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EXPOSURE TO GLUTARALDEHYDE
ALONE OR IN A FUME MIX:
A REVIEW OF 26 CASES
Bill Glass, FAFOM, FFOM (Lond.) FFOM (I.) Occupational
Presented to the Marjorie Gordon Memorial Seminar, March 1997.
Published in SHADOWS, Journal of the NZMRT, VOLUME 40, NO 2, 13-17.
I would like to begin with a personal tribute to Marjorie Gordon.
She recognised the reality of the relationship between an illness and
work. She was tenacious in the face of disbelief.
She had an open mind.
She was not blinded by prejudice, ignorance or the security of the
status quo. These are the qualities and attitudes which take society
Thank you Marjone.
This paper reviews the effect of glutaraldehyde on the health of 26
referred patients over a 6 year period.
The patients fall into 2 groups. Group A includes those who worked
predominantly with glutaraldehyde, Group B those who worked with a
chemical cocktail which included glutaraldehyde, with the exception of
two cases where formaldehyde and benzaldehyde replaced
Referrals came from either the ACC, lawyers or general practitioners.
They thus tend to reflect those more seriously affected.
Group A patients worked with glutaraldehyde used as a cold sterilant
or, on occasions, as a bench wipe and comprised nurses and technicians
employed in hospitals or general practice.
Group B patients worked predominantly in photographic or x-ray
departments in hospitals. They were exposed to a mix of chemicals in the
developing and fixing processes. In the developer there was
glutaraldehyde, acetic acid, hydroquinone, a glycol ether, potassium
hydroxide, sodium sulphite and 1 phenyl-3 pyrazolidone. In the fixer
there was acetic acid, aluminiurn sulphate, ammonium thiosulphate,
sodium acetate, sodium sulphite and a glycol ether.
The method of processing has evolved over time from a predominantly
hands on process with mixing and diluting of chemicals and manually
removing the film to automatic processing systems.
METHODS OF USE AND EXPOSURE LEVELS
1. Glutaraldehyde as a Cold Sterilant
Glutaraldehyde is a volatile irritating chemical which can also act
as a sensitiser. The odour threshold is 0.04ppm and the irritant
threshold 0.3ppm. The workplace exposure standard (short term, 10
minutes) is 0.2ppm.
The chemical is used as a 2% solution and is activated for use by
buffering with sodium bicarbonate which enhances its irritating effects.
It has been frequently used in open containers, buckets and shallow
dishes and for cleaning surfaces (bench wipe).
A Scandinavian study(1) recorded glutaraldehyde in air levels as
-When used as a bench wipe in a 0.5% and 3% solution, 0.04 to
-During manual procedures, <0.01 to 0.2ppm.
-With automatic sterilisers, <0.01 to 0.06ppm.
-In poorly ventilated rooms, 0.04 to 0.06ppm.
-In well ventilated rooms, up to 0.01ppm.
An investigation in the UK(2) produced results similar to those
reported above. However, a NIOSH investigation recorded 6 out of 13
tests greater than 0.2ppm.
2. Glutaraldehyde as a Hardener During Film Processing
In a review of use in the UK(3) it was noted that dark rooms and
processing areas are typically very small with little attention to
design, drains are often open, local exhaust ventilation poor and
general dilution ventilation inadequate. Skin contact can occur during
mixing of the chemicals, cleaning of the equipment and cleaning of the
floors. Hands on use is gradually being replaced with more automatic
An investigation into levels of pollutants in automated processing
units indicated that only acetic acid and sulphur dioxide were detected at
measurable levels (<0.lppm) although still below the exposure
standards. It was not possible to investigate workplaces where health
problems had occurred.
Results from overseas studies have shown both high and low air levels
when glutaraldehyde has been used either as a cold sterilant or in
photographic processing. Few measurements in New Zealand workplaces have
been carried out; one will be presented in a case
The tables which follow list the reported symptoms and the frequency
of occurrence of the symptoms in the two groups.
- TABLE 1
- FREQUENCY OF OCCURRENCE OF SYMPTOMS IN THE TWO GROUPS
Shortness of Breath
Skin Irritation 10 4
Muscle aches and pains
(Neuropsychological ) Mood
From Table 1 there is clearly little difference in the frequency of
occurrence of symptoms between Group A and Group B except for skin
irritation. The most commonly occurring symptoms are those which are
irritative to the eye, nose, throat, lower respiratory tract and skin,
together with headache and fatigue.
There were 5 cases of asthma confirmed by respiratory physicians, 2
among Group A and 3 among Group B. There were 4 cases of dermatitis
confirmed by dermatologists, 2 in each Group. I was also diagnosed as
having scleroderma (See Gase Study.)
Symptoms of a neuropsychological nature involving mood, memory and
concentration occurred more frequently among the Group A cases than Group
10 of the 13 cases in Group A were also given Questionnaire 16 and the
results are shown in Table 2.
Questions 1, 2, 3, and 4 involve memory, question 6 understanding,
question 6 concentration and questions 7 and 8, mood.
More detailed short battery psychological tests were completed by 4
patients (Table 3) and a full clinical neuropsychological
evaluation was carried out on 6 patients. These further tests confirm
the neuropsyochological damage suffered by the patients.
2 Questionnaire 16
A Questionnaire for CNS Symptoms
||Do you have a short memory?
||Have your relatives told you that you have
a short memory?
||Do you often have to make notes about what
you have to remember?
Do you often have to go back and check things you have done such
as turned off the stove, locked the door etc?
Do you generally find it hard to get the meaning from rcading
newspapers and books?
||Do you often have problems with
||Do you often feel irritated without any
||Do you often feel depressed without any
||Are you abnormally tired?
||Are you less interested in sex than what
you think is normal?
Do you have palpitations of the heart even when you don't exert
||Do you sometimes feel oppression in your
||Do you perspire without any particular
||Do you have a headache at least once a
||Do you often have painful tingling in some
parts of your body?
||Do you have problems with buttoning and
NEUROPSYCHOLOGICAL - SHORT BATTERY TESTS
- Case l
- Male 46
- Case 2
- Male 46
- Case 3
- Female 44
- Case 4
- Female 47
|Attention (Digit Span)
|Normal Range for age:
|(S.D. 1.12 /1.11) Sensory Motor (Digit Symbol)
| Normal for age:
|a) Verbal (Associated Learning)
|Normal for age
|b) Short Term (Digit Span)
c) Long Term (Controlled Oral Word Fluency)
Normal for age
d) Visual (Visual Reproduction)
Exposure to glutaraldehyde and consequential health effects have been
well documented in the medical literature(7) since the original work of
Marjorie Gordon(8). The effects of exposure are both irritative and
allergic with symptoms predominantly on the upper and lower respiratory
tract(9-14) and the skin(15-17). Undue fatigue and headache have also
However, it is clear from the review of these 26 cases that other
symptoms have occurred to a significant degree and include
neuropsychological symptoms and cross sensitivity reactions. It is of
interest that these symptoms were not recorded in the paper by Spicer and
Gordon in 1986(18).
Questionnaire 16 is a screening questionnaire developed initially by
Hogstedt et al(19) to test for early disturbance in central nervous
A recent study in New Zealand (in publication) has validated
Questionnaire 16 as a useful tool. It suggested that Q16 effectively
screens men with suspected Type 2 occupational solvent neurotoxicity (WHO
classification of mild toxic encephalopathy with symptoms of abnormality
of performance on neuropsychological testing).
While not all of the 26 cases were tested with Q16, among those ten who
were tested in Group A, evidence of memory, mood and concentration
impairment was evident. Confirmation by a short battery neuropsychological
test procedure or complete neuropsychological assessment was shown in 6 of
In an interesting paper by Teo(20) given at the Australian Institute of
Occupational Hygienists Conference in 1994, three staff exposed to
glutaraldehyde in a theatre while cleaning endoscopes were tested by the
auditory evoked potential method. They showed prolongation of the response
time (p3 latency) a dysfunction related to the depression of the cortical
function of the brain.
TABLE 4 FULL NEUROPSYCHOLOGICAL ASSESSMENT
- INTELLECTUAL CAPACITY (NART)
|GENERAL INTELLECTUAL ABILITY (WAIS-R) VERBAL AND PERFORMANCE
||Above av generally. Verbal abstraction
||Performance better than
verbal. Digit span similarities reduced
||Memory retrieval abstract thought reduced
||Digit span reduced
||Below predicted on sub-tests
||Assoc learning reduced. Selective
||Assoc learning good. Logical memory reduced
||Assoc learning reduced. Immediate recall
||Assoc learning reduced
||Assoc learning reduced
||WVR good REY figure fair. Delayed
||WVR & REY figure good
||Both results good
||WVR average. REY figure difficulty
||WVR & REY figure reduced
TIME - VERBAL
||Reduced latter half
Cross sensitivity, a term used to categorise those who developed a
reaction to other chemicals, was a disturbing reaction in a number of
patients. There were 7 cases among Group A and 8 cases among Group B.
Common substances to which patients reacted included petrol fumes,
cigarette smoke, deodorants, hairsprays. paper and household cleaners.
Many of these substances contain formaldehyde, a chemical relative of
Tachycardia and palpitations were noted by 7 patients in Group A and
3 patients in Group B. A report by Connaughton(2l) in Australia recorded
a similar finding. However, "unusual heart rhythms" were also noted in
the survey by Spicer and Gordon in 18 out of 367 radiographers.
Questions have arisen as to whether the cause of radiographers'
illnesses is glutaraldehyde alone, given that other hazardous chemicals
are present. For example, sulphur dioxide, a respiratory irritant, and
acetic acid are more commonly found in detectable quantities in air
sampling than is glutaraldehyde. In fact in one report an analogy is
made between the symptoms of radiographers and those who suffer sick
Certainly working circumstances for many radiographers are dreadful
with confined space and inadequate ventilation, both local and general,
being frequent findings.
It is a well accepted premise in occupational medicine that the toxic
effects of a chemical are more severe when the dose is high and dose is
a consequence of concentration and exposure time, with the former being
influenced by confined space conditions. It is also well accepted that
working in poorly ventilated work areas, even when the chemical
concentration is modest, will lead to symptoms such as headache and
As is so often the case, a specific causative agent for illnesses
which occur to workers exposed to a mixture of chemicals is rarely
isolated but this does not invalidate the "mix" as causative. Smelter
asthma in the aluminum industry, solvent neurotoxicity (when the solvent
is frequently a solvent mix) and chronic bronchitis from welding fumes,
are well known examples.
Energy and money spent on providing good working conditions and
better technical systems is more effective in these cases than fruitless
research on trying to identify a single causative agent.
I will conclude, therefore, by reminding us all that the essence of the
law in New Zealand, The Health and Safety in Employment Act 1992, is
compliance with a few basic principles. These include:
- hazard identification
- hazard assessment (measuremeut)
- hazard significance (is it a health
Principles of intervention for significant hazards are:
- minimisation and monitoring.
The emphasis of the Act is that employers shall take all practicable
steps to ensure the safety of employees while at work.
More detailed assistance is provided by the 0SH booklet "The Safe
Occupational Use of Glutaraldehyde in the Health Industries", 1992 and
the ACC booklet "Guidance Notes to the Provision of a Safe Work
Environment and Safe Work Practice for Radiographers and Darkroom
Specific control measures include
1. Attention to workplace design, size, construction, and
2. Attention to local and general ventilation principles.
3. Engineering solutions to handling and decanting, i.e. process
4. Good housekeeping and hygiene practice.
5. Planned contingencies for spillages.
6. Proper waste disposal.
7. Education and training.
8. Personal and protective equipment.
9. Health surveillance and environmental monitoring.
10. Compliance with the law.
Finally, given the history of the management of glutaraldehyde in
photographic chemicals to date and the disastrous outcomes for many
workers, there is clearly a need for a new technological approach for
both cold sterilising and film processing.
- 1. Norback D.
- Skin and respiratory symptoms from exposure to
alkaline glutaraldehyde in medical services.
- Scand.J. Work Environ. HIth, 1988; 14,366-71.
- 2. Leinster PL , Baum JM, Baxter PJ.
- An assessment of exposure to glutaraldehyde in
hospitals: typical exposure levels and recommended control
- Brit. J. Ind. Med. 1993; 50 :107-111.
- 3. Symptoms of irritation associated with exposure to
glutaraldehyde - Colorado.
- Epid. Notes and Reports, MMMR 1987 (April)
- 4. From Literature on Virkon.
- 5. Hewitt PJ.
- Occupational health problems in processing of x-ray
- Ann. Occup Hyg 1993; 37: 287-295.
- 6. Scobbie E, Groves JA.
- An investigation of the composition of the vapour
evolved from aqueous glutaraldehyde solutions. Ann. Occup. Hyg. 1995;
- 7.Burge PS.
- Occupational risks of glutaraldehyde may cause
respiratory. nasal and skin problems at low concentrations. BAl3 1989:
- 8. Gordon M.
- The effects on health of inhaling toxic chemical
fumes given off during 'processing' of X-ray films.
- Shadows 1984; 27(4): 28-33.
- 9. Benson WG.
- Gase report exposure to glutaraldehyde.
- J.Soc Occup Med 1984; 34: 63-64.
- 10. Gannon PFG, Bright P, Campbell M, O'Hickey SP,
Burge Sherwood P.
- Occupational asthma due to glutaraldehyde and
formaldehyde in endoscopy and x-ray departments.
- Thorax 1995; 50 :156-158.
- 11. Trigg CT, Heap DC, Herdman MJ, Davies RJ. A
- Resp Med 1992; 86:167-169.
- 12. Smedley J, lnskip H, Wield C, Coggon D.
- Work related respiratory symptoms in
- Occup & Env Med 1996; 53: 450-454.
- 13. Corrado OJ, Osman J, Davies RJ.
- Asthma and rhinitis after exposure to glutaraldehyde in
- Human Toxicol 1986; 5: 325-327.
- 14. Chan-Yeung M, McMurran T, Catonio-Begley F, Iain
- Occupational asthma in a technologist exposed to
- J Allergy Clin Immunol 1983; 91:974.978.
- 15. Tam M, Freeman S.
- Occupational allergic contact dermatitis due to
- J Occup Hlth & Safety Aust. NZ 1989; 5(6):
- 16. Fowler JE
- Allergic contact dermatitis from
- J Occup Med 1989; 31(10): 852-853.
- 17. Nethercott JR, Holness DL, Page E. Occupational
contact dermatitis due to glutaraldehyde in health care workers.
- Contact Derm 1988; 18:193-196.
- 18. Spicer J, Hay DM, Gordon M.
- Workplace exposure reported health in New Zealand
- Aust Radiol 1986; 30: 281-6.
- 19. Hogsted, Anderson, Hane.
- A questionnaire approach to the monitoring of early
disturbances in central nervous function. Aillo et al (edit).
- Biological Monitoring and Surveillance of workers
exposed to chemicals - Washington.
- 20. Teo RKC. Naido VA.
- The effects of glutaraldehyde exposure on human brain
- Workcover Australia paper presented to the 13 Annual
Conference of the Australian Institute of Occupational Hygienists
- 21. Connaughton P.
- Occupational exposure to glutaraldehyde associated
with tachycardia and palpitations. Med J Aust; 1993; 159: 567
- 22. Hewitt P.
- Reducing the risks in x-ray film processing.
- Occupational Health 1994, 46 (7): 244-246.
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