Bull Environ Contam Toxicol (2013) 90:742–749
DOI 10.1007/s00128-013-0998-3
Outline of Occupational Chromium Poisoning in China
Yuan Yang • Hong Liu • Xian-hong Xiang •
Fu-you Liu
Received: 3 September 2012 / Accepted: 12 April 2013 / Published online: 20 April 2013
Ó Springer Science+Business Media New York 2013
Abstract The present study analyzed the feature of
occupational chromium poisoning in China since the
1980s. The collected data were acquired from 18 previous
surveys of chromium poisoning in 14 cities of China. The
method of risk assessment was applied to calculate the
relative risk and 95 % CI, p \ 0.05 was considered as a
significant risk. The results showed that nasal disease was
the most common sign of occupational chromium poison-
ing, and the prevalence rate of nasal disease was 17.83 %
in total population of 6,998. Further, the risk analysis
showed that occupational chromium poisoning led to an
increased risk of lung or liver cancer in male workers due
to the definite carcinogenicity of hexavalent chromium.
Significantly, an increased risk of spontaneous or threa-
tened abortion was also found in female workers. In con-
clusion, these studies suggest that early detection of
impaired reproductive function or impaired lung or liver
function in female or male workers is essential for con-
trolling occupational chromium poisoning in China.
Y. Yang
H. Liu
F. Liu (&)
Post-doctoral Research Stations, Nephrology Institute,
The Second Xiangya Hospital, Central South University,
Changsha Hunan 410011, China
e-mail: fuyoul213@163.com; LFY410@yahoo.com.cn
Y. Yang
Department of Clinical Laboratory, Huaihua Medical College,
Huaihua Hunan 418000, China
X. Xiang
Department of interventional Radiology, The First Affiliated
Hospital, Sun Yat-sen University, Guangzhou GuangDong 510080,
China
123
Keywords Occupational chromium poisoning

Epidemiological characteristics
China
The heavy metal chromium (Cr) exists widely in the
environment in the hexavalent form (chromate) and can be
refined through the process of industrial melting. Hexava-
lent chromium [Cr (VI)] is frequently used in making
stainless steel, leather tanning, pigment production, elec-
troplating and in other applications. Therefore, in the pro-
cess of Cr (VI) production or use, workers can suffer from
extensive damage to the respiratory system, digestive
system and skin as result of constant exposure to chromium
through the respiratory tract, alimentary canal and skin.
The presence of these conditions can indicate the occur-
rence of occupational chromium poisoning (OCP). At
present, nasal disease, dermatitis, hepatomegaly, damage to
reproductive functions and cancers of the lung, liver or
breast are considered as common clinical features of OCP
(Cohen et al. 1993; IARC 1990; Costa 1997).
Occupational chromium poisoning is widespread in
industrialized countries worldwide. Therefore, some epi-
demiological studies of the association between lung or
gastrointestinal tract cancers and OCP were conducted in
the United States (Gatto et al. 2010; Pastides et al. 1994;
Sheffet et al. 1982). For China, the OCP is really no single
case report in many cities. Many epidemiological studies
had revealed that OCP was prevalent to varying degrees in
Cr (VI)-exposed workers in many big cities since the
1980s. Despite this, there has never been a comprehensive
and systematic analysis of all the epidemiological studies
of OCP in China in the last three decades. Therefore, the
present study synthesized the survey results of OCP from
the last 30 years and analyzed the epidemiological features
of nasal disease, dermatitis, hepatomegaly, reproductive
Bull Environ Contam Toxicol (2013) 90:742–749
function damage and cancer of the lung or liver associated
with occupational chromium exposure.
Materials and Methods
The data were acquired from 18 previous epidemiological
studies of occupational chromium poisoning in 14 cities in
China, which was retrieved openly and available online.
The study was permissive for using the data from all authors
of these surveys. The areas of survey consisted of 14 cities
of more than one million people, or 6 provinces and 3
municipalities. The studies were conducted between 1983
and 2010 involved in 18 retrospective surveys of occupa-
tional chromium poisoning in China. The linked web sites
for 18 surveys were shown as Table 1. In these epidemio-
logical studies, workers with Cr (VI) exposure in production
workshops were considered as the exposed group, while
coworkers with no Cr (VI) exposure were designated as
controls. For occupational chromium-induced nasal disease,
the diagnostic criteria of (GBZ12-2002) and clinical
examination were used to make medical diagnoses. Stan-
dard Mortality Ratio (SMR) analysis was performed
according to age-specific mortality references for Chinese
cities from 1975 to 1978 (Health ministry office of cancer
prevention and control research in China 1987). For the
statistical analysis, the method of risk assessment was
applied to calculate the relative risk (RR) and 95 % CI
(95 % CI), p \ 0.05 was considered as a significant risk.
Table 1 The linked web sites for 18 surveys of occupational chromium poisoning in China
No References
1 Wen-bin et al. (2010)
2 Jun-qi et al. (2006)
3 Wen-bin et al. (2004)
4 Guo-jin (2004)
5 Mei-li and Shen-xi (2004)
6 Yong-ling et al. (2001)
7 Deng-jiu et al. (2001)
8 Chun-lian and Ling-ping (1994)
9 Guang-zhi et al. (1992)
10 Jian-yu et al. (1991)
11 Zheng-ping (1988)
12 Shou-kang et al. (1988)
13 Hui-ren et al. (1987)
14 Zheng and Chun-ling (2003)
15 Rui-mei et al. (2003)
16 Qiong-yu et al. (1997)
17 Shi-xiong and Mei-yuan (1994)
18 Shi-xiong et al. (1986)
743
Results
Distribution of Occupational Chromium Poisoning
in Large Chinese Cities
There are about forty big cities in China. As shown in
Fig. 1, OCP in China is mostly concentrated in fourteen
cities: Tianjin, Taiyuan, Jinzhou, Jinan, Qingdao,
Zhengzhou, Chongqing, Changsha, Shenzhen, Nanjing,
Suzhou, Wuxi, Changzhou and Shanghai. Based on the
studies we have used, OCP is most concentrated in five
coastal cities of Shanghai and Jiangsu provinces. In central
China, OCP is found in Zhengzhou, Changsha and Taiyuan,
and Chongqing is a representative city with high OCP
prevalence located in the western inland area.
Rank of Occupational Chromium-Induced Diseases
Prevalence
As shown in Table 2, nasal disease was the most frequently
occurring disease associated with occupational chromium
exposure. In addition to nasal disease, occupational chro-
mium exposure can also cause occurrences of dermatitis,
hepatomegaly, reproductive system lesions and malignant
tumors. In Fig. 2, these diseases are arranged by prevalence
rate from highest to lowest: nasal disease (17.83 %), der-
matitis (12.94 %), spontaneous abortion (11.10 %), threa-
tened abortion (6.33 %), hepatomegaly (5.70 %), and
maliganant tumors (3.93 %).
The linked web sites
http://www.cnki.com.cn/Article/CJFDTotal-ZYJK201014003.htm
http://wuxizazhi.cnki.net/Search/ZYJK200621002.html
http://www.cnki.com.cn/Article/CJFDTotal-ZYJK200412017.htm
http://www.cnki.com.cn/Article/CJFDTotal-SOLE200401026.htm
http://www.cnki.com.cn/Article/CJFDTotal-ZYJK200404016.htm
http://www.cnki.com.cn/Article/CJFDTotal-ZYJK200102001.htm
http://mall.cnki.net/magazine/Article/LDBK200103015.htm
http://www.cnki.com.cn/Article/CJFDTotal-GYWZ404.019.htm
http://www.cnki.com.cn/Article/CJFDTotal-XYYX199205008.htm
http://lib.cqvip.com/qk/97285X/199101/657570.html
http://www.cnki.com.cn/Article/CJFDTotal-XYYX198803004.htm
http://www.cnki.com.cn/Article/CJFDTotal-XYYX198802004.htm
http://www.cnki.com.cn/Article/CJFDTotal-LDYX198704018.htm
http://www.cnki.com.cn/Article/CJFDTotal-SAFE200303010.htm
http://www.cnki.com.cn/Article/CJFDTotal-GGWS200301054.htm
http://www.cnki.com.cn/Article/CJFDTotal-GYWZ199703026.htm
http://wuxizazhi.cnki.net/Search/SOLE406.000.html
http://www.cnki.com.cn/Article/CJFDTotal-ZHLD198604007.htm
123
744 Bull Environ Contam Toxicol (2013) 90:742–749

Fig. 1 Geographic distribution

map of occupational Cr (VI)
exposure in China. Red and
green colors are indicative of
cities and regions in which
occupational Cr (VI) exposure
occurs (Color figure online)

Table 2 Prevalence rate of

OCAD Time Average age Examination number/ Occurred Prevalence
nasal disease, dermatitis,
(year) (A) times frequency ( %)
hepatomegaly, abortion and
malignant tumors Nasal disease 1983–2010 33.88 6,998 1,248 17.83
Dermatitis 1983–2010 32.7 3,716 481 12.94
Hepatomegaly 1983–2004 35.6 3,316 189 5.70
Spontaneous 1997–2002 34.0 216 24 11.10
abortion
Threatened 2002 32.5 158 10 6.33
OCAD occupational chromium abortion
exposure-associated diseases, Maliganant 1958–1989 m 2,545 100 3.93
m is indicative of missing data tumors
in literatures

Distribution of Nasal Disease Prevalence and Its

Association With Chromium Exposure

As shown in Table 3, between 1983 and 2010, 15 surveys

Fig. 2 Prevalence of diseases related to occupational chromium
poisoning in China
of nasal disease were performed in factories of ten cities.
There were 6,998 workers with occupational chromium
exposure in these studies between the ages of 17 and
59 years. The time of working ranged from 0.1 to 32 years.
The ratio of male to female workers ranged from 1.01 to
3.13. In this population, 1,248 cases of nasal disease were
diagnosed. Among these, there were 333 cases of nasal
septum ulcers or perforations, 26.68 % of the total. As
shown in Figs. 3a, b, the regional distribution of occupa-
tional chromium-associated nasal disease suggested the

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Bull Environ Contam Toxicol (2013) 90:742–749 745

Table 3 Characteristics of occupational chromium-induced nasal disease in China

City Time n Average age (A) WY Ratio (M:F) Nasal disease ( %)
Erosion ulcer/hole Total

Changzhou 2010 248 29.0 8.0 3.13 6 6 12 (4.84)

Suzhou 2005 1,228 32.0 7.0 1.15 13 8 21 (1.7)
Changzhou 2004 357 32.5 10.2 1.11 113 22 135 (37.82)
Wuxi 2004 472 35.6 6.7 3.03 0 41 41 (8.69)
Tianjin 2004 121 34.0 [1.0 1.16 28 2 30 (24.8)
Changsha 2001 233 33.0 12.8 1.77 23 1 24 (10.33)
Jinan 2001 363 35.0 7.5 2.86 60 47 107 (29.48)
Taiyuan 1994 333 36.2 0.5–21 1.64 47 39 86 (25.8)
Shanghai 1992 656 35.8 0.2–12 1.01 143 70 213 (32.5)
Chongqing 1989 247 33.5 0.1–23 1.6 67 4 71 (28.74)
Chongqing 1988 251 34.5 0.1–22 2.22 118 4 122 (48.61)
Nanjing 1988 1,941 32.8 0.3–9.0 1.02 204 26 230 (11.85)
Shanghai 1987 151 33.3 0.8–12 1.40 0 25 25 (16.7)
Chongqing 1985 198 35.0 0.4–32 1.87 93 9 102 (51.5)
Wuxi 1983 199 36.0 0.8–10 1.42 0 29 29 (14.6)
Total 6,998 33.88 915 333 1,248 (17.83)
WY is represented as working years for chromium exposure; M male, F female

A (29.93 %) from 1989 to 1994. However, there was an

Suzhou 1.7
obvious decrease for the nasal disease prevalence (2.24 %)
Changsha 10.33
from 2005 to 2010. Furthermore, the result of correlation
Wuxi 10.43
analysis suggested a significant association between chro-
Changzhou 24.3 mium concentration in working place and nasal disease
Tianjin 24.8 prevalence, more details were shown in and Table 4.
Taiyuan 25.8
Jinan 29.48 Risk Analysis of Nasal Disease Due to Occupational
Shanghai 29.49 Chromium Exposure
Chongqing 42.39

0 5 10 15 20 25 30 35 40 45
As shown in Table 5 and Fig. 4, compared with polishing
Prevalence (%) workers, the incidence rate of nasal disease among elec-
troplaters increased obviously, and the risk of nasal disease
B 35
in electroplaters increased by 4.27 times compared to
29.93
30 polishing workers. In factory workshops where the con-
Prevalence (%)

25
21.8 centration of chromium exceeds hygienic standards, the
20 18.54 incidence of nasal disease increased obviously, and the risk
15 of nasal disease increased by 2.91 times compared to fac-
10 tory workshops where the concentration of chromium met
5 2.24
hygienic standards. However, the difference of incidence
0 rates and risk of nasal disease were not statistically sig-
1983-1988 1989-1994 1999-2004 2005-
nificant between groups working less than 10 years and
Temporal distribution of occupational
chromium-induced nasal disease those working longer.

Fig. 3 a Distribution of occupational chromium-induced nasal dis- Risk of Abortion Occurring in Female Workers
ease in cities of China. b Temporal distribution of occupational
chromium-induced nasal disease in China of Occupational Chromium Exposure

highest prevalence occurred in Chongqing (42.39 %), the As shown in Table 6 and Fig. 5, an increased risk of
lowest in Suzhou (1.7 %). The time distribution of nasal spontaneous abortion or threatened abortion was observed in
disease suggested that there was a higher prevalence female workers, compared to the control of non-occupational

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Table 4 Correlation between chromium exposure dose in working place and nasal disease
Data source Sample sizeb Overproof rates (%) Cr exposure (mg/m3)c Workers (n) Prevalence ( %) Correlation
coefficient

Changzhou (2010) 147 12.93 0.026 248 4.84 0.619*

Changzhou (2004) 111 19.82 0.156 357 37.82
Wuxi (2004) 116 16.28 0.154 472 31.99
Tianjin (2004) 121 100.00 0.296 121 24.88
Changsha (2001) 15 60.00 0.183 233 10.30
Jinan (2001) 141 78.70 0.287 363 29.48
Taiyuan (1994) 60 70.00 0.578 220 33.60
Chongqing (1991)a 64 98.44 3.090 696 45.69
Shanghai (1988) 72 18.10 0.074 151 16.75
a
Chongqing (1991) is represented as the result of Chongqing (1985, 1988, 1989), referred in Jian-yu et al. 1991
b
The collection place of air sample is limited in operation site of chromium exposure, which is not involved in workshop office, worker’s lobby,
employee’s dinning room
c
Cr exposure is represented as average chromium concentration in workshop, according to GBZ2.1-2007, the occupational exposure limits for
chromium is 0.05 mg/m3
* Pearson correlation test between average chromium concentration and nasal disease prevalence indicates the p value is 0.076, p \ 0.10

Table 5 Risk analysis of occupational chromium-induced nasal disease in China

Districts Groups Cases group Controls group AR (%) OR (95 % CI)

Nanjing Factory (?) 129 630 10.42 2.91* (2.11–3.99)

Factory (-) 63 894
Changsha, Taiyuan Working year 0- 54 289 2.07 0.86 (0.57–1.29)
Working year 10- 57 263
Taiyuan Electroplater 74 146 23.02 4.27* (2.20–8.26)
Polisher 12 101
Factory (?) is indicative of factory exceeding chromium standard; Factory (-) is indicative of factory meeting chromium standard; Exceeding
the standard indicates Cr2O3 concentration in the workshop exceeds the maximum allowable concentration of Hygienic Standards for the Design
of Industrial Enterprises (TJ36—79)- ([0.05 mg per cubic meter or [0.05 mg/m3)
* p \ 0.05, the value of OR was significant following analysis with the Chi squared test

9
6.00 %, respectively. So the risk of spontaneous abortion
8
OR value of nasal disease

or threatened abortion increased by 2.31 or 20.47 times,

7
respectively, compared to unexposed controls.
6
5
4.27 Risk Analysis of Malignant Tumors in Workers
4
2.91 Exposed to Chromium
3
2
1
1.00 1.00 As shown in Table 7 and Fig. 6, cancers of the lung or liver
0 in male workers were closely associated with occupational
electroplater polisher Factory(+) Factory(-) chromium exposure compared with unexposed controls.
Taiyuan Nanjing The risk of lung or liver cancer incidence in occupationally
exposed workers increased by 3.53 and 2.03 times,
Fig. 4 Risk analysis of occupational chromium-induced nasal dis-
ease. The upper limit of 95 % CI was labelled on the top of the respectively. Similarly, the death risk of cancer of the lung
diagram or liver also increased by 2.27 (average value of 1.97 and
2.57) and 1.29 times (average value of 1.28 and 1.30),
chromium exposure. For female workers with occupational respectively, compared to mortality of the general popu-
chromium exposure, the incidence rate of spontaneous lation. For breast cancer in female workers, the incidence
abortion or threatened abortion increased by 5.58 % or rate was slightly higher than those who were unexposed to

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Bull Environ Contam Toxicol (2013) 90:742–749 747

Table 6 Risk analysis of abortion occurring in female workers exposed to chromium in China
Reproductive toxicity Groups Number of pregnancies Abortion Non-abortion AR (%) OR (95 % CI)

Spontaneous abortion Exposure 232 24 208 5.58 2.31* (1.25–4.27)

Non-exposure 420 20 400
Threatened abortion Exposure 158 10 148 6.00 20.47* (2.60–161.44)
Non-exposure 304 1 303
* p \ 0.05, the value of OR was significant following analysis with the Chi squared test

12 role in the regulation of blood glucose (Valko et al. 2006;

10.34 Singh et al. 1998a, b). While Cr (VI) exhibits strong oxi-
Incidence of abortion (%)

10
8 that of Cr (III) (Valko et al. 2005). Cr (VI) can readily enter
6 cells through the nonspecific anion channel of the cyto-
4.76
4
2 dative stress and form Cr-DNA adducts, and DNA–protein
0
Exposure Non-exposure
Spontaneous abortion
Fig. 5 Risk analysis of spontaneous or threatened abortion in female
workers
chromium, but the between-group difference was not sig-
nificant (p [ 0.05).
Besides the above characteristics of chromate poisoning,
hepatomegaly can also be found in workers of chromate
production workshops (referred in Zheng and Chun-ling
2003; Deng-jiu et al. 2001). The survey disclosed that the
incidence rate of hepatomegaly increased by 9.04 %, and
the incidence risk increased by 2.97 times compared to
other local workers without chromium exposure.
Discussion
Chrome is a heavy metal element, the common forms of
chemical valence are Cr (III) and Cr (VI). Cr (III) is an
essential trace element for humans, playing a significant
dation activity, and its toxicity is 100 times greater than
6.33
membrane. Activated redox reactions in cells can generate
a variety of reactive oxygen species (ROS), lead to oxi-
0.33 or DNA-Cr-DNA crosslinks. Further, activation of DNA-
Exposure Non-exposure dependent protein kinases (DNA-PK) and the P53 gene
Threatened abortion induces subsequent cell apoptosis (Hamilton et al. 1998;
Blankenship et al. 1994; Manning et al. 1994; Singh et al.
1998a, b). Apoptosis is an important factor influencing the
malignant transformation of cells, involving the activation
of specific oncogenes and consequent carcinogenesis. Due
to the occupational Cr (VI) exposure is an inevitable risk
factor in industries using Cr (VI), so some epidemiological
studies have shown that occupational Cr (VI) exposure
leads to an increased risk of lung or breast cancer in the
United States, Britain and other countries, and some
research also found a close association between an
increased cancer risk and Cr (VI) exposure in drinking
water (Dayan and Paine 2001; Kilic et al. 2004; Goldbohm
et al. 2006; Scientific American 2009; Allan et al. 2009;
Beaumont et al. 2008).
For China, the present study collected 18 epidemiolog-
ical surveys studying occupational chromium poisoning
from 1983 to 2010 and analyzed them for incidence or
relative risk of occupational Cr (VI) nasal disease, chrome
dermatitis, hepatomegaly, abortion, and malignant tumor.

Table 7 Risk analyses of malignant tumors in occupational workers exposed to chromium

Sex Groups Cancer Cases Controls AR (%) OR (95 % CI) SMR

Male Exposure Lung cancer 31 1,810 1.2 3.53* (1.97–6.32) 1.971 2.572
Non-exposure 18 3,709
Exposure Liver cancer 17 1,824 0.47 2.03* (1.04–3.99) 1.283 1.304
Non-exposure 17 3,710
Female Exposure Breast cancer 4 700 0.43 4.19 (0.77–22.95) m
Non-exposure 2 1,468
* p \ 0.05, the value of OR was significant following analysis by the Chi square test; according to the results of surveys conducted from 1975 to
1978, age-specific mortality of lung or liver cancer in large1, 3 and medium-sized2, 4 cities was considered for each as the standard calculation of
standard mortality ratio-SMR (Health ministry office of cancer prevention and control research in China 1987); m is indicative of missing data in
literatures

123
748
7 examination of reproductive function in female workers or
6 functions of lung and liver in male workers is significant to
Risk of malignant tumors
5
4 3.53
3 reducing the chrome concentration in workshops,
2.27 2.03
2
1.29
1
0 economic development in China and improvement of liv-
OR SMR OR SMR
Lung cancer Liver cancer
Fig. 6 Risk analyses of lung or liver cancer in workers exposed to
chromium. The upper limit of 95 % CT was labelled on the top of the
diagram
Our goals were to produce an overview of Chinese occupa-
tional chromium poisoning and help guide the future work on
prevention and control. The present study involved 14 big
cities in China and investigated about 9,701 workers in 270
factories producing chromate salts, performing electroplat-
ing, or engaging in other uses of chromium. There were 7,096
workers without Cr (VI) exposure who were also studied and
regarded as controls. The results showed that nasal disease
had the highest incidence among occupational chromium
exposure-related disease (17.83 %), followed by chromium
dermatitis (12.94 %), spontaneous abortion (11.1 %),
threatened abortion (6.33 %), hepatomegaly (5.7 %)and
malignant tumors (3.93 %). Based on analysis of regional
distribution, nasal disease incidence was highest in Chon-
gqing (42.39 %),followed by Shanghai (29.49 %), Jinan
(29.48 %), Taiyuan (25.8 %), Tianjin (24.8 %), and
Changzhou (24.3 %); the lowest incidence was in Suzhou
(1.7 %).
Further, analysis of risk showed that the risk of nasal
disease among electroplating workers was 3.17 times that
of a polisher, and risk of nasal disease in factories
exceeding chromium hygienic standards was 2.58 times
that of factories not exceeding the standard. Risk analysis
of hepatomegaly showed that occupational chromium
exposure risk increased 2.97 times compared with unex-
posed controls. For exposed female workers, the risk of
natural abortion or threatening miscarriage increased 2.17
and 19.18 times, respectively. The analysis also found that
occupational chromium exposure increased the risk of lung
or liver carcinoma by 3.48 and 2.02 times, respectively. In
conclusions, this study suggests that the nasal disease is the
most common result of occupational chromium poisoning.
Furthermore, chromium poisoning could lead to an
increased risk of abortion or threatening miscarriage in
female workers, and an increased risk of lung or liver
carcinoma in male workers. For the control of occupational
chromium poisoning, we believe that the regular
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Bull Environ Contam Toxicol (2013) 90:742–749
improve the life quality of workers in occupational chro-
mium exposure. On the other hand, we can also take some
other measures, such as improving production processes,
strengthening personal protection and health education.
These measures would reduce the occurrence of occupa-
tional chromium poisoning as much as possible. With
ing standards, prevention and control of occupational
chromium poisoning is receiving more attention from
government departments and the people.
Acknowledgments This study was sponsored by the Postdoctoral
Science Foundation of Central South University, China (2013–2015).
We sincerely thanks for the contribution of authors in 18 surveys of
occupational chromium poisoning in China. YY performed the col-
lection, clearance, analysis of epidemiological data and drafted the
manuscript, and XXH proposed many valuable advices on the man-
uscript. LFY and LH checked and revised the manuscript. All authors
declare that they have no competing interests.
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