In the last 9 months over 20 employees at a healthcare center have developed severe rashes and respiratory symptoms (including asthma). After being out of the building for several hours, the symptoms subside, only to come back after returning. Our employer claims that there is nothing in the building that can cause such problems. Can you help us? S.H., South Dakota

The symptom pattern you describe indicates that employees are being affected as a result of being in the building or as a result of something they are being exposed to in the performance of their work. Because of the diverse nature of activities at healthcare facilities, a variety of chemical exposures may be responsible for the symptoms being reported.

Rashes indicate that employees are touching materials that are contact irritants or produce allergenic irritant responses. In healthcare facilities these can include carbonless copy paper forms (used as patients' charts, etc.), and disinfectants such as glutaraldehyde and other biocides.

Exposure to carbonless copy paper is common in healthcare facilities as it is used for patient charts and other medical records. The nature of chemicals used in carbonless copy paper depends on the manufacturer of the base paper as well those added by custom printing services. Rashes can develop on the hands and face or other parts of the body touched by hands using carbonless copy paper. Rash symptoms are typically distinct reflecting the user's handling/behavior patterns. Frequent hand washing will reduce the risk of developing skin rashes from carbonless copy paper (as well as other paper products). Handling carbonless copy paper can also cause respiratory symptoms such as runny nose, dry/sore throat, sinus irritation and hoarseness. Hoarseness is a unique symptom that characterizes carbonless copy paper exposure in many exposed individuals.

Glutaraldehyde is a very potent irritant chemical that is widely used to disinfect medical instruments such as endoscopes. It has been reported to cause skin rashes and respiratory symptoms (including asthma). Glutaraldehyde is a very effective disinfectant; unfortunately it is also highly irritating to those who use it.

Healthcare facilities use a variety of disinfectants (or biocides). Some of these work by producing formaldehyde, a somewhat less potent (than glutaraldehyde) skin and respiratory irritant.

I recommend that you work with your healthcare facility's risk management personnel to identify disinfectants/biocides to which employees may be exposed and evaluate their potential to affect employees. The use of carbonless copy paper by affected employees should also be evaluated.