Carbonless copy paper and workplace safety: a review.

Carbonless copy paper (CCP), introduced in 1954, is ubiquitous in the U.S. marketplace, and because of this, many workers come into contact with it. Its safety to workers who handle large amounts of CCP has been addressed in numerous studies and reports; and the National Institute for Occupational Safety and Health (NIOSH) on two occasions has sought to determine what, if any, hazards to health CCP might pose. This review encompasses the world's literature on CCP and provides a weight-of-evidence analysis of the safety of CCP to workers in the United States. CCP is systematically studied on large groups of humans using repeat insult patch tests. Consistently, CCP in U.S. commerce since 1987 (the focus of this review) has produced neither primary skin irritation nor skin sensitization under exaggerated test conditions, demonstrating that no irritation or sensitization is expected on contact with CCP under normal conditions of manufacture and use. Years after the introduction of CCP, the first case reports appeared in 1974 suggesting an association between CCP use and various generic symptoms. Most of the earliest reports occurred in Sweden in response to negative publicity concerning the product, and to date approximately half of all published articles originate in Scandinavia. Many early reports were questionnaire/interview studies which suffered from suggestive questions, biases, and lack of control for confounding factors. Few studies included a comparison group (i.e., people not exposed to CCP) making it impossible to estimate risk values. Later, sick building syndrome studies, accounting for many relevant factors in the office environment, found no association between CCP exposure and symptoms unexplained by other factors. Animal studies showed that compounds used to manufacture CCP do not have acute toxic potential and are not genotoxic. Finally, very few published complaints have come from the manufacturing sector where the closest and most voluminous contact occurs. A few reports of symptoms have emanated from printing facilities (with a multiplicity of other chemical exposures), but generally most symptoms are reported in the office setting where the exposure is lower than in the manufacturing or printing settings. Based on the weight of the evidence, CCP currently in commerce in the United States is shown not to be the causative agent for the reported general symptoms sometimes associated with it over the years. Recently NIOSH evaluated the literature as to possible hazards to health posed by CCP, and NIOSH is anticipated to conclude that CCP is not a hazard to workers and has only a small possibility of producing mild and transient skin irritation.