HETA 2000-0341-2839 Dallas Institute of Acupuncture and Oriental Medicine Dallas, Texas Yvonne Boudreau, MD, MSPH Angela Weber, MS This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved. Additional HHE reports are available at http://www.cdc.gov/niosh/hhe/reports This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved. Additional HHE reports are available at http://www.cdc.gov/niosh/hhe/reports This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved. applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved. Additional HHE reports are available at http://www.cdc.gov/niosh/hhe/reports
Transcript
HETA 2000-0341-2839Dallas Institute of Acupuncture and Oriental Medicine
Dallas, Texas
Yvonne Boudreau, MD, MSPHAngela Weber, MS
This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved. Additional HHE reports are available at http://www.cdc.gov/niosh/hhe/reports
This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved. Additional HHE reports are available at http://www.cdc.gov/niosh/hhe/reports
This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved. Additional HHE reports are available at http://www.cdc.gov/niosh/hhe/reports
This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved.
This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved. Additional HHE reports are available at http://www.cdc.gov/niosh/hhe/reports
applicable. Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved. Additional HHE reports are available at http://www.cdc.gov/niosh/hhe/reports
PREFACEThe Hazard Evaluations and Technical Assistance Branch (HETAB) of the National Institute forOccupational Safety and Health (NIOSH) conducts field investigations of possible health hazards in theworkplace. These investigations are conducted under the authority of Section 20(a)(6) of the OccupationalSafety and Health (OSH) Act of 1970, 29 U.S.C. 669(a)(6) which authorizes the Secretary of Health andHuman Services, following a written request from any employer or authorized representative of employees,to determine whether any substance normally found in the place of employment has potentially toxic effectsin such concentrations as used or found.
HETAB also provides, upon request, technical and consultative assistance to Federal, State, and localagencies; labor; industry; and other groups or individuals to control occupational health hazards and toprevent related trauma and disease. Mention of company names or products does not constitute endorsementby NIOSH.
ACKNOWLEDGMENTS AND AVAILABILITY OF REPORTThis report was prepared by Yvonne Boudreau, MD, MSPH and Angela Weber, MS of HETAB, Divisionof Surveillance, Hazard Evaluations and Field Studies (DSHEFS). Desktop publishing was performed byNichole Herbert and Pat Lovell. Review and preparation for printing were performed by Penny Arthur.
Copies of this report have been sent to employee and management representatives at the Dallas Institute ofAcupuncture and Oriental Medicine and the Occupational Safety and Health Administration Regional Office.This report is not copyrighted and may be freely reproduced. Single copies of this report will be availablefor a period of three years from the date of this report. To expedite your request, include a self-addressedmailing label along with your written request to:
NIOSH Publications Office4676 Columbia ParkwayCincinnati, Ohio 45226
800-356-4674
After this time, copies may be purchased from the National Technical Information Service (NTIS) at5825 Port Royal Road, Springfield, Virginia 22161. Information regarding the NTIS stock number may beobtained from the NIOSH Publications Office at the Cincinnati address.
For the purpose of informing affected employees, copies of this report shall beposted by the employer in a prominent place accessible to the employees for a periodof 30 calendar days.
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Highlights of the NIOSH Health Hazard Evaluation
of the Dallas Institute of Acupuncture and Oriental MedicineManagers at the Dallas Institute of Acupuncture and Oriental Medicine (DIAOM) asked investigators fromthe National Institute for Occupational Safety and Health (NIOSH) to see if procedures at their clinic putemployees at risk of exposure to certain pathogens. The primary pathogens of concern were the Hepatitis Band C viruses and the human immunodeficiency virus which are found in blood and body fluids.
What NIOSH Did
# We met with managers and employees to discussclinic policies and procedures.
# We performed a visual inspection of the clinicprocedure rooms and offices.
# We observed acupuncture, moxibustion, andcupping procedures performed at the clinic.
What NIOSH Found
# Sharps containers were generally not locatedwithin easy reach of the practitioner whiletreatments were being performed.
# The cupping jars, gauze, and gloves used by thepractitioner were contaminated with blood duringcupping procedures.
# The protective sheath around the acupunctureneedles provides some protection fromneedlesticks. However, there is still a potential forneedlesticks after the needle is removed from thepatient’s skin.
# An ozone generator is used to control odors frommoxa smoke and other herbs.
# Latex and non-latex gloves are stored outside thetreatment rooms and not within easy reach whenneeded.
What the DIAOM Can Do
# Insist that employees report all exposures to bloodor body fluids.
# Offer Hepatitis B vaccination to employees.
# Refer employees who have had blood or body fluidexposures to a physician who is familiar withbloodborne pathogen exposures.
# Reduce exposure to latex as much as possible byproviding non-latex gloves or powder-free, low-protein gloves.
# Stop using ozone generators.
# Move gloves and sharps containers closer to thepractitioner during procedures.
What DIAOM Employees Can Do
# Report all blood exposures.
# As soon as possible after a blood exposure, see aphysician who is familiar with bloodborne pathogenexposures.
# When using gloves, wear non-latex gloves wheneverpossible.
# Get the Hepatitis B vaccination.
What To Do For More Information:We encourage you to read the full report. If you
would like a copy, either ask your health and safetyrepresentative to make you a copy or call 1-513-841-
4252 and ask for HETA Report # 2000-0341-2839
iv
Health Hazard Evaluation Report 2000-0341-2839Dallas Institute of Acupuncture and Oriental Medicine
Dallas, TexasApril 2001
Yvonne Boudreau, MD, MSPHAngela Weber, MS
SUMMARYIn June 2000, the National Institute for Occupational Safety and Health (NIOSH) received a request frommanagement personnel at the Dallas Institute of Acupuncture and Oriental Medicine (DIAOM) to evaluatethe potential for occupational exposures to bloodborne pathogens (BBPs; e.g., the human immunodeficiencyvirus [HIV], Hepatitis B virus [HBV] and Hepatitis C virus [HCV]) from procedures performed at DIAOM.In response to this request, NIOSH investigators conducted a site visit in October 2000. During this visit,we met with management and employee representatives to discuss clinic policies and procedures; performeda visual inspection of the clinic procedure rooms and offices; and observed acupuncture, moxibustion, andcupping procedures.
Although there have been reports of acupuncture procedures resulting in patients becoming infected withHIV, HBV, and HCV, these incidents were, in most cases, related to exposure to improperly sterilizedreusable needles. With the current standard practice of using single-use, sterile acupuncture needles, thisrisk is greatly decreased. However, there is still a potential risk to the acupuncture practitioner for BBPexposures from needles freshly removed from a patient’s skin. Furthermore, the cupping procedure usedat DIAOM extracts several milliliters of blood and the cupping jars, gauze, and gloves used by thepractitioner can be contaminated with blood from this procedure, posing another potential risk for infectionwith BBPs. In addition, we noted that sharps containers and gloves were located beyond easy reach of thepractitioner during treatments and an ozone generator was occasionally used in the clinic for odor control.We offer several recommendations for decreasing the risk of occupational exposures to the employees atDIAOM.
NIOSH investigators found that acupuncture and cupping procedures can expose employees toBBPs. All exposures to blood should be evaluated by a physician. Ozone generators and latexgloves used at the DIAOM have the potential to cause illness in susceptible employees. Exposureto ozone and latex should be minimized.
Keywords: SIC 8049 (Offices and Clinics of Health care Practitioners, Not Elsewhere Classified),acupuncture, bloodborne pathogens, BBP, Human Immunodeficiency Virus, HIV, Hepatitis B virus, HBV,Hepatitis C virus, HCV, cupping, moxa.
Health Hazard Evaluation Report No. 2000-0341-2839 Page 1
INTRODUCTIONIn June 2000, the National Institute forOccupational Safety and Health (NIOSH)received a request from management personnel atthe Dallas Institute of Acupuncture and OrientalMedicine (DIAOM) to evaluate the potential foroccupational exposures to bloodborne pathogens(BBPs; e.g., the human immunodeficiency virus[HIV], Hepatitis B virus [HBV] and Hepatitis Cvirus [HCV]) from acupuncture and otherprocedures. In response to this request, NIOSHinvestigators conducted a site visit in October2000.
BACKGROUNDAcupunctureThe Chinese tradition of acupuncture dates backat least 2000 years.1 This practice gainedattention in the United States (US) in 1972 whena New York Times reporter wrote about havingreceived acupuncture while traveling withPresident Nixon in China.2 In 1975, the first USacupuncture school (The New England School ofAcupuncture) was opened in Watertown,Massachusetts. In 1982, the profession foundedthe Accreditation Commission for Colleges ofAcupuncture and Oriental Medicine (ACAOM)which, in 1990, became recognized by the USDepartment of Education as an agency foraccreditation at the master's degree level.3 In1997, the National Institutes of Health issued aconsensus statement declaring acupuncture to bean effective treatment for certain medicalconditions.4 There are roughly 10,500 licensedacupuncturists in the US providing about 9-12 million patient visits annually. Mostacupuncture practitioners are required to takeboard exams offered by the National Commissionfor the Certification of Acupuncture and OrientalMedicine (NCCAOM) to become certifiedpractitioners.5 Local acupuncture regulatoryagencies may offer an additional certificationprocess in certain states.
Acupuncture involves the insertion of very fineneedles into the skin at specific points.6 Other
procedures often used in conjunction withacupuncture include moxibustion, which involvesthe burning of moxa (Latin name: Artemesiavulgaris; also called “mugwart” and “wildchrysanthemum”),7 and cupping, in which alancet is used to puncture the skin, after which asmall glass jar is heated and placed over thepunctured area, creating a vacuum that draws outapproximately three to five milliliters (mL) ofblood.8 Transfer of viral infections, includingHIV, HBV, and HCV, may occur betweenpatients or from patients to practitioners ifneedles are not properly sterilized betweenuses.9,10,11,12,13,14 However, sterile, single-useneedles are almost universally used in the UStoday and are regulated by the US Food and DrugAdministration (FDA) as approved medicaldevices.15 The needles are surrounded by aprotective plastic sheath, or guide tube, thatprevents the needle from being inserted toodeeply into the skin. This sheath also helpsprevent inadvertent needlesticks to thepractitioner. Many herbal products are used byacupuncture practitioners to treat a variety ofpatient concerns. These are classified by theFDA as dietary supplements and as such are notsubject to the strict regulations required forcompounds classified as drugs.16
Dallas Institute ofAcupuncture & OrientalMedicinePractitioners at the DIAOM have been offeringacupuncture and other Oriental medicineprocedures since 1996. They maintain a staff ofapproximately 14 faculty and 60 students whoprovide care to approximately 25 clients perweek. All students must complete a clean needletechnique course prior to beginning their trainingat the DIAOM. This course is sponsored by theCouncil of Colleges of Acupuncture and OrientalMedicine (CCAOM),17 and its content is based onrecommendations from the Centers for DiseaseControl and Prevention (CDC) regardingpreventing transmission of BBPs.18 Neitherstudents nor faculty are required to receive amedical exam or any vaccinations to work at theDIAOM. If they sustain a needlestick or other
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sharp object injury, they are sent to a physicianfor evaluation.
Solid-bore, individually packaged, 28-38 gaugesingle-use needles are utilized for acupunctureprocedures. Needles, gauze, and cotton that havebeen contaminated with blood or other bodyfluids are disposed of into sharps containerslocated in each treatment room. Tweezers,forceps, and other reusable devices are soaked ina bleach solution between uses. Latex and non-latex gloves are available for all practitioners, andtheir use is encouraged but not mandatory. Thegloves are stored in a supply room outside of thetreatment rooms. All surfaces in the treatmentrooms are cleaned with a 3% hydrogen peroxidesolution between patient treatments.
The DIAOM maintains a collection of over300 Oriental herbs and pills in a room withintheir office facility (Appendix A). Theseproducts are imported from China and, becausethey are classified as “dietary supplements” (notas “drugs”), they are not subject to any routineregulatory oversight in the US.16 Specific herbsand/or pills are selected for treatment of a client’sillness and then may be burned, ground with amortar and pestle, or used in their original form.An ozone (O3) generator is occasionally used forthe purpose of controlling odors.
METHODSDuring the site visit, NIOSH investigators metwith management and employee representativesto discuss clinic policies and procedures,performed a visual inspection of the clinicprocedure rooms and offices, and observedacupuncture, moxibustion, and cuppingprocedures utilized at the clinic.
EVALUATION CRITERIABloodborne Pathogens
In the health care setting, BBP transmission canoccur when health care workers (HCWs) areexposed to the blood or body fluids of infectedpatients.19 Occupational exposures that mayresult in HIV, HBV, or HCV transmissioninclude needlestick and other sharps injuries;direct inoculation of a virus into scratches,lesions, abrasions, or burns on the skin(percutaneous); and inoculation of virus onto themucosal (mucous membrane) surfaces of theeyes, nose or mouth through splashes. HIV,HBV, and HCV do not spontaneously penetrateintact skin, and airborne transmission of theseviruses does not occur.
In 1987, CDC developed universal precautions tohelp protect HCWs and patients from infectionwith BBPs in the health care setting.20 Theserecommendations stress that blood is the mostimportant source of HIV, HBV, and other BBPsand that infection control efforts should focus onthe prevention of exposures to blood and the useof available vaccines. In 1991, the OccupationalSafety and Health Administration (OSHA) issuedthe BBP Standard.21 It requires that (a) HBVvaccine be made available to HCWs who are atrisk of occupational HBV exposure, (b) writtenexposure control plans be developed, (c)engineering and work practice exposure controlsbe implemented, and (d) HCWs receive annualtraining in BBP exposure prevention. In 1995,CDC introduced the concept of standardprecautions emphasizing that blood and bodyfluids of all patients should be consideredpotentially infectious.20,22,23 The core elements ofstandard precautions comprise hand washing afterpatient contact, the use of barrier precautions(e.g., gloves, gowns, goggles, and face shields) toprevent mucocutaneous contact, minimal manualmanipulation of sharp instruments and devices,and disposal of these items in puncture-resistantcontainers.
Needlesticks and SharpsInjuriesOn November 6, 2000, the Needlestick Safetyand Prevention Act (NSPA) became public law.24
This Act mandates specific revisions to OSHA’s
Health Hazard Evaluation Report No. 2000-0341-2839 Page 3
BBP Standard21 in accordance with specificlanguage included in the NSPA. These revisionsinclude a requirement that in workplaces wherethere is a risk for percutaneous exposures toblood or other body fluids, a sharps injury log bekept in addition to the OSHA Log and Summaryof Occupational Injuries and Illnesses (Form200). This sharps injury log must includedetailed information on the injury, including thetype and brand of device involved in the incident,the department or work area where the exposureincident occurred, and an explanation of how theincident occurred.
Hepatitis BPersons infected with HBV are at risk for chronicliver disease (e.g., chronic active Hepatitis,cirrhosis, and primary hepatocellular carcinoma)and can potentially infect others. The probabilityof HBV transmission after an occupationalexposure is dependent upon the concentration ofthe virus in the implicated body fluid, the volumeof infective material transferred, and the route ofinoculation (e.g., percutaneous or mucosal). Oneof the most common modes of HBV transmissionin the health care setting is an unintentionalinjury from a needle contaminated with bloodfrom a patient who is Hepatitis B surface antigen(HBsAg) positive.25 The risk of transmissionafter a needlestick exposure, if the exposedperson is not immune, is about 30% if the sourcepatient is positive for Hepatitis B e antigen(HBeAg).26,27
The incidence of HBV infection among HCWshas decreased since the early 1980s.28 Thedecline is attributed to the implementation ofstandard precautions in health care settings,including the increasing use of barrierprecautions and personal protective devices(gloves, goggles, etc.) and increasing levels ofHepatitis B vaccination coverage amongHCWs.29,30,31 The Advisory Committee onImmunization Practices (ACIP) and the HospitalInfection Control Practices Advisory Committee(HICPAC) recommend that workers potentiallyexposed to blood or blood-contaminated bodyfluids receive vaccination with the HBV vaccine,which provides pre- and post-exposure protectionagainst HBV infection.32,33 Three intramuscular
doses induce a protective antibody response in>90% of healthy recipients for at least 12 years,and routine booster doses of Hepatitis B vaccineare not considered necessary.34,35,36 One to twomonths after completion of the three-dose series,post-vaccination testing should be done for allHCWs who are at risk for BBP exposures.Persons who do not show the presence ofantibodies to HBV after the primary vaccineseries should complete a second three-dosevaccine series or be evaluated to determine ifthey are HBsAg positive. Re-vaccinated personsshould be retested at the completion of the secondvaccine series. Non-responders who are HBsAgnegative should be considered susceptible toHBV infection and should be counseledregarding precautions to prevent HBV infectionand the need to obtain Hepatitis B immuneglobulin (HBIG) prophylaxis for any known orprobable exposure to HBsAg-positive blood.20
For exposed persons who are not immune, eitherbecause they have not received the HBV vaccineseries or because they are non-responders,multiple doses of HBIG have been shown toprovide an estimated 75% protection from HBVinfection following percutaneous exposure toHBsAg-positive blood when initiated within oneweek of exposure.37,38,39 These individuals shouldalso receive the HBV vaccine series.40
HBV is resistant to drying, simple detergents, andalcohol, and has been found to be stable onenvironmental surfaces for at least sevendays.41,42,43,44,45,46 Thus, indirect inoculation canoccur via inanimate objects (e.g., contaminatedmedical equipment or environmental surfaces).However, HBV has been shown to be inactivatedby several intermediate-level disinfectants,including 0.1% glutaraldehyde and 500 parts permillion (ppm) free chlorine from sodiumhypochlorite (i.e., household bleach).47,48 Heatingto 98°C for two minutes also inactivates HBV.49
Hepatitis CHCV was identified in 1988 as the primary causeof non-A, non-B Hepatitis, and as a major causeof acute and chronic Hepatitis worldwide. HCVtypically circulates at lower titers in infectedblood than HBV and is not transmitted efficientlythrough occupational exposures to blood.50,51
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Hence, HCV is most likely to be transmitted onlyby large exposures to blood, such as through thetransfusion of blood or blood products frominfectious donors or sharing of contaminatedneedles among injection drug users.19 The actualrisk of infectivity has not been well-defined forHCV. The average incidence of HCV infectionafter needlestick or sharps exposure from aknown HCV-positive source patient ranges from0 to 7%, with one study reporting thattransmission occurred only from hollow-boreneedles compared with other sharps.51,52,53,54,55 Notransmission to HCWs has been documentedfrom intact or non-intact skin exposures toblood.51 The risk for transmission after exposureto fluids or tissues other than blood has not beenquantified, but is expected to be low.40
There is currently no vaccine available for HCV,and post-exposure prophylaxis with immuneglobulin does not appear to be effective inpreventing HCV infection.56 Even in the absenceof available pre- or post-exposure prophylaxis,individual worksites should establish policies andprocedures for follow-up after percutaneous ormucosal exposure to anti-HCV positive blood toaddress individual worker’s concerns about theirrisk and outcome.57 The HCV status of thesource and the exposed person should bedetermined and, if indicated, follow-up HCVtesting should be performed to determine ifinfection develops in the exposed worker.50
Data are limited on survival of HCV in theenvironment. Rapid degradation of HCV occurswhen serum containing HCV is left at roomtemperature.58 In contrast to HBV, the datasuggest that environmental contamination withblood containing HCV does not pose a significantrisk for transmission in the health care setting,with the possible exception of the hemodialysissetting where HCV transmission related toenvironmental contamination and poor infectioncontrol practices has been implicated.59,60,61,62,63,64
Human ImmunodeficiencyVirusMost occupational exposures to HIV do not resultin infection. The risk of infection varies with thetype of exposure and factors such as the amount
of blood involved in the exposure, the amount ofvirus in the blood, and whether treatment wasgiven after the exposure. Among HCWs, theaverage risk of HIV infection after a needlestickor cut exposure to HIV-infected blood fromfreshly contaminated sharps is 0.3% (about 1 in300).65 Stated another way, 99.7% ofneedlestick/cut exposures do not result ininfection. The risk of HIV infection afterexposure of the eye, nose, or mouth to HIV-infected blood is estimated to be 0.09% (about 1in 1000).66 There have been no documentedcases of HIV transmission due to an exposureinvolving a small amount of blood on intact skin.Although episodes of HIV transmission afternon-intact skin exposure have been documented,the average risk for transmission by this route isestimated to be less than the risk for mucousmembrane exposures.67,68 The risk fortransmission after exposure to fluids or tissuesother than HIV-infected blood also has not beenquantified, but appears to be considerably lowerthan for blood exposures.69
After an occupational exposure to HIV,employees should be tested for HIV status, and ifnot positive, should be followed-up for up to sixmonths. Post-exposure prophylaxis is animportant element in the management of anoccupational exposure to HIV.70 The use ofzidovudine (ZDV) and other antiviral drugs aftercertain occupational exposures may reduce thechance of HIV infection.71 A physician familiarwith the risks of HIV infection and the sideeffects of the drugs should be consultedimmediately after an exposure to determinewhether post-exposure treatment is appropriateand, if so, the selection of the regimen to use.Prevention of occupational exposures,particularly percutaneous injuries, is the primarymeans of avoiding occupationally acquired HIVinfection.
Studies have indicated that HIV is readilysusceptible to a variety of disinfectants.72 Thetiter of HIV in blood is reduced by 90-99%within several hours after drying, and it furtherdiminishes with time.20,73 There is no evidencefor HIV transmission from environmentalsurfaces.
Health Hazard Evaluation Report No. 2000-0341-2839 Page 5
Sterilization andDisinfectionStandard sterilization and disinfection proceduresrecommended for patient care equipment areadequate to sterilize or disinfect itemscontaminated with blood or other body fluidsfrom people infected with BBPs.20 Becauseforeign material may interfere with thesterilization or disinfection procedure, devicesmust first be adequately cleaned.74 All spills ofblood and blood-contaminated body fluids shouldbe promptly cleaned by a person wearingappropriate gloves and using an EnvironmentalProtection Agency-approved disinfectant or a1:10 to 1:100 solution of household bleach.20
Visible material should first be removed withdisposable towels or other means to preventdirect contact with blood. The area should thenbe decontaminated with an appropriatedisinfectant.20
LatexNatural latex is an intracellular milky fluidproduced by the laticifer cells of the tropicalrubber tree, Hevea brasiliensis. It is manuallyharvested and, through multiple processes, isconverted into natural rubber latex (NRL). This,in turn, is used for the manufacture ofcommercial latex products, including latexgloves, balloons, and condoms. Over the last 20years, reports of adverse reactions to NRL haveincreased, and latex allergy has been recognizedas an occupational health hazard. Studies inHCWs have shown latex allergy prevalence ratesof 2-16.9%.75,76,77 Several reasons may exist forthe increase in reports of latex allergy and otheradverse reactions to latex. The use of latexgloves has increased significantly since theintroduction of universal precautions to preventthe transmission of HIV, HBV, and otherinfectious agents. To meet the increased demandfor latex gloves, some manufacturers mayproduce more allergenic gloves because ofchanges in raw materials, processing, ormanufacturing procedures. Also, physician andpublic awareness of latex allergy has increased.Routes of exposure to NRL include dermal,mucosal, percutaneous, and inhalation. NRL
sensitization is also associated with allergies tocertain foods, including banana, avocado, potato,tomato, passion fruit, kiwi fruit, papaya, andchestnut.78,79 The prevention of adverse latexreactions depends on the identification ofindividuals who are allergic so that they canavoid exposure to NRL-containing products. Iflatex allergy is suspected, a physician familiarwith latex allergy should be consulted.
RESULTSDuring our observation of procedures at theDIAOM, we noted the following:
1. Sharps containers were generally located in acorner of the treatment rooms beyond easy reachof the practitioner while treatments were beingperformed. Approximately 30 pounds of sharpscontainers are disposed of as biohazardous wasteon a monthly basis.
2. Three to five mL of blood were extractedduring the cupping procedures. The cupping jars,gauze, and gloves used by the practitioner werecontaminated with blood from this procedure.Contaminated cupping jars are placed on a traycovered with a reusable, absorbent liner. Thepotential for cross-contamination exists if thisliner cannot be appropriately decontaminated.Decontamination procedures were not observedduring the NIOSH site visit, but the DIAOMmanagement told us that they planned to replacethe liners with a disposable adsorbent product.
3. The protective sheath around the acupunctureneedles provides some protection fromunintentional needlesticks. However, there is stilla potential for needlesticks after the needle isremoved from the patient’s skin.
4. The burning of moxa created a noticeable,strong odor and visible smoke in the treatmentroom. DIAOM personnel reported that asmokeless form of moxa is available.
5. Gloves are stored outside of treatment rooms;none were available in the individual treatmentrooms.
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6. An O3 generator is occasionally used for thepurpose of controlling odors. The O3 generatorwas not used during the NIOSH site visit.
7. There is no exhaust ventilation or containmentprovided in the herbal storage room where theherbs and other products are prepared (i.e.,crushed or mixed).
DISCUSSIONAlthough the practice of acupuncture hashistorically resulted in HIV, HBV, and HCVinfections in patients, these incidents were, inmost cases, related to the utilization of reusableneedles that were not properly sterilized.9-14 Withthe incorporation of single-use, sterileacupuncture needles, this risk is greatlydecreased. However, there is still a potential riskto the acupuncture practitioner of exposures fromneedles freshly removed from a patient’s skin. Inaddition, the cupping procedure used at DIAOMproduces several milliliters of blood, andexposure to this blood is a potential risk forinfection with any of the BBPs. O3 generators(electronic devices that emit O3 by design) arecommercially available and widely promoted asair cleaning devices that eliminate chemicalpollutants, remove indoor allergens, kill moldsand bacteria, and “freshen air” in the indoorenvironment. However, no carefully conductedstudies (published in the peer-reviewed literature)have substantiated that O3 removes thesepollutants innocuously.80,81 In fact, studies havefound that in addition to being a primarypulmonary irritant, O3 can react with otherchemicals in the indoor environment to createinsidious and more irritating chemicalcompounds.82,83
RECOMMENDATIONS1. Immediately following an exposure to bloodor body fluids, or to objects potentiallycontaminated with blood or body fluids, thefollowing should occur: areas of skin exposed toneedlesticks and cuts should be washed with soapand water; after splashes to the nose, mouth, orskin, the area should be flushed with water; andafter splashes to the eyes, the eyes should be
irrigated with clean water, saline, or sterileirrigants.23
2. All workplace needlesticks, cuts from othersharp objects, or splashes onto the skin, eyes,nose, or mouth should be immediately reportedand evaluated by a physician familiar withoccupational BBP exposures. A program shouldbe put into place that emphasizes and ensures thatthis reporting and medical follow-up is takingplace.21, 84
3. In accordance with CDC recommendationsand OSHA requirements for HCWs, allemployees should be offered the HBV vaccinefree of charge.32,85 One to two months aftercompletion of the three-dose vaccination series,employees should be tested for antibody toHepatitis B surface antigen (anti-HBs). Boosterdoses of Hepatitis B vaccine are not considerednecessary, and periodic serologic testing tomonitor antibody concentrations after completionof the vaccine series is not recommended.
4. Employers should provide education toemployees regarding the prevention of HCV inthe occupational setting, and such informationshould be routinely updated to ensure accuracy.57
The DIAOM should establish policies andprocedures for follow-up after percutaneous ormucosal exposure to anti-HCV positive blood toaddress individual worker’s concerns about theirrisk and outcome.
5. A sharps injury log should be kept inaccordance with the 2000 NSPA.24
6. Employees should be provided with accurateand up-to-date information on the risk andprevention of infection from all bloodbornepathogens. After any sharp injury or splash to theeyes, nose, or mouth, DIAOM managementshould refer the exposed worker to anoccupational or infectious disease physician todiscuss the need for post-exposure treatment andfollow-up.40
7. Consider placing the sharps containers onmovable carts that can be placed near thepractitioner during procedures to decrease the
Health Hazard Evaluation Report No. 2000-0341-2839 Page 7
2. Ceniceros S, Brown GR [1998].Acupuncture: a review of its history, theories,and indications. South Med J 91(12):1121-5.
3. Department of Education, Office ofPostsecondary Education [1995]. NationallyRecognized Accrediting Agencies andAssociations. Criteria and Procedures for Listingby the US Secretary For Education and CurrentList. Washington, DC, US Department ofEducation.
4. National Institutes of Health [1997]. NIHConsensus S ta temen t : acupunc ture .15(5):1-34. http://odp.od.nih.gov/consensus/cons/107/107statement.htm.
5. Council of Colleges of Acupuncture andOriental Medicine. Spring 2000 Newsletter.http://www.ccaom.org/spring_2000.htm.
6. Firebrace P [1988]. Acupuncture: restoringthe Body's Natural Healing Energy. New York,New York: Harmony Books.
7. Therapeutics of Acupuncture &Moxibustion: English-Chinese Encyclopedia ofPractical Therapeutic Chinese Medicine [1991].Xu Xiangcai (Ed). Hong Kong: HigherEducation Press.
8. Chirali, IZ [1999]. Cupping Therapy:Traditional Chinese Medicine. London, UK:Churchill Livingstone.
9. Peuker ET, White A, Ernst E, Pera F, FillerTJ [1999]. Traumatic complications ofacupuncture. Arch Fam Med 8:553-558.
handling time of contaminated gauze, cotton, andacupuncture needles.
8. Because of the potential for employees todevelop allergy to latex, the use of latex glovesshould be limited to those situations where latexis considered necessary to prevent skin exposureto infectious agents. If latex gloves are chosen,use powder-free low-protein gloves. Considermaking gloves available in treatment rooms sothat practitioners will have easy access to themduring procedures.
9. All spills of blood and blood-contaminatedbody fluids should be promptly cleaned by aperson wearing appropriate gloves and using anEnvironmental Protection Agency-approveddisinfectant or a 1:10 to 1:100 solution ofhousehold bleach.20,40 Visible material shouldfirst be removed with disposable towels or othermeans to prevent direct contact with blood. Thearea should then be decontaminated with anappropriate disinfectant. Latex gloves do notprovide adequate protection from disinfectionagents, since the chemicals may causedeterioration of the glove material. Considerationshould be given to using vinyl or nitrile rubbergloves instead of latex. Nitrile, for example,could safely be used with most disinfectantsincluding ethyl alcohol, hydrogen peroxide,glutaraldehyde, and sodium hypochlorite(bleach).86 Nitrile also offers adequate protectionfrom bodily fluids.
10. The use of O3 generators should be avoided.If an ozone generator is used, employees need tobe informed of ozone exposures as part of theOSHA Hazard Communication Standard orWorker Right-to-Know regulations.87 Sourcecontrol, dilution ventilation, proper filtration, andprudent mechanical hygiene practices are farmore effective alternatives to managing andalleviating indoor environmental pollutants thanuse of O3 generators.
11. The use of source control ventilation shouldbe considered when dust-producing (e.g.,crushing) activities are performed. Additionally,since a smokeless version of moxa is available,consider its use where feasible.
REFERENCES
Page 8 Health Hazard Evaluation Report No. 2000-0341-2839
10. Kent GP, Brondum J, Keenlyside RA,LaFazia LM & Scott HD [1988]. A largeoutbreak of acupuncture-associated Hepatitis B.Am J Epidemiol 127:591-8.
11. Vittecoq D, Mettetal JF, et al. [1989].Acute HIV infection after acupuncturetreatments. NEJM 320:250-1.
12. Stryker WS, Gunn RA, Francis DP [1986].Outbreak of Hepatitis B associated withacupuncture. J Fam Pract 22(2):155-8.
13. Sun CA, Chen HC, Lu CF, et al. [1999].Transmission of Hepatitis C virus in Taiwan:prevalence and risk factors based on a nationwidesurvey. J Med Virol 59(3):290-6.
14. Phoon WO, Fong NP, Lee J [1988]. Historyof blood transfusion, tattooing, acupuncture andrisk of Hepatitis B surface antigenemia amongChinese men in Singapore. Am J Pub Hlth78:958-60.
15. Department of Health and Human Services,Food and Drug Administration [1996]. 21 CFRPart 880 [Docket Number 94P-0443], MedicalDevices: reclassification of acupuncture needlesfor the practice of acupuncture, final rule.Federal Register 61(236):64616-7.
16. US Food and Drug Administration [1999].FDA Consumer Publication No. FDA 99-2323.
17. Council of Colleges of Acupuncture andO r i e n t a l M e d i c i n e [ 2 0 0 1 ] .http://www.ccaom.org/.
18. Clean Needle Technique Manual forAcupuncturists: guidelines and standards for theclean and safe clinical practice of acupuncture[1997]. Fourth Ed. National AcupunctureFoundation.
19. Beltrami EM, Williams IT, Shapiro CN &Chamberland ME [2000]. Risk and Managementof Bloodborne Infections in Health Care
Workers. Clin Microbiol Rev July 2000:385-407.
20. Centers for Disease Control & Prevention[1987]. Recommendations for prevention of HIVtransmission in health-care settings. MMWR36(2S);1-18.
21. US Department of Labor, OccupationalSafety and Health Administration [1991]. 29CFR Part 1910.1030. Occupational exposure tobloodborne pathogens: final rule. Fed Regist56:64004-182.
22. Garner JS & the Hospital Infection ControlPractices Advisory Committee [1996].Guidelines for isolation precautions in hospitals.Inf Cont Hosp Epi 17:53-80.
23. Centers for Disease Control [1988].Update: universal precautions for prevention oftransmission of HIV, HBV & other bloodbornepathogens in health-care settings. MMWR37:377-82, 387-8.
24. United States Congress [2000]. Public Law106-430. Needlestick Safety and Prevention Act.HR5178.
25. Alter HJ, Seell LB, Kaplan PM, McAuliffeVJ, et al. [1976]. Type B Hepatitis: theinfectivity of blood positive for e antigen andDNA polymerase after accidental needlestickexposure. NEJM 295:909-13.
26. Grady GF, Lee VA, Prince AM, et al.[1978]. Hepatitis B immune globulin foraccidental exposures among medical personnel:final report of a multicenter controlled trial. J InfDis 138:625-38.
27. Werner BG & Grady GF [1982]. AccidentalHepatitis B surface antigen positive inoculations:use of e antigen to estimate infectivity. AnnIntern Med 97:367-9.
Health Hazard Evaluation Report No. 2000-0341-2839 Page 9
28. Centers for Disease Control & Prevention[1994]. Hepatitis surv. report, Atlanta. p. 3-6.
29. Beckman SE, Vlahow F, Koziol DE, et al.[1994]. Temporal association betweenimplementation of universal precautions and asustained progressive decrease in percutaneousexposures to blood. Clin Inf Dis 18:562-9.
30. Haiduven DJ, Domain TM, Stevens DA[1992]. A five-year study of needlestick injuries:significant reduction associated withcommunication, education and convenientplacement of sharps containers. Inf Cont HospEpi 13:265-71.
31. Wong ES, Stotka JL, Chinchilli DS, et al.[1991]. Are universal precautions effective inreducing the number of occupational exposuresamong health care workers? A prospective studyof physicians on a medical service. JAMA265:1123-8.
32. Centers for Disease Control & Prevention[1997]. Immunization of health-care workers:recommendations of the Advisory Committee onImmunization Practices (ACIP) and the HospitalInfection Control Practices Advisory Committee(HICPAC). MMWR 46:RR-18, December 26.
33. Centers for Disease Control [1982].Recommendation of the Immunization PracticesAdvisory Committee (ACIP) - inactivatedHepatitis B virus vaccine. MMWR 31:317-28.
34. Wainwright RB, McMahon BJ, Bulkow LR,et al. [1989]. Duration of immunogenicity andefficacy of Hepatitis B vaccine in a YupikEskimo population. JAMA 261:2362-6.
35. West DJ, Watson B, Lichtman J, et al.[1994]. Persistence of immunologic memory fortwelve years in children given Hepatitis Bvaccine in infancy. Pediatr Inf Dis J 13:745-7.
36. Whittle HC, Maine J, Pilkington M, et al.[1995]. Long-term efficacy of continuing
Hepatitis B vaccination in infancy in twoGambian villages. Lancet 345:1089-92.
37. Grady GF, Lee VA, Prince AM, et al.[1978]. Hepatitis B immune globulin foraccidental exposures among medical personnel:final report of a multicenter controlled trial. J InfDis 138:625-38.
38. Seeff LB, Zimmerman HJ, Wright EC, et al.[1977]. A randomized, double blind controlledtrial of the efficacy of immune serum globulin forthe prevention of post-transfusion Hepatitis: aVeterans’ Administration cooperative study.Gastroenterology 72:11-21.
39. Prince AM, Szmuness W, Mann MK, et al.[1975]. Hepatitis B “Immune” globulin:effectiveness in prevention of dialysis-associatedHepatitis. NEJM 293:1063-7.
40. Centers for Disease Control & Prevention[2001]. Updated Public Health ServiceGuidelines for the Management of OccupationalExposures to HBV, HCV and HIV andRecommendations for Postexposure Prophylaxis(PEP). Preliminary draft, March, 2001.
41. Favero MS [1985]. Sterilization,disinfection and antisepsis in the hospital, p. 129-37. In Lennette EH, Balows A, Hausler WJ &Shadomy HJ (eds.). Manual of clinicalmicrobiology, 4th ed. American Society forMicrobiology, Washington, DC.
42. Pattison CP, Boyer KM, Maynard JE &Kelly PC [1974]. Epidemic Hepatitis in a clinicallaboratory: possible association with computercard handling. JAMA 230:854-7.
43. Bond WW, Favero MS, Peterson NJ, et al.[1981]. Survival of Hepatitis B virus afterdrying and storage for one week [Letter]. Lancet1:550-1.
44. Hennekens CH [1973]. Hemodialysis-associated Hepatitis: an outbreak among hospital
Page 10 Health Hazard Evaluation Report No. 2000-0341-2839
46. Snydman DR, Bryan JA, Macon EJ, GreggMB [1976]. Hemodialysis-associated Hepatitis:a report of an epidemic with further evidenceon mechanisms of transmission. Am J Epi104:563-70.
47. Bond WW, Favero MS, Peterson NJ & EbertJW [1983]. Inactivation of Hepatitis B virus byintermediate-to-high-level disinfectant chemicals.J Clin Micro 18:535-8.
48. Favero MS & Bond WW [1993].Disinfection and sterilization, p. 565-75. InZuckerman AJ & Thomas HC (eds.). ViralHepatitis; scientific basis and clinicalmanagement. Churchill Livingston, New York,NY.
49. Kubayashi H, Tsuzoki M, Koshimizu K, etal. [1984]. Susceptibility of Hepatitis B virus todisinfectants and heat. J Clin Microbiol 20:214-6.
50. Bradley DW, Krawczynski K, Beach MJ &Purdy MA [1991]. Non-A, non-B Hepatitis:toward the discovery of Hepatitis C & E viruses.Semin Liver Dis 11:128-46.
51. Davis GL & Lau JYN [1995]. Hepatitis C.p. 2082-114. In WS Haubrich, F Schaffner & JEBerk (eds), Gastroenterology, 5th ed. WBSaunders & Co., Philadelphia, PA.
52. Alter MJ [1997]. The epidemiology of acuteand chronic Hepatitis C. Clin Liver Dis 1:559-68.
53. Lanphear BP, Linnemann CC, Jr., CannonCG, et al. [1994]. Hepatitis C virus infection inhealth care workers: risk of exposure andinfection. Inf Cont Hosp Epi 15:745-50.
54. Puro V, Petrosillo N, Ippolito G, ItalianStudy Group on Occupational Risk of HIV andOther Bloodborne Infections. Risk of HepatitisC seroconversion after occupational exposure inhealth care workers. Am J Inf Cont 23:273-7.
55. Mitsui T, Iwano K, Masuko K, et al. [1992].Hepatitis C virus infection in medical personnelafter needlestick accident. Hepatology 16:1109-14.
56. Alter MJ [1994]. Occupational exposure toHepatitis C virus: a dilemma. Inf Cont Hosp Epi15:742-44.
57. Centers for Disease Control & Prevention[1998]. Recommendations for the prevention andcontrol of Hepatitis C virus (HCV) infection andHCV-related chronic disease. MMWR 47(RR-19):1-39.
58. Cuypers HT, Bresters MD, Winkel IN, et al.[1992]. Storage conditions of blood samples andprimer selection affect yield of cDNA polymerasechain reaction products of Hepatitis C virus. JClin Microbiol 30:3320-4.
59. Davis GL, Lau JY, Urdea MS, et al. [1994].Quantitative detection of Hepatitis C virus RNAwith a solid-phase signal amplification method:definition of optimal conditions for specimencollection and clinical application in interferon-treated patients. Hepatology 19:1337-41.
60. Polish LB, Tong MJ, Co RL, Coleman PJ,Alter MJ [1993]. Risk factors for Hepatitis Cvirus infection among health care personnel in acommunity hospital. Am J Inf Cont 21:196-200.
61. Niu MT, Coleman PJ, Alter MJ [1993].Multicenter study of Hepatitis C virus infectionin chronic hemodialysis patients and staff. Am JKidney Dis 22:568-73.
62. Hardy NM, Sandroni S, Danielson S, WilsonWJ [1992]. Antibody to Hepatitis C virusincreases with time on hemodialysis. Clin
Health Hazard Evaluation Report No. 2000-0341-2839 Page 11
Nephrol 38:44-8.
63. Niu MT, Alter MJ, Kristensen C, MargolisHS [1992]. Outbreak of hemodialysis-associatednon-A, non-B Hepatitis and correlation withantibody to Hepatitis C virus. Am J Kidney Dis4:345-52.
64. Favero MS, Alter MJ [1996]. Thereemergence of Hepatitis B virus infection inhemodialysis centers. Sem Dialysis 9:373-4.
65. Bell DM [1997]. Occupational risk ofhuman immunodeficiency virus infection inhealth care workers; an overview. Am J Med102(Suppl. 5B):9-14.
66. Ippolito GV, Puro G, et. al. [1993]. The riskof occupational human immunodeficiency virusinfections in health care workers. Arch Int Med153:1451-58.
67. Centers for Disease Control [1987]. Update:human immunodeficiency virus infections inhealth-care workers exposed to blood of infectedpatients. MMWR 36:285-89.
68. Fahey BJ, Koziol De, Banks SM, HendersonDK [1991]. Frequency of nonparenteraloccupational exposures to blood and body fluidsbefore and after universal precautions training.Am J Med 90:145-53.
69. Henderson DK, Fahey BJ, Willy M, et al.[1990]. Risk for occupational transmission ofhuman immunodeficiency virus type 1 (HIV-1)associated with clinical exposures: a prospectiveevaluation. Ann Int Med 113:740-46.
70. Centers for Disease Control & Prevention[1998]. Public Health Service guidelines for themanagement of health-care worker exposures toHIV and recommendations for postexposureprophylaxis. MMWR 47(RR-7):1-34.
71. Cardo DM, Culver DH, et al. [1997] A case-control study of HIV seroconversion in health
care workers after percutaneous exposure. NEJM337:1485-90.
72. Sattar SA & Springthorpe VS [1991].Survival and disinfectant inactivation of thehuman immunodeficiency virus. Rev Inf Dis13:430-47.
73. Van Bueren J, Simpson RA, Jacobs P &Cookson BD [1994]. Survival of humanimmunodeficiency virus in suspension and driedonto surfaces. J Clin Microbiol 32:571-74.
74. Martin MA, Reichelderfer M, and theAssociation for Professionals in Infection Controland Epidemiology, Inc. [1994]. APIC guidelinefor infection prevention and control in flexibleendoscopy. Am J Inf Cont 22;19-38.
75. Arellano R, Bradley J, Sussman G.Prevalence of latex sensitization among hospitalphysicians occupationally exposed to latexgloves. Anesthesiology 77: 905-908, 1992.
76. Wrangsjo K, Osterman K, van Hage-Hamsten M. Glove-related skin symptoms amongoperating theatre and dental care unit personnel.II. Clinical examination, tests and laboratoryfindings indicating latex allergy. ContactDermatitis 30: 139-143, 1994.
77. Yassin MS, Lierl MB, Fisher TJ, O'Brien K,Cross J, Steinmetz C. Latex allergy in hospitalemployees. Annals of Allergy 72: 245-249, 1994.
78. Blanco C, Carrillo T, Castillo R, Quiralte J,Cuevas M. Latex allergy: clinical features andcross-reactivity with fruits. Ann Allergy 73: 309-314, 1994.
79. Beezhold DH, Sussman GL, Liss GM,Chang M. Latex allergy can induce clinicalreaction to specific foods. Clin Exp Allergy 26:416-422, 1996.
80. Boeniger M [1995]. Use of OzoneGenerating Devices to Improve Indoor Air
Page 12 Health Hazard Evaluation Report No. 2000-0341-2839
Quality. Am Ind Hyg J 56 June:590-8.
81. Shaughnessy RJ, Oatman L [1991]. The Useof Ozone Generators for Control of Indoor AirContaminants in an Occupied Environment.Proceedings of ASHRAE Conference IAQ 91.Healthy Buildings. ASHRAE, Atlanta, GA.
82. Weschler CJ, Shields H [1997]. PotentialReactions among Indoor Pollutants. AtmosphericEnvironment 31(21):3487-95.
83. Zhang J & Lioy P [1994]. Ozone inResidential Air: Concentrations, I/O Ratios,Indoor Chemistry and Exposures. Indoor Air4:95-102.
84. Centers for Disease Control [1990]. PublicHealth Service statement on management ofo c c u p a t i o n a l e x p o s u r e t o h u m a nimmunode f i c i ency v i rus , inc lud ingconsiderat ions regarding zidovudinepostexposure use. MMWR 39(RR-1):1-14.
85. Kopfer AM, McGovern PM. 1993.Transmission of HIV via a needlestick injury:practice recommendations and researchimplications. AAOHN Journal 41(8):374-81.
86. Forsberg K and Mansdorf SZ, eds [1997].Quick selection guide to chemical protectiveclothing. 3nd ed. New York:Van NostrandReinhold.
87. Esswein EJ & Boeniger M [1994]. Effect ofan Ozone Generating Air-Purifying Device onReducing Concentrations of Formaldehyde inAir. App Occ Env Hyg 9(2):139-46.
Health Hazard Evaluation Report No. 2000-0341-2839 Page 13
Appendix A – Herbs and Tea Pills at DIAOMRaw Herbs
Ai Ye Da Fu Pi Hai Zao Lu RangAi Ye Tan Da Huang Han Fang Ji Luo Bu MaBa Dou Da Ji Han Lian Cao Luo Shi TengBai Bu Da Qing Ye He Huan Pi Ma Chi XianBai Dou Kou Dai Zhe Shi He Shou Wu Ma HuangBai Fu Zi Dan Shen He Ye Ma Huang GenBai Guo Dan Zhu Ye He Zi Mai Meng DongBai He Dang Gui Pian Hei Zhi Ma Mai YaBai Hua She She Cao Dang Gui Wei Hong Hua Man Jing ZiBai Ji Dang Shen Hong Ling Zhi Mang XiaoBai Ji Li Deng Xin Cao Hou Po Mao Dong QingBai Ji Tian Di Fu Zi Hu Gu Ming FanBai Jiang Cao Di Gu Pi Hu Huang Lian Ma YaoBai Jie Zi Di Huang (sheng) Hu Jiao Mu Dan PiBai Mao Gen Di Long Hu Zhang Mu GuaBai Qian Di Yu Hua Shi Mu LiBai Shao Yao Dong Gua Ren Hua Zhi Shen Mu Li FenBai Tou Weng Du Huo Huai Hua Mi Mu TongBai Xian Pi Du Zhong Huang Bai Mu XiangBai Zhi Du Zhong Ye Huang Jing Nan Sha ShenBai Zhu E Jiao Huang Lian Niu Bang ZiBai Zi Ren E Zhu Huang Qi Niu XiBan Lan Gen Fan Xie Ye Huang Qin Nu Zhen ZiBan Xia Fang Feng Huo Ma Ren Ou JieBei Xie Fang Ji Huo Xiang Ou Jie TanBi Ba Fa Shou Jing Jie Pang Da HaiBian Dou Fu Hai Shi Ji Guan Hua Pj Pa YeBian Xu Fu Ling Ji Nei Jin Pu Gong YingBie Jia Fu Ling (curled) Ji Xue Teng Pu HuangBing Lang Fu Ling Pi Jiang Can Qian Cao GenBing Pian Fu Pen Zi Jiang Huang Qian HuBo He Fu Shen Jie Geng Qian Nian JianBu Gu Zhi Fu Xiao Mai Jin Qian Cao Qian Niu ZiCang Er Zi Gan Cao Shen Jin Yin Hua Qian ShiCang Zhu Gan Cao Zhi Jing Ying Zi Qiang HuoCe Bai Ye Gan Jiang Ju Hua Qin JiaoChai Hu Gan Sui Jue Ming Zi Qing HaoChanTui Gao Ben Ku Lian Gen Pi Qing PiChe Qian Cao Gao Liang Jiang Ku Shen Qing Tian KuiChe Qian Zi Ge Gen Kuan Dong Hua Qing Xian ZiChen Pi Gou Ji Kun Bu Qu MaiChen Xiang Gou Qi Zi Lai Fu Zi Quan XieChi Shao Gou Teng Lian Qiao Ren Dong TengChi Xiao Dou Gu Sui Bu Lian Zi Ren Shen Chuan Bei Mu Gu Ya Lian Zi Xin Ren Shen (Korean)Chuan Bei Xie Gua Lou Liu Huang Ren Shen XuChuan Lian Zi Gua Lou Pi Liu Ji Nu Rou Dou KoChuan Niu Xie Gua Lou Ren Long Dan Cao Rou GuiChuan Shan Long Gui Ban Long Gu Rou Kong RongChuan Wu Gui Zhi Long Yan Rou Ru XiangChuan Wu Pian Hai Feng Teng Lu Gen San LengChuan Xiong Hai Piao Xiao Lu Hui San QiCi Shi Hai Tong Pi Lu Lu Tong Sang Bai Pi
Page 14 Health Hazard Evaluation Report No. 2000-0341-2839
Appendix A (continued) – Herbs and Tea Pills at DIAOM
Raw Herbs (continued)
Sang Ji Sheng Tong Cao Ze LanSang Shen Tu Fu Ling Ze XieSang Ye Tu Si Zi Zhang NaoSang Zhi Wang Bu Liu Xiang Zhe Bei MuSha Ren Wei Ling Xian Zhen ZuSha Yuan Zi Wu Gong Zhi KeShan Yao Wu Jia Pi Zhi Mu Shan Zha Wu Ling Zhi Zhi Nan XingShan Zhu Yu Wu Mei Zhi ShiShang Lu Wu Wei Zi Zhi Zi She Gan Wu Yao Zhu RuShe Tui Wu Zhu Yu Zi CaoShen Qin Cao Xi Xin Zi Cao WuShen Qu Xi Yang Shen Zi Hua Di DingSheng Chuang Zi Xia Ku Cao Zi Ran TongSheng Ma Xian He Cao Zi Su YeShi Chang Pu Xian Mao Zi Su ZiShi Gao Xiang Fu Zi WanShi Gao (powder) Xiao Hui Xiang Zi ZhuShi Hu Xie Bai Zhu LingShi Jian Chuang Xin Yi HaShi Jue Ming Xing RenShi Wei Xu DuanShu Di Huang Xuan Fu HuaShu Fu Zi Xuan ShenShui Niu Jiao Ya Dan ZiShui Zhi Yan Hu SuoSi Gua Luo Ye Jiao TengSong Jie Ye Ju HuaSong Xian Yi Mu CaoSuan Zao Ren Yi Yi RenSuo Yang Yi Zhi RenTai Zi Shen Yin Chen HaoTao Ren Ying Yang HuoTian Hua Fen Yuan ZhiTian Ma Yu JinTian Nan Xing Yu Li RenTian Qi Yu Xing CaoTing Li Zi Yu Zhu
Yuan Hua
Health Hazard Evaluation Report No. 2000-0341-2839 Page 15
Appendix A (continued) – Herbs and Tea Pills at DIAOM
Golden Flower Herbs
ASTRAGALUS & LIGUSTRUM FORMULA LILY PRESERVE METAL FORMULAASTRAGALUS FORMULA MING MU FORMULAASTRAGALUS FORMULA SYRUP MINOR BLUEGREEN DRAGON FORMULABLOOD PALARE FORMULA PEARL CREAMBUPLEURUM & TANG KUEI FORMULA MINOR BUPLEURUM FORMULABUPLEURUM D FORMULA NOURISH ESSENCE FORMULACHASE WING, PENETRATE BONE FORMULA PEACEFUL SPIRIT FORMULACINNAMMON & PORIA FORMULA PERSICA AND CISTANCHES FORMULACINNAMMON D FORMULA PINELLIA & MAGNOLIA BARK FORMULACLEMATIS & STEPHANIA FORMULA PORIA & FENNEL FORMULACOPTIS RELIEVE TOXICITY FORMULA PORIA 15 FORMULACORYDALIS FORMULA PUERARIA FORMULADUHUO & LORANTHUS FORMULA PULSATILLA INTESTINAL FORMULAEASE DIGESTION FORMULA REHMANNIA & SCROPHULARIAEIGHT IMMORTALS FORMULA REHMANNIA COOL BLOOD FORMULAESSENTIAL YANG FORMULA SALVIA TEN FORMULAFREE & EASY WANDERER PLUS FORMULA SAN QI TABLETSFRITILLARAIA & PINELLIA SYRUP SEA OF QI FORMULAGASTRODIA & UNCARIA FORMULA SIBERIAN GINSENG TABLETSGENERAL TONIC FORMULA SIX GENTLEMEN FORMULAGENTIANA DRAIN FIRE FORMULA TANG KUEI & PEONY FORMULAGINKGO FORMULA TANG KUEI & SALVIA FORMULAGINSENG & ASTRAGALUS FORMULA TIEH TA FORMULAGINSENG NOURISHING FORMULA TRUE YIN FORMULAHE SHOU WU TABLETS TWO IMMORTALS FORMULAHEAVENLY EMPEROR'S FORMULA VIOLA CLEAR FIRE FORMULAINTESTINAL FUNGUS FORMULA WOMEN'S PRECIOUS FORMULAJADE SCREEN & XANTHIUM FORMULA WU HUA FORMULAJING QI FORMULA YIN CHIAO FORMULAJUAN BI FORMULA
Page 16 Health Hazard Evaluation Report No. 2000-0341-2839
Appendix A (continued) – Herbs and Tea Pills at DIAOM
Patent Herbs Tea Pills
Alrodeer Pill Rhematic Plaster Anmien PenArmadillo Counter Poison Pill Run Chang Wan Bu Fei TeapillsBai Zi Yang Xin Wan Sai Mei An Calm in the Sea of Life TeapillsBanlangen Chongji San Bow Soul Calm Spirit Teapills Bao Ji Wan San She Dan Chuan Bei Ye Calm Stomach TeapillsBaohe Wan San She Tan Chuan Xin LianBHI Cold Sang Chu Tablets Clean Air TeapillsBHI Cough Sciatica Pills Clear Mountain TeapillsBHI Spasm-Pain Sea Horse Combination Clear Wind Heat TeapillsBu Zhong Yi Qi Wan Shen Qi Da Bu Pills Curing PillCataract Vision-lmproving Pills Shen Qi Wu Wei Zi Wan Eight Righteous TeapillsChing Fei Yi Huo Pien Shi Hu Ye Guang Wan Emperors TeapillsChing.Wan Hung Shilintong Five Peel TeapillsChuan Xiong Cha Tiao Wan Shui De An Capsules Four Gentlemen TeapillsChuang Yao Tonic Shu Gan Wan Gan Mao Ling Crocodile Bile Pill Superior Sore Throat Powder Spray Great Corydalis TeapillsDa Bu Wan Imperial Tang Kwei Gin Great Pulse TeapillsDa Bu Yin Wan Tian Ma Wan Great Yang Restoration TeapillsDang Gui Su Tieh Ta Yao Gin Jade Screen TeapillsDermocure Ointment Tiger Balm Jade Spring TeapillsDiet Tea To Jing Wan Ledebouriella Sagely Unblocks TeapillsDragon Diet Traumeel Lidan PianEr Chen Wan Wan Hua Shi Oil Llycium Rehmannia TeapillsEr long Zuo Ci Wan Watermelon Frost Lycu-Chrysanthemum TeapillsEssential Balm Wu Chi Paifeng Wan Magnolia FlowerImperial Panax Ginseng Extract Wuling San Margari te Acne PillsGripp-Heel Xiang Sha Yang Wei Wan Nei Xiao luo Li TeapillsGuci Pian Xiao Chai Hu Tang Wan Panta TeapillsGui Pi Wan Xiao Yao Wan Pe Min Kan WanHuang Lien Yudai Pills (100 pills) Pinellia Root TeapillsHuo Xiang Zhen Qi Wan Yudai Pills (200 pills) Salvia TeapillsJiang Ya Pien Yunnan Pai Yao Six Flavor TeapillsJie Geng Wan Yunnan Pai Yao (box) Solitary Hermit TeapillsJigucao Wan Zheng Gu Shui (large) Soothe LiverJin Gui Di Huang Wan Zheng Gu Shui (small) Stasis in the Mansion of Blood TeapillsJin Suo Gu Jing Wan Zhi Bai Di Huang Wan Suan Zao Ren TengKai Yeung Pil The Snake & Dragon TeapillsLigaplex II You Gui TeapillsLiu Shen Shui Zuo Gui TeapillsLong Dan Xie Gan WanLuobuma Chaing Yapien Ma Wei Di Huang Wan Ming Mu Di Huang Wan Ming Mu Shang Ching PienNu Ke Ba Zhen WanPasswan Pearl CreamPiantoutong WanPlacenta Compound Restorative PillsPo Sum On Medicated OilPro Botanixx CR-21 0 (Jiang Zhi)
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