General Profile

Commercial laundries began as domestic enterprises, but have developed into businesses with many unique health and safety concerns. Laundries specializing in services for hospitals must deal with possible biological hazards, and those laundering work clothes for manufacturing or service workers may risk exposure to specific chemical hazards.

Dry cleaning reputedly originated in France in 1825 when a worker in a dye and cleaning factory spilled lamp oil on a soiled tablecloth (IARC 1995a). After the tablecloth dried, the spots had disappeared. Lamp oil is a hydrocarbon. Similar hydrocarbon solvents - turpentine, kerosene, benzene and gasoline - were used in the fledgling dry-cleaning industry. All these solvents had one major disadvantage: they were flammable, often resulting in fires and explosions (Wentz 1995). In 1928, W.J. Stoddard introduced a nearly odourless, petroleum-based solvent with a higher flashpoint, which reduced the risk of fire. Stoddard solvent gained widespread acceptance in the industry and is still used today.

At the turn of the century, advances in the synthesis of chlorinated hydrocarbons permitted development of nonflammable solvents for dry cleaning. Initially, carbon tetrachloride was preferred, but because of its toxicity and aggressiveness to metals, textiles and dyes, it was gradually replaced in the 1940s and 1950s by trichloroethylene and tetrachloroethylene (also commonly known as perchloroethylene, or PERC) (Wentz 1995). PERC (C₂Cl₄) is a colourless, clear, heavy liquid with an ethereal odour. Today, approximately 90% of US dry cleaners use PERC (EPA 1991a).

Although cleaning practices vary from country to country and from shop to shop, laundries and dry-cleaning shops are usually small businesses; about 70% of US dry-cleaning shops have fewer than four employees, who usually perform the cleaning at the same location as the shop. The employees of such a small business, many of whom typically labour more than eight hours per day, may be members of one family, sometimes including children. In many countries, the dry-cleaning family lives in the same building as the shop. An increasing trend among larger corporations is to operate multiple “drop” shops where customers leave soiled garments. The garments are transported to a central facility for cleaning, and later returned to the drop shops for customer pick-up. This arrangement confines hazardous waste to one site and reduces the solvent exposure of drop shop workers.

The Laundry and Dry-Cleaning Process

The dry-cleaning or laundry process usually begins when a customer brings soiled garments to a shop. Modern clothing is made from many different fibres and fabrics. Garments are inspected and sorted according to weight, colour, finish and fabric type prior to machine loading. Visible stains are treated at a spotting station with various chemicals, before or after cleaning, depending on the type of stain.

Cleaning is a three-step process: washing, extracting and drying (figure 1). Wet-process washing (laundering) uses detergent, water and possibly steam. In dry cleaning, detergent and water are added to the solvent to aid in soil removal. Clothes are manually loaded into the machine, and the cleaning solution is automatically injected. Machine contents are agitated for a period, then spun at high speed to extract the water or solvent and tumbled dry. Once garments have been removed from the dryer, they are pressed to remove wrinkles and restore their shape.

Figure 1. The dry cleaning process flow diagram.

Many countries have recently imposed stringent regulations for the control of PERC exposures and emissions because of associated health effects and environmental problems. In response to these regulations, dry-cleaning processes are changing. Improved solvent purification and vapour-recovery systems are available, alternative solvents are being developed, and wet methods using water immersion are being refined to clean garments traditionally cleaned in solvent. These processes are described below.

Transfer versus dry-to-dry equipment

Two basic types of machines used in dry cleaning are transfer and dry-to-dry. Transfer machines, older and less expensive, require manual transfer of solvent-laden clothing from the washer to the dryer. The transfer activity causes excessive worker exposure to PERC. Because of high solvent usage rates, emissions and exposures during transfer, PERC transfer machines are no longer manufactured in the United States; however, older used or reconditioned ones can still be purchased.

In 1994, at least 70% of PERC machines in the United States, for example, were dry-to-dry machines, using a one-step process that eliminates clothing transfer. Many shops are replacing or have replaced transfer machines with dry-to-dry machines because of the trend towards stricter environmental regulations; however, some shops still use transfer equipment for increased productivity and to avoid the capital expenditure required for new machines. In the United States, petroleum machines are primarily transfer units.

Dry-to-dry machines may be vented or ventless. Vented dry-to-dry machines vent residual solvent vapours directly to the atmosphere or through some form of vapour-recovery system during the aeration process. Ventless dry-to-dry machines are essentially closed systems, open to the atmosphere only when the machine door is opened. They recirculate the heated drying air through a vapour-recovery system and back to the drying drum. There is no aeration step.

Solvent purification: Filtration and distillation

Dry cleaners use filtration and/or distillation to recover and purify solvents. Filtration removes insoluble soils, non-volatile residues and loose dyes from the solvent. It is also sometimes used, primarily in the United States, to remove soluble soils. Filtration is a continuous process. The solvent passes through an adsorbent powder, cartridge or spin-disc filter, all requiring some level of periodic maintenance. Each filtration system produces contaminated cartridges or powders.

Distillation, used by 90% of US cleaners, removes soluble oils, fatty acids and greases not removed by filtration (International Fabricare Institute 1990). Distillation occurs when PERC is heated to its boiling point so that it vaporizes and later condenses back to liquid form. During this process, non-volatile impurities, which cannot be boiled off, remain in the still and are discarded as hazardous waste. Both filtration and distillation produce some solid wastes containing PERC; however, dry-cleaning machine manufacturers are striving to develop new filtration and distillation technologies that reduce the amount of hazardous waste produced. This ultimately results in important savings to the owner by reducing the cost of hazardous-waste disposal.

Recovery of PERC vapours

Two primary technologies are used to recover PERC vapours: the carbon adsorber and the refrigerated condenser. These two technologies, traditionally separate, are used together in more modern machines. Carbon adsorption is used in about 35% of the controlled machines in the United States, for example. Carbon adsorbers achieve a 95 to 99% vapour reduction by removing PERC from the air. Solvent-laden vapours pass over activated carbon having a high adsorption capacity. The carbon is later desorbed and the PERC recovered, or the carbon is discarded as hazardous waste when it becomes saturated with PERC. Carbon desorption typically occurs with steam or hot air. Desorption can be done automatically after each load, or it can be done at the end of the day. If not performed regularly, the carbon bed will become saturated and be ineffective for PERC recovery. The adsorption system can handle high volumes of air, having relatively low solvent concentrations while maintaining a high PERC removal efficiency, but frequent desorbing is needed and steam regeneration produces contaminated waste water.

Refrigerated condensers cool solvent-laden air below the dew point of the vapour to recover PERC, and operate on the principle that the ability of air to hold a solvent in the vapour state varies with temperature. Refrigerated condensers are used in approximately 65% of controlled machines. The process can achieve 95% vapour control in dry-to-dry machines and 85% control in transfer machines. Condensers require little maintenance and minimize the potential for waste water because steam regeneration is not required. They do require higher solvent concentrations than a carbon adsorber. Water vapour may pose a problem because it can condense and freeze, impeding gas flow and heat transfer (EPA 1991b).

Solvent alternatives to PERC

Alternative dry-cleaning solvents have been substituted for PERC. Flammable, petroleum-based solvents generally have higher exposure limits than PERC. These petroleum-based solvents are less aggressive at removing soils than PERC. Because their vapour pressures are lower than PERC, exposures from inhalation will generally be lower. However, adverse health effects are possible, including asphyxiation, central nervous system depression and skin and mucous membrane irritation. Contamination of aliphatic hydrocarbons with benzene will significantly increase the hazard.

Two different approaches have been taken in Germany to reduce the fire hazard posed by petroleum-based solvents: developing safer solvents and redesigning machines.

Recently developed petroleum-based solvents, widely used in Germany, are either straight-chain, branched or cyclic paraffins with a chain length of between 10 and 12 carbons. These petroleum-based solvents have an atmospheric lifetime of only a few days, are halogen-free, do not lead to ozone depletion and play only a minor role in the greenhouse effect. Some of the German requirements for petroleum-based, dry-cleaning solvents are outlined below (Hohenstein Institute 1995):

• Boiling range between 180° and 210ºC

• Aromatic, benzene, halogen and polycyclic aromatic content less than 0.01 wt%

• Flashpoint higher than 55ºC

• Thermally stable at operating conditions.

Dry-cleaning machines manufactured for petroleum-based solvents in Germany today are much safer than those of the past. Because petroleum-based solvents are combustible, additional safety measures are required on machines using them. Technical advances improve machine safety and greatly reduce the risk of fire/explosion. The following measures can be taken in combination or separately:

• Using an inert gas, such as nitrogen or argon, to displace oxygen in the drum and ensure that oxygen concentration is sufficiently low (approximately 4%) to prevent combustion

• Operating under a vacuum to remove oxygen and lower its concentration to below 4%

• Ensuring that the lower explosive limit (LEL) is not exceeded, or if the LEL is not known, ensuring that operating temperature remains 15ºC below the flashpoint

• Ensuring that vapour concentration remains below 50º of the LEL, by controlling operating temperatures or by providing sufficiently high airflow.

Wet cleaning

Wet cleaning is a developing technology, distinct from traditional laundering in that it is a more gentle process and can be used on many fabrics that were formerly dry cleaned. Four factors play an essential role in soil removal: temperature, time, mechanical action and chemical agents. Only the proper blend of these factors achieves the best cleaning results (Vasquez 1995). There are minor variations of machine wet cleaning, but all techniques use:

• Specially formulated wet-cleaning soaps and spotting agents

• Increased extraction of water prior to drying (extraction speeds as high as approximately 1,000 revolutions per minute)

• Close monitoring of heat and moisture content during the drying process

• Machines having less mechanical action during washing, accomplished by speed reduction and time limits.

Garments are washed with various levels of limited mechanical action, based on garment type and amount of soilage. The greatest risk occurs during drying. Many fibres can be fully dried with little or no difficulty. However, delicate garments or garments susceptible to shrinkage must be dried for only a few minutes before being hung to air dry. Because of these problems, most wet-cleaned garments require more finishing work than solvent-cleaned garments. Long drying times and more finishing work substantially increase processing time (Earnest and Spencer 1996).

Today, wet cleaning use is limited because the technology does not yet completely eliminate the need for solvents. It has been estimated that wet cleaning can safely clean approximately 30 to 70% of garments traditionally cleaned in solvent (Rice and Weinberg 1994). There are still problems with fibre damage, bleeding of dyes and, most importantly, cleaning ability. Inappropriate use of wet cleaning can expose shop owners to liability for damaged clothing. For this reason wet-cleaning advocates are working to persuade garment manufacturers to use fabrics that can be more easily wet cleaned.

Hazards in Laundries and Dry Cleaning Facilities

PERC hazards

In the workplace PERC can enter the human body through both respiratory and dermal exposure (ATSDR 1995). Symptoms associated with respiratory exposure include depression of the central nervous system; damage to the liver and kidneys (RSC 1986); impaired memory; confusion; dizziness; headache; drowsiness; and eye, nose and throat irritation. Repeated dermal exposure may result in dry, scaly and fissured dermatitis (NIOSH 1977).

US National Cancer Institute and National Toxicology Program studies have established a link between PERC exposure and cancer in animals. Human studies show an elevated risk of urinary tract (Duh and Asal 1984; Blair et al. 1990b; Katz and Jowett 1981), oesophageal (Duh and Asal 1984; Ruder, Ward and Brown 1994) and pancreatic cancer (Lin and Kessler 1981) among dry-cleaning workers. The International Agency for Research on Cancer (IARC) recently classified PERC in group 2A (probably carcinogenic to humans) and dry cleaning in group 2B (possibly carcinogenic to humans) (IARC 1995b). The Environmental Protection Agency (EPA) regulates PERC as a hazardous air pollutant.

US Occupational Safety and Health Administration (OSHA) data include numerous personal samples in dry-cleaning shops over the permissible exposure limit (PEL) of 100 ppm, 8-hour time-weighted average (TWA) (OSHA 1993). The machine operator is typically exposed to the greatest concentrations of PERC. US National Institute for Occupational Safety and Health (NIOSH) studies have shown that in many dry-cleaning shops having traditional machines, extremely high operator exposures occur during loading and unloading. Because loading/unloading occurs frequently throughout the day, in many instances exposure during this activity can account for 50 to 75% of the operator’s TWA exposure (Earnest 1996). Occupational exposures can be reduced by using modern dry-cleaning machines, solvent substitution, isolation of the process and effective local and general ventilation near the dry-cleaning machines.

Exposure to chemicals other than PERC

A wide variety of chemicals is present in laundries and dry-cleaning establishments. There is potential exposure through skin or eye contact or inhalation of vapours. Skin damage may occur from chronic or acute exposure. Chemicals that readily vaporize and have a high toxicity may pose a risk from inhalation, although this is generally considered to be of less concern than injury to the eyes or skin. The chemicals commonly used in the United States to treat stains through spotting are trichloroethylene; ketones, especially methyl isobutyl ketone (MIBK); petroleum naphtha; and hydrofluoric acid. Oxidizers, such as chlorine bleaches, may pose a hazard if used in the presence of many common compounds, such as turpentine, ammonia or fuel gases. Detergents containing enzymes may cause immune reactions in many workers. The combined exposures of the dry-cleaning solvent, PERC and various other chemicals is also a concern.

Ergonomic risk factors

Ergonomic hazards in the cleaning industry primarily occur among pressers. Pressing is a dynamic and repetitive task requiring reaching, precision gripping and awkward postures. Ergonomic risk factors are also present during material handling when heavy lifting may occur, especially in commercial laundries.

Fire hazards

The dry-cleaning industry has traditionally had a problem with fires. Part of the reason for this problem has been the widespread use of flammable and combustible liquids as a cleaning medium. The flammability of petroleum-based solvents continues to present an acute health and safety hazard. Approximately 10% of dry-cleaning shops in the United States use traditional, petroleum-based solvents, such as Stoddard solvent or mineral spirits. Even dry-cleaning shops that use non-flammable PERC face important fire hazards. If heated sufficiently, PERC will decompose into hydrogen chloride and phosgene gases. The production of hydrogen cyanide or carbon monoxide is another cause for concern during a fire. Hydrogen cyanide is produced when materials that contain nitrogen, such as many natural and synthetic fibres burn. Carbon monoxide is formed during incomplete combustion. All dry-cleaning shops have a large number of potential fuels and ignition sources.

Dry-cleaning machine designers must avoid conditions that can lead to a fire to occur and must ensure that their machines operate safely. Likewise, shop owners must take appropriate steps to prevent hazardous conditions from developing. Some common causes of fires in all businesses are electrical malfunctions, friction, open flames, sparks, static electricity, hot surfaces and smoking (NIOSH 1975).

Thermal burns

Cleaning facilities have several possible sources of severe burns. In the pressing station, burns may result from contact with the head of a press, lines transporting steam, or the steam itself. Insulation of pipes and surfaces, and use of various guarding techniques, can help prevent burns.

Although modern boilers are of safer design than earlier models, they are still used to produce large quantities of steam and must be operated safely. Many of the needed precautions can be found in the US National Fire Protection Association’s Code 32, Standard for Dry Cleaning Plants, and its Fire Protection Handbook (NFPA 1991). Recommendations in these documents include building code requirements, proper storage and isolation of flammables, fire extinguishers and sprinkler systems. Recommendations concerning the build-up of gases around the boiler address ways to eliminate gas leakage and ensure proper ventilation.

Mechanical hazards

Mechanical hazards are always a concern when powered equipment is used. Presses pose a significant mechanical hazard. Presses designed to be activated by only one hand leave a potential for the worker’s free hand to be caught between the presses. Belts, drive chains, shafts and couplings should be guarded to prevent accidental contact. All moving components of machines should be guarded to prevent body parts from becoming caught in a pinch, nip or shear point. The most common methods of guarding a hazard are enclosing the operation, interlocking devices, moving barriers, removal devices, remote controls, two-hand tripping devices and electronic safety devices.

Electrical hazards

Numerous measures can be taken to limit electrical hazards. Especially important is proper insulation and grounding. Identification and guarding of live parts also helps to prevent injury from electrical current. Electrical hazards can be compounded by the presence of moisture. Ground-fault circuit interrupters are designed to shut off power if high current passes through an unintended path. When selecting electrical equipment, the recommendations of established codes and standards, such as the US National Fire Protection Association 70, the National Electrical Code and the American National Standards Institute’s C2, should be followed. Guidelines for appropriate use of electrical equipment are given elsewhere in this Encyclopaedia.

Heat stress

Heat stress can afflict workers who must labour for extended periods of time in the hot environments that exist in many cleaning facilities. Heat stress may be compounded in the summer months, particularly if the shop is not air conditioned (air conditioning is not common in this industry). Both physical and environmental factors will modify the effects of heat. Acclimatization, body surface area to weight ratio, age and diseases, water and salt balance and physical fitness all play a role in the likelihood an individual will be affected by heat stress.

Slips, trips and falls

The hazard of slips, trips and falls are especially pertinent to cleaning facilities, which are often crowded with people and equipment. Without clearly established aisles and with a large number of containers holding solvents or water, spills can easily occur, resulting in a slippery floor. To control this hazard, regular housekeeping must be emphasized, facility layout must be carefully planned, and floor surfaces should be of non-slip materials. The workplace should be maintained in a clean, orderly, sanitary condition, and any spills should be cleaned up promptly.

Biological hazards

Laundering hospital linens puts sorters at risk from overlooked sharp objects in sheets or uniform pockets. Both dry cleaners and launderers may encounter freshly soiled garments that have been contaminated with human body fluids. Garments that have come from dental and medical offices or labs, blood banks, drug treatment centers, clinics, mortuaries, ambulances and other health-care facilities can be reasonably suspected to contain potentially infectious materials. In many countries, shops that handle garments from these sources must comply with the occupational standards governing exposures, such as the OSHA regulations governing bloodborne pathogens.

Environmental and Public Health Concerns

Environmental and public health concerns have resulted in dramatic changes in environmental regulations affecting the dry-cleaning industry in recent years. Adjacent apartments and businesses can be exposed to PERC vapours by diffusion through walls or ceilings; indoor airflow through holes in ceilings, pipe chases or vents; and through PERC emissions vented outside of the shop that are re-entrained through opened windows or ventilation units. Groundwater or soil contamination can occur through frequent or large solvent spills that might occur during transfer of solvent from a delivery truck to the dry-cleaning machine. Soil contamination might also occur through improper disposal of separator water into the sanitary sewer. Finally, consumers may be exposed from PERC residuals in poorly dried garments. This is of particular concern if the cleaning machine is not functioning properly or the dry cycle is shortened to improve productivity.

Acknowledgement: This article is largely based on materials assembled and published by the US National Institute for Occupational Safety and Health (NIOSH).

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General Profile

Assuming a world population of 5 billion, between one-quarter and one-half of a million people die each day. Many of the dead are infants or children, but eventually everyone who is born will also die. Despite the diversity in culture and religious beliefs surrounding death, the bodily remains of each person must be disposed of. In general, the two main methods of disposing of human remains consist of burial and cremation. Both of these disposal methods often have been applied to the untreated human remains. Many cultures, however, have developed funeral rites that prescribe some treatment of the dead body. Simpler rites may include the washing of the external surface with herbs and spices to slow or mask the onset of decay and the smell associated with dead tissue. More sophisticated rites include intrusive procedures such as embalming and removal of internal organs. Embalming usually involves replacement of blood with an embalming or preserving fluid. The Egyptians were among the first culture to develop and practice embalming of the dead. Embalming has been extensively practiced in the twentieth century throughout Western Europe and North America. Embalming may be followed either by burial or cremation. Outside of Western Europe and North America, burial or cremation is usually not preceded by embalming.

Funeral Processes

The preparation and burial of a deceased person can involve many processes, including:

• washing the surface of the body with various preparations

• dressing the body in burial clothes

• autopsies, in certain circumstances, which involve intrusive procedure, such as dissection and analysis of blood and body tissues

• embalming and removal of internal organs

• application of cosmetics to cover up visible damage if the body is to be viewed

• transporting the body to place of burial or cremation

• lifting of body and casket, and lowering it into the grave

• digging and filling of the grave

• possible exhumation of the body and subsequent autopsy.

Three types of hazard are always associated with the handling of deceased humans: microbial, psychological and ergonomic. A fourth type of hazard - chemical exposure - is introduced when embalming is performed. In the United States many states have enacted laws that require a body to be embalmed if the deceased person will be viewed in a open casket.

Microbial Hazards

Death is often caused by disease. After death the germs that caused the disease may continue to live in the deceased person and can infect the people handling the dead body.

Contagious diseases such as the plague and smallpox have been spread by improper handling of victims who died from the diseases. The route of exposure must be considered when evaluating the microbial hazard associated with the handling of dead bodies. Many diseases are spread by touching a source of contamination and then introducing that disease-causing organism, or pathogen, to one’s mucous membranes by rubbing the eyes or nose, or by ingesting the pathogen. Some diseases can be contracted simply by inhaling the pathogen. Inhalation can be a special hazard during exhumation, when the remains are dry, or during procedures that aerosolize parts of the human body, such as sawing through the bone of a deceased person. The contagion of diseases is further exacerbated when procedures with sharp instruments are used in funeral rites. Such practices introduce the possibility of parenteral exposure.

Microbial hazards can be classified in many different ways, including the type of disease-causing organism, the type of disease, the severity of the disease and the route of infection. Perhaps the most useful way of discussing microbial hazards encountered by funeral workers is by route of infection. The routes of infection are ingestion, inhalation, touch or surface contact and parenteral, or puncture of a body surface.

Ingestion as a route of exposure can be controlled by proper personal hygiene - that is, always washing hands before eating or smoking, and by keeping food, drink or any object that will be put in the mouth (such as cigarettes) out of areas of possible contamination. This is important for controlling chemical exposure as well. In addition to careful personal hygiene, wearing impermeable gloves when handling the dead can reduce the probability of infection.

Inhalation exposure occurs only when disease-causing organisms become airborne. For funeral workers the two primary ways that pathogens can become airborne are during an exhumation or during autopsy procedures in which a saw is used to cut through bone. A third possibility of aerosolizing a pathogen - tuberculosis, for example - is when air is forced out of the lungs of a corpse during handling. Although the epidemics of the past have included plague, cholera, typhoid, tuberculosis, anthrax and smallpox, only the organisms causing anthrax and smallpox appear capable of surviving any length of time after burial (Healing, Hoffman and Young 1995). These pathogens would be found in any of the soft tissues, not the bones, and particularly in soft tissues that have become mummified and/or dried out and friable. The anthrax bacterium can form spores that remain viable for long periods, especially under dry conditions. Intact smallpox viruses taken from the tissues of bodies buried in the 1850s were identified under the electron microscope. None of the viruses grew in tissue culture and they were deemed to be non-infective (Baxter, Brazier and Young 1988). Smallpox virus has remained infective, however, after 13 years in dry storage under laboratory conditions (Wolff and Croon 1968). An article appearing in the Journal of Public Health (UK) during the 1850s reports concern about smallpox infectivity from remains buried two hundred years earlier in Montreal, when smallpox was widespread in the New World (Sly 1994).

Perhaps a more probable source of inhalation exposure during exhumation are fungal spores. Whenever old material of any sort is disturbed, protection against the inhalation of fungal spores should be provided. Disposable high efficiency particulate (HEPA) respirators, developed primarily for protection against tuberculosis and lead dust, are quite effective against fungal spores as well. In addition to microbial concerns, the possibility of exposure to wood dust and/or lead needs to be evaluated before any exhumation proceeds.

The primary route of infection for tuberculosis is inhalation. The incidence of tuberculosis has increased during the last quarter of the twentieth century, primarily due to decreased public health vigilance and the emergence of bacterial strains that are resistant to several groups of antibiotics. A recent study conducted at Johns Hopkins School of Public Health (Baltimore, Maryland, US) indicates that 18.8% of embalmers demonstrated positive results to tuberculin skin tests. Only 6.8% of people employed in the funeral business who are not embalmers demonstrated positive results to the same test. The lower rate of reactivity is similar to the general public (Gershon and Karkashion 1996).

Hepatitis B virus (HBV) and the human immunodeficiency virus (HIV) are infective if they come in contact with mucous membranes or are introduced into the bloodstream through a cut or puncture. A study of funeral service practitioners in Maryland indicated that 10% had a mucous membrane exposure within the past 6 months and 15% reported a needle stick within the past 6 months (Gershon et al. 1995). Other US studies reported that between 39 and 53% of morticians had a needle stick within the past 12 months (Nwanyanwu, Tubasuri and Harris 1989). In the United States, the reported prevalence of HBV is between 7.5 and 12.0% in unvaccinated funeral directors, and 2.6% or less in vaccinated funeral workers. The reported vaccination rate varies between 19 and 60% of morticians in the United States. Although there is a vaccine for HBV, there is currently no vaccine for HIV.

HIV and HBV are infective only when the virus comes into contact with the mucous membranes or is introduced into the bloodstream of another human. The virus is not absorbed through intact skin. Mucous membranes include the mouth, nose and eyes. These viruses can be introduced into the bloodstream through a cut or abrasion in the skin, or by puncturing or cutting the skin with an instrument that is contaminated with the virus. Hands that are cracked due to dryness or a hangnail may provide routes of entry for these viruses. Therefore, to prevent transmission of these diseases it is important to provide a barrier impermeable to body fluids, to avoid splashing contaminated fluids on the eyes, nose or mouth, and to prevent puncturing or cutting the skin with an instrument contaminated with HIV or HBV. Use of latex gloves and a face shield can often provide this protection. Latex gloves, however, have a limited shelf life depending on the amount of sunlight and heat to which they have been exposed. In general, the latex should be stress tested if the gloves have been stored for more than a year. Stress testing involves filling the glove with water and observing if any leaks develop during a minimum of two minutes. Some countries in the West, such as the United States and Great Britain, have adopted the idea of universal precautions, which means that every corpse is treated as if it were infected with HIV and HBV.

Psychological Hazards

In many cultures the family of the deceased prepares the body of their dead relative for burial or cremation. In other cultures a specialized group of individuals prepares the bodies of the dead for burial or cremation. There is a psychological effect on the living when they are involved in handling dead bodies. The psychological effect is real regardless of the procedures used in the funeral rites. Recently there has been an interest in identifying and evaluating the effects of performing funeral rites on those who actually perform them.

Although the psychological hazards of being a professional funeral worker have not been extensively studied, the psychological effects of dealing with the human remains of traumatic death have been recently analyzed. The main psychological effects appear to be anxiety, depression and somatization (the tendency to report physical ailments), as well as irritability, appetite and sleep disturbances, and increased alcohol use (Ursano et al. 1995). Post-traumatic stress disorder (PTSD) occurred in a significant number of individuals who handled the victims of traumatic deaths. Immediately after a disaster in which human remains were handled by rescue workers, between 20 and 40% of the rescue workers were considered to be in a high risk category, as demonstrated by psychological testing, but only about 10% of the rescue workers were diagnosed with PTSD. The psychological effects were still present in rescue workers one year after the disaster, but the incidence was greatly reduced. Adverse psychological effects, however, have been detected in individuals several years after the traumatic event.

Many of these studies were performed on military personnel. They indicate that generalized stress rates are higher in inexperienced individuals who were not volunteers, and that there was an increased incidence of stress indicators up to one year after a traumatic incident. Empathy or self-identification of the mortuary worker with the deceased appeared to be associated with an increased level of psychological stress (McCarroll et al. 1993; McCarroll et al. 1995).

One study evaluated the causes of death in 4,046 embalmers and funeral directors in the United States between 1975 and 1985, and reported a proportionate mortality ratio (PMR) of 130 for suicide. The PMR is a ratio of the actual number of suicides in the embalmers and funeral directors divided by the number of suicides that would be expected in a group of individuals comparable in age, race and sex who are not embalmers or funeral directors. This ratio is then multiplied by 100. The purpose of this study was to assess the risk of cancer in morticians, and the suicide statistic was not elaborated any further.

Ergonomics

A deceased human adult is heavy and usually must be carried to a designated place of burial or cremation. Even when mechanical means of transportation are used, the dead body must be transferred from the place of death to the vehicle and from the vehicle to the burial or cremation site. Out of respect for the dead person, this transfer is usually performed by other humans.

Morticians are required to move corpses many times during the course of body preparation and funerals. Although there were no studies found that addressed this issue, low-back pain and injury is associated with prolonged repetitive lifting of heavy objects. There are lifting devices available which can assist with these types of lifts.

Chemical Hazards

Embalming procedures introduce a number of potent chemicals into the workspace of funeral workers. Perhaps the most widely used and toxic of these is formaldehyde. Formaldehyde is irritating to the mucous membranes, the eyes, the nasal lining and the respiratory system, and has been associated with mutagenic cell changes and the development of cancer, as well as occupational asthma. During the past several decades the occupational exposure level associated with no adverse effects has been consistently lowered. Current 8-hour time-weighted average permissible exposure limits range from 0.5 ppm in Germany, Japan, Norway, Sweden and Switzerland to 5 ppm in Egypt and Taiwan (IARC 1995c). Formaldehyde levels between 0.15 and 4.3 ppm, with instantaneous levels as high as 6.6 ppm, have been reported for individual embalmings. An embalming typically takes between 1 and 2 hours. Additional formaldehyde exposure is associated with the application of embalming creams and drying and hardening powders, and during spills.

Rats that have been chronically exposed to 6 to 15 ppm of formaldehyde (Albert et al. 1982; Kerns et al. 1982; Tobe et al. 1985), or repeatedly exposed to 20 ppm for 15-minute periods (Feron et al. 1988), have developed nasal carcinomas (Hayes et al. 1990). The IARC reports limited epidemiological evidence for an association between formaldehyde exposure in industry and the development of human nasal and pharyngeal cancers (Olsen and Asnaes 1986; Hayes et al. 1986; Roush et al. 1987; Vaughan et al. 1986; Blair et al. 1986; Stayner et al. 1988). Several studies of morticians, however, have reported an increased incidence of leukaemias and brain tumours (Levine, Andjelkovich and Shaw 1984; Walrath and Fraumeni 1983). In addition to the carcinogenic effects, formaldehyde is irritating to the mucous membranes and has been considered a strong sensitizer in the development of adult-onset asthma. The mechanism or mechanisms by which formaldehyde precipitates asthma are even less well characterized than its role in the development of cancer.

Other potentially toxic chemicals used in embalming fluids include phenol, methanol, isopropyl alcohol and glutaraldehyde (Hayes et al. 1990). Glutaraldehyde appears to be even more irritating than formaldehyde to the mucous membranes, and affects the central nervous system at levels well above 500 ppm. Methanol also affects the central nervous system and, in particular, the vision system. Phenol appears to affect the nervous system as well as the lungs, heart, liver and kidneys, and is absorbed quite rapidly through the skin. Our understanding of the toxicology of, and our ability to perform risk assessment for, exposure to multiple chemicals simultaneously are not sufficiently sophisticated to analyse the physiological effects of the mixtures to which embalmers and funeral directors are exposed. Blair et al. (1990a) thought that the increased incidence of leukaemias and brain tumours reported in professional, but not industrial, workers was a result of exposure to chemicals other than formaldehyde.

Recent advances in the design of dissecting tables indicate that local downdrafting of vapours significantly reduces the exposure of individuals working in the vicinity (Coleman 1995). Wearing gloves while performing procedures that require skin contact with embalming fluids and creams also reduces the hazard. There has been some concern, however, that some of the latex gloves on the market may be permeable to formaldehyde. Therefore, protective gloves should be selected carefully. In addition to the immediate concerns about the hazards of formaldehyde exposure, evidence has been accumulating that leachate from cemeteries may lead to formaldehyde contamination of groundwater.

Exhumation of bodies may also involve chemical exposures. Although used sporadically for centuries, lead was commonly used to line coffins beginning in the eighteenth and continuing into the nineteenth century. Inhalation of wood dust is associated with respiratory problems, and fungus-contaminated wood dust is a double-edged sword. Arsenic and mercury compounds were also used as preservatives in the past and could present a hazard during exhumation.

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General Profile

Domestic work is characterized by labour for another family within their home. The term domestic workers should not be confused with homemakers and housewives, who work in their own home, or housekeepers, who work in institutions such as a hospital or school. The position of employment within a home is a unique and often isolated work environment. The position of domestic worker is almost always considered menial or inferior to the family for which they are employed. Indeed in the past, domestic work was sometimes done by slaves or indentured or bonded servants. Some of the job titles today for domestic workers include: servant, maid, housekeeper, au pair and nanny. While domestic workers can be either female or male, female workers are both much more commonly employed and most often paid less than males. Domestic workers are customarily immigrants or members of ethnic, national or religious minorities of the country of employment.

One should distinguish between domestic workers who are employed as live-in servants from those who live in their own home and commute to their place of work. Live-in domestic workers are isolated from their own family, as well as often from their own country of nationality. Because of the worker’s disenfranchisement, work contracts and health and other benefits are negligible. Sometimes, room and board are considered part or even complete payment for services rendered. This situation is particularly critical for the overseas domestic worker. Sometimes, infractions concerning agreed-upon salary, sick leave, working hours, vacation pay and regulation of working hours and duties cannot even be addressed because the worker is not fluent in the language, and lacks an advocate, union, work contract or money with which to exit a dangerous situation (Anderson 1993; ILO 1989). Domestic workers usually have no workers’ compensation, nowhere to report a violation, and are often unable to quit their employment.

Places where major employers of domestic workers are found include Britain, the Persian Gulf and Arab States, Greece, Hong Kong, Italy, Nigeria, Singapore and the United States. These domestic workers are from various countries, including Bangladesh, Brazil, Colombia, Ethiopia, Eritrea, India, Indonesia, Morocco, Nepal, Nigeria, the Philippines, Sierra Leone and Sri Lanka (Anderson 1993). In the United States, many domestic workers are immigrants from Central and Latin America and the Caribbean islands. Domestic workers are sometimes illegal immigrants, or have special limited visas. They are often not eligible for the basic social services available to others.

General Tasks

Tasks for domestic workers can include:

• Kitchen work: shopping for food, cooking and preparation of meals, waiting on the family and serving meals, cleaning up after mealtime and taking care of tableware

• Housecleaning and housekeeping: care of furniture and bric-a-brac, washing dishes, polishing silver and cleaning the house including bathrooms, floors, walls, windows and sometimes annexes, such as guest houses, garages and sheds

• Clothing care: washing, drying, ironing of clothing, sometimes mending of clothing or delivery/pick-up of clothing that is dry cleaned

• Child and elder care: babysitting or childcare, changing diapers and other clothes, washing children, supervision of meals and activities and delivery to and from school. Domestic workers will sometimes be given tasks that revolve around elder care such as supervision, bathing, companionship tasks, delivery to and from doctor visits and light medical chores.

Hazards and Precautions

In general, the intensity of hazards associated with live-in domestic workers is much greater than domestic workers who commute to work daily.

Physical hazards

Some physical hazards include: long working hours, insufficient rest time and sometimes insufficient food, exposures to hot and cold water, exposure to hot kitchen environments, musculoskeletal problems, especially back and spinal pain, from lifting children and furniture, and kneeling to clean floors. “Housemaid’s knee” has been likened to “carpet layer’s knee”, the injury sustained by carpet layers. While mechanization of certain floor-polishing and waxing processes has resulted in less work from the knees, many domestics still must work from their knees, and almost always without padding or protection (Tanaka et al. 1982; Turnbull et al. 1992).

Precautions include limitations of working hours, adequate rest and food breaks, gloves for dishwashing and other water immersion, training in proper lifting techniques, mechanized carpet cleaners and floor polishers to minimize the time spent on the knees and provision of knee pads for occasional tasks.

Chemical hazards

Domestic workers can be exposed to a wide variety of acids, alkalis, solvents and other chemicals in household cleaning products which can cause dermatitis. (See also “Indoor cleaning services” in this chapter). Dermatitis can often be exacerbated by the immersion of hands in hot or cold water (Scolari and Gardenghi 1966). Domestic workers may not know enough about the materials they use or how to use these products safely. There is inadequate training in chemical handling or hazard communication for materials that they use. For example, a severe poisoning case in a servant who was using cadmium carbonate silver-cleaning powder has been reported. The worker used the product for one-and-a-half days, and suffered abdominal cramps, tightness of the throat, vomiting and low pulse. Recovery took 24 days (Sovet 1958).

Many products used or handled by domestic workers are known allergens. These include natural rubber protective gloves, house plants, waxes and polishes, detergents, hand creams, antiseptics and impurities in detergents and whiteners. Irritant dermatitis may be a precursor to allergic contact dermatitis in housekeepers, and often starts with the development of erythema patches on the backs of hands (Foussereau et al. 1982). Inhalation of solvents, household pesticides, dusts, moulds and so on can cause respiratory problems.

Precautions include using the least toxic household cleaning products possible, training in materials handling and safety of the various detergents and cleaning fluids, as well as the use of protective hand creams and gloves. Unscented products may be better for those individuals prone to allergy (Foussereau et al. 1982).

Biological hazards

Domestic workers with responsibility for the care of young children in particular are at greater risk of becoming infected with a variety of illnesses, especially from changing diapers, and from contaminated food and water. Precautions include washing hands carefully after changing and handling soiled diapers, proper disposal of soiled items and proper food-handling procedures.

Psychological and stress hazards

Some psychological and stress hazards include isolation from one’s family and community; lack of paid vacation and sick or maternity leave; inadequate protection of wages; rape, physical and mental abuse; over-extended working hours; and general lack of benefits or contracts. Live-in domestic workers face greater danger from hazards including violence, harassment, physical and mental abuse and rape (Anderson 1993).

During a six-month period in 1990, there were eight deaths - six suicides and two murders - of Filipino domestic helpers recounted in a report filed by the Philippine Embassy in Singapore. Suicide is under-reported and not well documented; however, there were as many as 40 suicides reported to the Philippine Embassy in one time period (Gulati 1993).

To a lesser extent, these same hazards are relevant to non-residential domestic workers. In an Ohio (United States) study that looked at workers’ compensation claims filed for sexual assault from 1983 to 1985, 14% of the rapes occurred in motel maids and housekeepers (Seligman et al. 1987).

Prevention of abuses of domestic workers can be aided by establishment of laws that protect these comparatively defenceless workers. In the United States, the hiring of illegal immigrants as domestic workers was a common practice until the passage of the Immigration Reform and Control Act of 1986. This act increased the penalties that could be imposed on the employers of these workers. However, in developed countries the demand for domestic help is steadily increasing. In the United States, domestic workers must be paid at least the minimum wage and, if they earn $1,000 or more annually from any single employer, they are entitled to unemployment compensation and social security (Anderson 1993).

Other countries have taken steps to protect these vulnerable domestic workers. Canada started its Live-in Care-giver Program in 1981, which was amended in 1992. This programme involves recognition of immigrant domestic workers.

Acknowledgement of the immigrant domestic worker is the first step in being able to address heath and safety preventive issues for them. As initial recognition of these workers and their difficulties is achieved, dangerous working conditions can be addressed and improved with government regulations, unionization, private support groups and women’s health initiatives.

Health Effects and Disease Patterns

One study of mortality data of 1,382 female domestic workers in British Columbia (Canada) showed higher mortality than expected from cirrhosis of the liver, accidental death due to exposure, homicides and accidents of all types combined. Also, deaths due to pneumonia and rectal and eye cancer were higher than anticipated. The authors suggest that a major factor in the elevated deaths due to liver cirrhosis is because many domestic workers in British Columbia are from the Philippines, where hepatitis B is endemic (McDougal et al. 1992). Other studies point to alcoholism as a factor. In a review of a California (United States) mortality study, it was noted that the following occupations were associated with increased cirrhosis mortality rates in women: private housecleaner and servant; waitress; and nursing aide, orderly and attendant. The authors conclude that the study supports an association between occupation and cirrhosis mortality and, furthermore, that the greatest cirrhosis mortality is associated with low-status employment and jobs where alcohol is easily available (Harford and Brooks 1992).

In their 1989 study of occupational skin disease, the British Association of Dermatologists found that of 2,861 reported cases (of which 96%were contact dermatitis), the occupation of “cleaners and domestics” was the second-highest category of work listed for women (8.4%) (Cherry, Beck and Owen-Smith 1994). Similarly, in positive responses to dermatological patch tests performed on 6,818 patients, the most common professions of women studied were housekeeper, office worker, cleaner, needleworker and cosmetologist. Housework accounted for 943 of the positive responses to the patch tests (Dooms-Goossens 1986).

Other research has pointed to respiratory allergy and disease. Organic chemical-induced occupational allergic lung diseases were reviewed, and the category of domestic workers was noted as one occupation particularly affected by respiratory allergens (Pepys 1986). A Swedish study on mortality due to asthma looked at women who reported employment in the 1960 National Census. Smoking-adjusted standardized mortality ratios were calculated for each occupation. Increased mortality due to asthma was seen in caretakers, maids, waitresses and housekeepers (Horte and Toren 1993).

There is a lack of statistics and health information concerning domestic workers, especially for overseas immigrant workers, perhaps because of these workers’ temporary or even illegal status in their countries of employment. Governmental acknowledgement will only help enable more research and protection of these workers’ health.

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Many of the processes described in the articles in this chapter can generate hazardous waste such as solvents, acids, alkalis, formaldehyde and so forth.

In dry cleaning, there has been concern about perchloroethylene vapours polluting the air of apartments above the dry-cleaning shops. The installation of machinery for purification and recovery of solvent vapours, the centralization of dry cleaning (using local shops just as drop-off and pickup places) and the development of wet cleaning methods that minimize solvent use are all methods that can minimize these problems.

Funeral parlours using embalming generate both chemical hazardous waste (e.g., formaldehyde) and biological hazardous waste (blood and blood-containing materials). Most countries where embalming is practised require these to be disposed of as hazardous waste. In crematoria, airborne mercury contamination can result from mercury amalgam fillings in teeth.

Most cosmetology shops that generate chemical waste pour it down the drain or place containers with residues in the trash. This is also true of cleaning personnel, both in homes and in institutions, who can generate waste in the form of solvents, acids and other cleaning products containing hazardous chemicals. The existence of many generators individually producing small amounts of waste creates a control problem; focused and standard control technologies are not easily implemented in these cases. For example, even in large institutions like hospitals, the cleaning chemicals are used in small amounts throughout the building, with cleaning chemicals often stored at many locations.

There are several solutions to this problem. One is the ongoing development of less hazardous substitutes, especially the replacement of solvents with water-based products. Another solution is the adoption of procedures to ensure that only the amounts of products needed for the near future are purchased, to avoid the accumulation of old products that must be disposed of. Using all the product in a container before discarding it in the trash can reduce the pollution from that source. In recent years, some countries, like the United States and Canada, have established local household hazardous waste programmes where waste such as solvents and cleaning products can be taken to central collection points that will accept the hazardous waste free of charge and dispose of it according to proper procedures.

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