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n 1987, the Occupational Safety and Health Administration (OSHA) requested that the National Institute for Occupational Safety and Health (NIOSH) investigate the validity of reported adverse health effects in workers occupationally exposed to chemicals contained in or released from carbonless copy paper (CCP). Because of limited published information, NIOSH issued a Federal Register notice soliciting information about possible adverse health effects from CCP exposure [52 Fed. Reg. 22534 (1987)]. On the basis of information available at that time, no strong conclusion could be reached concerning a consistent link between CCP and major health effects. Between 1987 and 1997, additional reports involving health problems potentially related to CCP were identified. Therefore, in 1997 NIOSH issued a second Federal Register notice soliciting new information [62 Fed. Reg. 8023 (1997)]. This report contains a review of the published literature on CCP and the submissions to the NIOSH docket from the two Federal Register notices.

CCP was introduced in 1954 by the National Cash Register Company as no-carbon-required (NCR) paper—an alternative to separate sheets of carbon paper [Sandberg 1955; Green 1955; Miller and Phillips 1972; Calnan 1979; Buring and Hennekens 1991]. A given CCP can vary greatly as to its constituents, weight and types of paper coatings, paper color, dye colors and combinations of dyes used on coatings, solvents and solvent mixtures (including variations from different suppliers), physical form of the paper (rolls versus sheets), and final form of the product (i.e., bound with adhesives). Thus the product known as CCP is not a single product but includes thousands of different and often unique products [Mead Corporation 1997]. This fact needs to be considered when interpreting the findings from the scientific literature.

About 10 years after the introduction of CCP, medical complaints began to be reported by office workers [North Carolina Medical Journal 1982; Magnusson 1974; Göthe et al. 1981; Buring and Hennekens 1991]. Since 1965, various health effects associated with exposure to CCP have been reported in the literature appearing from Denmark, Finland, England, Sweden, Germany, the Netherlands, France, Italy, Belgium, Japan, Norway, and the United States.

NIOSH has reviewed the published and unpublished literature on CCP. The following paragraphs summarize the findings from this review regarding the primary health effects associated with CCP exposure.

Irritation of the Skin, Eyes, and Upper Respiratory Tract

The most common findings from the human studies are symptoms consistent with irritation of the skin, eyes, and upper respiratory system following exposure to some types of CCP. These symptoms have also been described in numerous case reports and case series of persons exposed to CCP, and associations between these symptoms and

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