Determinants of respirable crystalline silica exposure in construction in western Canada.

Task-based respirable crystalline silica (RCS) exposure monitoring data was collected from construction work sites across 3 Canadian provinces: Alberta, British Columbia (BC), and Manitoba. In total 373 RCS samples were obtained from 70 worksites across 44 companies. Sampling was conducted between May 2015 and August 2020. The overall geometric mean (GM) RCS exposure was 0.045 mg/m3 (geometric standard deviation, GSD = 6.8). Alberta had the highest average exposure and the highest variability with GM of 0.060 mg/m3 (GSD = 9.3), the GM in BC was 0.044 (GSD = 4.3), and in Manitoba the GM was 0.033 (GSD = 7.0). A multivariable model was built using forward stepwise linear regression modeling. Province, task type, work environment (indoor vs. outdoor), construction material, sampling duration, and engineering control use were all statistically significant predictors of exposure level in partial F-tests (P < 0.05). Overall, the model explained 42% of the RCS concentration variability. Task type contributed most to the model's explanatory power. The task type with highest average exposure levels was demolition (GM 0.30 mg/m3, GSD 0.49). Breaking (GM 0.16 mg/m3, GSD 8.4) and grinding (GM 0.081 m/m3, GSD 7.4) also had high-exposure levels. Working outdoors was associated with exposure levels 39% lower than indoors. Exposure control measures such as local exhaust ventilation and wetting were also associated with lower exposure levels. Among construction materials, Cement, sand, and stone were associated with higher RCS exposure levels relative to the reference material, concrete. The results of this study indicate that workers in western Canada remain exposed to RCS at levels that exceed the health-based American Congress for Governmental Industrial Hygienists Threshold Limit Value of 0.025 mg/m3. Although there were some differences in exposure levels between the provinces, the determinants of exposure were similar in all 3. The overall GM RCS exposure was 0.045 mg/m3 (geometric standard deviation, GSD = 6.8). Alberta had the highest average exposure and the highest variability with GM of 0.060 mg/m3 (GSD = 9.3), the GM in BC was 0.044 (GSD = 4.3), and in Manitoba the GM was 0.033 (GSD = 7.0).

Assessing Exposures from the Deepwater Horizon Oil Spill Response and Clean-up.

The GuLF Study is investigating adverse health effects from work on the response and clean-up after the Deepwater Horizon explosion and oil release. An essential and necessary component of that study was the exposure assessment. Bayesian statistical methods and over 135 000 measurements of total hydrocarbons (THC), benzene, ethylbenzene, toluene, xylene, and n-hexane (BTEX-H) were used to estimate inhalation exposures to these chemicals for >3400 exposure groups (EGs) formed from three exposure determinants: job/activity/task, location, and time period. Recognized deterministic models were used to estimate airborne exposures to particulate matter sized 2.5 µm or less (PM2.5) and dispersant aerosols and vapors. Dermal exposures were estimated for these same oil-related substances using a model modified especially for this study from a previously published model. Exposures to oil mist were assessed using professional judgment. Estimated daily THC arithmetic means (AMs) were in the low ppm range (<25 ppm), whereas BTEX-H exposures estimates were generally <1000 ppb. Potential 1-h PM2.5 air concentrations experienced by some workers may have been as high as 550 µg m-3. Dispersant aerosol air concentrations were very low (maximum predicted 1-h concentrations were generally <50 µg m-3), but vapor concentrations may have exceeded occupational exposure excursion guidelines for 2-butoxyethanol under certain circumstances. The daily AMs of dermal exposure estimates showed large contrasts among the study participants. The estimates are being used to evaluate exposure-response relationships in the GuLF Study.

GuLF DREAM: A Model to Estimate Dermal Exposure Among Oil Spill Response and Clean-up Workers.

Tens of thousands of individuals performed oil spill response and clean-up (OSRC) activities following the 'Deepwater Horizon' oil drilling rig explosion in 2010. Many were exposed to oil residues and dispersants. The US National Institute of Environmental Health Sciences assembled a cohort of nearly 33 000 workers to investigate potential adverse health effects of oil spill exposures. Estimates of dermal and inhalation exposure are required for those individuals. Ambient breathing-zone measurements taken at the time of the spill were used to estimate inhalation exposures for participants in the GuLF STUDY (Gulf Long-term Follow-up Study), but no dermal measurements were collected. Consequently, a modelling approach was used to estimate dermal exposures. We sought to modify DREAM (DeRmal Exposure Assessment Method) to optimize the model for assessing exposure to various oil spill-related substances and to incorporate advances in dermal exposure research. Each DREAM parameter was reviewed in the context of literature published since 2000 and modified where appropriate. To reflect the environment in which the OSRC work took place, the model treatment of evaporation was expanded to include vapour pressure and wind speed, and the effect of seawater on exposure was added. The modified model is called GuLF DREAM and exposure is estimated in GuLF DREAM units (GDU). An external validation to assess the performance of the model for oils, tars, and fuels was conducted using available published dermal wipe measurements of heavy fuel oil (HFO) and dermal hand wash measurements of asphalt. Overall, measured exposures had moderate correlations with GDU estimates (r = 0.59) with specific correlations of -0.48 for HFO and 0.68 for asphalt. The GuLF DREAM model described in this article has been used to generate dermal exposure estimates for the GuLF STUDY. Many of the updates made were generic, so the updated model may be useful for other dermal exposure scenarios.

Diesel Engine Exhaust Exposure in the Ontario Civil Infrastructure Construction Industry.

OBJECTIVES: Diesel engine exhaust (DEE) is a known lung carcinogen and a common occupational exposure in Canada. The use of diesel-powered equipment in the construction industry is particularly widespread, but little is known about DEE exposures in this work setting. The objective of this study was to determine exposure levels and identify and characterize key determinants of DEE exposure at construction sites in Ontario. METHODS: Elemental carbon (EC, a surrogate of DEE exposure) measurements were collected at seven civil infrastructure construction worksites and one trades training facility in Ontario using NIOSH method 5040. Full-shift personal air samples were collected using a constant-flow pump and SKC aluminium cyclone with quartz fibre filters in a 37-mm cassette. Exposures were compared with published health-based limits, including the Dutch Expert Committee on Occupational Safety (DECOS) limit (1.03 µg m-3 respirable EC) and the Finnish Institute of Occupational Health (FIOH) recommendation (5 µg m-3 respirable EC). Mixed-effects linear regression was used to identify determinants of EC exposure. RESULTS: In total, 149 EC samples were collected, ranging from <0.25 to 52.58 µg m-3 with a geometric mean (GM) of 3.71 µg m-3 [geometric standard deviation (GSD) = 3.32]. Overall, 41.6% of samples exceeded the FIOH limit, mostly within underground worksites (93.5%), and 90.6% exceeded the DECOS limit. Underground workers (GM = 13.20 µg m-3, GSD = 1.83) had exposures approximately four times higher than below grade workers (GM = 3.56 µg m-3, GSD = 1.94) and nine times higher than above ground workers (GM = 1.49 µg m-3, GSD = 1.75). Training facility exposures were similar to above ground workers (GM = 1.86 µg m-3, GSD = 4.12); however, exposures were highly variable. Work setting and enclosed cabins were identified as the key determinants of exposure in the final model (adjusted R2 = 0.72, P < 0.001). The highest DEE exposures were observed in underground workplaces and when using unenclosed cabins. CONCLUSIONS: This study provides data on current DEE exposure in Canadian construction workers. Most exposures were above recommended health-based limits, albeit in other jurisdictions, signifying a need to further reduce DEE levels in construction. These results can inform a hazard reduction strategy including targeted intervention/control measures to reduce DEE exposure and the burden of occupational lung cancer.

Estimation of Dermal Exposure to Oil Spill Response and Clean-up Workers after the Deepwater Horizon Disaster.

The GuLF STUDY is investigating health outcomes associated with oil spill-related chemical exposures among workers involved in the spill response and clean-up following the Deepwater Horizon disaster. Due to the lack of dermal exposure measurements, we estimated dermal exposures using a deterministic model, which we customized from a previously published model. Workers provided information on the frequency of contact with oil, tar, chemical dispersants applied to the oil spill and sea water, as well as the use of protective equipment, by job/activity/task. Professional judgment by industrial hygienists served as a source of information for other model variables. The model estimated dermal exposures to total hydrocarbons (THC), benzene, ethylbenzene, toluene, xylene, n-hexane (BTEX-H), polycyclic aromatic hydrocarbons (PAHs), and dispersants in GuLF DREAM units (GDUs). Arithmetic means (AMs) of THC exposure estimates across study participants ranged from <0.02 to 5.50 GDUs for oil and <0.02 to 142.14 GDUs for tar. Statistical differences in the estimates were observed among the AMs of the estimates for some broad groups of worker activities over time and for some time periods across the broad groups of activities. N-Hexane had ranges similar to THC for oil exposures (e.g. AMs up to 2.22 GDUs) but not for tar (up to 5.56 GDUs). Benzene, ethylbenzene, toluene, and xylene, in contrast, were characterized by higher exposure levels than THC for oil (AMs up to 12.77, 12.17, 17.45, and 36.77 GDUs, respectively) but lower levels than THC to tar (AMs up to 3.69, 11.65, 42.37, and 88.18 GDUs, respectively). For PAHs, the AMs were as high as 219.31 and 587.98 for oil and tar, respectively. Correlations of these seven substances to each other were high (>0.9) for most of the substances in oil but were lower for some of the substances in tar. These data were linked to the study participants to allow investigation of adverse health effects that may be related to dermal exposures.

Development of a Web-Based Tool for Risk Assessment and Exposure Control Planning of Silica-Producing Tasks in the Construction Sector.

We describe the development and implementation of a novel, on-line risk assessment tool for respirable crystalline silica (RCS) exposure for use in the construction sector. It was motivated by the introduction of new OHS regulation in British Columbia that allowed for the substitution of exposure measurement data with "objective air monitoring data" collected at "equivalent work operations." This allowance encouraged the introduction of quantitative risk assessment in a notoriously challenging work environment but it was concluded that without assistance, the typical construction employer would struggle to identify, extract, and interpret validate objective data. The tool described here was based on a continually-updatable RCS exposure database, and a predictive regression model based on the database to generate exposure risk estimates. The model was embedded in an adaptive web-based application that can be run on common platforms. The design followed standard web conventions and features so that no specialized training is required for its use. It was designed to be usable by end-users with varying expertise, including non-OHS experts. Users describe the RCS-dust generating task they will perform, and associated control measures. The tool estimates both uncontrolled and controlled task-based exposure concentrations. Using additional information entered by the user, the on-line tool generates an "exposure control plan" or ECP, a legally regulated document for those undertaking work potentially exposing workers to RCS particulate. The development of the tool was a community-based, tri-partite effort of the local OHS regulator, construction employers, and exposure scientists. In addition to being a practical risk assessment tool, the designers wanted it to function as an educational tool, and that it should explore novel methods for exposure data collection and use. The strengths of this approach include the publicly shared updateable database that encourages continuous improvement and illustrates best practices; and the timely and cost effective collection and sharing of exposure data in a value-added manner. It is however limited to a single task per ECP, and only considers exposure to task operators, and not adjacent workers. Currently in BC, users generate up to 3,900 ECP's per year with the tool.

Field Measurements of Inadvertent Ingestion Exposure to Metals.

The determinants of inadvertent occupational ingestion exposure are poorly understood, largely due to a lack of available exposure measurement data. In this study, perioral exposure wipes were used as a surrogate for inadvertent ingestion exposure to measure exposure to eight metals (chromium, nickel, aluminium, cobalt, lead, arsenic, manganese, and tin) among 38 workers at 5 work sites in the UK. This work was done alongside a previously reported observational study of hand/object-to-mouth contact frequency. Systematic wipes of the perioral area, and of both hands were taken with proprietary cellulose wipes pre-moistened with deionized water. Measurements were taken at the beginning, middle and end of the shift. Mixed-effect models of exposure measurements were built with area of skin sampled, time during shift, and job group entered as fixed effects and worker identification as a random effect. Linear regression modelling was used to study the effect of hand/object-to-mouth contact frequency on perioral exposure, adjusting for the measured exposure on the hand and observed respirator use. Hand and perioral exposure measurements were correlated with one another (r = 0.79) but mass per unit area exposure was significantly higher on the perioral area than on the hands for seven of the metals (at P < 0.05). There were no significant differences between measurements taken at the middle or the end of the shift for five of the metals suggesting that dermal loading may remain relatively constant for much of the workday. This applies to both hand and perioral measurements. In linear regression modelling there was no relationship between hand/object-to-mouth contact frequency and perioral exposure, but hand exposure was significantly positively related to perioral exposure and workers who used respirators had significantly higher perioral exposure than those who did not. The results suggest the levels of exposure on the hand and respirator use are important determinants of potential inadvertent ingestion exposure. The results did not demonstrate a relationship between perioral exposure and hand-to-mouth contact frequency. Perioral wipe sampling may be a useful surrogate measure for exposure by the inadvertent ingestion route, but further research is required to confirm the link between perioral levels and actual exposure, measured using biological monitoring.

A Web-based Tool to Aid the Identification of Chemicals Potentially Posing a Health Risk through Percutaneous Exposure.

Occupational hygiene practitioners typically assess the risk posed by occupational exposure by comparing exposure measurements to regulatory occupational exposure limits (OELs). In most jurisdictions, OELs are only available for exposure by the inhalation pathway. Skin notations are used to indicate substances for which dermal exposure may lead to health effects. However, these notations are either present or absent and provide no indication of acceptable levels of exposure. Furthermore, the methodology and framework for assigning skin notation differ widely across jurisdictions resulting in inconsistencies in the substances that carry notations. The UPERCUT tool was developed in response to these limitations. It helps occupational health stakeholders to assess the hazard associated with dermal exposure to chemicals. UPERCUT integrates dermal quantitative structure-activity relationships (QSARs) and toxicological data to provide users with a skin hazard index called the dermal hazard ratio (DHR) for the substance and scenario of interest. The DHR is the ratio between the estimated 'received' dose and the 'acceptable' dose. The 'received' dose is estimated using physico-chemical data and information on the exposure scenario provided by the user (body parts exposure and exposure duration), and the 'acceptable' dose is estimated using inhalation OELs and toxicological data. The uncertainty surrounding the DHR is estimated with Monte Carlo simulation. Additional information on the selected substances includes intrinsic skin permeation potential of the substance and the existence of skin notations. UPERCUT is the only available tool that estimates the absorbed dose and compares this to an acceptable dose. In the absence of dermal OELs it provides a systematic and simple approach for screening dermal exposure scenarios for 1686 substances.

Inadvertent ingestion exposure: hand- and object-to-mouth behavior among workers.

Contact between contaminated hands and the mouth or the area around the mouth (the perioral area) can result in inadvertent ingestion exposure. Exposure by this route is known to occur among children, but adults may also be exposed. Observations of 48 workers were carried out in 8 UK worksites to study hand- and object-to-mouth behavior. Each subject was observed in real-time for ~60 min during normal work activities. Each contact was recorded along with information about time of contact, glove use, respirator use, task and object type. Subjects were interviewed to gather information about smoking, nail biting and risk perception. The effects of factors (glove use, respirator use, smoking, nail biting, risk perception, work sector and task group) on contact frequency were assessed using non-parametric tests and Poisson regression models. Several determinants of contact frequency were identified, including time spent "between" work tasks, glove and respirator use, smoking and nail biting. Hand-to-mouth contact frequencies were particularly high while workers were "between" work tasks (23.6 contacts per hour, compared with the average contact frequency of 6.3 per hour). The factors that were related to contact frequency differed between object- and hand-to-mouth contacts, suggesting that these should be considered separately. These findings could be used for developing exposure models, to inform measurements of inadvertent ingestion among adults and to identify control strategies.

Simulated transfer of liquids and powders from hands and clothing to the mouth.

A series of laboratory experiments was carried out to assess transfer of liquids (vinegar) and powders (calcium acetate and magnesium carbonate) from hands, arms, gloves, respirators, clothing, and pens to the oral cavity or the perioral area (the area surrounding the mouth). Experiments were carried out with four volunteers. The donor area (the hands, arms, gloves, and so on) was loaded with a known mass of the test substance and was then brought into contact the receiver area (the oral cavity or the perioral area). The percentage of the substance on the donor that transferred to the receiver (the transfer efficiency or TE) was assessed using saliva samples and gauze wipes of the perioral area. Magnesium carbonate was measured on gauze and in saliva using inductively coupled plasma/atomic emission spectrometry. Calcium acetate and vinegar were measured using ion chromatography/electrochemical detection. Average transfer efficiencies were calculated for each substance and transfer scenario; these were compared using ANOVA and Kruskal-Wallis tests. Overall, direct transfer from the hands to the oral cavity was significantly higher (mean TE = 51.6) than indirect transfer from the hands to the oral cavity via the perioral area by licking the lips (mean TE = 11.5). The results suggested higher TEs for liquids than for solids and that hand-to-mouth TEs may increase with water solubility. Transfer from bare arms to the perioral area was higher than from arms covered by cotton sleeves for both liquids and powders. Although TE data are often required by models estimating exposure by inadvertent ingestion, relatively few published data are available. This study has provided evidence of some factors that may influence transfer of chemicals from hands or objects to the mouth (physical form, use of clothing, and so on) and has provided data that are essential for the development of predictive exposure models of inadvertent ingestion exposure.

Properties of liquids and dusts: how do they influence dermal loading during immersion, deposition, and surface contact exposure pathways?

BACKGROUND: Although dustiness and viscosity are potential determinants of dermal exposure, their effect on exposure is poorly understood. The goal of this study was to investigate the effect of dustiness and viscosity on dermal exposure by each of three dermal exposure pathways (deposition, surface contact, and immersion). METHODS: The hands of four volunteers were exposed to non-toxic substances: particulate with varying dustiness (calcium acetate, zinc oxide, and Epsom salt) and liquids of varying viscosity (three glycerol/water solutions containing 20, 50, or 85% glycerol) by each pathway. Dermal exposure was measured by a systematic wipe of the entire hand. Calcium acetate, zinc oxide, and Epsom salts were analysed on wipes by inductively coupled plasma/atomic emission spectrometry and glycerol was measured by gas chromatography with a flame ionization detector. The relationship between exposure and either dustiness or viscosity was examined using either parametric (analysis of variance) or non-parametric (Kruskal-Wallis) tests. RESULTS: Both viscosity and dustiness appeared to have an effect on dermal exposure. Increasing viscosity lead to higher exposures by the immersion pathway (P < 0.001) but lower exposures by the deposition pathway (although this relationship was not statistically significant: P = 0.19). Viscosity had no apparent effect on exposure from surface contact. Dustiness did not affect transfer of particulate to the skin by immersion (P = 0.403) but it did affect exposure by the surface transfer and deposition pathways. The dustiest substance (calcium acetate) transferred to skin more readily following contact with contaminated surfaces than zinc oxide or Epsom salts (P = 0.016). For the deposition pathway, the highest exposures were seen for the dustiest substance (calcium acetate) but statistical analysis was not conducted as 67% of measurements were below detection limits. CONCLUSION: The results suggest that both viscosity and dustiness can affect dermal exposure. They also show that the determinants of dermal exposure can be different for each of the dermal exposure pathways.

Fertilizer use and self-reported respiratory and dermal symptoms among tree planters.

In British Columbia, some tree planting operations require workers to fertilize planted seedlings with polymer-coated nitrogen, phosphorus, and potassium (NPK) fertilizers. This study examined respiratory and dermal health associated with fertilizer exposure among tree planters. We interviewed 223 tree planters using an adapted version of the American Thoracic Society questionnaire supplemented with questions on dermal health. Subjects were grouped by categories of increasing duration of exposure, with workers who had not worked with fertilizer as a reference group. The relationship between exposure and reported work-related symptoms was analyzed using logistic regression, adjusting for age, cumulative tobacco cigarettes smoked, marijuana smoking status, sex, and exposure to abrasive spruce needles. An elevated odds ratio was seen for work-related cough, phlegm, nasal symptoms, nosebleed, and skin rash in the highest exposure group (>37 days of fertilizer use in the past 2 years) but was significant only for phlegm (odds ratio = 3.59, 95% confidence interval = 1.10-11.70). Trends of increasing odds ratios with increasing exposure were seen for cough, phlegm, nasal symptoms, and skin rash. The results suggest a weak association between respiratory and dermal irritation and work with fertilizer. Results highlight the need for further exposure monitoring within the tree planting industry, and larger studies to investigate the relationship between work with fertilizer and respiratory and dermal health symptoms. [Supplementary materials are available for this article. Go to the publisher's online edition of the Journal of Occupational and Environmental Hygiene for the following free supplemental resource: a PDF file containing a respiratory and dermal health questionnaire.].

The relationship between inadvertent ingestion and dermal exposure pathways: a new integrated conceptual model and a database of dermal and oral transfer efficiencies.

Occupational inadvertent ingestion exposure is ingestion exposure due to contact between the mouth and contaminated hands or objects. Although individuals are typically oblivious to their exposure by this route, it is a potentially significant source of occupational exposure for some substances. Due to the continual flux of saliva through the oral cavity and the non-specificity of biological monitoring to routes of exposure, direct measurement of exposure by the inadvertent ingestion route is challenging; predictive models may be required to assess exposure. The work described in this manuscript has been carried out as part of a project to develop a predictive model for estimating inadvertent ingestion exposure in the workplace. As inadvertent ingestion exposure mainly arises from hand-to-mouth contact, it is closely linked to dermal exposure. We present a new integrated conceptual model for dermal and inadvertent ingestion exposure that should help to increase our understanding of ingestion exposure and our ability to simultaneously estimate exposure by the dermal and ingestion routes. The conceptual model consists of eight compartments (source, air, surface contaminant layer, outer clothing contaminant layer, inner clothing contaminant layer, hands and arms layer, perioral layer, and oral cavity) and nine mass transport processes (emission, deposition, resuspension or evaporation, transfer, removal, redistribution, decontamination, penetration and/or permeation, and swallowing) that describe event-based movement of substances between compartments (e.g. emission, deposition, etc.). This conceptual model is intended to guide the development of predictive exposure models that estimate exposure from both the dermal and the inadvertent ingestion pathways. For exposure by these pathways the efficiency of transfer of materials between compartments (for example from surfaces to hands, or from hands to the mouth) are important determinants of exposure. A database of transfer efficiency data relevant for dermal and inadvertent ingestion exposure was developed, containing 534 empirically measured transfer efficiencies measured between 1980 and 2010 and reported in the peer-reviewed and grey literature. The majority of the reported transfer efficiencies (84%) relate to transfer between surfaces and hands, but the database also includes efficiencies for other transfer scenarios, including surface-to-glove, hand-to-mouth, and skin-to-skin. While the conceptual model can provide a framework for a predictive exposure assessment model, the database provides detailed information on transfer efficiencies between the various compartments. Together, the conceptual model and the database provide a basis for the development of a quantitative tool to estimate inadvertent ingestion exposure in the workplace.

Exposure to pesticides and metal contaminants of fertilizer among tree planters.

In British Columbia, Canada, harvested forests are manually replanted by seasonal workers. The work is known to be physically demanding and ergonomically difficult, and recently, there have been concerns over chemical exposures due to pesticide residues on seedlings, fertilizers (often applied alongside seedlings), and potential metal contamination of these fertilizers. This study aimed to characterize metal and pesticide exposure among a sample of British Columbia tree planters. Between May 2006 and April 2007, exposure measurements were taken from 54 tree planters at five geographically disperse worksites throughout British Columbia. Four worksites were using fertilizer and one was not. Metal concentrations were measured by inductively coupled plasma mass spectrometry on post-shift hand wipes, full-shift personal air sample, bulk soil, seedling root balls, and fertilizer samples. Pesticides were measured on post-shift hand wipes and on bulk seedling samples. Seedling nursery pesticide application records were used to focus pesticide analyses on pesticides known to have been applied to the seedlings used at the study sites. Carbamate pesticides were analyzed by high-performance liquid chromatography/mass spectroscopy and all other pesticides by gas chromatography mass spectrometry. No evidence was found that tree planters who worked with fertilizer were at an elevated risk of exposure to arsenic, lead, cadmium, chromium, and nickel relative to tree planters who did not. Pesticide residues were found on seedlings taken from work sites early in the tree planting season in April 2007. At these worksites, the fungicides chlorothalonil and iprodione were found on the skin of workers at low levels (range 0.37-106.3 ng cm(-2) and 0.48-15.9 ng cm(-2), respectively), providing evidence for exposure potential. Very poor hygiene conditions were observed at all tree planting work sites. Hand washing facilities were not available at work sites and only 5.6% of subjects reported hand washing during the work day, including prior to eating or smoking. Gloves were worn by all subjects but no personal protective equipment programs existed to train workers in the correct use or selection of gloves, and consequentially, many glove choices were inappropriate. The lack of hand washing facilities combined with incorrect glove use could increase the duration of dermal exposure and increase the risk of hand-to-mouth ingestion exposure.