breathlessness, cough, sputum, wheezing, and smoking status.
• The initial exam also serves as a baseline for future comparisons.

Cited requirement: 1910.1018 App C.

It depends on age and years of exposure — Under 1910.1018 App C, periodic examinations are annual for covered employees 45 years of age or younger with fewer than 10 years of employment in areas where exposure exceeds the action level (5 µg/m3), and every six months for other covered employees.

• Annual periodic exams for: employees ≤45 years old with <10 years exposure in covered areas (need only an updated medical history; chest X-ray and sputum cytology need not be repeated).
• Semiannual periodic exams for: employees >45 or with ≥10 years exposure (these must include the tests required in the initial exam except the chest X-ray; the history only needs updating).

Cited requirement: 1910.1018 App C.

No — Under 1910.1018 App C, periodic examinations for employees 45 years or younger with fewer than 10 years of employment in exposed areas need only an updated medical history and do not need sputum cytology or chest X-ray.

• For employees requiring six-month exams, the chest X-ray is not required, but the periodic exam must include the other tests from the initial exam and an updated history.

Cited requirement: 1910.1018 App C.

Include lymph node and blood checks — Under 1910.1018 App C, workers exposed to copper acetoarsenite, potassium arsenite, or sodium arsenite (three arsenicals associated with lymphatic cancer) should have an examination that includes palpation of superficial lymph nodes and a complete blood count (CBC).

• These additional checks are intended to screen for lymphatic system involvement and blood abnormalities related to those specific arsenicals.

Cited requirement: 1910.1018 App C.

Yes — Under 1910.1018 App C, the listed examination contents are minimum requirements and the physician may order additional tests (for example, lateral or oblique X‑rays or pulmonary function tests) if they are useful because of the employee's exposure or respirator use.

• Employers should be prepared to provide additional diagnostic tests when recommended by the examining physician to appropriately evaluate exposure-related health effects.

Cited requirement: 1910.1018 App C.

Document exposure and symptoms — Under 1910.1018 App C, the initial work and medical history must include the employee's occupational history, smoking history, and presence and degree of respiratory symptoms such as breathlessness, cough, sputum production, and wheezing.

• A thorough history lets the physician establish a baseline and identify signs or risk factors (like smoking) that could affect interpretation of findings.

Cited requirement: 1910.1018 App C.

Because it establishes a baseline — Under 1910.1018 App C, the initial medical examination provides not only immediate diagnostic information but also a baseline against which future test results can be compared to detect changes from workplace exposure.

• Baselines help physicians detect early signs of disease progression and assess whether changes are occupationally related.

Cited requirement: 1910.1018 App C.

Yes — Under 1910.1018 App C, employees who have had 10 years or more exposure above the action level for more than 30 days per year while working for the present or a predecessor employer must be provided medical examinations even if they are no longer currently exposed above the action level.

• This provision ensures long-term exposure history with previous employers is considered when determining need for surveillance.

Cited requirement: 1910.1018 App C.

Watch for respiratory, skin, neurologic, and gastrointestinal signs — Under 1910.1018 App C, symptoms to watch for include cough, breathlessness, sputum production, wheezing, conjunctivitis, nasal inflammation and perforation, dermatitis, keratoses (palms/soles), weight loss, nausea, diarrhea, peripheral neuropathy ("glove and stocking" numbness), and nail striations.

• These signs can indicate local irritant effects, chronic arsenical poisoning, or systemic toxicity and should prompt medical evaluation.

Cited requirement: 1910.1018 App C.

No — Under 1910.1018 App C, inhalation of arsenic trioxide and other inorganic arsenical dusts does not give rise to radiological evidence of pneumoconiosis, although other nonneoplastic effects (skin lesions, nasal septum perforation, neuropathy) can occur.

• Physicians should still perform chest X‑rays as part of initial exams for baseline purposes and to detect other lung disease if clinically indicated.

Cited requirement: 1910.1018 App C.

Yes — Under 1910.1018 App C, the medical surveillance program includes a nasal and skin examination in the initial exam because inorganic arsenic exposure can produce skin changes such as keratoses (especially palms and soles) and increase risk of skin cancer.

• Regular skin checks in surveillance help detect keratotic changes or suspicious lesions early.

Cited requirement: 1910.1018 App C.

Only as part of the periodic exam requirements — Under 1910.1018 App C, for covered employees 45 years or younger with fewer than 10 years exposure in exposed areas, the periodic examination may be limited to an updated medical history (which can be a questionnaire), and need not include sputum cytology or chest X‑ray.

• Any questionnaire or history must be adequate to update the initial baseline and identify new or worsening symptoms.
• For employees who require six‑month exams, the periodic medical must include the initial-exam tests (except chest X‑ray) rather than just a questionnaire.

Cited requirement: 1910.1018 App C.

Yes — Under 1910.1018 App C, an initial medical examination must be provided at the time of initial assignment to employees first assigned to areas in which exposure will probably exceed 5 µg/m3 (after August 1, 1978).

• This ensures a baseline is established before or soon after the start of increased exposure.

Cited requirement: 1910.1018 App C.