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 investigators did not consider the phenomenon to indicate any large health risk, but they noted that CCP seems to be somewhat more irritating than ordinary paper in equivalent amounts.

In Canada, Harris [1983] reported that the symptoms directly associated with use of CCP (and shown to decrease outside of work or at other tasks) develop primarily in office workers who use CCP and less in those who make it. He stated that the symptoms (1) appear to be quickly reversible when exposure ceases, (2) are rarely caused by allergic reactions, and (3) vary greatly from office to office (which may depend on combinations of factors including the brand of CCP, the intensity of use, and office conditions such as ventilation and humidity). He further stated that no individual chemicals such as formaldehyde, oils, or paper dust had been identified as causing the related symptoms and that measurements in the office air were generally too low to account for the symptoms. Harris [1983] concluded that the reported health problems were due to the mixture of chemicals used in CCP and to mechanical irritation by the clay coatings on the paper.

To provide a comparison with the information available on CCP, Brissette and Paquette [1987] summarized the known information about the prevalence of health problems associated with carbon paper in Quebec, Canada. They reported that 34 of 390 cases of industrial dermatitis reported in 1929 and 5 of 5,000 cases reported between 1932 and 1936 were related to carbon paper, but the observations were not based on patch testing. They further reported that at the Finsen Institute in Copenhagen, cutaneous toxicity to carbon paper was evaluated in 40,000 people. Only four cases of allergic contact dermatitis were recorded, and the agents responsible were triorthocresyl phosphate, oleic alcohol, nigrosine, and violet methyl. None of these agents are reported to be used in CCP.

On February 13, 1986, the National Swedish Board of Occupational Safety and Health decreed that the CCP Announcement No. 1976:2 [National Swedish Board of Occupational Safety and Health 1976] (which recommended actions to be taken when CCP-exposed workers showed symptoms of irritation) was no longer valid: "The problems which were previously considered to be caused by carbonless paper are now regarded as being of an extremely complex nature and have been linked directly to the paper only in a small number of cases (see Arbete Och Hälsa [Work and Health] 1983:2, Report on Problems Caused by Carbonless Paper).

This NIOSH report is based on published and unpublished information. The published information includes case studies and case series, cross-sectional epidemiological studies, patent literature, and some reports of human and animal experimental studies. The unpublished materials were submitted to the NIOSH Docket in response to the Federal Register notices in 1987 and 1997 [52 Fed. Reg. 22534 (1987) and 62 Fed. Reg. 8023 (1997)]. These unpublished materials generally include human repeat insult patch test (RIPT) studies, animal exposure studies, and medical records of workers who indicated that they had exposure to CCP.