Occupational Medicine

 Hexavalent Chromium Medical Surveillance Exams

Last Updated: January 24, 2024
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Introduction

Hexavalent Chromium (Cr(VI)) is one form of the element chromium. There are three primary forms of chromium, including Cr(0), Cr(III), and Cr(VI). The Institute of Medicine categorizes Cr(III) as an essential nutrient necessary for cellular metabolism. Bread, cereal, fish, vegetables, meats, and spices contain Cr(III).

Chromium is a naturally occurring element; however, industrial processes incorporate Cr(VI) for its hardness and corrosion resistance.

Cr(VI) is in pigments used for paints, inks, and plastics; anti-corrosion coatings; stainless steel; textile dyes; wood preservation; and leather tanning.

​Military Processes Associated with Occupational Cr(VI) Exposure:

  • Maintenance
  • Brazing
  • Soldering
  • Welding and cutting
  • Coating and painting operations
  • Metal treatment and machining​​

​Exposure

Occupational exposure to Cr(VI) most commonly occurs through inhalation or dermal exposure but can also occur through ingestion.

Inhalation

  • Cr(VI) is classified as a known carcinogen by the International Agency for Research on Cancer and associated with lung and nasopharyngeal cancers. Other, more common respiratory effects include irritation of the nose, nose bleeds, perforated septum, and nasal ulcerations. It is also associated with pneumoconiosis, asthma, allergies, and decreased pulmonary function.

Dermal exposure

  • Dermal exposure can result in chrome ulcers, which are usually painless but can lead to a bacterial infection.
  • This can also result in irritant or allergic dermatitis.
    • Medical providers can order allergy patch testing to assess an allergic reaction from chromium.

 

Medical Surveillance​ 

OSHA established medical surveillance standards for workers exposed to Cr(VI), found in 29 CFR 1910.1026(k), Toxic and Hazardous Substances.

A physician or other licensed healthcare professional (PLHCP) performs or supervises the medical surveillance examination at no cost to the employee. The exam aims to detect pre-clinical disease or biological evidence of exposure to Cr(VI); recommend public health and medical interventions to mitigate, prevent, or medically manage Cr(VI) exposure; and to qualify workers' fitness to wear a respirator. ​

The Services apply Cr(VI) hazard management based on the exposure limits in Table 1. The action level indicates the Cr(VI) level which requires employers to conduct medical surveillance for their emp​loyees.​

 Table 1. Chromium VI Exposure Limits/Levels as Followed by the Services​

​​​​​
ServiceExposure Limit(s)SourceNotes
Air ForceAction Level (AL): 2.5 µgm/m3 as an 8-hour TWAOSHA 1910.1026
Permissible exposure limit (PEL): 5 µgm/m3 as an 8-hour
NavyAction& Level (AL): 2.5 µgm/m3 as an 8-hour TWA
OSHA 1910.1026
Permissible exposure limit (PEL): 5 µgm/m3 as an 8-hour
ArmyThreshold limit value-Time weighted average (TLV-TWA): 0.0002 µgm/m3 (0.2 µgm/m3)ACGIH TLV* (March 2018)Stricter than OSHA (per DA PAM 40-503, Chapter 1-8.b.(3) and DA ​PAM 40-11 Chapter 7-10.c.(1))
Threshold limit value-Short term exposure limit (TLV-STEL): 0.0005 mg/m3 (0.5 µgm/m3)
*TLV is a registered trademark of the American Conference of Governmental Industrial Hygienists (ACGIH)

Additionally, military employers must provide medical surveillance to workers who experience Cr(VI)-related health symptoms or unintentional exposure to Cr(VI). Medical surveillance must occur within 30 days of job assignment with Cr(VI) exposure, then annually after any suspected emergency exposure, and at termination of employment or acute exposure.

The medical surveillance examination must include the following:

  • A medical history focusing on workers' past, present, and future exposure to Cr(VI)
  • History of smoking
  • History of respiratory system dysfunction, including asthma
  • Examination of the respiratory system
  • Examination of the skin​

Role of a Physician or other Licensed Healthcare Professional (PLHCP)

  • They will counsel workers who smoke due to the harmful synergistic effect of smoking and Cr(VI) exposure on lung function.
  • They may order additional tests they feel are necessary, such as spirometry.
  • PLHCPs must provide spirometry following American Thoracic Society standards.
  • They are responsible for providing a written statement to the worker within 30 days of the conclusion of the medical surveillance examination.
  • The written statement must address any medical condition detected that places the worker at increased risk of impairment due to Cr(VI). The statement must provide recommendations for using personal protection equipment, including other elements in the Hierarchy of Workplace Controls, and an explanation of medical surveillance findings, including recommended medical restrictions and follow-up.​​