ACOEM GUIDANCE STATEMENT

Arsenic Exposure, Assessment, Toxicity, Diagnosis,

and Management
Guidance for Occupational and Environmental Physicians
Beth A. Baker, MD, MPH, Victoria A. Cassano, MD, MPH, and Carolyn Murray, MD, MPH,
ACOEM Task Force on Arsenic Exposure

highlight changing trends in sources of occupational exposure pathway. Dermal

Arsenic is ubiquitous in the environment and
arsenic, as well as applicable United States exposure is considered a minor pathway
human exposure can occur from multiple possi-
(US) arsenic regulations from the Occupa- in comparison to inhalation and ingestion
ble routes including diet. Occupational medi-
tional Safety and Health Administration and one that would not pose a significant
cine physicians asked to evaluate workers with
(OSHA), Environmental Protection health risk in most settings.4
elevated urine arsenic levels may be unaware
Agency (EPA), and Food and Drug Admin- Arsenic in the food supply is an
that many sources of arsenic exposure are not
istration (FDA). We also review how to increasingly recognized exposure path-
work related. In this paper, we address arsenic
evaluate, counsel, and manage patients with way. Rice can absorb inorganic arsenic
exposure sources and pathways, adverse health
potential arsenic exposure and assess for (iAs) from soil and water up to 10 times
effects of arsenic exposure and those subpopu-
possible health effects. This includes how more efficiently than other food crops.5
lations at increased risk, and the evaluation and
to differentiate between organic and inor- Rice flour is a common ingredient in
treatment of those exposed to elevated arsenic
ganic arsenic sources and order and inter- processed foods, and brown rice syrup is
levels.
pret urine speciation, when necessary. used as a sweetener in many snack foods.
As a natural occurring element, arsenic is
A rsenic is ubiquitous in the environ-
ment, and human exposure can occur
from myriad natural and anthropogenic
EXPOSURE SOURCES AND
PATHWAYS
incorporated into many other terrestrial
and marine foods at low levels. Market-
based studies have found varying concen-
sources. Inorganic arsenic is a metalloid Arsenic occurs naturally in geologi- trations of iAs in a wide range of
compound with known cancerous and non- cal formations and is abundant in the earth’s food products.6 Studies using National
cancerous health effects. Arsenic in food is crust.1,2 Arsenic, primarily in its inorganic Health and Nutrition Education Survey
an increasingly recognized exposure path- form (iAs), can be found in soil, air, and (NHANES) data have calculated that arse-
way. We discuss dietary sources of arsenic water. Human exposure can occur through nic exposure from food may exceed the
and approaches to mitigating exposure. many different pathways, through occupa- quantity ingested from drinking water that
Physicians need to understand that many tions, the environment, and in food. Some meets the current EPA MCL.7 Individuals
sources of arsenic may be nonwork-related of the major potential arsenic exposure who are not at risk of arsenic exposure
and recognize populations at particular risk sources are listed in Tables 1 and 2. The from their drinking water or their occupa-
of elevated exposures. Physicians need to widespread contamination of tube wells in tion may still have significant exposure to
identify potential routes of exposure and Bangladesh is an example of an exposure iAs from food sources.8
select appropriate biomarkers for exposure pathway from naturally present iAs of geo-
evaluations. logic origin. Arsenic contamination of
In this paper, the multiple possible drinking water from geologic and man- FEDERAL REGULATIONS
routes of arsenic exposure are discussed, made sources has been found globally as OSHA regulations regarding iAs are
well as in regions of the US. The US EPA found in 29 Code of Federal Regulations
From the ACOEM, Elk Grove Village, Illinois.
maximum contaminant level (MCL) for (CFR) 1910.1018.9 The permissible expo-
This position paper was developed by the ACOEM arsenic in drinking water is 10 mg/L or sure level (PEL) for iAs is 10 mg/m3 of air,
Task Force on Arsenic Exposure under the 10 ppb for public water supplies. Human averaged over an 8-hour period without
auspices of the Council of Scientific Advisors. activity, including mining, smelting, pesti- regard to the use of a respirator. The action
It was reviewed by the Committee on Policy,
Procedures, and Public Positions, and approved
cide use, and coal ash disposal, has been level is 5 mg/m3 of air. A medical surveil-
by the ACOEM Board of Directors on July 28, linked to water and soil contamination. Use lance program must be established for all
2018. ACOEM requires all substantive contrib- of arsenic contaminated water for agricul- employees exposed at or above the action
utors to its documents to disclose any potential tural irrigation extends the exposure path- level, for at least 30 days per year without
competing interests, which are carefully consid-
ered. ACOEM emphasizes that the judgments
way to soil and food crops. Other sources of regard to the use of respirators. Areas where
expressed herein represent the best available soil contamination with arsenic include exposure is anticipated to be above the PEL
evidence at the time of publication and shall release of arsenates in pressure-treated must be designated and demarcated as a
be considered the position of ACOEM and not lumber (eg, chromated copper arsenate) regulated area. All personnel entering a reg-
the individual opinions of contributing authors.
The authors declare no conflicts of interest.
and localized industrial activities. The ulated area are required by OSHA to be
Address correspondence to: Marianne Dreger, MA, use of arsenical drugs in animal agriculture supplied with the proper respiratory protec-
ACOEM, 25 Northwest Point Blvd, Suite 700, and the subsequent use of animal wastes tion,9 and employers must have a respiratory
Elk Grove Village, IL 60007 and processed human biosolids as fertil- protection program in accordance with 29
([email protected]).
Copyright ß 2018 American College of Occupa-
izers are another potential soil and food CFR 1910.134.10 In regulated areas, food,
tional and Environmental Medicine crop contamination pathway.3 Inhalation of beverages, chewing tobacco, and gum are
DOI: 10.1097/JOM.0000000000001485 arsenic has been a widely described not permitted.

e634 JOEM  Volume 60, Number 12, December 2018

Copyright © 2018 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited
 JOEM  Volume 60, Number 12, December 2018 Arsenic Exposures

TABLE 1. Potential Sources of Environmental or Nonoccupational Exposure to EPA REGULATIONS REGARDING

Arsenic2,8,18,24,57– 59 ARSENIC
The US EPA regulates arsenic and
Environmental Contamination from Natural Sources compounds containing arsenic under
Rock and soil: numerous different statutes including the
Dissolution of arsenic into groundwater Clean Water Act; Clean Air Act; Safe
Dust Drinking Water Act; Resource Conserva-
Volcanic activity
Environmental Contamination from Human Activity
tion and Recovery Act (RCRA); Compre-
Coal powered power plants hensive Environmental Response,
Incinerators Compensation and Liability Act (CER-
Mining, smelting, fossil fuel (coal) combustion CLA); Superfund Amendments and Reau-
Pesticide residue in soil and groundwater thorization ACT (SARA); and Federal
CCA-treated lumber Insecticide, Fungicide and Rodenticide
Application of soil amendments (fertilizer; poultry litter) and human biosolids Act (FIFRA). The new EPA Worker Pro-
Irrigation water (contamination from natural and/or human activity) tection Standard for Agricultural Workers
Groundwater (contamination from natural and/or human activity) also contains regulations regarding arsenic
Food contaminated with arsenic
Rice products – rice milk, rice cereal, rice flour, brown rice sweetener
containing herbicides and pesticides.
Apple juice, grape juice ADVERSE HEALTH EFFECTS AND
Wine, beer
Seafood SUBPOPULATIONS WITH AN
Bivalves—clams, mussels, oysters, scallops INCREASED RISK OF HEALTH
Crustaceans—crab, lobster EFFECT
Algae Arsenic is relatively unique com-
Seaweed, kelp pared with other hazardous chemicals in
Fish—cold water and bottom feeding fish-cod, herring, mackerel
Medications
that the majority of evidence of adverse
Melarsoprol—treatment for parasitic infections health effects is derived from studies of
Arsenic trioxide—treatment for promyelocyctic leukemia and other cancers human populations rather than animal
Folk or Ayurvedic medicine—primarily Chinese, Indian origin studies. Widespread exposure from con-
Seaweed supplements-kelp taminated drinking water has generated a
Homeopathic remedies significant body of epidemiological liter-
Thiacetarsamide (heartworm treatment for dogs) ature linking chronic ingestion of iAs to
Intentional poisoning both cancer and noncancer health effects.
Arsenic is well established as a cause of
cancer of the lung, bladder, and skin.11
There is less evidence of an association
with other cancers, such as prostate, kid-
ney, and liver. Noncancer health effects of
TABLE 2. Potential Sources of Occupational Exposure to Arsenic2,8,18 arsenic exposure have been described for
numerous organ systems, including the
Agriculture and Gardening respiratory, cardiovascular, hematological,
Pesticides gastrointestinal, immune, dermal, repro-
Currently used in US ductive, and endocrine systems as well
Monosodium methyl arsenate (MSMA)
Use banned by EPA in US, but maybe used in other countries
as the central and peripheral nervous
Inorganic arsenics, lead arsenate system.2,12 – 16
Organic arsenics Occupational physicians should rec-
Disodium methyl arsenate (DSMA) ognize unique subpopulations that may be
Cacodylic acid at an increased risk for elevated arsenic
Lumber preservatives exposure and increased susceptibility to
Ammoniacal copper zinc arsenate (ACZA) adverse health effects. Underlying genetic
Chromated copper arsensate (CCA)—nonresidential applications only in US or metabolic factors, life stages where vul-
Manufacturing nerability may be increased, and dietary
Ammunition
Glass and ceramics—arsenic trioxide, inorganic arsenic
exposures influenced by individual prefer-
Lead acid batteries—elemental or inorganic arsenic ences, cultural practices, age, and dietary
Metal alloys (eg, lead, brass, bronze) —elemental or inorganic arsenic restrictions (eg, gluten free) all may result
Optical industries—light emitting or laser diodes, fiber optic crystals in increased arsenic exposure. For example,
Coal burning power plants—byproduct, exposure depends on level of arsenic in coal children may have three times the exposure
Electronics/aerospace/telecom industries to arsenic of adults, partly due to their
Gallium Arsenide microchips and circuit board, arsine gas, tributylarsine higher consumption per kilogram body
Fireworks (manufactured outside of US) weight and because of the presence of rice
Hide preserving and leatherwork-leather preservative and rice products in foods marketed for
Metallurgy
children.8 Individuals on gluten-free diets
Mining—elemental or inorganic arsenic, arsine gas
Pigments and paint—primarily historical use in US also ingest more rice flour and rice-based
Smelting of copper, lead, zinc, sulfide mineral products. NHANES participants who were
Byproduct or contaminant—inorganic arsenic, arsenic trioxide on gluten-free diets had elevated urine arse-
nic levels compared with nongluten-free

ß 2018 American College of Occupational and Environmental Medicine e635

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 Baker et al JOEM  Volume 60, Number 12, December 2018

diet controls.17 Genetic polymorphism for as lead or copper and other nonferrous of the Health Effects of Arsenic Longitu-
several of the enzymes involved in arsenic metals. Monosodium methanearsonate dinal Study (HEALS) data on 20,000 sub-
metabolism may be in part responsible for (MSMA) may still be used as a pesticide jects in Bangladesh with elevated well
the individual variation in sensitivity to in the US. Arsenic exposure can occur from water arsenic exposure found evidence
arsenic health effects.18 coal-fired power plants or incinerators from for increased pre-malignant skin lesions,
coal or other products that contact arsenic high blood pressure, neurological dysfunc-
EXPOSURE EVALUATION from the ash or environmental release.24 tion, and all-cause mortality.27 Other
Arsenic is also used in metal alloys, battery effects of chronic arsenic exposure include
Environmental Exposures grids, bearing, ammunition, and some types peripheral neuropathy, gastrointestinal
Well-water contamination with iAs of glass manufacturing.25 Arsenic is also symptoms, diabetes, renal system effects,
from natural geologic sources and/or indus- used in the manufacture of semiconductor enlarged liver, non-cirrhotic portal hyper-
trial processes is present throughout the chips (particularly gallium arsenide chips) tension, peripheral neuropathy, anemia,
US populations in these regions who use and circuit boards used in the electronics, hypertension, and cardiovascular disease
private wells may be exposed to iAs at aerospace, and telecommunications indus- (CVD).2,13 Exposure to low to moderate
levels exceeding the recommended EPA try.25 Table 2 lists potential occupational levels of arsenic in drinking water
MCL.19,20 Drinking and cooking with iAs exposures to arsenic. (<100 mg/L) have been associated with
contaminated water and the use of contam- elevated cardiovascular risks in several
inated water to irrigate crops that can mobi- Signs and Symptoms of Toxicity studies.15,16 For example, a 2017 meta-
lize arsenic, such as rice, presents multiple Signs or symptoms of arsenic tox- analysis of 12 studies showed a pooled
pathways for human exposure. Table 1 lists icity depend on the type of arsenic, route of statistically significant increased risk of
potential environmental or nonoccupa- exposure, and whether the exposure is several CVD outcomes such as coronary
tional exposures to arsenic. acute, subacute, or chronic. Inorganic arse- vascular disease incidence and mortality
Dietary exposure to organic arsenic nic (iAs) and trivalent arsenite (Asþ3) are and coronary heart disease and mortality
is of less concern than iAs exposure. Fish, generally more acutely toxic than pentava- (relative risks of 1.07 to 1.16) with chronic
seafood, seaweed, and aquatic sediment lent arsenate (Asþ5), which is usually more exposure to 20 mg/L water arsenic com-
may contain organic arsenic, commonly acutely toxic then organic arsenic. Cellular pared with 10 mg/L water arsenic.16
in the form of arsenobetaine and to a lesser membranes are more permeable to triva- Blackfoot disease is an obliterative
extent, as arsenocholine and arsenosu- lent arsenic (Asþ3) then pentavalent arse- peripheral vascular disease seen in popula-
gars.21 Some seafood such as fin fish or nic (Asþ5).18 In vivo interconversion of tions exposed to inorganic arsenic in drink-
crustaceans contain high levels of arseno- Asþ5 and Asþ3 occur, and chronic expo- ing water from wells in southwestern
betaine, an organic arsenic that is relatively sure to both forms has resulted in a similar Taiwan.13,28 Vasospastic or Raynaud dis-
nontoxic and excreted intact in urine.13,22 pattern of toxicity. Arsine gas is highly ease have been reported in smelter workers,
Seaweed and marine algae contain arsen- toxic, causing hemolysis. Exposure may German vineyard workers, and in popula-
osugars. These may also be present in occur in the semiconductor and electronics tions with elevated exposure to arsenic in
bivalves such clams, mussels, oysters, industry. drinking water.13 Chronic arsenic exposure
and scallops and other marine food, which may result in pulmonary fibrosis, hepatic
feed on the algae and seaweed.23 These Signs and Symptoms of Chronic fibrosis, and bone marrow suppression (leu-
arsenosugars may be metabolized to dime- Exposure kopenia and anemia).13,24
thylarsinic acid (DMAV) and thio-dimethy- Chronic arsenic poisoning is most The International Agency for
larsinic acid (thio-DMAV), which have likely due to environmental or occupational Research on Cancer (IARC) and the US
been associated with cellular toxicity and exposure and has a more insidious onset. EPA have classified arsenic in drinking
genotoxicity, although their impact on The most specific overt sign of chronic water as a human carcinogen leading to
human health is unclear.23 inorganic arsenic ingestion is skin or cancers of the skin, bladder, and lung based
Ingestion of food contaminated with dermal effects.2,13,22 Gastrointestinal largely on epidemiological studies of large
iAs poses a greater health concern. Chil- effects may occur but are less common than highly exposed populations in Taiwan,
dren tend to eat or drink a smaller variety of with acute toxicity. Hyperpigmentation is Argentina, Chile, Bangladesh, and West
foods so ingestion of contaminated apple the most common dermal effect, but hypo- Bengal (India).11,29 Arsenic is also classi-
juice, infant formula, or rice cereal may pigmentation or alternating hyperpigmen- fied as a human carcinogen by the National
represent a significant source of exposure tation and hypopigmentation (raindrops on Academy of Sciences and the National
during a period of heightened vulnerability a dusty road) may occur. Hyperkeratosis Toxicology Program (NTP). Arsenic
to adverse effects. FDA has promulgated with bilateral thickening of the palms and ingestion has been associated with squa-
action levels for iAs in apple juice and soles may also occur.2 Focal hyperkeratotic mous cell skin carcinoma, basal cell skin
infant rice cereal due to this concern. As lesions or corns may occur on the feet, carcinoma, lung cancer, and bladder can-
previously noted, individuals who consume palms, face, or other parts of the body. Skin cer. Arsenic-related cancer usually takes
a gluten-free diet tend to eat more rice- lesions may progress to nonmelanoma skin more than 10 years to develop.2 Lung
based foods and thus have a higher poten- cancers such as squamous cell carcinoma, cancer has also been associated with inha-
tial for increased iAs exposure.17 Arsenic basal cell carcinoma, and Bowen dis- lation exposure to smelter workers and
toxicity may also occur after use of some ease.13,14 pesticide workers with chronic arsenic
traditional remedies or ayurvedic medica- An Indian study found the most exposure.13 More limited evidence has
tion from several Asian countries. common symptoms in a group of 4865 associated arsenic exposure in drinking
subjects with elevated arsenic in their water with other cancers, including cancer
Occupational Exposures drinking water were diffuse hyperpigmen- of the kidney, angiosarcoma of the liver,
Occupational exposure is typically tation, rain drop pigmentation, hypopig- and other liver cancers.30,31 Both mono-
due to inhalation exposure and may occur mentation, and palmar and plantar methylarsonic acid (MMA) and DMA are
through the semiconductor manufacturing keratosis and less commonly asthmatic also classified as possible human carcino-
industry or mining or smelting of ores such bronchitis and hepatomegaly.26 A review gens (IARC Group 2B).2

e636 ß 2018 American College of Occupational and Environmental Medicine

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 JOEM  Volume 60, Number 12, December 2018 Arsenic Exposures

A 2015 systematic review and meta- Normal total urine arsenic levels reflect changes to these demographic fac-
analysis of adverse pregnancy outcomes may vary from laboratory to laboratory tors that affect the creatinine denominator
following exposure to high levels of arsenic but may be defined by the laboratory as a and not actual differences in arsenic expo-
in water (arsenic levels 50 mg/L or greater) urine arsenic greater than 50 mg/L, 100 mg/ sure.37,50 Creatinine adjustment of urinary
showed an increased risk of spontaneous g creatinine, or 100 mg total arsenic.22,24,38 arsenic in children or malnourished indi-
abortion and stillbirth and a moderate With acutely symptomatic arsenic toxicity, viduals may yield a value that seems inor-
increased risk of neonatal and infant mor- total urine arsenic is typically greater than dinately high compared with values in
tality.2,32 Children exposed early in life to 1000 mg/L.25 The American Conference similarly exposed well-nourished adults
inorganic arsenic (in utero or postnatally) of Governmental Industrial Hygienist’s because children and malnourished individ-
had an increased risk of bronchiectasis and (ACGIH) Biological Exposure Index for uals excrete relatively less creatinine.37
lung cancer.2,33,34 Adults with exposure to arsenic is 35 mg/L urine arsenic (inorganic Ingestion of shellfish, fish, or sea-
elevated levels of arsenic in utero had ele- arsenic and methylated metabolites) at the weed, which contains primarily nontoxic
vated bladder and lung cancer rates as end of the workweek.45,46 Laboratory organic arsenicals, can cause elevated total
adults despite their arsenic exposure ending reports of minimally elevated urine arsenic urine arsenic and confound the estimation of
as much as 40 years earlier.35 In general, levels cannot be interpreted by just com- iAs exposure.22,25 Speciation of urine arse-
exposure to iAs in drinking water has been paring results to a ‘‘normal range’’ to deter- nic levels allows the quantification of inor-
associated with fetal deaths, congenital mine whether arsenic toxicity is present, ganic arsenic and its methylated metabolites
heart abnormalities, delay in growth and particularly chronic toxicity. It is important (MMA and DMA) in the urine and nontoxic
neurological development, and increased to look for signs of actual arsenic toxicity forms of organic arsenic such as arsenobe-
susceptibility to respiratory infection.18 A and compare urine levels to a known or taine or arsenocholine 22,44 However, it is
New Hampshire study showed a 10% calculated toxicity threshold from the lit- important to keep in mind that some seafood
increase in risk of gestational diabetes mel- erature or a suitable reference work.47 and fish contain DMA and organosugars in
litus with each 5 mg/L increase in well Other considerations that arise when seafood and algae are also metabolized to
water arsenic concentration.36 testing for urine arsenic include whether to DMA, underscoring the importance of a
adjust for urinary concentration (by adjust- thorough dietary history.51 Alternatively, a
Laboratory Analysis ing for creatinine) and whether to request spot urine arsenic could be collected again
Diagnosis of arsenic toxicity should speciation of the urine arsenic.22 Adjusting after 1 to 2 weeks abstinence from seafood or
be based on the integration of exposure the urine arsenic by the creatinine concen- fish consumption.
history, clinical findings, and if possible tration may theoretically account for dilu- Urine should be collected in metal-
laboratory confirmation of exposure. Tradi- tion or concentration of the spot urine (mg/g free polyethylene containers but not acid-
tionally, a 24-hour urinary arsenic was con- creatinine). Many laboratories report the rinsed containers, as the acid may alter the
sidered the most definitive diagnostic 24-hour urine arsenic level as both mg/L arsenic species.38 If urine arsenic is normal
laboratory test.13,37–39 However, a spot urine (not corrected for creatinine) and mg/g Cr and arsenic toxicity is still suspected, hair
arsenic is much easier to collect and is now (corrected for creatinine). Adjusting arse- or nail testing may help identify arsenic
more commonly used to assess individual nic concentration for creatinine concentra- exposure. Arsenic accumulates in hair and
patients and in large populations studies. tion is less important in 24-hour urine nail with iAs as the predominant form.22
Two studies have shown that spot urine specimens, as urine concentration is typi- The potential for external contamination
arsenic levels did correlate well with 24-hour cally a 24-hour average and not as variable must also be considered, as it could result
urine arsenic levels and that random spot as may occur with a spot specimen. Adjust- in a false-positive hair or nail assay. In
urine arsenic levels were stable throughout ing the arsenic concentration for creatinine population studies, hair and nail testing
the day.40,41 Another study showed that spot concentration is recommended by some have been used to identify arsenic expo-
random urine arsenic levels correlated well authors for spot urine arsenic samples to sure. If individuals ingest and bathe in
with first morning void urine arsenic lev- correct for variable urine concentration at arsenic contaminated water, have contact
els.42 Blood arsenic does not appear to be a the time of a spot urine specimen collection with arsenic in soil, or encounter airborne
reliable biomarker of arsenic exposure and may be most helpful when comparing arsenic or arsenic containing dust in the
because arsenic is rapidly cleared from the serial spot urine arsenic levels over time in workplace, the arsenic levels in hair or nails
blood,22,38 and may have a low correlation a single individual patient.21 probably reflect both internal consumption
with recent exposure. Many population studies of drinking and external exposure.22
Total urine arsenic is the most com- water arsenic exposure use spot urine arse-
monly used biomarker of arsenic expo- nic levels, which are not adjusted for creat- Treatment Options
sure.22,43 After it is absorbed, inorganic inine.21,43,48,49 However, a study of US Significant acute arsenic toxicity,
arsenic is methylated in the body to NHANES data stressed the need to report though rare, can be life-threatening and
MMA and DMA.22,43,44 The sum of inor- levels as both unadjusted and adjusted for may require hospitalization, as maintaining
ganic arsenic (such as Asþ3, Asþ5, MMA, creatinine and to assess whether a creati- appropriate fluid and electrolyte balance
and DMA) and organic arsenic (such as nine adjusted value was ‘‘abnormal’’ by and EKG monitoring are crucial. It is
arsenobetaine) in the urine are often com- considering the body weight, gender, and important to identify the source of arsenic
bined by the laboratory and reported as the age of the subjects.50 This approach would exposure and remove the patient from
total arsenic level. A study of total urine be most important if the arsenic value exposure as much as possible. In the US,
arsenic and speciated arsenic from 2557 adjusted for creatinine is significantly dif- private wells or very small community
NHANES participants found MMA, ferent from the unadjusted arsenic value or water systems are a more likely source of
DMA, and arsenobetaine were the major if there is only an adjusted arsenic value to arsenic exposure than are large community
contributors to the total urine arsenic review. Because urine creatinine concentra- water supplies regulated by EPA. If drink-
level.21 At these background exposure lev- tion is significantly associated with age, ing water is considered a possible source of
els, the upper 95th percentile for total uri- sex, race/ethnicity, and body mass index, exposure, then the physician needs to deter-
nary arsenic was 65.4 mg/L or 50.2 mg/g between individual variations in urine arse- mine the source of a patient’s drinking
creatinine.21 nic levels reported as mg/g creatinine may water. Patients who are suspected to have

ß 2018 American College of Occupational and Environmental Medicine e637

Copyright © 2018 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited
 Baker et al JOEM  Volume 60, Number 12, December 2018

drinking water exposure to arsenic should gloves, eye goggles, and respiratory protec- to wheat and barley. Environ Sci Technol.
2007;41:6854–6859.
have their well water tested. They should tion.24 Other recommendations to reduce
use bottled water until their well has been the elevated risk of cancer in subjects with 6. Jackson BP, Taylor VF, Karagas MR, et al.
Arsenic, organic foods, and brown rice syrup.
shown to not be a source of arsenic expo- ongoing arsenic exposure is to advise them Enviorn Health Perspect. 2012;120:623–626.
sure or until an appropriate filtration system to stop smoking cigarettes and to limit sun 7. Xue J, Zartarian V, Wang SW, Liu SV, et al.
can be put in place to remove the arsenic. exposure and use sunscreen. Probabilistic modeling of dietary arsenic expo-
Chelation therapy is typically There is currently no FDA standard sure and dose and evaluation with 2003-2004
reserved for patients with severe acute for iAs in rice, aside from the current NHANES data. Environ Health Perspect.
2010;118:345–350.
toxicity and is most effective when initi- guidance document for infant rice cereal.
8. European Food Safety Authority. EFSA Panel
ated within minutes to hours, as efficacy The amount of iAs in rice varies widely on Contaminants in the Food Chain: scientific
declines or disappears as the time interval with the highest levels seen in rice grown in opinion on arsenic in food. EFSA J. 2009;7:
between exposure and onset of chelation the southern regions of the US, largely on 60–71.
increases.24,52 In the 1940s, dimercaprol, former cotton fields where arsenical pesti- 9. US Occupational Safety and Health Adminis-
aka British antilewisite (BAL) was devel- cide residues remain in the soil. As arsenic tration. 29 CFR 1910.1018. OSHA Standard for
Inorganic Arsenic. Available at: www.osha.gov/
oped,53 and it is still used occasionally for is deposited in the rice hull, brown rice pls/oshaweb/owadisp.show_document?p_ta-
severe arsenic toxicity.54 Dimercaprol and tends to have higher iAs content than white ble=STANDARDS&p_id=10023. Accessed
2,3-Dimercaptosuccinic acid (DMSA) are rice of the same type. According to exten- August 8, 2018.
the two most common chelators available sive testing done by The Consumers Union, 10. US Occupational Safety and Health Adminis-
in the US. DMPS (2,3 Dimercaptopropa- white basmati rice from California, India, tration. 29 CFR 1910.134 OSHA Standard for
nesulfonate) may be the chelating agent of and Pakistan, and sushi rice from the US Personal Protective Equipment. Available at:
https://www.osha.gov/pls/oshaweb/owadisp.-
choice for arsenic according to several have on average half the level of iAs than show_document?p_table=standard-
studies but has not been approved by the all other rice types. Rinsing rice well before s&p_id=12716. Accessed August 8, 2018.
US FDA. An FDA advisory committee has use and cooking rice such as pasta, in a 11. International Agency for Research on Cancer. A
recommended that intravenous DMPS be larger amount of water, can reduce iAs Review of Human Carcinogens: Arsenic, Met-
available for compounding in hospital set- content. Alternating rice with other grains als, Fibres, and Dusts. Lyon: World Health
Organization Press; 2012.
tings for the treatment of severe acute such as millet and quinoa that do not take
12. Naujokas MF, Anderson B, Ahsan H, et al. The
poisoning by arsenic.55 up arsenic from the soil is a good option for broad scope of health effects from chronic
DMPS and DMSA have a higher patients concerned with dietary arsenic arsenic exposure: update on workwide public
therapeutic index than BAL and offer thera- exposure.56 health problem. Environ Health Perspect.
peutic advantages, as they do not redistribute 2013;121:295–302.
arsenic to the brain.52 Chelation therapy is CONCLUSION 13. US Agency for Toxic Substances and Disease
Registry. Arsenic Toxicity Case Study. Public
rarely indicated with less severe acute toxic- Occupational and environmental Health Services: US Department of Health and
ity or with chronic toxicity. Removal from medicine (OEM) physicians need to be Human Services; 2009.
further arsenic exposures, if possible, is aware that multiple exposure pathways 14. Melkonian S, Argos M, Chen Y, et al. Intake of
important. Arsenic has a relatively short for arsenic exist beyond occupational expo- several nutrients are associated with incidence
half-life of about 4 hours in the urine. sure. They also must be able to differentiate of arsenic-related keratotic skin lesions in
Although chelation following chronic expo- Bangladesh. J Nutrition. 2012;142:2128–2134.
between organic and inorganic arsenic and
sure may accelerate metal excretion, poten- 15. James KA, Byers T, Hokanson JE, et al. Asso-
be able to assess arsenic exposure. They ciation with lifetime exposure to inorganic arse-
tial therapeutic efficacy in terms of decreased need to select appropriate biomarkers for nic in drinking water and coronary heart disease
morbidity and mortality is largely unestab- exposure and appropriate treatment and in Colorado Residents. Environ Health Per-
lished for chronic arsenic intoxication.52 provide counseling for those with arsenic spect. 2015;123:128–134.
Arsine gas poisoning treatment exposure. With both the US EPA and FDA 16. Moon KA, Oberoi S, Barchowsky A, et al. A
should focus on maintaining fluid balance dose response meta-analysis of chronic arsenic
having active policy reviews underway per- exposure and incident cardiovascular disease.
with intravenous hydration. Osmotic diure- taining to arsenic in drinking water and Int J Epidemiol. 2017;46:1924–1939.
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 JOEM  Volume 60, Number 12, December 2018 Arsenic Exposures

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