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 relationship could be shown only between exposure to CCP and mucous membrane irritation of the upper respiratory tract. The authors stated that the same phenomenon occurs with ordinary paper and carbon paper but that CCP can produce symptoms when lower volumes of paper are handled.

Kolmodin-Hedman et al. 1981. At a clinic for occupational medicine in Uppsala, Sweden, Kolmodin-Hedman et al. [1981] conducted an inquiry among those employed by an insurance office (total of 145 workers) and a hospital laboratory (12 workers). A comparison group of 20 was composed of hospital office staff who did not handle CCP. The investigation was triggered by six cases in an insurance office; the main symptoms were irritation of the upper respiratory tract. The prevalence of symptoms was greatest in the hospital laboratory (92%), where about 1,000 forms were handled per day by each of the ﬁve receptionists and seven computer operators. The insurance office workers worked with fewer forms (number not given) than the laboratory workers; they reported a 32% prevalence. The comparison group reported a 10% prevalence of symptoms. Of those in the insurance group who complained of symptoms (46), 17 were diagnosed as atopic and 6 with underlying allergic or eczematous conditions. Of the remaining 23, one had symptoms connected with handling "wet copies," and another had a complaint that was clearly linked to the use of a certain type of stamp pad. The remaining 21 had skin and/or mucous membrane complaints: 13 stated that they had the most trouble at work, and 8 stated that their symptoms were independent of where they were. None of the six types of CCP forms used were known to contain D-inks, and three contained hydrogenated terphenyls, diethylethane, and diisopropylnaphthalenes. Two contained unknown solvents. Among the workers who handled only clay-based paper at the insurance office, the frequency of mucous membrane symptoms was approximately equal to that of the comparison group. The skin (hands and face) and eye symptoms were considered likely to be related to CCP exposure, since their frequency (21% among insurance workers versus 67% in laboratory workers) was much higher than that of the comparison group (5%).

Kleinman and Horstman 1982. In the United States, persistent health complaints attributed to the use of CCP by office workers on the campus of the University of Washington led to a preliminary study by Kleinman and Horstman [1982]. The goals were (1) to estimate the extent of the problem in a population of known CCP users, (2) to describe the health problems that the users attributed to CCP, and (3) to make a preliminary determination of the chemical constituents of the paper. An unknown number of office workers were asked to complete a health questionnaire and to attach to it copies of the forms they used. Among the 265 subjects respondng to the survey, 71 (27%) reported complaints. Across different offices, the minimum estimate was 10.7 health complainants per 100 users, similar to that found by investigators in the United Kingdom and Denmark [Calnan 1979; Menne' et al. 1981], but this estimate was lower than that reported by other investigators and by anecdotal material. Of the 108 respondents who answered "yes" (n=71) or "don't know" (n=37) to the question relating symptoms to CCP, 53 participated in a medical exam. The positive findings are tabulated in Table 4-8. Kleinman and Horstman [1982] also reported a significant relationship (X$1$$2$-0.0002) between the amount of CCP used daily and worker reports of health effects they attributed to CCP: 41.3% of the heavy users of CCP (those who handled 51 or more forms/day) responded "yes" to the question relating health effects with CCP, compared with 29.9% of moderate users (11 to 50 forms/day) and 18.8% of minimal users (1 to 10 forrns/day). The authors hypothesized that concurrent factors such as poor