International Journal of Occupational Safety and

Ergonomics

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/tose20

The comparing of formaldehyde risk assessment

in histopathology laboratories staff by using three
methods based on US-EPA approaches in the west
of Iran

Azam Karami Mosafer , Elnaz Taheri , Abdulrahman Bahrami , Seyed

Mohammad Zolhavarieh & Mohammad Javad Asari

To cite this article: Azam Karami Mosafer , Elnaz Taheri , Abdulrahman Bahrami , Seyed
Mohammad Zolhavarieh & Mohammad Javad Asari (2020): The comparing of formaldehyde
risk assessment in histopathology laboratories staff by using three methods based on US-EPA
approaches in the west of Iran, International Journal of Occupational Safety and Ergonomics, DOI:
10.1080/10803548.2020.1865618

To link to this article: https://doi.org/10.1080/10803548.2020.1865618

Accepted author version posted online: 22

Dec 2020.

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Publisher :Taylor & Francis & Central Institute for Labour Protection – National Research Institute
(CIOP-PIB)

Journal :International Journal of Occupational Safety and Ergonomics

DOI: 10.1080/10803548.2020.1865618

The comparing of formaldehyde risk assessment in histopathology laboratories staff by

using three methods based on US-EPA approaches in the west of Iran

Azam Karami Mosafer1, Elnaz Taheri2, Abdulrahman Bahrami3, Seyed Mohammad

Zolhavarieh4, Mohammad Javad Asari5*

1Department of Occupational Health ,School of Public Health, Hamadan university of Medical

Sciences, Hamadan, Iran E-mail address: karamimosafer@yahoo.com.

2Department of Occupational Health ,School of Public Health, Hamadan university of Medical

Sciences, Hamadan, Iran. E-mail address: Elnaztaheri1992@gmail.com. ORCID number:
0000-0002-8752-6210

3Center of Excellence for Occupational Health, Occupational Health and Safety Research

Center, School of Public Health, Hamedan University of Medical Sciences, Hamedan, Iran, E-

mail address: Bahrami@umsha.ac.ir. OCIRD number: 0000-0002-6391-5588

4Department of Anesthesiology, Urology & Nefrology Research Center, Faculty of Medicine,

Hamedan University of Medical Sciences, Hamedan, Iran, E-mail address:

dsmbszolhavarieh@gmail.com. ORCID number: 0000000334017145

5*Research Center for Health Sciences, School of Public Health, Hamadan University of

Medical Sciences, E-mail address: Asari@umsha.ac.ir. ORCID number: 0000-0001-5609-

717X

*Corresponding author. Associate Professor, Research Center for Health Sciences, School of

Public Health, Hamadan University of Medical Sciences, Tel: +98 81 38380090. Fax: +98 81

38380590. E-mail address: Asari@umsha.ac.ir

Abstract

Background. In different studies, various models have been used for exposure risk assessment

of formaldehyde, so this study was conducted to compare existing methods.

Method. This cross-sectional analytical study was performed in the pathology section of four

hospitals in the west of Iran in 2016. Personal air sampling was performed using the National

Institute for Occupational Safety and Health (NIOSH) 3500 method. Then risk assessment

with existing methods and comparison between them was performed with the statistical tests.

Results. 27.58% were exposed to values above the Threshold Limit Value (TLV). The

average of carcinogenic risk obtained from the staff of the studied hospitals ranged from 3×10-
5
to 3.07×10-4. The average potential dose (PD) of exposure to formaldehyde varied from

73.22 to 3216.06 (μg·day-1). The hazard quotients (HQ) value was more than 1 in 71.4% of

cases.

Conclusion. The results of the existing methods for carcinogenic risk assessment are almost

similar. In general, the Risk Assessment Information System (RAIS) software is

recommended because of its simplicity, reduction of error probability, saving time and cost.

The results of this study can be used as a guide to select the appropriate risk assessment method

for planning, providing appropriate control measures and, risk management.

Keywords: Formaldehyde, histopathology laboratories, Health Risks, Occupational Exposure

1. Introduction

Formaldehyde is a colourless gas with a sharp and irritating smell produced by

oxidation of methanol, and it has relatively long durability in the air [1]. Formaldehyde was

previously classified as a 2A group (probably human carcinogens) by the International

Agency for Research on Cancer (IARC) but changed to 1 group (human carcinogens) in the

new classification [2, 3]. According to the American Conference of Governmental

Industrial Hygienists (ACGIH) classification, formaldehyde is in group A2 (suspected

human carcinogens) [2, 4]. This compound is very dangerous to human health due to the

potency of toxicity and cancer. Formaldehyde causes, upper airway inflammation and shortness

of breath, allergic contact dermatitis, chronic bronchitis, asthma, significant changes in

spirometric parameters, and has sensitivity and irritation effects on the eye [5]. Epidemiologic

studies on industrial workers, pathologists and anatomists have shown a relationship between

formaldehyde exposure and increased risk of various types of cancer, including the nasal

cavity, nasopharyngeal, lung, brain, pancreas, prostate, colon, and lymphohematopoietic

system [6].

In recent years, much attention has been paid to the potential health risks of

formaldehyde in occupational exposures, but despite the global constraints that so far have

been made, formaldehyde still exists in some medical services such as hospital histopathology

laboratories. In this laboratory formaldehyde was used as a tissue stabilizer [7]. Ahmed [8]

investigated the concentration of formaldehyde in the laboratories of Sharjah university

in the United Arab Emirates. The highest amount of formaldehyde was related to the

anatomy laboratory and the lowest was related to the environmental health laboratory.

Because some obtained values were higher than the recommended levels of the National

Institute for Occupational Safety and Health (NIOSH), they suggested continuous

monitoring and some effective control measures. Ghasemkhani et al. [7] were investigated

the exposure to formaldehyde in pathology laboratories, surgery rooms and endoscopy

wards of eight hospitals in Tehran. The results showed that the average long-term

exposure in the pathology laboratory is higher than other wards. This studies showed the

importance of pathology laboratories for review and study. Few studies on formaldehyde

exposure health risk assessment have been performed in hospitals [9]. LU et al. [10] assessed

the risk of exposure to formaldehyde in four hospitals in Guangzhou, China, and founded that
the potential dose (PD) of exposure to formaldehyde was 41.8 (μg·day-1) (inhalation rate used

was 0.63 (m3·h-1)). The findings of Sousa et al. [11] in two Fortaleza-Brazil hospitals showed

that the carcinogenic risk of this compound is from 2.4×10-6 to 3.07×10-5 and the average PD

is higher than the limit set by NIOSH at inhalation rate of 1.02 (m3·h-1). Pourtaghi et al. [9]

conducted a risk assessment on 72 staffs at four military hospitals, with the average

carcinogenic risk ranging from 1.4×10-4 to 30×10-4 that were higher than recommended by the

Environmental Protection Agency (EPA). The average PD ranged from 124 to 1141 (μg·day-
1
). According to the results, there was a significant difference in carcinogenic risk and PD in

different hospitals and wards. The highest mean carcinogenic risk in the wards was related to

clinic, pathology, dissection, office and laboratory, respectively. However, in the study of

sections, pathology and dissection had the highest percentage of definite risk. Zain et al. [12]

investigated the health risk assessment of formaldehyde exposure and the symptoms of

poor health in histopathology laboratory (exposed) and administrative staffs (non-

exposed) in four hospitals in the Klang Valley, Selangor, Malaysia. Their study showed

that histopathology staffs were exposed with 140-480% higher concentration than

administration staffs. 67% and 57% of histopathology staff and non-exposed individuals

had similar health symptoms, respectively. Symptoms of eye irritation, headache,

drowsiness, and chest tightness were more prevalent among exposed than none-exposed

group. The amount of hazard quotients (HQ) for all work activities performed by the

laboratory staffs was more than 1. The carcinogenic risk for laboratory staffs, although

less than 10-4, was 2-4 times higher than for administration staffs.

In each of these studies, different methods recommended by EPA have been used.

According to the importance and necessity of risk assessment, it is important to choose a more

accurate method [10, 11]. Therefore, the aim of this study was comparing available methods

for health risks assessment, through estimation of the carcinogenic and non-carcinogenic risks,
of the employees of histopathology laboratories exposed to formaldehyde by inhalation at four

selected hospitals in western Iran.

2. Materials and methods

This cross-sectional analytical study was carried out on 28 staff in the histopathology

laboratories of four selected hospitals (A, B, C, D) in the west of Iran in 2016. The demographic

characteristics of staff such as age, gender, weight and work experience recorded by a

questionnaire. The data collection method was census-based. Subjects were classified in

different occupational groups to perform the risk assessment. Then, the risk assessment was

carried out according to the existing conditions and information needed in each method.

2.1. Air sampling and analysis

The levels of formaldehyde in personal and indoor sites samples were determined by using the

NIOSH Method No. 3500 [13]. Briefly, two series impingers containing 20 (ml) sodium

bisulphite 1% and a trapped impinger were used for sampling. All samples were individual,

with the personal sampling pump (SKC-224-PCMTX8, USA). Before sampling personal

sampling pumps was calibrated by an electronic flow meter (DC- Lite BIOS Drycal, SKC,

USA) at 1 (L·min-1). The preparation and analysis of samples was performed according

to the method: First, the calibration stock solution was prepared by dilution of 1 mL of 1

mg·mL-1 formaldehyde stock solution to 100 mL 1% sodium bisulfite solution. Second,

the daily calibration was done with the working standards. For this purpose adjusted

values of calibration stock solution was pipetted into 25 mL flasks. Then was added 1%

sodium bisulfite solution to bring the volume of each working standard to 4 mL. To

prepare samples, 4 mL aliquots from each sample solution was pipetted into 25 mL glass-

stoppered flasks. 1 mL of chromotropic acid 1% and 6 mL of sulfuric acid 98% added

into each one of them. Then samples placed at 95 °C for 15 minutes. Finally, the samples

absorbance was readed at 580 nm by UV-VIS-NIR spectrophotometer (Perkin Elmer

Spectrometer UV/Vis, Lambada 950, USA). Also the reagent blanks were prepared and

analyzed together with samples. As shown in the Fig. 1 the calibration curve was prepared

(absorbance vs. µg formaldehyde·mL-1). For quality control purpose, all samples

containing over 20 µg formaldehyde was diluted and reanalyzed. The recovery rate was

found 100% with less than 5% relative standard deviation for three replicates.

2.2. Risk Assessment calculation

2.2.1. Method 1 (used by Sousa W et al.)

Potential Dose:

PD in this method determines the exposure potential (effective dose of pollution that

can cause human health effects in an environment). To calculate PD, the following equation

used [11]:

PDi = C j ×(IR) i × Ti j ,

Where; Cj: is the concentration of pollutant (μg·m-3), (IR)i: represents the inhalation

rate (equal to 0.72 and 1.02 (m3·h-1) for low and medium inhalation at 8-hour exposure,

respectively), and Tij: displays the exposure time (ET) (h·day-1).

Cancer Risk assessment:

To obtain carcinogenic risk (CR), chronic daily intake (CDI) is multiplied by the slope

factor (SF). SF determined by the Integrated Risk Information System (IRIS) equal to

0.0455 (mg·kg-1·day-1) for formaldehyde [11].

CR = CDI×SF,

CDI calculated with the following equations[11]:

CA×IR× ED× EF× L

CDI = ,
BW× ATL× NY

Where; CA: demonstrates contaminant concentration (mg·m-3), ED: displays exposure

duration (ED) (an hour per week), EF: represent the frequency of exposure (EF) per day, L:
indicates the length of exposure (mg·kg-1·day-1), BW: shows the body weight (Kg), ATL: is an

average lifetime (for man=69 (years) and woman=72 (years)), and NY represent the number

of days of exposure per year. Other parameters of the equation were introduced in the previous

section.

2.2.2. Method 2 (used by Wu et al.)

Cancer Risk assessment:

The lifetime cancer probability (LCP) is defined as an increased incidence of cancer

against a background of continuous exposure to formaldehyde. The LCP is estimated using the

following equation [14]:

R FA = CFA ×IUR FA ×Lworker ,

Where; RFA: is the excess LCP for formaldehyde, CFA: demonstrates the concentration

of formaldehyde (μg·m-3), IURFA: displays inhalation unit risk (IUR) (1.3×10-5 (μg·m3)-1 for

this compound [15]), Lworker: represents the adjustment factor for the ratio of the workplace

time to 70 years that its value can be estimated using the following equation:

8 5.5 45
35 years× hours× days× weeks
L worker = 24 7 52 ,
70 years

In this equation assumed that the staff's works, 8 hours per day, 5.5 days per week, 45

weeks per year, and 35 years in a fixed location throughout the 70-year lifetime [14].

Non-cancer Risk assessment:

The hazard index (HI) equation used for determining the non-carcinogenic risk of

formaldehyde.

CFA
HI FA = ,
RfCFA

Where; RfCFA: indicates the inhalation reference exposure level for chronic non-

cancer health effects (RfC) (RfC=3.6 μg·m-3 for formaldehyde) [14].

2.2.3. Method 3 (RAIS software)

The Risk Assessment Information System (RAIS) software in the main site of EPA

(https://rais.ornl.gov/cgi-bin/prg/RISK_search?select=rad) was used to estimate the

carcinogenic and non-carcinogenic risks of formaldehyde [16]. According to the exposure

conditions, items including indoor worker, air, chemicals data source, chronic or subchronic

(according to less or more than one-year exposure) and the chemicals of interest were selected.

The following equations used for calculations in RAIS software:

Carcinogenic risk assessment:

  g  250(days)   8hours   1day 

Cair  3  ×EFiw  ×EDiw (25(years))×ETiw  ×
  day   24 hours 
CDI iw-air-ca=
m   year 
 365days 
,
ATiw  ×LT(70 years)
 year 

Where: CDIiw-air-ca: demonstrates the carcinogen risk (μg·m-3), Cair: is the concentration

in ambient air (μg·m-3), ATiw: displays the averaging time (equal to 365 (days·year-1)), LT:

indicates the worker’s lifetime (equal to 70 years). EF, ED and ET: shows the frequency,

duration (year) and time (h·day-1) of the exposure, respectively.

Then the CDI placed in the following equation for calculating inhalation risk (IR):

IR = CDI×IUR,

The effective parameters were introduced in the previous sections.

Non-carcinogenic risk assessment:

 mg   250days   8hours   1day 

Cair  3  ×EFiw  ×ED(25(years))×ETiw  ×
  day   24 hours 
 mg 
CDI iw-air-nc  =
 m3 
m   year 
 365days   1000  g 
,
ATiw-a  ×EDiw(25years) ×
 year   1mg 

Where: CDIiw-air-nc: is the non-carcinogenic risk (mg·m-3). Other parameters of the

equation introduced in the previous section.

 Then CDI was placed in the below equation which the components previously has been

described (RfC=9.8×10-3 (mg·m-3) for formaldehyde in RAIS) [15].

CDI
HQ = ,
RfC

The numbers 8, 250, and 24 are not fixed in the equations and are determined by the

user according to the conditions.

The acceptable carcinogenic risk by the World Health Organization (WHO) range

from 10-6 to 10-5 or less, and numbers greater than 10-5 represent an unacceptable risk of cancer

[17]. While the EPA recommended carcinogenic risk less than 10-6 [18]. According to the

other studies, the carcinogenic risk higher than 10−4 can be considered as a “definite risk,” in

the range of 10−5 and 10−4 as a “probable risk” and in the range of 10−5 and 10−6 as a “possible

risk” [17, 19-21]. Based on EPA recommendation the non-carcinogenic risk more than 1

considered as definitive [14].

All risk factors which were used for calculation in this study summarized in the

table 1.

2.3. Data analysis

The analysis of the data obtained from the three used methods was performed by SPSS

version 20 and Excel 2016. Kruskal-Wallis test was used to compare quantitative variables in

different wards and hospitals. Spearman correlation coefficient test was used to investigate the

relationship between demographic characteristics and quantitative variables with the results of

the models. Due to the similarity of the subjects, the models were compared using Friedman

and Wilcoxon tests. Meanwhile, after converting quantitative data into qualitative the

differences among the methods were evaluated by the κ test.

3. Results

The demographic characteristics of the subjects are presented in Table 2. Most of the

subjects under study are from Hospital A. There is a large difference between the

frequency of work between hospitals, which is related to the job, the number of days and

working hours that vary in hospitals. More details about the working hours per day,

frequency and duration of exposure for each jobs are shown in Table 3. The lowest mean

of frequency and working hours per day and the highest mean of average 8-hour time-

weighted average (TWA) (equal to 54.0±25.6, 2.8±1.5, and 1139.81±969.23 respectively)

are related to pathologists. 21% and 71% of staffs had higher exposure than the Permissible

Exposure Limit (PEL) (922.5 (µg·m-3)) and TLV (123 (µg·m-3)) established by the

Occupational Safety and Health Administration (OSHA) and ACGIH for formaldehyde,

respectively [22]. The high concentration observed in hospitals B and C is related to the

lack of proper ventilation system. In addition, the number of working days per week in

these hospitals is less, which leads to an increase in workload.

In Table 4, personal exposure is described as PD for the measured concentration of

formaldehyde. The highest PD was observed in the medical laboratory scientists at hospital D.

The results show the highest average of carcinogenic risk in three approaches is related

to medical laboratory scientist in hospital B and D. The highest non-carcinogenic risk in

method 2 and RAIS was related to pathologists and medical laboratory scientists.

The results of the Kruskal-Wallis test for comparing quantitative variables in different

wards and hospitals are shown in Table 5. The mean of EF, TWA, and non-carcinogenic risk

in Method 2 is different between hospitals (Pvalue<0.05) (Table 5). In various wards, TWA, ET,

EF and non-carcinogenic risk in Method 2 have a difference in mean (Pvalue<0.05) (Table 5).

The results of the Spearman correlation coefficient test showed that there is a positive

and significant relationship between TWA and ED with PD. All carcinogenic risk assessment
models in this study had a positive and significant relationship with age and ED. The non-

carcinogenic risk of Method 2 is exactly correlated with TWA, which was also expected

according to its equation. Non-carcinogenic risk in the RAIS method has a positive and

significant relationship with ED and EF (Table 5).

Friedman test showed the difference between at least two carcinogenic methods

(Pvalue<0.001). The results of the methods comparison showed that there is a difference between

the average of carcinogenic risks of three methods (Pvalue<0.001). Also, comparing the average

of non-carcinogenic risk showed that there is a significant difference between the methods 2

and RAIS (Pvalue<0.001).

After converting quantitative data into qualitative, κ coefficients were used to

investigate the agreement between methods. Two-by-two comparison of carcinogenic methods

showed a high agreement between them (Table 6). The methods used to assess non-

carcinogenic risk also have a 71.4% agreement.

4. Discussion

4.1. Personal exposure to formaldehyde

In most studies, the mean concentration of formaldehyde in the pathology laboratories

is more than other sections. Its cause was related to workload (or occupational activity), the

difference between work processes and other environmental factors [7]. Therefore, this study

was conducted to the risk assessment of staff in the pathology laboratory and to compare three

existing methods in this field.

100% and 57% of pathologists and medical laboratory scientists have exposure to

excessive amounts TLV, respectively. Also, the exposure of all hospital staffs B and D was

higher than TLV, which indicates the need to plan to implement control measures. Also, all
subjects had higher exposure than Recommended Exposure Limit (REL) suggested by

NIOSH (19.68 (µg·m-3)) [22].

The PD values have a moderate correlation with TWA values and working hours per

day and increase with their increase. In calculating the PD, the inhalation rate is an important

variable that can increase uncertainty in risk estimation [23]. In this study, the PD values for

moderate inhalation rate were estimated. The PD value in hospital B and D are higher than

others. Sousa FW et al. [11] in the investigation of the exposure and cancer risk assessment of

formaldehyde and acetaldehyde in Fortaleza-Brazil, founded that the PD values were slightly

over 120 (μg·kg-1). The difference between the results of this study with theirs is due to the

higher concentration level of formaldehyde. The PD obtained by Lu et al. [10] that studied

formaldehyde and acetaldehyde levels in Chinese hospitals, was 41.5 (μg·day-1), that it is much

less than the results of the present study. Because their considered an inhalation rate equal to

0.63 (m3·h-1), which was not recommended in other studies. The PD value in the study of

Pourtaghi et al. [9] in military hospitals varied between 124 and 1141 (μg·day-1), which is in

accordance with the results of this investigation. The PD value is not enough to judge the risk

of formaldehyde because its amount is only affected by TWA and exposure hours per day.

4.2. Carcinogenic risk assessment

The differences of carcinogenic risk observed in similar jobs in different hospitals

are related to building conditions (number of windows), ventilation status, frequency of

work, and workload. The total range of obtained cancer risk was from 3×10-5 to 3.07×10-4.

The cancer risk of formaldehyde in the investigate of Sousa FW et al. [11] was between

2.84×10-6 and 3.58×10-5, which was lower than the values obtained in this study. The reason

for the difference was disagreement in the amounts placed in the carcinogenic risk equation

(instead of some parameters, they were used of EPA recommended values to facilitate

calculation, while that in the present study, actual values were placed). Also, there is a
difference in the examined sections and formaldehyde concentrations. The carcinogenic risk

obtained by Zain et al. [12] was from 1.7×10-5 to 4.3×10-5. Differences in results may be

due to various concentrations, building conditions, ventilation rate, EF, and other

effective parameters. Pourtaghi et al. [9] found that the carcinogenic risk in the studied

hospitals varies from 1.4×10-4 to 30×10-4, which is in accordance with the results of the present

study.

The EPA risk assessment models have advantages such as considering many effective

parameters, the use of reference concentrations (IUR, SF and RfC) that are the result of

extensive epidemiological and empirical studies, an appropriate assessment quantitative and

qualitative carcinogenic and non-carcinogenic effects and obtaining risk values for determining

risk levels.

κ test results showed that all three methods have at least 92.9% agreement with each

other. RAIS and method 2 completely agree with each other because the parameters affecting

them are the same. All three methods have a strong correlation with work experience (0.758)

and the results are almost similar. The slight difference between the results of Method 1 and

the others is due to the effect of a person's weight on the results. Therefore, using each method

gives the same results, but the RAIS model reduces the probability of error due to automatic

calculations by entering information and saves time and money.

4.3. Non-carcinogenic risk assessment

The difference of non-carcinogenic risk observed in similar jobs in different

hospitals is related to the formaldehyde concentration that subjects are exposed to it.

The concentration is affected by the time of exposure, the condition of building and the

ventilation system. On the other hand, in RAIS method, in addition to the mentioned

cases, EF and ED are effective in the results and lead to its difference.
 The average HQ for all laboratory staff (except Medical laboratory scientists in

hospital D and Orderly in hospital A in RAIS method) is higher than 1. These results

are consistent with the Zain et al. study [12] in which the HQ for the three hospitals (A,

C, and D) investigated and all work activities performed by the laboratory staffs were

higher than 1.

The results of the non-carcinogenic risk assessment showed 71.4% agreement between

methods. In Method 2, all subjects have an HQ higher than 1, which is due to its complete

dependence on TWA. In method 2 and RAIS, RfC is equal to 3×10-3 and 9.8×10-3 mg.m-3

respectively. In method 2, in addition to TWA, other parameters influencing the risk are also

effective and 71.4% of staffs have an HQ higher than 1. These various results in addition to the

effective parameters are related to the different RfCs used in each method (In method 2 and

RAIS, RfC is equal to 3×10-3 and 9.8×10-3 (mg·m-3) respectively). Therefore, it seems that the

RAIS method is more appropriate to non-carcinogenic risk assessment by considering the

parameters affecting the risk, reducing the probability of error, simplicity, saving time and cost.

5. Conclusion

In this study, risk assessment was performed using three EPA methods. Investigations

have shown that all three methods are suitable for carcinogenic risk assessment of

formaldehyde. Meanwhile, the RAIS method is more suitable for non-carcinogenic risk

assessment due to the consideration of several factors such as duration, frequency and time of

exposure. Also, this study emphasizes the necessity of creative planning to do engineering and

administrative control measures based on effective parameters on risk and prevent of creation

the adverse health effects in the hospital histopathology laboratories staffs. One of the

limitations of health risk assessment methods is that they are associated with uncertainty, which

can be reduced or eliminated by developing new methods in future studies. Therefore, it is

recommended that more extensive studies be conducted on risk assessment methods and efforts

to improve them in the future.

Funding information:

The authors received financial support, from the Hamadan University of Medical

Sciences, Hamadan Iran (Grant No. 950207390).

Conflicts of Interest: The authors declare no conflict of interest

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Figure 1. The calibration curve of formaldehyde

Table1. All risk factors influencing the calculations used in this study.

Risk factors Description References

Concentration* Concentration of pollutant in air. [24]
Exposure The amount of time that an individuals are exposed to the purpose
[24]
duration (ED)* pollutant (years).
Exposure time
Frequency that exposure occurs (h·day-1) [24]
(ET)*
 Exposure
Frequency that exposure occurs (days·year-1) [24]
frequency (EF)*
Inhalation
Demonstrate the volume of air inhaled over a specified time. [24]
rate**
Body weight* Usually expressed in kilograms (kg), used to the dose normalized. [24]
Slope factor** Indicant a measure of cancer risk from a lifetime exposure to an agent. [25]
Inhalation unit Estimation of the increased cancer risk from inhalation exposure to a
[26]
risk** concentration of 1 µg·m-3 for a lifetime.
Inhalation
Reference Estimation of a continuous inhalation exposure in the human population,
Concentration which is likely to be without significant risk of adverse effects during a [26]
lifetime.
(RfC)**
Worker EPA used of 70 years lifetime duration to characterize lifetime cancer
[27]
lifetime** risk.
* Data obtained from: measurements, observations and questionnaires.
** Data obtained from various sources.

Table 2. The demographic characteristics of subjects in the pathology section of the hospitals.
Hospita Number of Gender Weight Age Hight Duratio Workin Frequency
l name person Women Man (Kg) (year) (year) n of g time of work
under (percentag (percentag work (h·day- (days·year-
investigatio e) e) (year) 1)
1)
n
A 12 100 0 64.7±8.2
34.6±6. 164.4±4. 10.1±8. 5.7±2.3 225±81.0
1 7 6
B 3 33.3 66.7 81.7±6.6 35.3±9. 173.3±1. 9.8±9.1 7±00 45±00
9 5
C 7 87.5 12.5 57.8±8.6 33.4±7. 165.6±7. 8.6±6.5 5.3±2.1 64.3±32
4 2
D 6 83.3 16.7 67±13.2 39.5±5. 167.8±8. 12±7.0 3.8±2.5 157.5±123.
2 4 2
Total* 28 85.7 14.3 65.3±11. 35.5±6. 166.4±6. 10.1±7. 5.3±2.3 151.0±106.
1 7 4 5 7
* Indicates the overall frequency of gender among the persons under investigation and overal mean of other
parameters

Table 3. Mean of 8-hour time-weighted average (TWA) of formaldehyde, frequency of exposure, and
compare with allowed values in each hospitals and jobs.
work and overall frequency of other variables. †Information about duration of work, working hours per day,
Hospital Number of Frequency
Mean of Percentage Percentag
person Duration Workin of work of subject
and job of work g time concentration e of
title under (days · year- that have subject
(year) (h·day ) (µg·m-3)
-1
investigatio 1) higher that have
n exposure
Hospital A than the
higher
Pathologist 3 4.0±0.00 2.0±0.0 90.0±0.00 1070.38±675.19 67%
PEL exposure
100%
0 (percentage than the
Medical 6 10.6±8.7 7.0±0.0 270.00±0.0 120.69± 128.31 0% 17%
) TLV
laboratory
Admission 2 21.5±2.1 0
7.0±0.0 0
270.00±0.0 140±41.01 0% 50%
(percentage
scientist
s clerk 0 0 )
Orderly 1 3.00 7.00 270.00 33 0% 0%
Ward 12 - † - - 354.024±527.13 17% 42%
Hospital B
Pathologist 1 7.0 7.0 45.0 2150 100% 100%
Medical 1 20.0 7.0 45.0 1670 100% 100%
laboratory
Admission 1 2.5 7.0 45.0 570 0% 100%
scientist
sWard
clerk 1 - - - 1463±10.02 67% 100%
Hospital C
Pathologist 3 8.0±3.5 3.0±0.0 30.1±0.00 1491.67±1565.3 67% 100%
Medical 4 9.0±8.7 7.0±0.0 90.0±0.00 1
356.25±264.49 0% 75%
laboratory
Ward 7 - - - 842.857±114.55 28.6% 86%
scientist
Hospital D
Pathologist 3 10.0±0.0 2.0±0.0 45.0±0.00 520.66±207.56 0% 100%
Medical 3 0
14.0±10. 0
5.7±2.4 270.0±0.00 525.50 0% 100%
laboratory
ward 6 6- - - 523.08±131.299 0% 100%
scientist
Total*
Hospitals 28 - - - 631.31±749.27 21% 71%
Pathologist 10 7.3±2.98 2.8±1.5 54.0±25.6 1139.81±969.23 50% 100%
Medical 14 11.5±8.6 6.7±1.1 202.5±94.6 385.4±431.9 7.14% 57.1%
laboratory
Admission 3 15.2±11. 7.0±0.0 195.0±129. 283.33±249.94 0% 67%
scientist
s clerk 1 0 9
Orderly 1 3.0 7.0 270.0 33±0.00 0% 0%
and frequency of work in each hospital is given in Table 2.
Note: PEL= Permissible Exposure Limit; TLV=Threshold Limit Value.

Table 4. The average of PD, carcinogenic and non-carcinogenic risk calculated by three methods for each section
and hospital.

Formaldehyde (μg·day-1)
Job title A B C D
623.87±3
Pathologist 2193 436.88±458.45 151.73±60.48
93.54
Medical laboratory 738.63±7
1703.4 726.75±539.56 2603.477±1061.02
scientist 85.29
856.8±25
Admissions clerk 581.4
0.99
Orderly 201.96 -
The average of carcinogenic risk
 Hospi
A B C D
tal
Job C RF
CR† RFA†† IR¶ IR CR RFA IR CR RFA IR
title R A
Pathol 0.2± 0.16± 0.16 1. 1.0 0.2±0. 0.16±0. 0.16±0 0.12±0. 0.099±0 0.099±
1.01
ogist 0.19 0.1 ±0.1 02 07 13 103 .1029 044 .039 0.039
Medic
al
labora 0.7± 0.65± 0.65 2. 2.2 0.86±1 0.58±0. 0.57±0 2.3±0.4 1.9±0.
2.23 1.9±0.5
tory 1.1 1.1 ±1.1 25 3 .03 72 .72 8 5
scienti
st
Admis
1.4± 1.1±0. 1.1± 0. 0.0 0.09
sions
0.2 2 0.2 1 95 5
clerk
Orderl 0.03
0.04 0.039
y 9
The average of non-carcinogenic risk
Hospi
A B C D
tal
Job H
HIFA‡ HQ‡‡ HIFA HIFA HQ HIFA HQ
title Q
Pathol 297.32±18 2.23±1. 7. 414.35±434.8 144.62±57.
597.22 1.56±1.648 0.54±0.21
ogist 7.55 41 87 09 65
Medic
al
labora 33.52±35. 2.65±2. 6. 145.97±0.0
463.88 98.95±73.47 2.6±1.93 9.31±3.78
tory 64 81 11 0
scienti
st
Admis
38.88±11. 3.075±0 2.
sions 158.33
39 .898 09
clerk
Orderl
9.16 0.72
y
*All numbers in the section of carcinogenic risk in the table should be multiplied by 10-4
†
: The method used by Sousa FW et al. (Method 1); †† and ‡: The Method used by Wu et al. (Method 2); ¶
and ‡‡: RAIS software (Method 3).

Table 5. The result of Kruskal-Wallis and Spearman correlation tests to investigate the differences between different
wards and hospitals and the relationships between the methods and effective parameters.
 - - - - -
Hight 0.16 0.22 0.14 0.21 0.33 0.33 0.22 0.23 0.14
0.28 0.24 0.19 0.19 0.28
(Cm) 1 4 7 6 4 4 7 6 7
2 1 0 0 2
Age 0.41 0.85 0.88 0.02 0.39 0.02 0.42 0.02 0.42 0.11 0.55 0.88 0.02
0.04
(years) 8 4 9 8 0 3 8 3 8 7 4 9 8
Wight 0.27 0.83 0.60 0.10 0.30 0.30 0.28 0.21 0.83 0.04
0.27 0.42 0.2 0.2
(Kg) 5 0 7 2 8 8 2 1 0 2
TWA 0.02 0.01 0.03 0.40 0.05 0.36 0.08 0.32 0.08 0.32 0.03 0.40
- 1
(µg·m-3) 5 8 2 5 9 1 9 8 9 8 2 5
ED 0.73 0.50 0.00 0.71 0.00 0.75 0.00 0.75 0.25
- - - - 0.2
(years) 2 6 1 5 1 8 1 8 0
ET 0.19 0.00 0.21 0.24 0.23 0.23 0.23 0.23 0.03 0.41
- - - -
(h·day-1) 9 1 7 1 3 3 3 3 0 0
EF
0.00 0.00 0.41 0.16 0.27 0.13 0.28 0.13 0.28 0.12 0.29
(days·ye 0.03 - -
ar-1)
3 2 0 5 0 8 7 8 7 8 5
PD
0.47 0.11
(μg·day- - - - - - - - - - - - -
1) 2 1
Cancer
Risk 0.64 0.13
- - - - - - - - - - - -
(method 1 8
1)
Cancer
Risk 0.55 0.20
- - - - - - - - - - - -
(method 2 1
2)
Cancer
Risk 0.55 020
- - - - - - - - - - - -
(method 2 1
3)
Non-
Cancer
0.02 0.01
Risk - - - - - - - - - - - -
5 8
(method
2)
Non-
Cancer
0.47 0.11
Risk - - - - - - - - - - - -
2 1
(method
3)
Not: ED= Duration of exposure (years); EF= Exposure frequency (days.year-1); ET= Exposure time (h·day-1);
PD= Potential dose ; TWA= time-weighted average
Table 5. The result of Kruskal-Wallis and Spearman correlation tests to investigate the differences between
different wards and hospitals and the relationships between the methods and effective parameters.
Kruskal-
Test Spearman correlation test
Wallis
Diffe Diffe
Non-Cancer Non-Cancer
rent rent Cancer Risk Cancer Risk Cancer Risk
PD Risk Risk
Hosp War (method 1) (method 2) (method 3)
(method 2) (method 3)
Para ital d
meter Correl Correl Correl Correl Correl Correl
Pva ation Pva ation Pva ation Pva ation Pva ation Pva ation
Pvalue Pvalue
lue coeffi lue coeffi lue coeffi lue coeffi lue coeffi lue coeffi
cient cient cient cient cient cient
Hight 0.16 0.22 0.1 0.2 0.3 0.3 0.2 0.1
-0.282 -0.241 -0.190 -0.190 0.236 -0.282
(Cm) 1 4 47 16 34 34 27 47
Age
0.41 0.85 0.8 0.0 0.0 0.0 0.1 0.8
(years 0.028 0.390 0.428 0.428 0.554 0.028
8 4 89 4 23 23 17 89
)
Wight 0.27 0.8 0.6 0.3 0.3 0.2 0.8
0.27 0.42 0.102 0.2 0.2 0.211 0.042
(Kg) 5 30 07 08 08 82 30
TWA
0.02 0.01 0.0 0.0 0.0 0.0 0.0
(µg·m- 0.405 0.361 0.328 0.328 - 1 0.405
3) 5 8 32 59 89 89 32
ED
0.73 0.50 0.0 0.0 0.0
(years - - 0.715 0.758 0.758 - - 0.2 0.250
)
2 6 01 01 01
ET
0.19 0.00 0.2 0.2 0.2 0.0
(h·day - - 0.241 0.233 0.233 - - 0.410
-1) 9 1 17 33 33 30
EF
0.00 0.00 0.0 0.1 0.1 0.1 0.1
(days· 0.410 0.270 0.287 0.287 - - 0.295
year-1)
3 2 3 65 38 38 28
PD
0.47 0.11
(μg·da - - - - - - - - - - - -
y-1)
2 1
Cance
r Risk 0.64 0.13
- - - - - - - - - - - -
(meth 1 8
od 1)
Cance
r Risk 0.55 0.20
- - - - - - - - - - - -
(meth 2 1
od 2)
Cance
r Risk 0.55
0201 - - - - - - - - - - - -
(meth 2
od 3)
Non-
Cance
0.02 0.01
r Risk - - - - - - - - - - - -
5 8
(meth
od 2)
Non-
Cance
0.47 0.11
r Risk - - - - - - - - - - - -
2 1
(meth
od 3)
Not: ED= Duration of exposure (years); EF= Exposure frequency (days.year-1); ET= Exposure time (h·day-1);
PD= Potential dose ; TWA= time-weighted average

Table 6. The result of κ tests to investigate agreements between methods.

Carcinogenic Risk
The investigation of
agreement between two Value Pvalue Percent agreement
method
The agreement of
0.892 0.001 92.9%
method 1 with 2
The agreement of
0.892 0.001 92.9%
method 1 with 3
The agreement of
1 0.001 100%
method 2 with 3
Non-carcinogenic Risk
The investigation of
agreement between Value Pvalue Percent agreement
methods
The agreement of
- - 71.4%
method 2 with 3