OCCUPATIONAL EXPOSURE TO

HOT ENVIRO NM ENTS

Revised Criteria 1986

NIOSH
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
CENTERS FOR DISEASE CONTROL
NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH
 C r i t e r i a fo r a Recommended S tandard------

Occupational Exposure to Hot Environments

Revised C r i t e r i a 1986

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service
Centers for Disease Control
National Institute for Occupational Safety and Health
Division of Standards Development and Technology Transfer

F o r s a le b y th e S u p e rin te n d e n t of D o c u m e n t» , U .S . G o v e rn m e n t
P rin tin g O ffic e , W a s h in g to n , D .C . 20402

ApriI 1986
 DISCLAIMER

Mention of the name of any company or product does

not constitute endorsement by the National Institute
for Occupational Safety and Health.

DHHS (NIOSH) Publication No. 86-113

 FOREWORD

The Occupational Safety and Health Act of 1970 (Public Law 91-596) states
that the purpose of Congress expressed in the Act is "to assure so far as
possible every working man and woman in the Nation safe and healthful
working conditions and to preserve our human resources.. .by," among other
things, "providing medical criteria which will assure insofar as practicable
that no worker will suffer diminished health, functional capacity, or life
expectancy as a result of his work experience." In the Act, the National
Institute for Occupational Safety and Health (NIOSH) is authorized to
"develop and establish recommended occupational safety and health
standards..." and to "conduct such research and experimental programs
as...are necessary for the development of criteria for new and improved
occupational safety and health standards..."

The Institute responds to these mandates by means of the criteria document.

The essential and distinguishing feature of a criteria document is that it
recommends a standard for promulgation by an appropriate regulatory body,
usually the Occupational Safety and Health Administration (OSHA) or the Mine
Safety and Health Administration (MSHA) of the U.S. Department of Labor.
NIOSH is also responsible for reviewing existing OSHA and MSHA standards and
previous recommendations by NIOSH, to ensure that they are adequate to
protect workers in view of the current state of knowledge. Updating
criteria documents, when necessary, is an essential element of that process.

A criteria document, Criteria for a Recommended Standard....OccupationaI

Exposure to Hot Environments, was prepared in 1972. The current revision
presented here takes into account the vast amount of new scientific
information on working in hot environments which is pertinent to safety and
health. Included are ways of predicting the health risks, procedures for
control of heat stress, and techniques for prevention and treatment of
heat-related illnesses.

External review consultants drawn from academia, business associations,

labor organizations, private consultants, and representatives of other
governmental agencies, contributed greatly to the form and content of this
revised document. However, responsibility for the conclusions reached and
the recommendations made, belongs solely to the Institute. All comments by
reviewers, whether or not incorporated into the document are being sent with
it to the Occupational Safety and Health Administration (OSHA) for
consideration in standard setting. f

Assistant Surgeon General

Director, National Institute for
Occupational Safety and Health
Centers for Disease Control
 ACKNOWLEDGMENTS

This revised document was prepared by the staff of the Division of Standards
Development and Technology Transfer with assistance from the Division of
Biomedical and Behavioral Sciences. The responsibility for the development
of the document was that of Austin Henschel, Ph.D., with the assistance of
Francis N. Dukes-Dobos, M.D., Jay Klemme, M.D., and Nelson A. Leidel, Sc.D.
Robert Bernstein, M.D., Ph.D., Paul Caplan, Burt J. Cooper, Jim Ferguson,
Jerome Flesch, John Jankovic, Richard Ronk, William D. Wagner, Mary Kay
White, Ph.D., and Ralph D. Zumwalde are gratefully acknowledged for their
contributions to the critical review of this document. A special
appreciation is extended to Carolyn A. Browning and Myrtle Heid for their
editorial review, and to Judy Cur less and Constance Klinker for their
support in typing and finalizing the document for publication.

iv
 REVIEW CONSULTANTS

Howard Ayer
Institute of Environmental Health
University of Cincinnati Medical Center
3223 Eden Avenue
Cincinnati, OH 45267

Edward J. Bai er, Jr.

Occupational Safety and Health Administration
U.S. Department of Labor
Washington, DC 20210

Louis S. Beliczky
United Rubber Workers
87 High Street
Akron, OH 44308

Thomas E. Bernard
Human Sciences
Research and Development Center
1310 Beulah Road
Pittsburgh, PA 15235

E . R . Buskirk, Ph . D .
Laboratory, Human Performance
The Pennsylvania State University
University Park, PA 16802

Geraldine V. Cox, Ph.D.

Technical Di rector
Chemical Manufacturers Association
2501 M Street, N.W.
Wash ing ton, DC 20037

B . D . Dinman, M .D ., P h .D .
Vice President, Health and Safety
Aluminum Company of America
1501 Alcoa Bui Iding
Pittsburgh, PA 15219

F. H. Fuller
E. I . du Pont de Nemours & Company
Engineering Department
Louviers Bui Iding
Wilmington, DE 19898

P. A. Gagge, Ph.D.
John B. Pierce Foundation
New Haven, CT 06519

v
 REVIEW CONSULTANTS (CONTINUED)

Ralph F. Goldman, Ph.D.

Multi-Tech Corporation
One Strathmore Road
Natic, MA 01760

John E. Green leaf, Ph.D.

NASA
Ames Research Center
Moffett Field, CA 94035

Bruce A. Hertig, Ph.D.

306 West High Street
Urbana, I 11inois 61801
(the American Industrial Hygiene Association)

Steven M. Horvath, Ph.D.

Institute for Environmental Stress
University of California, Santa Barbara
Santa Barbara, CA 93106

Murray Jacobson
Assistant Director for Health
Office of Technical Support
Mine Safety and Health Administration
U.S. Department of Labor
4015 Wilson Boulevard
Arlington, VA 22203

Herbert H. Jones
Consultant - Occupational Health and Safety
119 Broad Street
Warrensburg, MO 64093

E. Kamon, Ph.D.
The Pennsylvania State University
119 NolI Laboratory
University Park, PA 16802

J . AIlen Overton, J r .
President
American Mining Congress
Suite 300, 1920 N Street, N.W.
Washington, DC 20036

Kent B. Pandolf, Ph.D.

U.S. Army RIEM
Natick, MA 01760

vi
 REVIEW CONSULTANTS (CONTINUED)

Jerry Ramsey, Ph.D.

Department Industrial Engineering
Texas Tech University
Lubbock, TX 79409

Manmohan V. Ranadine, M.D.

Chief, Preventive Medicine Consultants Division
Department of Army
Office of the Surgeon General
Washington, DC 20310

Co r inne J . So Iomon, R N , M P H , COHN

American Association Occupational Health Nurses
Sui te 400
3500 P iedmon t Ro a d , N .E .
Atlanta, GA 30305

Richard A. Uhlar
International Chemical Workers Union
1655 West Market Street
Akron, OH 44313
 CONTENTS

Page

FOREWORD ii i

ACKNOWLEDGMENTS iv

REVIEW CONSULTANTS v

LIST OF FIGURES xi

LIST OF TABLES xi

I. RECOMMENDATIONS FOR AN OCCUPATIONAL STANDARD FOR

WORKERS EXPOSED TO HOT ENVIRONMENTS 1

Sect ion 1 - Workplace Limits and Surveillance 2

Sect ion 2 - Medical Surveillance 5
Sect ion 3 - Surveillance of Heat-Induced
Sentinel Health Events 7
Sect ion 4 - Posting of Hazardous Areas 8
Sect ion 5 - Protective Clothing and Equipment 8
Sect ion 6 - Worker Information and Training 8
Sect ion 7 - Control of Heat Stress 10
Sect ion 8 - Recordkeeping 11

II. INTRODUCTION 16

III. HEAT BALANCE AND HEAT EXCHANGE 18

A. Heat Balance Equation 18

B. Modes of Heat Exchange 18
C. Effects of Clothing on Heat Exchange 21

IV. BIOLOGIC EFFECTS OF HEAT 29

A. Physiologic Responses to Heat 29

B. Acute Heat Disorders 40
C. Chronic Heat Disorders 46

V. MEASUREMENT OF HEAT STRESS 47

A. Environmental Factors 47
B. Prediction of Climatic Factors from the National
Weather Service Data 58
C. Metabolic Heat 58

VI. CONTROL OF HEAT STRESS 63

A. Engineering Controls 66
B. Work and Hygienic Practices and Administrative
Controls 67

ix
 CONTENTS

Page

C. Heat-Alert Program - Preventing Emergencies 71

D. Auxiliary Body Cooling and Protective Clothing 72
E. Performance Degradation 75

VII. PREVENT IVE MED ICAL PRACTICES 76

A. Protection of Workers Exposed to Heat in Excess

of the RAL 77
B. Medical Examinations 78
C. SurveiI lance 83
D. Biologic Monitoring of Workers Exposed to Heat Stress 84

VIM. BASIS FOR THE RECOMMENDED STANDARD 85

A. Estimation of Risks 85
B. Correlation Between Exposure and Effects 86
C. Physiologic Monitoring of Heat Strain 87
D. Recommendations of U.S. Organizations and Agencies 88
E. International Standards and Recommendations 92
F. Foreign Standards and Recommendations 96

IX. INDICES FOR ASSESSING HEAT STRESS AND STRAIN 101

A. Direct Indices 101

B. Rational Indices 102
C. Empirical Indices 104
D. Physiologic Monitoring 107

X . RESEARCH NEEDS 111

A. Exposure Times and Patterns 111

B. Deep Body Temperature 111
C. Electrolyte and Water Balance 111
D. Identifying Heat-Intolerant Workers 112
E. Effects of Chronic Heat Exposure 112
F. Circadian Rhythm of Heat Tolerance 112
G. Heat-Strain Monitoring 112
H. Accidents and Heat Stress 113
I. Effects of Heat on Reproduction 113
J. Heat Tolerance and Shift Work 113
K. Effects of Clothing and Benefits of Cooling Garments 114
L. Medical Screening and Biologic Monitoring Procedures 114

XI. REFERENCES 115

XII. APPENDIX A— GLOSSARY OF TERMS AND SYMBOLS 128

ADAPTED IN PART FROM REFERENCES 166 and 167
APPENDIX B— HEAT-EXCHANGE EQUATION UTILIZING THE SI UNITS 135

x
 LIST OF FIGURES

Page

Figure 1 RECOMMENDED HEAT-STRESS ALERT LIMITS—

HEAT-UNACCLIMATIZED WORKERS 14
Figure 2 RECOMMENDED HEAT-STRESS EXPOSURE LIMITS—
HEAT-ACCLIMATIZED WORKERS 15

LIST OF TABLES

Table III -1 CLO INSULATION UNITS FOR INDIVIDUAL ITEMS

OF CLOTHING AND FORMULA FOR OBTAINING TOTAL
INSULATION (IC |) 24

Table IV- 1 CLASSIFICATION, MEDICAL ASPECTS, AND

PREVENTION OF HEAT ILLNESS 41

Table V-1 ADVANTAGES, DISADVANTAGES AND LIMITATIONS,

AND FIELDS OF APPLICATION FOR DIFFERENT TYPES
OF TEMPERATURE MEASURING INSTRUMENTS 49

Table V-2 ADVANTAGES, DISADVANTAGES, AND FIELDS OF

APPLICATION FOR DIFFERENT AIR VELOCITY MEASURING
INSTRUMENTS 53

Table V-3 ESTIMATING ENERGY COST OF WORK BY TASK ANALYSIS 62

Table VI- I CHECKLIST FOR CONTROLLING HEAT STRESS AND STRAIN 64

Table VII 1-1 CRITERIA FOR THERMAL LIMITS BASED ON

AVERAGE VALUES 96

xI
 I. RECOMMENDATIONS FOR AN OCCUPATIONAL STANDARD
FOR WORKERS EXPOSED TO HOT ENVIRONMENTS

The National Institute for Occupational Safety and Health (NIOSH) recommends
that worker exposure to heat stress in the workplace be controlled by
complying with all sections of the recommended standard found in this
document. This recommended standard should prevent or greatly reduce the
risk of adverse health effects to exposed workers and will be subject to
review and revision as necessary.

Heat-induced occupational illnesses, injuries, and reduced productivity

occur in situations in which the total heat load (environmental plus
metabolic) exceeds the capacities of the body to maintain normal body
functions without excessive strain. The reduction of adverse health effects
can be accomplished by the proper application of engineering and work
practice controls, worker training and acclimatization, measurements and
assessment of heat stress, medical supervision, and proper use of
heat-protective clothing and equipment.

In this criteria document, total heat stress is considered to be the sum of

heat generated in the body (metabolic heat) plus the heat gained from the
environment (environmental heat) minus the heat lost from the body to the
environment. The bodily response to total heat stress is called the heat
strain. Many of the bodily responses to heat exposure are desirable and
beneficial. However, at some level of heat stress, the worker's
compensatory mechanisms will no longer be capable of maintaining body
temperature at the level required for normal body functions. As a result,
the risk of heat-induced illnesses, disorders, and accidents substantially
increases. The level of heat stress at which excessive heat strain will
result depends on the heat-tolerance capabilities of the worker. However,
even though there is a wide range of heat tolerance between workers, each
worker has an upper limit for heat stress beyond which the resulting heat
strain can cause the worker to become a heat casualty. In most workers,
appropriate repeated exposure to elevated heat stress causes a series of
physiologic adaptations called acclimatization, whereby the body becomes
more efficient in coping with the heat stress. Such an acclimatized worker
can tolerate a greater heat stress before a harmful level of heat strain
occurs.

The occurrence of heat-induced illnesses and unsafe acts among a group of

workers in a hot environment, or the recurrence of such problems in,
individual workers, represents "sentinel health events" (SHE's) which
indicate that heat control measures, medical screening, or environmental
monitoring measures may not be adequate [1 ]. One or more occurrences of
heat-induced illness in a particular worker indicates the need for medical
inquiry about the possibility of temporary or permanent loss of the worker's
ability to tolerate heat stress. The recommended requirements in the
following sections are intended to establish the permissible limits of total
heat stress so that the risk of incurring heat-induced illnesses and
disorders in workers is reduced.

1
Almost all healthy workers, who are not acclimatized to working in hot
environments and who are exposed to combinations of environmental and
metabolic heat less than the appropriate NIOSH Recommended Alert Limits
(RAL's) given in Figure 1, should be able to tolerate total heat without
substantially increasing their risk of incurring acute adverse health
effects. Almost all healthy workers, who are heat-acclimatized to working
in hot environments and who are exposed to combinations of environmental and
metabolic heat less than the appropriate NIOSH Recommended Exposure Limits
(REL's) given in Figure 2, should be capable of tolerating the total heat
without incurring adverse effects. The estimates of both environmental and
metabolic heat are expressed as 1-hour time-weighted averages (TWAs) as
described in reference [2 ].

At combinations of environmental and metabolic heat exceeding the Ceiling

Limits (C) in Figures 1 and 2, no worker shall be exposed without adequate
heat-protective clothing and equipment. To determine total heat loads where
a worker could not achieve thermal balance, but might sustain up to a
1 degree Celsius (1°C) rise in body temperature in less than 15 minutes, the
Ceiling Limits were calculated using the heat balance equation given in
Chapter III, Sect ion A.

In this criteria document, healthy workers are defined as those who are not
excluded from placement in hot environment jobs by the explicit criteria
given in Chapters I, IV, VI, and VII. These exclusionary criteria are
qualitative in that the epidemiologic parameters of sensitivity,
specificity, and predictive power of the evaluation methods are not fully
documented. However, the recommended exclusionary criteria represent the
best judgment of NIOSH based on the best available data and comments of peer
reviewers. This may include both absolute and relative exclusionary
indicators related to age, stature, gender, percent body fat, medical and
occupational history, specific chronic diseases or therapeutic regimens, and
the results of such tests as the maximum aerobic capacity (V0 2 max),
electrocardiogram (EKG), pulmonary function tests (PFTs), and chest x rays
(CXRs).

The medical surveillance program shall be designed and implemented in such a

way as to minimize the risk of the workers' health and safety being
jeopardized by any heat hazards that may be present in the workplace (see
Chapters IV, VI, and VII). The medical program shall provide for both
preplacement medical examinations for those persons who are candidates for a
hot job and periodic medical examinations for those workers who are
currently working in hot jobs.

Section 1 - Workplace L im its and S u rv e illa n c e

(a ) Recommended Lim its

(1) Unacclimatized workers: Total heat exposure to workers shall

be controlled so that unprotected healthy workers who are not
acclimatized to working in hot environments are not exposed to
combinations of metabolic and environmental heat greater than the
applicable RAL's given in Figure 1.

2
 (2) Acclimatized workers: Total heat exposure to workers shall be
controlled so that unprotected healthy workers who are acclimatized
to working in hot environments are not exposed to combinations of
metabolic and environmental heat greater than the applicable REL's
given in Figure 2.

(3) Effect of Clothing: The recommended limits given in Figures 1

and 2 are for healthy workers who are physically and medically fit
for the level of activity required by their job and who are wearing
the customary one layer work clothing ensemble consisting of not
more than long-sleeved work shirts and trousers (or equivalent).
The REL and RAL values given in Figures 1 and 2 may not provide
adequate protection if workers wear clothing with lower air and
vapor permeability or insulation values greater than those for the
customary one layer work clothing ensemble discussed above. A
discussion of these modifications to the REL and RAL is given in
Chapter III, Sect ion C.

(4) Ceiling Limits: No worker shall be exposed to combinations of

metabolic and environmental heat exceeding the applicable Ceiling
Limits (C) of Figures 1 or 2 without being provided with and
properly using appropriate and adequate heat-protective clothing
and equipment.

(b ) D eterm ination of Environmental Heat

(1) Measurement methods: Environmental heat exposures shall be

assessed by the Wet Bulb Globe Thermometer (WBGT) method or
equivalent techniques, such as Effective Temperature (ET),
Corrected Effective Temperature (CET), or Wet Globe Temperature
(WGT), that can be converted to WBGT values (as described in
Chapters V and IX). The WBGT shall be accepted as the standard
method and its readings the standard against which all others are
compared. When air- and vapor-impermeable protective clothing is
worn, the dry bulb temperature (ta ) or the adjusted dry bulb
temperature (tac|b) is a more appropriate measurement.

(2) Measurement requirements: Environmental heat measurements

shall be made at or as close as feasible to the work area where the
worker is exposed. When a worker is not continuously exposed in a
single hot area, but moves between two or more areas with differing
levels of environmental heat or when the environmental heat
substantially varies at the single hot area, the environmental heat
exposures shall be measured at each area and during each period of
constant heat levels where employees are exposed. Hourly TWA WBGTs
shall be calculated for the combination of jobs (tasks), including
all scheduled and unscheduled rest periods.

(3) Modifications of work conditions: Environmental heat

measurements shall be made at least hourly during the hottest
portion of each workshift, during the hottest months of the year,
and when a heat wave occurs or is predicted. If two such
sequential measurements exceed the applicable RAL or REL, then work

3
 conditions shall be modified by use of appropriate engineering
controls, work practices, or other measures until two sequential
measures are incompliance with the exposure limits of this
recommended standard.

(4) Initiation of measurements: A WBGT or an individual

environmental factors profile shall be established for each hot
work area for both winter and summer seasons as a guide for
determining when engineering controls and/or work practices or
other control methods shall be instituted. After the environmental
profiles have been established, measurements shall be made as
described in (b)(1), (2), and (3) of this section during the time
of year and days when the profile indicates that total heat
exposures above the applicable RAL's or REL's may be reasonably
anticipated or when a heat wave has been forecast by the nearest
National Weather Service station or other competent weather
forecasting service.

(c ) D eterm ination of M etabolic Heat

(1) Metabolic heat screening estimates: For initial screening

purposes, metabolic heat rates for each worker shall either be
measured as required in (c)(2 ) of this section or shall be
estimated from Table V-3 to determine whether the total heat
exposure exceeds the applicable RAL or REL. For determination of
metabolic heat, Table V-3 shall be used only for screening purposes
unless other reliable and valid baseline data have been developed
and confirmed by the indirect open-circuit method specified in
(c)(2) of this Section. When computing metabolic heat estimates
using Table V-3 for screening purposes, the metabolic heat
production in kilocalories per minute shall be calculated using the
upper value of the range given in Table V-3 for each body position
and type of work for each specific task(s) of each worker's job.

EXAMPLE:

As shown in Table V-3 (D, Sample calculation), for a task that

requires theworker to stand and use both arms, the values to be
added would be 0. 6 kilocalories per minute (kcal/min) for standing,
3.5 kcal/min for working with both arms, and 1.0 kcal/min for basal
metabolism, for a total metabolic heat of 5.1 kcal/min for a worker
who weighs 70 kilograms (kg)(154 lb). For a worker that has other
than a 70-kg weight, the metabolic heat shall be corrected by the
factor (actual worker weight in kg/70 kg). Thus for an 85-kg
worker the factor would be (85/70) = 1.21 and the appropriate
estimate for metabolic heat would be (1.21)(5.1) = 6.2 kcal/min for
the duration of the task.

(2) Metabolic heat measurements - Whenever the combination of

measured environmental heat (WBGT) and screening estimate of
metabolic heat exceeds the applicable RAL or REL (Figures 1 and 2),
the metabolic heat production shall be measured using the indirect
open-circuit procedure (see Chapter V) or an equivalent method.

4
 Metabolic heat rates shall be expressed as kilocalories per hour
(kcal/h), British thermal units (Btu) per hour, or watts (W) for a
1-hour TWA task basis that includes all activities engaged in
during each period of analysis and all scheduled and nonscheduled
rest periods (1 kcal/h = 3.97 Btu/h = 1.16 W).

EXAMPLE:

For the example in (c)(1), if the task was performed by an

acclimatized 70-kg worker for the entire 60 minutes of each hour,
the screening estimate for the 1-hour TWA metabolic heat would be
(5.1 kcal/min)(60 min) = about 300 kcal/h. Using the applicable
Figure 2, a vertical line at 300 kcal/h would intersect the
60 min/h REL curve at a WBGT of 27.8°C (82°F). Then, if the
measured WBGT exceeds 27.8°C, proceed to measure the worker's
metabolic heat with the indirect open-circuit method or equivalent
procedure.

If the 70-kg worker was unacclimatized, use of Figure 1 indicates

that metabolic heat measurement of the worker would be required
above a WBGT of 25°C (77°F).

(d ) P h ysiolog ic M onitoring

Physiologic monitoring may be used as an adjunct monitoring procedure to

those estimates and measurements required in the preceding Parts (a),
(b), and (c) of this section. The total heat stress shall be considered
to exceed the applicable RAL or REL when the physiologic functions
(e.g., core or oral body temperature, work and recovery pulse rate)
exceed the values given in Chapter IX, Section D.

Section 2 - MedicaI Survei11ance

(a ) General

(1) The employer shall institute a medical surveillance program

for al I workers who are or may be exposed to heat stress above the
RAL, whether they are acclimatized or not.

(2) The employer shall assure that all medical examinations and
procedures are performed by or under the direction of a licensed
physician.

(3) The employer shall provide the required medical surveillance

without cost to the workers, without loss of pay, and at a
reasonable time and place.

(b ) Preplacement Medical Examinations

For the purposes of the preplacement medical examination, all

workers shall be considered to be unacclimatized to hot
environments. At a minimum, the preplacement medical examination
of each prospective worker for a hot job shall include:

5
 (1) A comprehensive work and medical history, with special
emphasis on any medical records or information concerning any known
or suspected previous heat illnesses or heat intolerance. The
medical history shall contain relevant information on the
cardiovascular system, skin, liver, kidney, and the nervous and
respiratory systems;

(2) A comprehensive physical examination that gives special

attention to the cardiovascular system, skin, liver, kidney, and
the nervous and respiratory systems;

(3) An assessment of the use of therapeutic drugs,

over-the-counter medications, or social drugs (including alcohol),
that may increase the risk of heat injury or illness (see Chapter
VI I);

(4) An assessment of obesity (body fatness), that is defined as

exceeding 25% of normal weight for males and exceeding 30% of
normal weight for females, as based on age and body build;

(5) An assessment of the worker's ability to wear and use any

protective clothing and equipment, especially respirators, that is
or may be required to be worn or used; and

(6 ) Other factors and examination details included in Chapter VII,

Sect ion B - 1 .

(c ) P e rio d ic Medical Examinations

Periodic medical examinations shall be made available at least annually

to all workers who may be exposed at the worksite to heat stress
exceeding the RAL. The employer shall provide the examinations
specified in Part (b) above including any other items the examining
physician considers relevant. If circumstances warrant (e.g., increase
in job-related heat stress, changes in health status), the medical
examination shall be offered at shorter intervals at the discretion of
the responsible physician.

(d ) Emergency Medical Care

If the worker for any reason develops signs or symptoms of heat illness,
the employer shall provide appropriate emergency medical treatment.

(e ) Inform ation to be Provided to the Physician

The employer shall provide the following information to the examining

physician performing or responsible for the medical surveillance program:

(1) A copy of this recommended standard;

(2) A description of the affected worker's duties and activities

as they relate to the worker's environmental and metabolic heat
exposure;

6
 (3) An estimate of the worker's potential exposure to workplace
heat (both environmental and metabolic), including any available
workplace measurements or estimates;

(4) A description of any protective equipment or clothing the

worker uses or may be required to use; and

(5) Relevant information from previous medical examinations of the

affected worker which is not readily available to the examining
physician.

(f) P h y s ic ia n 's W ritte n Opinion

The employer shall obtain a written opinion from the responsible

physician which shall include:

(1) Thè results of the medical examination and the tests performed;

(2) The physician's opinion as to whether the worker has any

detected medical conditions which would increase the risk of
material impairment of health from exposure to anticipated heat
stress in the work environment;

(3) An estimate of the individual's tolerance to withstand hot

work ing cond it io n s ;

(4) An opinion as to whether the worker can perform the work

required by the job (i.e., physical fitness for the job);

(5) Any recommended limitations upon the worker's exposure to heat

stress or upon the use of protective clothing or equipment; and

(6 ) A statement that the worker has been informed by the physician

of the results of the medical examination and any medical
conditions which require further explanation or treatment.

The employer shall provide a copy of the physician's written

opinion to the affected worker.

Section 3 - S u rv e illa n c e of Heat-Induced S en tin el H ealth Events

(a ) D e fin itio n

Surveillance of heat-induced Sentinel Health Events (SHE's) is defined

as the systematic collection and analysis of data concerning the
occurrence and distribution of adverse health effects in defined
populations at risk to heat injury or illness.

(b ) Requirements

In order to evaluate and improve prevention and control measures for

heat-induced effects, which includes the identification of highly
susceptible workers, data on the occurrence or recurrence in the same

7
 worker, and distribution in time, place, and person of heat-induced
adverse effects shall be obtained and analyzed for each workplace.

Section 4 - Posting o f Hazardous Areas

(a ) Dangerous H e at-S tress Areas

In work areas and at entrances to work areas or building enclosures

where there is a reasonable likelihood of the combination(s) of
environmental and metabolic heat exceeding the Ceiling Limit, there
shall be posted readily visible warning signs containing information on
the required protective clothing or equipment, hazardous effects of heat
stress on human health, and information on emergency measures for heat
injury or illness. This information shall be arranged as follows:

DANGEROUS HEAT-STRESS AREA

HEAT-STRESS PROTECTIVE CLOTHING OR EQUIPMENT REQUIRED
HARMFUL IF EXCESSIVE HEAT EXPOSURE OR WORK LOAD OCCUR
HEAT-INDUCED FAINTING, HEAT EXHAUSTION, HEAT CRAMP,
HEAT RASH OR HEAT STROKE MAY OCCUR

(b ) Emergency S itu a tio n s

In any area where there is a likelihood of heat stress emergency

situations occurring, the warning signs required in (a) of this section
shall be supplemented with signsgiving emergency and first aid
instructions.

(c ) A d d itio n al Requirements fo r Warning Signs

All hazard warning signs shall be printed in English and where

appropriate in the predominant language of workers unable to read
English. Workers unable to read the signs shall be informed of the
warning printed on the signs and the extent of the hazardous area(s).
All warning signs shall be kept clean and legible at all times.

Section 5 - P ro te c tiv e C lothing and Equipment

Engineering controls and safe work practices shall be used to maintain

worker exposure to heat stress at or below the applicable RAL or REL
specified in Section 1. In addition,protective clothing and equipment
(e.g., water-cooled garments, air-cooled garments, ice-packet vests,
wetted-overgarments, heat-reflective aprons or suits) shall be provided by
the employer to the workers when the total heat stress exceeds the Ceiling
Limit.

Section 6 - Worker Inform ation and T rain in g

(a ) Inform ation Requirements

All new and current workers, who are unacclimatized to heat and work in
areas where there is reasonable likelihood of heat injury or illness,
shall be kept informed, through continuing education programs, of:

8
 (1) Heat stress hazards,

(2) Predisposing factors and relevant signs and symptoms of heat

injury and i 11 ness,

(3) Potential health effects of excessive heat stress and first

aid procedures,

(4) Proper precautions for work in heat stress areas,

(5) Worker responsibilities for following proper work practices

and control procedures to help protect the health and provide for
the safety of themselves and their fellow workers, including
instructions to immediately report to the employer the development
of signs or symptoms of heat stress overexposure,

(6 ) The effects of therapeutic drugs, over-the-counter

medications, or social drugs (including alcohol), that may increase
the risk of heat injury or illness by reducing heat tolerance (see
Chapter VII),

(7) The purposes for and descriptions of the environmental and

medical surveillance programs and of the advantages to the worker
of participating in these surveillance programs, and

(8 ) If necessary, proper use of protective clothing and equipment.

(b ) Continuing Education Programs

(1) The employer shall institute a continuing education program,

conducted by persons qualified by experience or training in
occupational safety and health, to ensure that all workers
potentially exposed to heat stress have current knowledge of at
least the information specified in (a) of this section. For each
affected worker, the instructional program shall include adequate
verbal and/or written communication of the specified information.
The employer shall develop a written plan of the training program
that includes a record of all instructional materials.

(2) The employer shall inform all affected workers of the location
of written training materials and shall make these materials
readily available, without cost to the affected workers.

(c ) H e at-S tress S a fety Data Sheet

(1) The information specified in (a) of this section shall be

recorded on a heat-stress safety data sheet or on a form specified
by the Occupational Safety and Health Administration (OSHA).

(2) In addition, the safety data sheet shall contain:

(i) Emergency and first aid procedures, and

9
 (ii) Notes to physician regarding classification, medical
aspects, and prevention of heat injury and illness. These
notes shall include information on the category and clinical
features of each injury and illness, predisposing factors,
underlying physiologic disturbance, treatment, and prevention
procedures (see Table IV-1).

Section 7 - Control of Heat Stress

(a ) General Requirements

(1) Where engineering and work practice controls are not sufficient
to reduce exposures to or below the applicable RAL or REL, they
shall, nonetheless, be used to reduce exposures to the lowest level
achievable by these controls and shall be supplemented by the use
of heat-protective clothing or equipment, and a heat-alert program
shall be implemented as specified in (d) of this section.

(2) The employer shall establish and implement a written program to

reduce exposures to or below the applicable RAL or REL by means of
engineering and work practice controls.

(b ) Engineering Controls

(1) The type and extent of engineering controls required to bring

the environmental heat below the applicable RAL or REL can be
calculated using the basic heat exchange formulae (e.g., Chapters
III and VI). When the environmental heat exceeds the applicable
RAL or REL, the following control requirements shall be used.

(a) When the air temperature exceeds the skin temperature,

convective heat gain shall be reduced by decreasing air
temperature and/or decreasing the air velocity if it exceeds
1.5 meters per second (m/sec) (300 ft/min). When air
temperature is lower than skin temperature, convective heat
loss shall be increased by increasing air velocity. The type,
amount, and characteristics of clothing will influence heat
exchange between the body and the environment.

(b) When the temperature of the surrounding solid objects

exceeds skin temperature, radiative heat gain shall be reduced
by: placing shielding or barriers, that are
radiant-reflecting or heat-absorbing, between the heat source
and the worker; by isolating the source of radiant heat; or by
modifying the hot process or operation.

(c) When necessary, evaporative heat loss shall be increased

by increasing air movement over the worker, by reducing the
influx of moisture from steam leaks or from water on the
workplace floors, or by reducing the water vapor content
(humidity) of the air. The air and water vapor permeability
of the clothing worn by the worker will influence the rate of
heat exchange by evaporation.

10
 (c ) Work and Hygienic P ra c tic e s

(1) Work modifications and hygienic practices shall be introduced

to reduce both environmental and metabolic heat when engineering
controls are not adequate or are not feasible. The most effective
preventive work and hygienic practices for reducing heat stress
include, but are not limited to the following parts of this section:

(a) Limiting the time the worker spends each day in the hot
environment by decreasing exposure time in the hot environment
and/or increasing recovery time spent in a cool environment;

(b) Reducing the metabolic demands of the job by such

procedures as mechanization, use of special tools, or increase
in the number of workers per task;

(c) Increasing heat tolerance by a heat acclimatization

program and by increasing physical fitness;

(d) Training supervisors and workers to recognize early signs

and symptoms of heat illnesses and to administer relevant
f irst aid procedures;

(e) Implementing a buddy system in which workers are

responsible for observing fellow workers for early signs and
symptoms of heat intolerance such as weakness, unsteady gait,
irritability, disorientation, changes in skin color, or
general malaise; and

(f) Providing adequate amounts of cool, i.e., 10° to 15°C

(50° to 59°F) potable water near the work area and encouraging
all workers to drink a cup of water (about 150 to 200 mL (5 to
7 ounces) every 15 to 20 minutes. Individual, not communal,
drinking cups shall be provided.

(d ) H e a t-A le rt Program

A written Heat-Alert Program shall be developed and implemented whenever

the National Weather Service or other competent weather forecast service
forecasts that a heat wave is likely to occur the following day or
days. A heat wave is indicated when daily maximum temperature exceeds
35°C (95°F) or when the dai ly maximum temperature exceeds 32°C (90°F)
and is 5°C (9°F) or more above the maximum reached on the preceding
days. The details for a Heat-Alert Program are described in Chapter VI,
Section C.

S ection 8 - Recordkeeping

(a ) Environmental S u rv e illa n c e

(1) The employer shall establish and maintain an accurate record

of all measurements made to determine environmental and metabolic

11
 heat exposures to workers as required in Section 1 of this
recommended standard.

(2) Where the employer has determined that no metabolic heat

measurements are required as specified in Section 1, Part (c)(2) of
this recommended standard, the employer shall maintain a record of
the screening estimates relied upon to reach the determination.

(b ) Medical S u rv e illa n c e

The employer shall establish and maintain an accurate record for each
worker subject to medical surveillance as specified in Section 2 of this
recommended standard.

(c ) S u rv e illa n c e of Heat-Induced S en tin el H ealth Events

The employer shall establish and maintain an accurate record of the data
and analyses specified in Section 3 of this recommended standard.

(d ) Heat-Induced 111 ness S u rv eiI lance

The employer shall establish and maintain an accurate record of any

heat-induced illness or injury and the environmental and work conditions
at the time of the illness or injury.

(e ) Heat S tress Tolerance Augmentation

The employer shall establish and maintain an accurate record of all heat
stress tolerance augmentation for workers by heat acclimatization
procedures and/or physical fitness enhancement.

(f) Record R etention

In accordance with the requirements of 29 CFR 1910.20(d), the employer

shall retain records described by this recommended standard for at least
the following periods:

(1) Thirty years for environmental monitoring records,

(2) Duration of employment plus 30 years for medical surveillance

records,

(3) Thirty years for surveillance records for heat-induced SHE's,

and

(4) Thirty years for records of heat stress tolerance augmentation

(g ) A v a i l a b i l i t y of Records

(1) The employer shall make worker environmental surveillance

records available upon request for examination and copying to the
subject worker or former worker or to anyone having the specific

12
 written consent of the subject worker or former worker in
accordance with 29 CFR 1910.20.

(2) Any worker's medical surveillance records, surveillance

records for heat-induced SHE's, or records of heat stress tolerance
augmentation that are required by this recommended standard shall
be provided upon request for examination and copying to the subject
worker or former worker or to anyone having the specific written
consent of the subject worker or former worker.

(h ) T ra n s fe r o f Records

(1) The employer shall comply with the requirements on the

transfer of records set forth in the standard, Access to Medical
Records, 29 CFR 1910.20(h).

13
 re
113 45

104 4 0

O
CD
$
I
95 35
LU
X

£
z
LÜ
2 86 30
Z
o
a:
> 'S
z
LU 15 min./h.

77 25
RA L

168 20
100 2 00 300 400 5 00 kcal/h.
400 800 1200 1600 2 0 0 0 Btu/h.
116 233 349 465 5 8 0 Watts

METABOLIC HEAT

Figure 1. Recommended Heat-Stress Alert Limits

Heat-Unacclimatized Workers

C = CeiIing Limit
RAL = Recommended Alert Limit
*For "standard worker" of 70 kg (154 lbs) body weight and
1.8 m^ (19.4 ft^) body surface.
Based on References 2,3,4,5, 6 ,7,8 .

14
 °F |°C
luz 4 5 1

104 40

(S>
m

< 95 35
UJ
X

z
UJ
86 30
'N
o I5min./h.
cc
> 30min./h.
z
UJ REL
^ m in ./ h .

77 25 60min./h.

100 200 300 400 500 kcal/h

400 800 1200 1600 2 0 0 0 B tu/h
116 233 349 465 580 Watts

METABOLIC HEAT

Figure 2. Recommended Heat-Stress Exposure Limits

Heat-AccIi mat ized Workers

C = CeiIing Limit
REL = Recommended Exposure Limit
*For "standard worker" of 70 kg (154 lbs) body weight and
1 .8 m^ (19.4 ft^) body surface.
Based on References 2,3,4,5, 6 ,7,8 .

15
 II. INTRODUCTION

Criteria documents are developed by the National Institute for Occupational

Safety and Health ONIOSH), in response to section 20(a)(3) of the
Occupational Safety and Health Act of 1970. In the Act, NIOSH is charged
with developing criteria documents for toxic chemical substances and harmful
physical agents which will describe exposure levels that are safe for
various periods of employment including but not limited to the exposure
levels at which no worker will suffer impaired health or functional
capacities or diminished life expectancy as a result of any work
experience. Environmental heat is a potentially harmful physical agent.
This document presents the criteria and recommendations for a standard that
were prepared to meet the need for preventing heat-induced health impairment
resulting from exposure to occupational heat stress.

This document is an update of the Criteria for a Recommended Standard....

Occupational Exposure to Hot Environments (HSM-10269) published by NIOSH in
January 1972 [9]. In June 1972, NIOSH sent the criteria document to the
Occupational Safety and Health Administration (OSHA). In January 1973, the
Assistant Secretary of Labor for Occupational Safety and Health appointed a
15 member Standards Advisory Committee on Heat Stress to review the NIOSH
criteria document and develop a proposed standard. The committee submitted
a proposed standard to the Assistant Secretary of Labor, OSHA, in January
1974 [7]. A standard on occupational exposure to hotenvironments was not
promulgated. The updating of this document is based on the relevant
scientific data and industry experience that have accrued since the original
document was prepared. The document presents the criteria, techniques, and
procedures for the assessment, evaluation, and control of occupational heat
stress by engineering and preventive work practices and those for the
recognition, treatment, and prevention of heat-induced illnesses and unsafe
acts by medical supervision, hygienic practices, and training programs.

The recommended criteria were developed to ensure that adherence to them

will (1 ) protect against the risk of heat-induced illnesses and unsafe acts,
(2 ) be achievable by techniques that are valid, reproducible, and available,
and (3) be attainable by existing techniques. This recommended standard is
also designed to prevent possible harmful effects from interactions between
heat and toxic chemical and physical agents. The recommended environmental
limits for various intensities of physical work as indicated in Figures 1
and 2 are not upper tolerance limits for heat exposure for all workers but
rather levels at which engineering controls, preventive work and hygienic
practices, and administrative or other control procedures should be
implemented in order to reduce the risk of heat illnesses even in the least
heat-tolerant workers.

Estimates of the number of industrial workers who are exposed to heat stress
on the job are at best rough guesses, A review of the Statistical Abstracts
of the United States, 105th edition 1985, for the number of workers in
industries where heat stress is a potential safety and health hazard
indicates that a conservative estimate wouId be 5 to 10 mi 11 ion workers [10].

16
A glossary of terms, symbols, abbreviations, and units of measure used in
this document is presented in X 11—A .

17
 III. HEAT BALANCE AND HEAT EXCHANGE

An essential requirement for continued normal body function is that the deep
body core temperature be maintained within the acceptable range of about
37°C (98.6°F) ± 1°C (1.8°F). To achieve this body temperature equilibrium
requires a constant exchange of heat between the body and the environment.
The rate and amount of the heat exchange are governed by the fundamental
laws of thermodynamics of heat exchange between objects. The amount of heat
that must be exchanged is a function of ( 1 ) the total heat produced by the
body (metabolic heat), which may range from about 1 kcal per kilogram (kg)
of body weight per hour (1.16 watts) at rest to 5 kcal/kg body weight/h
(7 watts) for moderately hard industrial work; and (2) the heat gained, if
any, from the environment. The rate of heat exchange with the environment
is a function of air temperature and humidity, skin temperature, air
velocity, evaporation of sweat, radiant temperature, and type, amount, and
characteristics of the clothing worn. Respiratory heat loss is generally of
minor consequence except during hard work in very dry environments.

A. Heat Balance Equation

The basic heat balance equation is:

A S = (M-*l) ± C ± R - E

where:

A S = change in body heat content

(M-W) = total metabolism - external work performed
C = convective heat exchange
R = radiative heat exchange
E = evaporative heat loss

To solve the equation, measurement of metabolic heat production, air

temperature, air water-vapor pressure, wind velocity, and mean radiant
temperature are required [2,7,11,12,13,14,15,16,17,18,19,20,21].

B. Modes of Heat Exchange

The major modes of heat exchange between man and the environment are
convection, radiation, and evaporation. Other than for brief periods of
body contact with hot tools, equipment, floors, etc., which may cause burns,
conduction plays a minor role in industrial heat stress.

The equations for calculating heat exchange by convection, radiation, and

evaporation are available in Standard International (SI) units, metric
units, and English units. In SI units heat exchange is in watts per square
meter of body surface (W/m2). The heat-exchange equations are available
in both metric and English units for both the seminude individual and the
worker wearing conventional long-sleeved workshirt and trousers. The values
are in kcal/h or British thermal units per hour (Btu/h) for the "standard
worker" defined as one who weighs 70 kg (154 lbs) and has a body surface
area of 1.8 m^ (19.4 ft^). For workers who are smaller or larger than

18
the standard worker, appropriate correction factors must be applied [13].
The equations utilizing the SI units for heat exchange by C, R, and E are
presented in Appendix B.

For these as well as other versions of heat-balance equations, computer

programs of different complexities have been developed. Some of them are
comme rci a 11y ava iIabIe.

1. Convection (C)

The rate of convective heat exchange between the skin of a person and
the ambient air immediately surrounding the skin is a function of the
difference in temperature b_etween the ambient air (ta ) and the mean
weighted skin temperature Ctsk) and the rate of air movement over the
skin (Va ). This relationship is stated algebraically for the
"standard worker" wearing the customary one-layer work clothing ensemble
as [13]:

C = 7.0 Va 0.6 (ta - ts k )

where: C = convective heat exchange, kcal/h

Va = air velocity in meters per second (m/sec)

ta = air temperature °C

ighted skin temperature usually assumed to be 35°C

when ta >35°C, there will be a gain in body heat from the ambient air
by convection;

when ta <35°C, heat will be lost from the body to the ambient air by
convect ion.

This basic convective heat-exchange equation in English units has been

revised for the "standard man" wearing the customary one-layer work
clothing ensemble as:

C = 0.65 Va 0.6 ( ta _ Ts k )

where: C = convective heat exchange in Btu/h

Va = air velocity in feet per minute (fpm)

ta = air temperature °F

tsk = mean weighted skin temperature usually assumed to be 95°F

(35°C)

19
2. Radiation (R)

The radiative heat exchange is primarily a function of the temperature

gradient between the mean radiant temperature of the surroundings (Tw)
and the mean weighted skin temperature (ts k ). Radiant heat exchange
is a function of the fourth power of the absolute temperature of the
solid surroundings less the skin temperature (Tw -Ts k ) 4 but an
acceptable approximation for the customary one-layer clothed individual
is [13]:

R = 6 . 6 (tyy ~ tg^)

R = radiant heat exchange kcal/h

tw= mean radiant temperature of the solid surrounding surface °C

*sk = mean weighted skin temperature

Forthe customary one-layer clothed individual and English units, the

equation becomes:

R = 15.0 (7W - 7 s k )

R = radiant heat exchange Btu/h

tw = mean radiant temperature °F

*sk = m^an weighted skin temperature

3. Evaporation (E)

The evaporation of water (sweat) from the skin surface results in a heat
loss from the body. The maximum evaporative capacity (and heat loss) is
a function of air motion (Va ) and the water vapor pressure difference
between the ambient air (pa ) and the wetted skin at skin temperature
(Psk)* The equation for this relationship is for the customary
one-layer clothed worker [13]:

E = 14Va 0.6 (Psk . P a )

E = Evaporative heat loss kcal/h

Va = air speed, m/sec

pa = water vapor pressure of ambient air, mmHg

Psk = vapor pressure of water on skin assumed to be 42 mnHg at a

35°C skin temperature

This translates in English units for the customary one-layer clothed

worker into:

E « 2.4Va 0.6 (psk . P a >

20
 E = Evaporative heat loss Btu/h

Va = air velocity, fpm

pa = water vapor pressure air, mmHg

Psk = water vapor pressure on the skin assumed to be 42 mmHg at a

95°F skin temperature

C. E ffe c ts o f C lothing on Heat Exchange

Clothing serves as a barrier between the skin and the environment to protect
against hazardous chemical, physical, and biologic agents. A clothing
system will also alter the rate and amount of heat exchange between the skin
and the ambient air by convection, radiation, and evaporation. When
calculating heat exchange by each or all of these routes, it is, therefore,
necessary to apply correction factors that reflect the type, amount, and
characteristics of the clothing being worn when the clothing differs
substantially (i.e., more than one-layer and/or greater air and vapor
impermeability) from the customary one-layer work clothing. This clothing
efficiency factor (Fc |) for dry heat exchange is nondimensional
[22,23,24], In general, the thicker and greater the air and vapor
impermeability of the clothing barrier layer or layers, the greater is its
interference with convective, radiative, and evaporative heat exchange.

Calculating heat exchange, when it must be modified by the Fc |, is a time

consuming and complex task that requires the use of a hand held programmable
calculator [133]. Corrections of the REL and RAL to reflect the Fc | based
on heat transfer calculation for a variety of environmental and metabolic
heat loads and three clothing ensembles have been suggested [168]. The
customary one layer clothing ensemble was used as the basis for comparisons
with the other clothing ensembles. When a two layer clothing system is
worn, the REL and RAL should be lowered by 2°C (3.8°F). When a partially
air and/or vapor impermeable ensemble or heat reflective or protective
aprons, leggings, gauntlets, etc. are worn, the REL and RAL should be
lowered 4°C (7.2°F). These suggested corrections of the REL or RAL are
scientific judgments that have not been substantiated by controlled
laboratory studies or long term industrial experience.

In those workplaces where a vapor and air impermeable encapsulating ensemble

must be worn, the WBGT is not the appropriate measurement of environmental
heat stress. In these instances, the adjusted air temperature (tacjb^ must
be mea'sured and used instead of the WBGT. Where the tacnj exceeds
approximately 20°C (6 8 °F) physiologic monitoring (oral temperature and/or
pulse rate) is required. This physiologic monitoring must be conducted on a
time schedule based upon metabolic heat production and tac|b- The
suggested frequency of physiologic monitoring for moderate work varies from
once every two hours at ta(jb of 24°C (75°F) to every 15 minutes for
moderate work at tadb of 32°C (90°F) [169].

21
1. Clothing Insulation and Nonevaporative Heat Loss

Even without any clothing, there is a thin layer of still air (the
boundary layer) trapped next to the skin. This external still air film
acts as a layer of insulation against heat exchange between the skin and
the ambient environment. Typically, without body or air motion this air
layer (la ) provides about 0.8 clo units of insulation. One clo unit
of clothing insulation is defined as allowing 5.55 kcal/m^/h of heat
exchange by radiation and convection (Hr + q ) for each °C of temperature
difference between the skin (at a mean sk_in temperature T sk) and
adjusted dry bulb temperature t ac||3= ( t a+Tr ) / 2 . For the average
man with 1.8 m 2 of surface area, the hourly heat exchange by
radiation and convection (Hr+q) can be estimated as:

HR+c=(10/clo)(7sk-tadb)
Thus, the 0.8 clo still air layer limits the heat exchange by radiation
and convection for the nude standard individual to about 12.5 kcal/h
(i.e., 10/0.8) for each °C of difference between skin temperature and
air temperature. A resting individual in still air producing 90 kcal/h
of metabolic heat will lose about 11 kcal/h (12 %) by respiration and
about the same by evaporation of the body water diffusing through the
skin. The worker will then have to begin to sweat and lose heat by
evaporation to eliminate some of the remaining 68 kcal/h of metabolic
heat if the tac|b is less than 5.5°C below tsk [14].

The still air layer is reduced by increasing air motion, reaching a

minimal value of approximately 0.2 clo at air speeds above 4.5 m/sec
(890 fpm or 10 mph). At this wind speed, 68 kcal/h can be eliminated
from the skin without sweating at an air temperature only 1.4°C below
skin temperature, i.e., 68/(10/0.2)=1.36°C.

Studies of clothing materials overa number of years have led to the

conclusion that the insulation provided by clothing is generally a
linear function of its thickness. Differences in fibers or fabric
weave, unless these directly affect the thickness or the vapor or air
permeability of the fabric, have only very minor effects on insulation.

The function of the fibers is to maintain a given thickness of still air

in the fabric and block heat exchange. The fibers are more conductive
than insulating; increasing fiber density (as when trying to fit two
socks into a boot which has been sized to fit properly with one sock)
can actually reduce the insulation provided [14].

The typical value for clothing insulation is 1.57 clo per centimeter of
thickness (4 clo per inch). It is difficult to extend this
generalization to very thin fabric layers or to fabrics which, like
underwear, may simply occupy an existing still air layer of not more
than 0.5 cm thickness. These thinlayers show little contribution to
the intrinsicinsulation of the clothing unless there is (a) "pumping
action" of the clothing layers by body motion (circulation of air
through and between layers of clothing due to body movement);
(b) compression of the clothing by pressure from other clothing, by

22
objects in contact with the body, or by external wind; or
(c) penetration of some of the wind (as a function of the air
permeability of the outer covering fabric) into the trapped air layer
[14,24,25]. Table 111-1 presents a listing for the intrinsic insulation
contributed by adding each of the listed items of civilian clothing.

The total intrinsic insulation is not the sum of the individual items,
but 80% of their total insulation value; this allows for an average loss
of 20 % of the sum of the individual items to account for the compression
of one layer on the next. This average 20% reduction is a rough
approximation which is highly dependent on such factors as nature of the
fiber, the weave, the weight of the fabric, the use of foam or other
nonfibrous layers, and the clothing fit and cut.

23
 TABLE 1 1 1 -1 .— Clo in s u la tio n u n its fo r in d iv id u a l items of c lo th in g
and form ula fo r o b tain in g t o ta l in s u la tio n CIc I >

C lo th in g Men C lothing Women

Underwear
Sleeveless 0.06 Bra and Panties 0.05
T-shi rt 0.09 Half si ip 0.13
Underpants 0.05 Full slip 0.19

Torso
Shirt Blouse
Light, short sleeve 0.14 Light 0.20a
long sleeve 0.22 Heavy 0 .29a

Heavy, short sleeve 0.25 Dress

long sleeve 0.29 Light 0 . 22a >b
(Plus 5% for tie or turtleneck) Heavy 0.90a -b

Vest Skirt
Light 0.15 Light 0.10b
Heavy 0.29 Heavy 0.22b

Trousers Slacks
Light 0.26 Light 0.26
Heavy 0.32 Heavy 0.44

Sweater Sweater
Light 0.20a Light 0 . 17a
Heavy 0.37a Heavy 0 .37a

Jacket Jacket
Light 0.22 Light 0.17
Heavy 0.49 Heavy 0.37

Footwear
Socks Stockings
Ankle length 0.04 Any length 0.01
Knee-high 0.10 Panty hose 0.01

Shoes Shoes
Sandals 0.02 Sandals 0.02
Oxfords 0.04 Pumps 0.04
Boots 0.08 Boots 0.08

Total lc | = 0.80 (individual items) plus the external air layer of 0.8

aLess 10% if short sleeve or sleeveless

bPlus 5% if below knee length, less 5% if above

Adapted from Reference 25.

24
In summary, insulation is generally a function of the thickness of the
clothing ensemble, and this, in turn, is usually a function of the
number of clothing layers. Thus, each added layer of clothing, if not
compressed, will increase the total insulation. That is why most
two-layer protective clothing ensembles exhibit quite similar insulation
characteristics; most three-layer systems are comparable, regardless of
some rather major differences in fiber or fabric type [14].

2. C lo th in g P e rm e a b ility and Evaporative Heat Loss

Evaporative heat transfer through clothing tends to be affected linearly

by the thickness of the ensemble. The moisture permeability index
(im ) is a dimensionless unit, with a theoretical lower limit value of
0 for a vapor- and ai r-impermeable layer and an upper value of 1 if all
the moisture that the ambient environment can take up (as a function of
the ambient air vapor pressure and fabric permeability) can pass through
the fabric. Since moisture vapor transfer is a diffusion process
limited by the characteristic value for diffusion of moisture through
still air, values of im approaching 1 should be found only with high
wind and thin clothing. A typical im value for most clothing
materials in still air is less than 0.5 (e.g., im will range from 0.45
to 0.48). Water repellent treatment, very tight weaves, and chemical
protective impregnations can reduce the im value significantly.
However, even impermeable layers seldom reduce the im value to zero
since an internal evaporation-condensation cycle is set up between the
skin surface and the inner surface of the impermeable layer which
effectively transfers some heat from the skin to the vapor barrier; this
shunting, by passing heat across the intervening insulation layers, can
be reflected as an im value of perhaps 0.08 even for a totally
impermeable overgarment.

Very few fiber treatments have been found to improve the im index
value of fabric layers; surfactants which increase the number of free
hydroxyl (OH) radicals on the fiber surface or which somehow improve
wicking appear to have improved the im value of a fabric. However,
the ultimate evaporative heat transferred from the skin through the
clothing and external air layers to the environment is not simply a
function of the im , but is a function of the permeability
index-insuI at ion ratio (im/clo). The maximum evaporative heat
exchange with the environment can be estimated for the H r + q of a man
with 1.8 m 2 of surface area, as:

HEmax= ^0 'ir/c l° x 2 .2 (psk-pa )

The constant 2.2 is the Lewis number; psk is the water vapor pressure
of sweat (water) at skin temperature (ts k ); and pa is the water
vapor pressure of the ambient air at air temperature, ta . Thus, the
maximum evaporative transfer tends to be a linear, inverse function of
insulation if not further degraded by various protective treatments
which range from total impermeability to water repellent treatments
[14,20,26].

25
3. P h ysiolog ic Problems o f C lothing

The percent of sweat-wetted skin surface area (w) that will be required
to eliminate the required amount of heat from the body by evaporation
can be estimated simply as the ratio of the required evaporative cooling
(Ereq) and the maximum water vapor uptake capacity of the ambient air
^max)- A totally wetted skin = 100 %.

w = E req^m ax

Some sweat-wetted skin is not uncomfortable; in fact, some sweating

during exercise in heat increases comfort. As the extent of skin wetted
with sweat approaches 20 %, the sensation of discomfort begins to be
noted. Discomfort is marked with between 20% and 40% wetting of the
body surface, and performance decrements can appear; they become
increasingly noted as w approaches 60%. Sweat begins to be wasted,
dripping rather than evaporating at 70%; physiologic strain becomes
marked between 60% and 80% w. Increases of w above 80% result in limited
tolerance even for physically fit, heat-acclimatized young workers. The
above arguments indicate that any protective work clothing will pose
some limitations on tolerance since, with la plus lc |0 rarely below
2.5 clo, their im /clo ratios are rarely above 0.20 [20].

The physiologic problem with clothing, heat transfer, and work can be
estimated from equations which describe the competition for the blood
pumped by the heart. The cardiac output (CO) is the stroke volume (SV)
(or volume of blood pumped per beat) times heart rate (HR) in beats per
minute (b/min) (C0=SVxHR). The cardiac output increases essentially
linearly with increasing work; the rate limiting process for metabolism
is the maximum rate of delivery of oxygen to the working muscle via the
blood supply. The blood supply (or cardiac output) is a function of HR
times SV (HRxSV). It is expressed in liters per minute (L/min). In
heat stress this total blood supply must be divided between the working
muscles and the skin where the heat exchange occurs.

Stroke volume rapidly reaches a constant value for a given intensity of

work. Thus, the work intensity, i.e., the rate of oxygen delivered to
the working muscles, is essentially indicated by heart rate; the
individual worker's maximum heart rate limits the ability to continue
work. Conditions that impair the return of blood from the peripheral
circulation to fill the heart between beats will affect work capacity.

The maximum achievable heart rate is a function of age and can be

roughly estimated by the relationship: 220 b/min minus age in years
[27,28]. Given equivalent HR at rest (e.g., 60 b/min), a 20-year-old
worker's HR has the capacity to increase by 140 b/min, i.e., (220-20)-60
while a 60-year-old worker can increase his HR only 100 b/min, i.e.,
(220-60)-60. Since the demands of a specific task will be roughly the
same for 2 0 - and 60-year-old individuals who weigh the same and do the
same amount of physical work, the decrease in HR increase capacity with
age increases both the perceived and the actual relative physiologic
strain of work on the older worker.

26
The ability to transfer the heat produced by muscle activity from the
core of the body to the skin also is a function of the cardiac output.
Blood passing through core body tissues is warmed by heat from
metabolism during rest and work. The basic requirement is that skin
temperature (tsk) must be maintained at least 1°C (1.8°F) below deep
body temperature (tre) if blood that reaches the skin is to be cooled
before returning to the body core. The heat transferred to the skin is
limited, ultimately, by the cardiac output and by the extent to which
tsk can be maintained below tre.

A worker's tre is a function of metabolic heat production (M) (tre =

36.7+0.004M) as long as there are no restrictions on evaporative and
convective heat loss by clothing, high ambient vapor pressures, or very
low air motion; e.g., at rest, if M = 105 watts, tre is about 37.1°C
(98.8°F). Normally, under the same conditions of unlimited evaporation,
skin temperatures are below tre by about 3.3°C + (0.006M); thus, at
rest, when tre is 37°C, the corresponding tsk is about 33°C, i.e.,
37-(3.3+0.6). This 3°-4°C difference between tre and tsk indicates
that at rest each liter of blood flowing from the deep body to the skin
can transfer approximately 4.6 watts or 4 kcal of heat to the skin.
Since tre increases and ts|< decreases due to the evaporation of
sweat with increasing M, it normally becomes easier to eliminate body
heat with increasing work since the difference between tre and tsk
increases by about 1°C (1.8°F) per 100 watts (86 kcal) of increase in M
(i.e., t re up 0.4°C (0.7°F), and tsk down 0.6°C (1.1°F) per
100 watts of M). Thus, at sustainable hard work (M=500 watts or
430 kcal/h), each liter of blood flowing from core to skin can transfer
9 kcal to the skin, which is 2.5 times that at rest [20,26].

Work under a heat-stress condition sets up a competition for cardiac

output, particularly as the blood vessels in the skin dilate to their
maximum and less blood is returned to the central circulation.
Gradually, less blood is available in the venous return to fully fill
the heart between beats, causing the stroke volume to decrease;
therefore, heart rate must increase to maintain the same cardiac output.

For a fit, young workforce, the average work heart rate should be
limited to about 110 b/min if an 8 -hour workshift is to be completed; an
average heart rate of 140 b/min for a maximum work time of 4 hours or
less, and 160 b/min should not be maintained for more than 2 hours
[29]. If the intensity of work results in a heart rate in excess of
these values, the intensity of work should be reduced. Thus, heat added
to the demands of work rapidly results in problems even in a healthy,
young workforce. These problems are amplified if circulating blood
volume is reduced as a resu-lt of inadequate water intake to replace
sweat losses, which can average one liter an hour over an 8 -hour
workshift (or by vomiting, diarrhea, or diuresis).

The crisis point, heat exhaustion and collapse, is a manifestation of

the inadequate blood supply to the brain; this occurs when cardiac
output becomes inadequate, because of insufficient return of blood from

27
the periphery to fill the heart for each beat, or because of inadequate
time between beats to fill the heart as heart rates approach their
max im a .

Unfortunately, clothing interferes with heat loss from the skin, and
skin temperature rises predictably with increased clothing. Because of
the insulation induced rise in tsk and the resultant limited ability
to dissipate heat that has been transferred from the core to the skin,
core temperature (tre) also rises when clothing is worn. Another type
of interference with heat loss from the skin arises when sweat
evaporation is required for body cooling (i.e., when M+Hp+Q>0), but is
limited either by high ambient water vapor pressure, low wind, or low
clothing permeability index (im/clo).

As E req approaches Em a x , skin temperature increases dramatically and

deep body temperature begins to increase rapidly. Deep body
temperatures above 38.0°C (1 0 0 .4°F) are considered undesirable for an
average industrial workforce. The risk of heat-exhaustion collapse is
about 25% at a deep body temperature of 39.2°C (102.6 °F) associated with
a skin temperature of 38°C (100.4°F) (i.e., tsk converging toward
tre and approaching the 1°C (1.8°F) limiting difference where one
liter of blood can transfer only 1 or 2 kcal to the skin). At a
similarly elevated ts|< where tre is 39.5°C (103.1°F), there is an
even greater risk of heat-exhaustion collapse, and as tre approaches
40°C (104°F), with elevated skin temperatures, most individuals are in
imminent danger of heat-induced illness. Finally, tre levels above
41°C (105.8°F) are associated with heatstroke, a life-threatening major
medical emergency. The competition for cardiac output is sorely
exacerbated by hypohydration (limited stroke volume), by age (limited
maximum heart rate), and by reduced physical fitness (compromised
cardiac output). These work-Iimiting and potentially serious deep body
temperatures are reached more rapidly when combinations of these three
factors are involved.

As indicated in the above statements, maximum work output may be

seriously degraded by almost any protective clothing worn during either
heavy work in moderately cool environments or low work intensities in
hot conditions, because of the clothing interfering with heat
elimination. The heat-stress problem is also likely to be increased
with any two-layer protective ensembles or any effective single-layer
vapor barrier system for protection against toxic products, unless some
form of auxiliary cooling is provided [20,26].

28
 IV . BIOLOGIC EFFECTS OF HEAT

A. P h ysiolog ic Responses to Heat

1. The C entral Nervous System

The central nervous system is responsible for the integrated

organization of thermoregulation. The hypothalamus of the brain is
considered to be the central nervous system structure which acts as the
primary seat of control. In general terms, the anterior hypothalamus
operates as a integrator and "thermostat" while the posterior
hypothalamus provides a "set point" of the core or deep-body temperature
and initiates the appropriate physiologic responses to keep the body
temperature at the "set point" if the core temperature changes.

The anterior hypothalamus is the area which receives the information

from receptors sensitive to changes in temperature in the skin, muscle,
stomach, other central nervous system tissues, and elsewhere. In
addition, the anterior hypothalamus itself contains neurons which are
responsive to changes in temperature of the arterial blood serving the
region. The neurons responsible for the transmission of the temperature
information use monoamines among other neurotransmitters; this has been
demonstrated in animals [30]. These monoamine transmitters are
important in the passage of appropriate information to the posterior
hypothalamus. Another neuronal transmitter is acetylcholine. It is
known that the "set point" in the posterior hypothalamus is regulated by
ionic exchanges.

The ratio of sodium to calcium ions is also important in

thermoregulation. The sodium ion concentration in the blood and other
tissues can be readily altered by exercise and by exposure to heat.
However, the "set-point" hypothesis has recently generated considerable
controversy [31].

When a train of neural traffic is activated from the anterior to the

posterior hypothalamus, it is reasonable to suppose that once a "hot"
pathway is activated, it will inhibit the function of the "cold" pathway
and vice versa. However, there is a multiplicity of neural inputs at
all levels in the central nervous system and many complicated neural
"loops" undoubtedly exist.

The.posterior hypothalamus, besides determining the "set-point," is also

responsible for mobilizing the physiologic mechanisms required to
maintain that temperature. In situations where the "set-point"
temperature is exceeded, the circulation is controlled on a regional
basis through the sympathetic nervous system to dilate the cutaneous
vascular bed and thereby increase skin blood flow, and if necessary, the
sweating mechanism is invoked. These mechanisms are designed to
dissipate heat in an attempt to return the "set-point" to its original
level.

A question that must be addressed is the difference between a

physiologically raised body temperature and a fever During a fever, it

29
is considered that the "set-point" is elevated as determined by the
posterior hypothalamus. At the onset of a fever, the body invokes
heat-conservation mechanisms (such as shivering and cutaneous
vasoconstriction) in order to raise the body temperature to its new
"set-point" [30]. In contrast, during exercise in heat, which may
result in an increase in body temperature, there is no change in
"set-point" temperature, and only heat-dissipat ion mechanisms are
invoked. Once a fever is induced, the elevated body temperature appears
to be normally controlled by the usual physiologic processes around its
new and higher "set-point."

2. Muscular A c t iv it y and Work Capacity

The muscles are by far the largest single group of tissues in the body,
representing some 45% of the body weight. The bony skeleton, on which
the muscles operate to generate their forces, represents a further 15%
of the body weight. The bony skeleton is relatively inert in terms of
metabolic heat production. However, even at rest, the muscles produce
about 20-25% of the body's total heat production. The amount of
metabolic heat produced at rest is quite similar for all individuals
when it is expressed per unit of surface area or of lean or fat-free
body weight. On the other hand, the heat produced by the muscles during
exercise can be much higher, all of which must be dissipated if a heat
balance is to be maintained. The heat load from metabolism is,
therefore, widely variable, and it is during work in hot environments
(which imposes its own heat load or restricts heat dissipation) that the
greatest challenge to normal thermoregulation exists.

The proportion of maximal aerobic capacity (V0 2 max) needed to do a

specific job is important for several reasons. First, the
cardiovascular system must respond with an increased cardiac output
which at levels of work of up to about 40% V 0 2 max is brought about by
an increase in both stroke volume and heart rate. When maximum stroke
volume is reached, additional increases in cardiac output can be
achieved solely by increased heart rate (which itself has a maximum
value). Further complexities arise when high work intensities are
sustained for long periods, particularly when work is carried out in hot
surroundings. Second, muscular activity is associated with an increase
in muscle temperature, which then is associated with an increase in core
temperature, with attendant influences on the thermoregulatory
controls. Third, at high levels of exercise even in a temperate
environment, the oxygen supply to the tissues may be insufficient to
meet the oxygen needs of the working muscles completely.

In warmer conditions, an adequate supply of oxygen to the tissues may

become a problem even at moderate work intensities because of
competition for blood distribution between the working muscle and the
skin. Because of the lack of oxygen, the working muscles must then
begin to draw on their anaerobic reserves, deriving energy from the
oxidation of glycogen in the muscles. That event leads to the
accumulation of lactic acid which may be associated with the development
of muscular fatigue. As the proportion of V0 2 max used increases
further, anaerobic metabolism assumes a relatively greater proportion of

30
the total muscular metabolism. An oxygen "debt" occurs when oxygen is
required to metabolize the lactic acid that accumulates in the muscles.
This "debt" must be repaid during the rest period. In hot environments,
the recovery period is prolonged as the elimination of both the heat and
the lactic acid stored in the body has to occur and water loss must be
replenished. These occurrences may take 24 hours or longer [31,32].

It is well established that, in a wide range of cool to warm

environments, 5°-29°C (41°-84.2°F), the deep body temperature rises
during exercise to a similar equilibrium value in subjects working at
the same proportion of VC^max [18,33]. However, two individuals doing
the same job and working at the same absolute load level and who have
widely different V0 2 max values will have quite different core
temperatures. Currently, recommendations for an acceptable proportion
of VC^max for daily industrial work vary from 30-40% of the V0 2 max,
which in comfortably cool surroundings [34] is associated with rectal
temperatures of, respectively, 37.4° and 37.7°C (99.3°-99.9°F), while
work at 50% V0 2 fnax yields a rectal temperature of 38°C (100.4°F) in
the absence of heat stress.

In addition to sex- and age-related variability, the inter individual

variability of V 0 2 max is high; therefore, the range of V0 2 max to
include 95 of every 100 individuals will be +20% of the mean V0 2 max
value. Differences in body weight (particularly the muscle mass) can
account for about half that variability when V02 max is expressed as
mL 0 2 /kg/min, but the source of the remaining variation has not been
precisely identified. Age is associated with a reduction in V0 2 max
after peaking at about 20 years of age, and falling in healthy
individuals by nearly 10% each decade after age 30. The decrease in
V0 2 max with age is less in individuals who have maintained a higher
degree of physical fitness. Women have levels of V 0 2 max which average
about 70% of that for men in the same age group due to lower absolute
muscle mass [34]. There are many factors to consider with respect to
the deep body temperature when the same job is done by both men and
women of varying body weights, ages, and work capacities.

Other sources of variability when individuals work in hot environments

are differences in circulatory system capacity, in sweat production, and
in the ability to regulate electrolyte balance, each of which may be
large.

Previously, work performance was comprehensively reviewed [35,36], and

little or no new data have been published. Work capacity is reduced to
a limited extent in hot surroundings if body temperature is elevated.
That reduction becomes greater as the body temperature is increased.
The V0 2 max is not reduced by hypohydration itself (except for severe
hypohydration) so that its reduction in hot environments seems to be
principally a function of body temperature. Core temperature must be
above 38°C (100.4°F) before a reduction is noticeable; however, a rectal
temperature of about 39°C (102.2°F) may result in some reduction of
V02max .

31
The capacity for prolonged exercise of moderate intensity in hot
environments is adversely affected by hypohydration which may be
associated with a reduction of sweat production and a concomitant rise
in rectal temperature and heart rate. If the total heat load is high
and the sweat rate is high, it is increasingly more difficult to replace
the water lost in the sweat (750-1,000 mL/h). The thirst mechanism is
usually not strong enough to drive one to drink the large quantities of
water needed to replace the water lost in the sweat. Existing evidence
supports the concept that as the body temperature increases in a hot
working environment, the endurance for physical work is decreased.
Similarly, as the environmental heat stress increases, many of the
psychomotor, vigilance, and other experimental psychologic tasks show
decrements in performance [37,38,39,40,41]. The decrement in
performance may be at least partly related to increases in core
temperature and hypohydration. When the rectal temperature is raised to
38.5°-39.0°C (101.3°-102.2°F), associated with heat exhaustion, there
are many indications of disorganized central nervous system activity,
including poor motor function, confusion, increased irritability,
blurring of vision, and changes in personality, prompting the unproven
suggestion that cerebral anoxia (reduced oxygen supply to the brain) may
be responsible [4,39,42].

3. C irc u la to ry Regulation

The circulatory system is the transport mechanism responsible for

delivering oxygen and foodstuffs to all tissues and for transporting
unwanted metabolites and heat from the tissues. However, the heart
cannot provide enough cardiac output to meet both the peak needs of all
of the body's organ systems and the need for dissipation of body heat.
The autonomic nervous system and endocrine system control the allocation
of blood flow among competing organ systems.

During exercise, there is widespread, sympathetic circulatory

vasoconstriction initially throughout the body, even in the cutaneous
bed. The increase in blood supply to the active muscles is assured by
the action of locally produced vasodilator substances which also inhibit
(in the blood vessels supplying the active muscles) the increased
sympathetic vasoconstrictor activity. In inactive vascular beds, there
is a progressive vasoconstriction with the severity of the exercise.
This is particularly important in the large vascular bed in the
digestive organs, where venoconstriction also permits the return of
blood sequestered in its large venous bed, allowing up to 1 liter of
blood to be added to the circulating volume [36].

If the need to dissipate heat arises, the autonomic nervous system

reduces the vasoconstrictor tone of the cutaneous vascular bed, followed
by "active" dilation which occurs by a mechanism which is, at present,
unclear. The sweating mechanism and an unknown critical factor that
causes the importantly large dilation of the peripheral blood vessels in
the skin are mutually responsible for man's remarkable thermoregulatory
capaci ty in the heat.

32
When individuals are exposed to continuous work at high proportions of
V0 2 max or to continuous work at lower intensities in hot surroundings,
the cardiac filling pressure remains relatively constant, but the
central venous blood volume decreases as the cutaneous vessels dilate.
The stroke volume falls gradually, and the heart rate must increase to
maintain the cardiac output. The effective circulatory volume also
decreases, partly due to hypohydration as water is lost in the sweat and
partly as the thermoregulatory system tries to maintain an adequate
circulation to meet the needs of the exercising muscles as well as the
circulation to the skin [36].

4. The Sweating Mechanism

The sweat glands are found in abundance in the outer layers of the
skin. They are stimulated by cholinergic sympathetic nerves and secrete
a hypotonic watery solution onto the surface of the skin. Sweat
production at rates of about 1 L/h has been recorded frequently in
industrial work and represents a large potential source of cooling if
all the sweat is evaporated; each liter of sweat evaporated from the
skin surface represents a loss of approximately 580 kcal (2320 Btu or
675 W) of heat to the environment. Large losses of water by sweat also
pose a potential threat to successful thermoregulation, because a
progressive depletion of body water content occurs if the water lost is
not replaced; hypohydration by itself affects thermoregulation and
results in a rise of core temperature.

An important constituent of sweat is salt or sodium chloride. In most

circumstances, a salt deficit does not readily occur, because our normal
diet provides 8-14 g/d. However, the salt content of sweat in
unacclimatized individuals may be as high as 4 g/L, while for the
acclimatized individual it will be reduced to 1 g/L or less. It is
possible for a heat-unacclimatized individual who consumes a restricted
salt diet to develop a negative salt balance. In theory, a prolonged
negative salt balance with a large fluid intake could result in a need
for moderate supplementation of dietary salt. If there is a continuing
negative salt balance, acclimatization to heat is diminished. However,
salt supplementation of the normal diet is rarely required except
possibly for heat-unacclimatized individuals during the first 2 or
3 days of heat exposure [32]. By the end of the third day of heat
exposure, a significant amount of heat acclimatization will have
occurred with a resulting decrease in salt loss in the sweat and urine
and. a decrease in salt requirement. In view of the high incidence of
elevated blood pressure in the U.S. worker population and the relatively
high salt content of the average U.S. diet, even in those who watch salt
intake, recommending increased salt intake is probably not warranted.
Salt tablets can irritate the stomach and should not be used [43].
Heavier use of salt at meals has been suggested for the
heat-unacclimatized individual during the first 2-3 days of heat
exposure (if not on a restricted salt diet by physician's orders).
Carefully induced heat acclimatization will reduce or eliminate the need
for salt supplementation of the normal diet.

33
Because potassium is lost in sweat, there can be a serious depletion of
potassium when workers, who are unacclimatized, suddenly have to work
hard in hot climates; marked depletion of potassium can lead to serious
physiologic consequences including the development of heatstroke [4], A
high table salt intake may increase potassium loss. However, potassium
loss is usually not a problem, except for individuals taking diuretics,
because potassium is present in most foods, particularly meats and
fruits [32]. Since diuretics cause potassium loss, workers taking such
medication while working in a hot environment may require special
medical supervision.

The rate of evaporation of sweat is controlled by the difference in

water vapor pressure on the sweat-wetted skin surface and the air layer
next to the skin and by the velocity of air movement over the skin. As
a consequence, hot environments with increasing humidity limit the
amount of sweat that can be evaporated. Sweat that is not evaporated
drips from the skin and it does not result in any heat loss from the
body. It is deleterious, because it does represent a loss of water and
salt from the body.

a. Water and E le c tr o ly te Balance and the In flu en c e of Endocrines

It is imperative to replace the water lost in the sweat. It is not

uncommon for workers to lose 6-8 quarts of sweat during a working
shift in hot industries. If the lost water is not replaced, there
will be a progressive decrease of body water with a shrinkage not
only of the extracellular space and interstitial and plasma volumes
but also of water in the cells. There is clear evidence that the
amount of sweat production depends on the state of hydration
[4,32,35] so that progressive hypohydration results in a lower sweat
production and a corresponding increase in body temperature, which
is a dangerous situation.

Sweat lost in such quantities is often difficult to replace

completely as the day's work proceeds, and it is not uncommon for
individuals to register a water deficit of 2-3% or greater of the
body weight. During exercise in either cool or hot environments, a
correlation has been reported between the elevation of rectal
temperature and the percentage of water deficit in excess of 3% of
body weight [44], Because the normal thirst mechanism is not
sensitive enough to ensure a sufficient water intake [32], every
effort should be made to encourage individuals to drink water or
low-sodium noncarbonated beverages. The fluid should be as
palatable as possible at 10°-15°C or 50°-60°F.Small quantities
taken at frequent intervals, about 150-200 mL or 5-7 ozs every 15-20
minutes, is a more effective regimen for practical fluid replacement
than the intake of 750 mL or more once an hour. Communal drinking
containers should be prohibited. Individuals are seldom aware of
just how much sweat they produce or how much water is needed to
replace that lost in the sweat; 1 L/h is not an uncommon rate of
water loss. With suitable instruction concerning the problems of
not drinking enough to replace water lost in sweat, most individuals

34
 will comply. Those who do not replace water loss while at work,
will at least diminish the amount of water deficit they generate and
will usually replenish that deficit in off-duty hours.

Two hormones are important in thermoregulation, the antidiuretic

hormone (ADH) and aldosterone. A variety of stimuli encourages the
synthesis and release of those hormones, such as changes in plasma
volume, plasma concentration of sodium chloride, etc. ADH is
released by the pituitary gland, which has direct neural connections
with the hypothalamus but may receive neural input from other
sources. Its function is to reduce water loss by the kidney, but it
has no effect on the water loss through sweat glands. Aldosterone
is released from the adrenal glands and reduces salt lost both in
the kidney and in the sweat glands.

b. D ie ta ry Factors

There is no reason to believe that a well-balanced diet for work in

temperate environments should not suffice for hot climates.

A very high protein diet might increase the obligatory urine output
for nitrogen removal, and thus increase water intake requirements
[31,32]. The importance of water and salt balance has been
emphasized above, and the possibility that it might be desirable to
supplement the diet with potassium has also been considered. In
some countries where the normal diet is low or deficient in
Vitamin C, supplementation may enhance heat acclimatization and
thermoregulatory function [45].

5. A c c lim a tiz a tio n to Heat

When workers are unexpectedly exposed to hot work environments, they

readily show signs of distress and discomfort; develop increased core
temperatures and heart rates; complaints of headache, giddiness, or
nausea; andsuffer other symptoms of incipient heatexhaustion
[4,8,39,44,46,47,48]. On first exposure, they may faint. On repeated
exposure there is a marked adaptation in which the principal physiologic
benefit appears to result from an increased sweating efficiency (earlier
onset, greater sweat production, and lower electrolyte concentration)
and a concomitant stabilization of the circulation, so that after daily
heat exposure for 7-10 days, the individuals perform the work with a
much lower core temperature and heart rate and higher sweat rate (i.e.,
a reduced thermoregulatory strain) and with none of the distressing
symptoms that were experienced at first. During that period there is at
first a rapid expansion of plasma volume, so that even though there is a
hemoconcentration throughout the exposure to heat, the plasma volume at
the end of the heat exposure in the acclimatized state is often equal to
or in excess of the value before the first day of heat exposure.
Acclimatization to heat is an unsurpassed example of physiologic
adaptation which is well demonstrated in laboratory experiments and
field experience [48,49]. However, acclimatization does not necessarily
mean that the individuals can work above the Prescriptive Zone as
effectively as below it (see Appendix A) [18].

35
Full heat acclimatization occurs with relatively brief daily exposures
to working in the heat. It does not require exposure to heat at work
and rest for the entire 24 h/d; in fact, such excessive exposures may be
deleterious, because it is hard for individuals without heat
acclimatization experience to replace all of the water lost in sweat.
The minimum exposure time for achieving heat acclimatization is a
continuous exposure of about 100 minutes daily [4,49]. Some daily
period of relief from exposure to heat, in air-conditioned surroundings,
is beneficial to the well-being of the individuals if for no other
reason, they find it hard to rest effectively in hot surroundings [44].

The level of acclimatization is relative to the initial level of

individual physical fitness and the total heat stress experienced by the
individual. Thus, a worker who does only light work indoors in a hot
climate will not achieve the level of acclimatization needed to work
outdoors with the additional heat load from the sun or to do harder
physical work in the same hot environment indoors.

Failure to replace the water lost in sweat will retard or even prevent
the development of the physiologic adaptations described. In spite of
the fact that acclimatization will be reasonably well maintained for a
few days of nonheat exposure, absence from work in the heat for a week
or more results in a significant loss in the beneficial adaptations.
However, usually heat acclimatization can be regained in 2 to 3 days
upon return to a hot job [47,49]. Heat acclimatization appears to be
better maintained by individuals who are physically fit [50].

The total sweat production increases with acclimatization, and sweating

begins at a lower skin temperature. The cutaneous circulation and
circulatory conductance decreases with acclimatization, reflecting the
reduction in the proportion of cardiac output that must be allocated for
thermoregulation, because of the more efficient sweating mechanism.
There is still no clear explanation of how these events are brought
about and what the underlying mechanisms are that alter the
cardiovascular and thermoregulatory responses so dramatically. It is
clear, however, that during exercise in heat, the production of
aldosterone is increased to conserve salt from both the kidney and the
sweat glands, while an increase in antidiuretic hormone conserves the
amount of water lost through the kidneys.

It is obvious from the foregoing description that sudden seasonal shifts

in environmental temperature may result in thermoregulatory difficulties
for exposed workers. At such times, cases of heat disorder may occur,
even for acclimatized workers, if the outside environment becomes very
hot.

Acclimatization to work in hot, humid environments provides adaptive

benefits which also apply in hot, desert environments, and vice versa;
the qualifying factor appears to be the total heat load experienced by
the individual.

36
6. Other Related Factors

a. Age

The aging process results in a more sluggish response of the sweat

glands, which leads to a less effective control of body
temperature. Aging also results in a curiously increased high level
of skin blood flow associated with exposure to heat. The cause of
this remains undetermined, but implies an impaired thermoregulatory
mechanism possibly related to a reduced efficiency of the
sympathetic nervous system [18,27,28]. For women, it has been found
that the skin temperature increases with age in moderate and high
heat loads, but not in low heat loads [27,28]. When two groups of
male coal miners of average age 47 and 27 years, respectively,
worked in several comfortable or cool environments, they showed
little difference in their responses to heat near the REL with light
work, but in hotter environments the older men showed a
substantially greater thermoregulatory strain than their younger
counterparts; the older men also had lower aerobic work capacities
[51]. In analyzing the distribution of 5 years' accumulation of
data on heatstroke in South African gold mines, Strydom [52] found a
marked increase in heatstroke with increasing age of the workers.
Thus, men over 40 years of age represented less than 10% of the
mining population, but they accounted for 50% of the fatal and 25%
of the nonfatal cases of heatstroke. The incidence of cases per
100,000 workers was 10 or more times greater for men over 40 years
than for men under 25 years of age. In all the experimental and
epidemiologic studies described above, the workers had been
medically examined and were considered free of disease. Total body
water decreases with age which may be a factor in the observed
higher incidence of fatal and nonfatal heatstroke in the older group.

b . Gender

Purely on the basis of a lower aerobic capacity, the average woman,

similar to a small man, is at a disadvantage when she has to perform
the same job as the average-sized man. While all aspects of heat
tolerance in women have not been fully examined, their
thermoregulatory capacities have been. When they work at similar
proportions of their V0 2 max, the women perform either similarly or
only slightly less well than men [53,54,55,56]. There seems to be
little change in thermoregulatory capacities at different times
during their menstrual cycles [57].

c . Body Fat

It is well established that obesity predisposes individuals to heat

disorders [4]. The acquisition of fat means that additional weight
must be carried, thereby calling for a greater expenditure of energy
to perform a given task and use of a greater proportion of the
VOomax. In addition, the body surface to body weight ratio
(m^ to kg) becomes less favorable for heat dissipation. Probably
more important is the lower physical fitness and decreased maximum

37
work capacity and cardiovascular capacity frequently associated with
obesity. The increased layer of subcutaneous fat provides an
insulative barrier between the skin and the deep-lying tissues. The
fat layer theoretically would reduce the direct transfer of heat
from the muscles to the skin [58].

d. Drugs

(1 ) Alcohol

Alcohol has been commonly associated with the occurrence of

heatstroke [4]. It is a drug which interferes with central and
peripheral nervous function and is associated with hypohydration
by suppressing ADH production. The ingestion of alcohol prior
to or during work in the heat should not be permitted, because
it reduces heat tolerance and increases the risk of heat
iIInesses.

(2 ) Therapeutic Drugs

Many drugs prescribed for therapeutic purposes can interfere

with thermoregulation [59]. Some of these drugs are
anticholinergic in nature or involve inhibition of monoamine
oxidative reactions, but almost any drug that affects central
nervous system (CNS) activity, cardiovascular reserve, or body
hydration could potentially affect heat tolerance. Thus, a
worker who requires therapeutic medications should be under the
supervision of a physician who understands the potential
ramifications of drugs on heat tolerance. In such instances, a
worker taking therapeutic medications who is exposed only
intermittently or occasionally to a hot environment should seek
the guidance of a physician.

(3 ) Social Drugs

It is hard to separate drugs used therapeutically from those

which are used socially. Nevertheless, there are many drugs
other than alcohol which are used on social occasions. Some of
those have been implicated in cases of heat disorder, sometimes
leading to death [59].

e. Nonheat Disorders

It has long been recognized that individuals suffering from

degenerative diseases of the cardiovascular system and other
diseases such as diabetes or simple malnutrition are in extra
jeopardy when they are exposed to heat, and when a stress is imposed
on the cardiovascular system. The outcome is readily seen during
sudden or prolonged heat waves in urban areas where there is a
sudden increase in mortality especially among older individuals who
supposedly have age-related reduced physiologic reserves
[4,60,61,62]. In prolonged heat waves, the mortality is higher in
the early phase of the heat wave [60,61]. While acclimatization may

38
 play a part in the decrease in mortality during the later part of a
prolonged heat wave, the increased death rate in the early days of a
heat wave may reflect an "accelerated mortality," with the most
vulnerable more likely to succumb at that time rather than more
gradually as a result of degenerative diseases.

f. Individual V a ria tio n

In all experimental studies of the responses of humans to hot

environmental conditions, a wide variation in responses has been
observed. These variations are seen not only between different
individuals but also to some extent in the same individual exposed
to high stress on different occasions. Such variations are not
totally understood. It has been shown [47] that the influence of
body size and its relationship to aerobic capacity in tolerance to
heat could account for about half of the variability, leaving the
remainder to be accounted for. Possibly, changes in hydration and
salt balance might be responsible for some of the remaining
variability [63]. However, the degree of variability in tolerance
to hot environments remains a vexing problem.

7. Heat-Related Health and Safety E ffects

The incidence of work-related heat illness in the United States is not

documented by an occupational injury/illness surveillance system.
However, the Supplementary Data System (SDS) maintained by the U.S.
Bureau of Labor Statistics (BLS) contains coded information from
participating states about workers' heat illness compensation claims.

Those workers' compensation cases which were coded to indicate that the
disorder was a heat illness which occurred during 1979 have been
analyzed by Jensen [64]. The results indicate that the industries with
the highest rate of reported compensation cases for heat illness per
100,000 workers are agriculture (9.16 cases/100,000 workers),
construction (6.36/100,000), and mining (5.01/100,000). The other
industrial divisions had case rates of fewer than 3 per 100,000
workers. Dinman et al . [65] reported an incidence rate of 6.2 per
1 ,0 0 0 , 0 0 0 man-hours in a study of three aluminum plants during a
May-September observation period. Minard reported 1 per 1,000 workers
had heat-related illnesses during a 5-month period in three aluminum and
two steel plants (presumably the same plants reported by Dinman et al.)
[6 6 ]. Janous, Horvath, and Horvath and Colwell also reported an
increased incidence of heat illnesses in the iron and steel industry
[67,68,69].

In 1979, the total U.S. incidence of work-related heat illnesses for

which the worker lost at least one day of work following the day of
onset ( lost-workday cases) was estimated to be 1,432 cases [64], The
estimation is based on the assumption that the proportion of cases of a
particular kind of injury in the SDS data base is equivalent to the
proportion of cases for that kind of injury or lost-workday cases
nationwide. It has been shown that when the thermal environmental
conditions of the workplace exceed temperatures which are typically

39
 preferred by most people, the safety-related behavior of workers is
detrimentally affected and increased exponentially with increasing heat
load [70,71].

In an analysis by cause (chemical and physical agent) of the

occupational illnesses and injuries reported in the 1973 State of
California, Division of Labor Statistics and Research, Dukes-Dobos [71]
found that 422 cases resulting in some lost time were the result of
"heat and humidity," which was the most frequent physical agent cause.
Forty-seven of these cases were hospitalized and three died. Chlorine
was the most frequently cited chemical hazard with 529 lost-time cases;
48 were hospitalized, and there were no deaths. Other chemical and
physical agents such as ammonia, trichloroethylene, noise, benzene,
lead, and chromium were less frequently involved than heat. Janous [67]
reported increased accidents in heat-exposed steelworkers.

B. Acute Heat Disorders

A variety of heat disorders can be distinguished clinically when individuals

are exposed to excessive heat [4,18,72,73,74,75]. These disorders range
from simple postural heat syncope (fainting) to the complexities of
heatstroke. The heat disorders are interrelated and seldom occur as
discrete entities. A common feature in all the heat-related disorders
(except simple postural heat syncope) is some degree of elevated body
temperature which may then be complicated by deficits of body water. The
prognosis depends on the abso ute level of the elevated body temperature,
the promptness of treatment to lower the body temperature, and the extent of
deficiency or imbalance of fluids or electrolytes, A summary of
classification, clinical features, prevention, and treatment of heat
illnesses is presented in Table IV— 1 . Recently, a new scheme for
differential diagnosis of heat-induced illnesses has been published [72].

40
 TABLE IV-1.— Classification, medical aspects, and prevention of heat illness

Underlying physiologic
Category and clinical features Predisposing factors disturbance_______ T reatment Prevention

1. Temperature Regulation
Heatstroke

Heatstroke: (1) Hot (1) Sustained exertion Failure of the central Immediate and rapid Medical screening of
dry skin usually red, in heat by unacclima- drive for sweating cooling by immersion workers, selection
mottled or cyanotic; tized workers; (2) Lack (cause unknown) leading in chilled water with based on health and
(2) t_e , 40.5°C of physical fitness and to loss of evaporative massage or by wrapping physical fitness,
(104°FJ and over; obesity; (3) Recent cooling and an uncon­ in wet sheet with acclimatization for
(3) confusion, loss of alcohol intake; (4) De­ trolled accelerating vigorous fanning with 5-7 days by graded
consciousness, convul­ hydration; (5) Indivi­ rise in t..e , there may cool dry ai r, avoid work and heat expo­
sions, tr„ continues dual susceptibility; and be partial rather than overcooling, treat sure, monitoring
to rise; fatal if (6) Chronic cardio­ complete failure of shock if present workers during sus­
treatment delayed vascular disease sweati ng tained work in
severe heat

2. Circulatory Hypostasis
Heat Syncope

Fainting while Lack of acclimatization Pooling of blood in dilated Remove to cooler Acciimatization,
standing erect and vessels of skin and lower area, rest recumbent intermi ttent
immobile in heat parts of body position, recovery activity to
prompt and complete assist venous
return to heart

3. Water and/or Salt

Depletion

(a) Heat Exhaustion

(1) Fatigue, nausea, (1) Sustained exertion in (1) Dehydration from de­ Remove to cooler Acclimatize workers
headache, giddiness; heat; (2) Lack of acclima- ficiency of water; environment, rest using a breaking-in
(2) Skin clammy and tization; and (3) Failure (2) Depletion of circu­ recumbent position, schedule for 5 to 7
moist; complexion pale, to replace water lost in lating blood volume; administer fluids by days, supplement
muddy, or hectic sweat (3) Circulatory strain from mouth, keep at rest dietary salt only

(continued)
 TABLE IV— 1.— Classification, medical aspects, and prevention of heat illness

Underlying physiologic
Category and clinical features Predisposing factors disturbance_______ Treatment Prevention

flush; (3) May faint competing demands for blood until urine volume during acclimatiza­
on standing with rapid flow to skin and to active indicates that water tion, ample drinking
thready pulse and low muscles balances have been water to be avail­
blood pressure; (4) Oral restored able at all times
temperature normal or and to be taken
low but rectal tempera­ frequently during
ture usually elevated work day
(37.5°-38.5°C) (99.5°-
101.3°F); water restric­
tion type: urine volume
small, highly concentrated;
salt restriction type:
urine less concentrated,
chlorides less than 3 g/L

(b) Heat Cramps

Painful spasms of (1) Heavy sweating during Loss of body salt in sweat, Salted liquids by Adequate salt intake
muscles used during hot work; (2) Drinking water intake dilutes electro- mouth, or more prompt with meals; in un­
work (arms, legs, or large volumes of water lytes, water enters muscles, relief by I-V in­ acclimatized workers
abdominal); onset without replacing salt causing spasm fusion supplement salt in­
during or after work loss take at meals
hours

4. Skin Eruptions

(a) Heat Rash

(miliaria rubra;
"prickly heat")

Profuse tiny raised red Unrelieved exposure to Plugging of sweat gland ducts Mild drying lotions, Cool sleeping
vesicles (blister-like) humid heat with skin con­ with retention of sweat and skin cleanliness to quarters to allow
on affected areas, tinuously wet with un­ inflammatory reaction prevent infection skin to dry between
pricking sensations evaporated sweat heat exposures
during heat exposure

(continued)
 TABLE 1V—1.— Classification, medical aspects, and prevention of heat illness

Underlying physiologic
Category and clinical features Predispositip factors disturbance_______ Treatment Prevention

(b) Anhidrotic Heat

Exhaustion
(miliaria profunda)

Extensive areas of skin Weeks or months of con­ Skin trauma (heat rash; No effective treat­ Treat heat rash and
which do not sweat on stant exposure to sunburn) causes sweat ment available for avoid further skin
heat exposure, but pre­ climatic heat with retention deep in skin, anhidrotic areas of trauma by sunburn,
sent gooseflesh previous history of ex­ reduced evaporative skin, recovery of periodic relief from
appearance, which sub­ tensive heat rash and cooling causes heat in­ sweating occurs grad­ sustained heat
sides with cool envi­ sunburn tolerance ually on return to
ronments; associated cooler climate
with incapacitation in
heat

5. Behavioral Disorders

(a) Heat Fatigue—

co T ransi ent

Impaired performance of Performance decrement Discomfort and physiologic Not indicated un­ Acclimatization and
skilled sensorimotor, greater in unacclima­ strain less accompanied by training for work
mental, or vigilance tized and unskilled other heat illness in the heat
tasks, in heat worker

(b) Heat Fatigue—

Chroni c

Reduced performance Workers at risk come Psychosocial stresses Medical treatment Orientation on life
capacity, lowering of from temperate climates, probably as important as for serious cases, in hot regions
self-imposed standards for long residence in heat stress, may involve speedy relief of (customs, climate,
of social behavior tropical latitudes hormonal imbalance but no symptoms on re­ living conditions,
(e.g., alcoholic over- positive evidence turning home etc.)
indulgence), inability
to concentrate, etc.

Adapted from Reference 73.

1. Heatstroke

The classical description of heatstroke includes: (1) a major

disruption of central nervous function (unconsciousness or convulsions);
(2) a lack of sweating; and (3) a rectal temperature in excess of 41°C
(105.8°F) [4,59,75,76]. The 41°C rectal temperature is an arbitrary
value for hyperpyrexia, because the disorder has not been produced
experimentally in humans so that observations are made only after the
admission of patients to hospitals, which may vary in time from about
30 minutes to several hours after the event. In some heatstroke cases,
sweating may be present [76]. The local circumstances of metabolic and
environmental heat loads which give rise to the disorder are highly
variable and are often difficult or impossible to reconstruct with
accuracy. The period between the occurrence of the event and admission
to a hospital may result in a quite different medical outcome from one
patient to another depending on the knowledge, understanding, skill, and
facilities available to those who render first aid in the intervening
period. Recently, the sequence of biologic events in some fatal
heatstroke cases have been described [77].

Heatstroke is a MEDICAL EMERGENCY, and any procedure from the moment of

onset which will cool the patient improves the prognosis. Placing the
patient in a shady area, removing outer clothing and wetting the skin,
and increasing air movement to enhance evaporative cooling are all
urgently needed until professional methods of cooling and assessment of
the degree of the disorder are available. Frequently, by the time a
patient is admitted to a hospital, the disorder has progressed to a
multisystem lesion affecting virtually all tissues and organs [77]. In
the typical clinical presentation, the central nervous system is
disorganized, and there is commonly evidence of fragility of small blood
vessels, possibly coupled with the loss of integrity of cellular
membranes in many tissues. The blood-clotting mechanism is often
severely disturbed, as are liver and kidney functions. It is not clear,
however, whether these events are present at the onset of the disorder,
or whether their development requires a combination of a given degree of
elevated body temperature and a certain period for tissue or cellular
damage to occur. Postmortem evaluation indicates there are few tissues
which escape pathological involvement. Early recognition of the
disorder or its impending onset, associated with appropriate treatment,
considerably reduces the death rate and the extent of organ and tissue
involvement. An ill worker should not be sent home or left unattended
without a physician's specific order.

2. Heat Exhaustion

Heat exhaustion is a mild form of heat disorder which readily yields to

prompt treatment. This disorder has been encountered frequently in
experimental assessment of heat tolerance. Characteristically, it is
sometimes but not always accompanied by a small increase in body
temperature (38°-39°C or 100.4°-102.2°F). The symptoms of headache,
nausea, vertigo, weakness, thirst, and giddiness are common to both heat
exhaustion and the early stage of heatstroke. There is a wide
interindividual variation in the ability to tolerate an increased body

44
temperature; some individuals cannot tolerate rectal temperatures of
38°-39°C, and others continue to perform well at even higher rectal
temperatures [78].

There are, of course, many variants in the development of heat

disorders. Failure to replace water may predispose the individual to
one or more of the heat disorders and may complicate an already complex
situation. Therefore, cases of hyperpyrexia can be precipitated by
hypohydration. It is unlikely that there is only one cause of
hyperpyrexia without some influence from another. Recent data suggest
that cases of heat exhaustion can be expected to occur some 10 times
more frequently than cases of heatstroke [59].

3. Heat Cramps

Heat cramps are not uncommon in individuals who work hard in the heat.
They are attributable to a continued loss of salt in the sweat,
accompanied by copious intake of water without appropriate replacement
of salt. Other electrolytes such as Mg+ + , Ca+ + , and K+ may also
be involved. Cramps often occur in the muscles principally used during
work and can be readily alleviated by rest, the ingestion of water, and
the correction of any body fluid electrolyte imbalance.

4. Heat Rashes

The most common heat rash is prickly heat (miliaria rubra), which
appears as red papules, usually in areas where the clothing is
restrictive, and gives rise to a prickling sensation, particularly as
sweating increases. It occurs in skin that is persistently wetted by
unevaporated sweat, apparently because the keratinous layers of the skin
absorb water, swell, and mechanically obstruct the sweat ducts
[21,79,80]. The papules may become infected unless they are treated.

Another skin disorder (miliaria crystal Iina) appears with the onset of
sweating in skin previously injured at the surface, commonly in
sunburned areas. The damage prevents the escape of sweat with the
formation of small to large watery vesicles which rapidly subside once
sweating stops, and the problem ceases to exist once the damaged skin is
sloughed.

Miliaria profunda occurs when the blockage of sweat ducts is below the
skin surface. This rash also occurs following sunburn injury, but has
been reported to occur without clear evidence of previous skin injury.
Discrete and pale elevations of the skin, resembling gooseflesh, are
present.

In most cases, the rashes disappear when the individuals are returned to
cool environments. It seems likely that none of the rashes occur (or if
they do, certainly with greatly diminished frequency) when a substantial
part of the day is spent in cool and/or dry areas so that the skin
surface can dry.

45
 Although these heat rashes are not dangerous in themselves, each of them
carries the possibility of resulting patchy areas which are anhidrotic,
and thereby adversely affects evaporative heat loss and
thermoregulation. In experimentally induced miliaria rubra, sweating
capacity recovers within 3-4 weeks [79,80]. Wet and/or damaged skin
could absorb toxic chemicals more readily than dry unbroken skin.

C. Chronic Heat Disorders

Some long term effects from exposure to heat stress (based on anecdotal,
historical, and some epidemiologic and experimental evidence) have been
suggested. Recently, the evidence was reviewed by Dukes-Dobos who proposed
a three-category classification of possible heat-related chronic health
effects [77], The three categories are Type I - those related to acute heat
illnesses such as reduced heat tolerance following heatstroke or reduced
sweating capacity; Type II - not clear clinical entities, but are similar to
general stress reactions; and Type III - which includes anhidrotic heat
exhaustion, tropical neurosthenia, and increased incidence of kidney
stones. The primary references cited in the review are suggestive of some
possible chronic heat effects. However, the available data do not
contribute information of value in protecting workers from heat effects.
Nevertheless, the concept of chronic health effects from heat exposure may
merit further formal laboratory and hot industry investigations.

46
 V. MEASUREMENT OF HEAT STRESS

The Occupational Safety and Health Administration (OSHA) defined heat stress
as the aggregate of environmental and physical factors that constitute the
total heat load imposed on the body [7]. The environmental factors of heat
stress are air temperature and movement, water vapor pressure, and radiant
heat. Physical work contributes to total heat stress of the job by
producing metabolic heat in the body in proportion to the work intensity.
The amount, thermal characteristics, and type of clothing worn also affect
the amount of heat stress by altering the rate of heat exchange between the
skin and the air [7].

Assessment of heat stress may be conducted by measuring the climatic and

physical factors of the environment and then evaluating their effects on the
human body by using an appropriate heat-stress index. This chapter presents
information on (1 ) measurement of environmental factors, (2 ) prediction of
climatic factors from National Weather Service data, and (3) measurement of
metaboli c heat.

A. Environmental Factors

The environmental factors which are of concern in industrial heat stress are
( 1 ) dry bulb (air) temperature, (2 ) humidity or more precisely water vapor
pressure, (3) air velocity, (4) radiation (solar and infrared), and
(5) microwave radiation.

1. Dry Bulb ( A i r ) Temperature

The dry bulb temperature (ta ) is the simplest to measure of the

climatic factors. It is the temperature of the ambient air as measured
with a thermometer; therefore. Temperature units proposed by the
International Standards Organization (ISO) are degrees Celsius (or
Centigrade) C=(°F-32)x5/9 and degrees Kelvin °K=°C+273.

The primary types of thermometers used for measuring dry bulb

temperature are (a) liquid-in-glass thermometers, (b) thermocouples, and
(c) resistance thermometers (thermistor). These thermometers are
basically different in the nature, properties, characteristics, and
materials of the sensing element.

General precautions which must be considered in using any thermometer

are as follows [81]:

• The temperature to be measured must be within the measuring range of

the thermometer.

• The time allowed for measurement must be greater than the time
required for thermometer stabilization.

• The sensing element must be in contact with or as close as possible

to the area of thermal interest.

47
• Under radiant conditions (i.e., in sunlight or where the temperature
of the surrounding surfaces is different from the air temperature),
the sensing element should be shielded.

Each type of these thermometers has advantages, disadvantages, and

fields of application as shown in Table V - 1 .

a. L iq u id -in -G la s s Thermometers

Although a thermometer is any instrument for measuring temperature,

this term is commonly identified with the liquid-in-glass
thermometer which is the simplest, most familiar, and the most
widely used thermometer.

Mercury and alcohol are the more commonly used liquids.

Mercury-in-glass thermometers are preferred under hot conditions,
while alcohol-in-glass thermometers are preferred under cold
conditions since the freezing point of mercury is -40°C (-40°F) and
that of alcohol is -114°C (-173.6°F).

Thermometers used for measuring dry bulb temperature must be total

immersion types. These thermometers are calibrated by total
immersion in a thermostatically controlled medium, and their
calibration scale depends on the coefficients of expansion of both
the glass and the liquid. Only thermometers with the graduations
marked on the stem should be used.

48
 TABLE V-1.— Advantages, disadvantages and limitations, and fields of application
for different types of temperature measuring instruments

Liquid-in-glass thermometers Thermocouples Resistance thermometers

Advantages 1. Simplest thermometers to use 1. Adaptability to remote or 1. Simple to use with

2. Most readily available in continuous recording minimum training
various temperature ranges 2. Equilibrium time is almost 2. Output signal may be
and with various degrees instantaneous recorded
of accuracy 3. Temperatures may be obtained 3. Variety of probes are
3. The least expensive of the within thin materials and available for different
temperature instruments narrow spaces applications
4. Compact, self-contained, 4. Less affected by radiation 4. Thermistors respond
and direct reading device 5. High accuracy (0.1°C) can quickly to changing
be obtained temperatures
5. Less affected by radiation
6 . Calibration procedure

Di sadvantages 1. Fragile 1. Require expensive 1. High cost and hard to repair

and 2. Affected by radiation measuring device 2. Thermistor probes may re­
Limitations 3. Long stabilization time 2. Require reference junction quire individual calibration
(at least 5 minutes) 3. Some kinds are subject to before use
4. Unsuitable for remote use oxidation 3. May require frequent cali­
bration
4. Unreliable above 510°C

Fields of 1. Measuring range is from 1. Measuring range is from 1. Measuring range is from
Appli cation -200 to 540°C -190 to 1650°C -240 to gso'c
2. Industrial-type are avail­ 2. Used for measuring physi­ 2. Remote measurement and
able for permanent installa­ ologic and surface tem­ recording
tion peratures 3. Frequently encountered in
3. Measuring temperatures of 3. Remote measurement and permanently installed tem­
gases and liquid by contact recording perature measurement or
4. Partial immersion thermom­ 4. For measuring high tem­ control systems
eters are used for wet bulb peratures 4. Calibration problems over
and globe temperature range where it may be used
measurements

Adapted from Reference 81.

 b. ThermocoupIes

A thermocouple consists of two wires of different metals connected

together at both ends by soldering, welding, or merely twisting to
form a pair of junctions. One junction is kept at a constant
reference temperature, e.g., usually at 0°C (32°F) by immersing the
junction in an ice bath. The second junction is exposed to the
measured temperature. Due to the difference inelectrochemical
properties of the two metals, an electromotive force (emf) or
voltage is created whose potential is a function of the temperature
difference between the two junctions. By using a mi 11ivoltmeter or
a potentiometer to measure the existing emf or the induced electric
current, respectively, the temperature of the second junction can be
determined from an appropriate calibration table or curve. Copper
and constantan are the metals most commonly used to form the
thermocouple.

c. Resistance Thermometers

A resistance thermometer or thermistor utilizes a metal wire (i.e.,

a resistor) as its sensing element; the resistance of the sensing
element increases as the temperature increases. By measuring the
resistance of the sensor element using a Wheatstone bridge and/or a
galvanometer, the measured temperature can be determined from an
appropriate calibration table or curve, or in some cases the
thermistors are calibrated to give a direct temperature reading.

2. Humidity

Humidity, the amount of water vapor within a given space, is commonly

measured as the relative humidity (rh), i.e., the percentage of moisture
in the air relative to the amount it could hold if saturated at the same
temperature. Humidity is important as a temperature-dependent
expression of the actual water vapor pressure which is the key climatic
factor affecting heat exchange between the body and the environment by
evaporation. The higher the water vapor pressure, the lower will be the
evaporative heat loss.

A hygrometer or psychrometer is an instrument which measures humidity;

however, the term is commonly used for those instruments which yield a
direct reading of relative humidity. Hygrometers utilizing hair or
other organic material are rugged, simple, and inexpensive instruments;
however, they have low sensitivity, especially at temperatures above
50°C (122°F) and an rh below 20%.

a. Water Vapor Pressure

Vapor pressure (pa ) is the pressure at which a vapor can

accumulate above its liquid if the vapor is kept in confinement, and
the temperature is held constant. SI units for water vapor pressure
are millimeters of mercury (mmHg). For calculating heat loss by

50
evaporation of sweat, the ambient water vapor pressure must be
used. The lower the ambient water vapor pressure, the higher will
be the rate of evaporative heat loss.

Water vapor pressure is most commonly determined from a

psychrometric chart. The psychrometric chart is the graphical
representation for the relationships among the dry bulb temperature
(ta ), wet bulb temperature (twb)> dew point temperature (tjp),
relative humidity (rh), and vapor pressure (pa ). By knowing any
two of these five climatic factors, the other three can be obtained
from the psychrometric chart.

b. N atural Wet Bulb Temperature

The natural wet bulb temperature (tnwb) is the temperature

measured by a thermometer which has its sensor covered by a wetted
cotton wick and which is exposed only to the natural prevailing air
movement.

In measuring tnwb a liquid-in-glass partial immersion thermometer,

which is calibrated by immersing only its bulb in a thermostatically
controlled medium, should be used. If a total immersion thermometer
is used, the measurements must be corrected by applying a correction
factor [82]. Accurate measurements of tnwb require using a clean
wick, distilled water, and proper shielding to prevent radiant heat
gain. A thermocouple, thermistor, or resistance thermometer may be
used in place of a liquid-in-glass thermometer.

c. Psychrometric Wet Bulb Temperature

The psychrometric wet bulb temperature (twb) is obtained when the

wetted wick covering the sensor is exposed to a high forced air
movement. The twb is commonly measured with a psychrometer which
consists of two mercury-in-glass thermometers mounted alongside of
each other on the frame of the psychrometer. One thermometer is
used to measure the twb by covering its bulb with a clean cotton
wick wetted with water, and the second measures the dry bulb
temperature (ta ). The air movement is obtained manually with a
sling psychrometer or mechanically with a motor-driven psychrometer.

The sling psychrometer is usually whirled by a handle, which is

jointed to the frame, for a period of approximately 1 minute. A
motor-driven psychrometer uses a battery or spring-operated fan to
pull air across the wick. When no temperature change occurs between
two repeated readings, measurement of twb is taken. Psychrometers
are simple, more precise, and faster responding than hygrometers;
however, they cannot be used under low temperatures near or below
the freezing point of water (humidity is usually 100 % and water
vapor pressure is about 3 mmHg).

51
 d. Dew Point Temperature

Dew point temperature (t<jp) is the temperature at which the

condensation of water vapor in air begins for a given state of
humidity and pressure as the vapor temperature is reduced. The dew
point hygrometer measures the dew point temperature by means of
cooling a highly polished surface exposed to the atmosphere and
observing the temperature at which condensation starts. Dew point
hygrometers are more precise than other hygrometers or psychrometers
and are useful in laboratory measurements; however, they are more
expensive and less rugged than the other humidity measuring
instruments and generally require an electric power source.

3. A ir V e lo c ity

Wind, whether generated by body movements or air movement (Va ), is the

rate in feet per minute (fpm) or meters per second (m/sec) at which the
air moves and is important in heat exchange between the human body and
the environment, because of its role in convective and evaporative heat
t ransfer.

Wind velocity is measured with an anemometer. The two major types are
(a) vane anemometers (swinging and rotating) and (b) thermoanemometers.
Table V-2 summarizes the advantages, disadvantages, and .fields of
application for these types of anemometers. It should be mentioned that
accurate determinations of wind velocity contour maps in a work area are
very difficult to make, because of the large variability in air movement
both with time and within space. In this case, the thermoanemometers
are quite reliable and are sensitive to 0.05 m/sec (10 fpm) but not very
sensitive to wind direction.

52
 TABLE V-2.— Advantages, disadvantages, and fields of application for
different air velocity measuring instruments

Vane anemometers (swing and cup) Thermoanemometers

Advantages 1. Light and suitable for field use 1. Convenient and practical for
2. Accurate when properly calibrated low velocities
3. Direct readout integrated over time 2. Can measure turbulent airflow
4. Relatively inexpensive 3. Light and suitable for field
5. Small use

Di sadvantages 1. Measure only directional air velocity 1. Need properly charged

2. Easily damaged from handling, vibra­ battery or a power supply
tion, and dust 2. The sensing elements are
3. Relatively insensitive for use below fragi 1e
1 m/sec 3. Some types of thermal
4. It is necessary to average visually anemometers are not
the needle movements to obtain portable
average velocity (does not apply to 4. Fluctuating needle movement
rotating) requires visual averaging
5. Require simultaneous measurement for velocity estimate
of time

Fields of 1. Measuring range is from 0.5 m/sec to 1. Measuring range is from 0.03
Application 150 m/sec to 300 m/sec
2. For indoors and ducts 2. For low and very high
3. More suitable for use in mine velocities measurements
shafts and tunnels 3. For directional and
4. Used outside in standard Weather turbulent measurements
Service set tip 4. For permanent stations

Adapted from Reference 81.

If an anemometer is not available for accurate air velocity measurement,
air velocity can be estimated as follows [81]:

vam/sec va fpm

No sensation of air movement (e.g., closed room va <0.2 39

without any air source)

Sensing light breezes (e.g., slight perception 0. 2 0 / ^ 1 .0 39-197

of presence of air movement)

Sensing moderate breezes (e.g., few meters 1.0<\^1.5 197-235

away from a fan; definite perception of air
movement; air causing tousling of hair and
movement of paper)

Sensing heavy breezes (e.g., located close va >1.5 >235

proximity to a fan; air causing marked
movement of clothing)

a. Vane Anemometers (swing and cup)

The two major types of vane anemometers are the rotating vane and
the deflecting or swinging vane anemometers. The propeller or
rotating vane anemometer consists of a light, rotating wind-driven
wheel enclosed in a ring. It indicates, using recording dials, the
number of revolutions of the wheel or the linear distance in meters
or feet. In order to determine the wind velocity, a stopwatch must
be used to record the elapsed time. The newer models have a digi tal
readout. The swinging anemometer consists of a vane enclosed in a
case which has an inlet and an outlet air opening The vane is
placed in the pathway of the air, and the movement of the air causes
the vane to deflect. This deflection can be translated to a direct
readout of the wind velocity by means of a gear train. Rotating
vane anemometers are more accurate than swinging vane anemometers.

Another type of rotating anemometer consists of three or four

hemispherical cups mounted radially from a vertical shaft. Wind
from any direction causes the cups to rotate the shaft and wind
speed is determined from the shaft speed [83].

b. Thermoanemometers

Air velocity is determined with thermoanemometers by measuring the

cooling effect of air movement on a heated element, using one of two
techniques to bring the resistance or the electromotive force (emf)
(voltage) of a hot wire or a thermocouple to a specified value,
measure the current required to maintain this value, and then
determine the wind velocity from a calibration chart; or heat the
thermometer (usually by applying an electric current) and then
determine the air velocity from a direct reading or a calibration

54
 chart relating air velocity to the wire resistance or to the emf for
the hot-wire anemometer and the heated-thermocouple anemometers,
respectively.

4. Rad i a t i on

Radiant heat sources can be classified as artificial (i.e., infrared

radiation in such industries as iron and steel industry, the glass
industry, foundries, etc.) or natural (i.e., solar radiation).

Instruments which are used for measuring occupational radiation (black

globe thermometers or radiometers) have different characteristics from
pyrheliometers or pyranometers which are used to measure solar
radiation. However, the black globe thermometer is the most commonly
used instrument for measuring the thermal load of solar and infrared
radiat ion on m a n .

a. A r tific ia l (O ccu p atio n al) R adiation

(1 ) Black Globe Thermometers

In 1932, Vernon developed the black globe thermometer to measure

radiant heat. The thermometer consists of a 15-cantimeter
(6 -inch) hollow copper sphere (a globe) painted a matte black to
absorb the incident infrared radiation (0.95 emissivity) and a
sensor (thermistor, thermocouple, or mercury-in-glass partial
immersion thermometer) with its sensing element placed in the
center of the globe. The Vernon globe thermometer is the most
commonly used device for evaluating occupational radiant heat,
and it is recommended by NIOSH for measuring the black globe
temperature (tg)[9]; it is sometimes called the standard
6 - inch black globe.

Black globe thermometers exchange heat with the environment by

radiation and convection. The temperature stabilizes when the
heat exchange by radiation is equivalent to the heat exchange by
convection. Both the thermometer stabilization time and the
conversion of globe temperature to mean radiant temperature are
functions of the globe size [84]. The standard 6 -inch globe
requires a period of 15 to 20 minutes to stabilize; whereas
small black globe thermometers of 4.2 centimeters (1.65-inch)
diameter, which are commercially available, require about
5 minutes to stabi Iize [85].

The tg is used to calculate the Mean Radiant Temperature

(MRT). The MRT is defined as the temperature of a "black
enclosure of uniform wall temperature which would provide the
same radiant heat loss or gain as the nonuniform radiant
environment being measured." The MRT for a standard 6 - inch
black globe can be determined from the following equation:

MRT=tg+(1 .8 Va °- 5 )(tg-ta )

55
where:

MRT = Mean Radiant Temperature (°C)

tg= black globe temperature (°C)
ta= air temperature (°C)
Va= air velocity (m/sec)

(2 ) Radiometers

A radiometer is an instrument for measuring infrared radiation.

Some radiometers, e.g., infrared pyrometers, utilize the
measured radiant energy to indicate the surface temperature of
the radiant source. Surface temperatures ranging from -30° to
3000°C can be measured with an infrared pyrometer.

The net radiometer consists of a thermopile with the sensitive

elements exposed on the two opposite faces of a blackened disc.
It has been used to measure the radiant energy balance of human
subjects [8 6 ]. A variety of radiometers has been used to
measure radiant flux [87], Radiometers are not, however,
commonly used in occupational radiant heat measurements. They
are used in laboratories or for measuring surface temperature.

b. N atural (S o la r ) R ad iatio n

Solar radiation can be classified as direct, diffuse, or reflected.

Direct solar radiation comes from the solid angle of the sun's
disc. Diffuse solar radiation (sky radiation) is the scattered and
reflected solar radiation coming from the whole hemisphere after
shading the solid angle of the sun's disc. Reflected solar
radiation is the solar radiation reflected from the ground or
water. The total solarheat load is the sum of the direct, diffuse,
and reflected solar radiation as modified by clothing worn and
position of the body relative to the solar radiation [8 8 ].

(1 ) Pyrheliom eters

Direct solar radiation is measured with a pyrheliometer. A

pyrhel iometer consists of a tube which can be directed at the
sun's disc and a thermal sensor. Generally, a pyrheliometer
with a thermopile as sensor and a view angle of 5.7° is
recommended [89,90]. Two different pyrheIiometers are widely
used: the Angstrom compensation pyrheIiometer and the
Smithsonian silver disc pyrheliometer, each of which uses a
slightly different scale factor.

(2 ) Pyranometers

Diffuse and total solar radiations can be measured with a

pyranometer. For measuring diffuse radiation the pyranometer is
fitted with a disc or a shading ring to prevent direct solar
radiation from reaching the sensor. The receiver usually takes
a hemispherical dome shape to provide a 180° view angle for

56
 total sun and sky radiation. It is used in an inverted position
to measure reflected radiation. The thermal sensor may be a
thermopile, a silicon cell, or a bimetallic strip. Pyranometers
can be used for measuring solar or other radiation between 0.35
and 2.5 micrometers ( pm) which includes the ultraviolet,
visible, and infrared range. Additional descriptions of solar
radiation measurement can be found elsewhere [89,91,92].

5. Mi crowaves

Microwaves comprise the band in the electromagnetic spectrum with

wavelength ranging from 1 to 100 centimeter and frequency from 0.3 to
300 gigahertz (GHz). Microwaves have been used basically for heating
and/or communications in a variety of applications and provide a broad
base for human exposure [93].

Most investigators agree that "high-power density" of microwaves can

result in pathophysiologic manifestations of a thermal nature. Some
reports have suggested that "lower-power density" microwave energy can
affect neural and immunologic function in animals and man [94], Since
1973, a large volume of literature on the biologic effects of microwave
radiation has become available [95]. The principal acute hazard from
microwave radiation is thermal damage to the skin and heating of the
underlying tissues [90,96,97].

In numerous investigations of animals and humans, cataracts attributed

to microwave exposure have been reported [94]. Exposure to microwaves
may result in direct or indirect effects on the cardiovascular system.
Other biologic effects have also been reported [98,99], and these
effects are more pronounced under hot environments [90].

Microwave detectors can be divided into two categories: thermal

detectors and electricaldetectors. Thermal detectors utilize the
principles of temperature changes in a thermal sensor as a result of
exposure to microwaves. Electrical detectors, however, rectify the
microwave signal into direct current which may be applied to a meter
calibrated to indicate power. Thermal detectors are generally preferred
over electrical detectors [90].

The American Conference of Governmental Industrial Hygienists (ACGIH)

Threshold Limit Values (TLV®) for occupational exposure to microwave
energy have been established [2]. These TLVs are based on the frequency
and the power density of the microwave. At the frequency range of
10 kilohertz (kHz) to 300 gigahertz (GHz) for continuous exposure with
total exposure time limited to an 8 -hour workday, the power density
level should not exceed 10 to 100 milliwatts per square centimeter
(mW/cm^) as the frequency increases from 10 kHz to 300 GHz. Under
conditions of moderate to severe heat stress, the recommended values may
need to be reduced.

57
B. P re d ic tio n o f C lim a tic Factors from the N ational Weather S ervice Data

The National Weather Service provides a set of daily environmental

measurements which can be a useful supplement to the climatic factors
measured at a worksite. The National Weather Service data include daily
observations at 3-hour intervals for air temperature (ta ), wet bulb
temperature ( t ^ ) , dew point temperature (tjp), relative humidity (rh),
and wind velocity (Va ), sky cover, ceiling, and visibility. A summary of
daily environmental measurements includes ta (maximum, minimum, average,
and departure from normal), average tjp type, precipitation, atmospheric
pressure (average at station and sea levels), wind velocity (direction and
speed), extent of sunshine and sky cover. These data, where available, can
be used for approximate assessment of the worksite environmental heat load
for outdoor jobs or for some indoor jobs where air conditioning is not in
use. Atmospheric pressure data can also be used for both indoor and outdoor
jobs. National Weather Service data have also been used in studies of
mortality due to heat-aggravated illness resulting from heat waves in the
United States [60,61,100].

Continuous monitoring of the environmental factors at the worksite provides

information on the level of heat stress at the time the measurements are
made. Such data are useful for developing engineering heat-stress
controls. However, in order to have established work practices in place
when needed, it is desirable to predict the anticipated level of heat stress
for a day or more in advance. A methodology has been developed based on the
psychrometric wet bulb for calculating the wet bulb globe temperature (WBGT)
at the worksite from the National Weather Service meteorologic data. The
data upon which the method is based were derived from simultaneous
measurements of the thermal environment in 15 representative worksites,
outside the worksites, and from the closest National Weather Service
station. The empirical relationships between the inside and outside data
were established. From these empirical relationships, it is possible to
predict worksite WBGT, effective temperature (ET), or corrected effective
temperature (CET) values from weather forecasts or local meteorologic
measurements. To apply the predictions model, it is first necessary to
perform a short environmental study at each worksite to establish the
differences in inside and outside values and to determine the regression
constants which are unique for each workplace, perhaps because of the
differences in actual worksite air motion as compared to the constant high
air motion associated with the use of the ventilated wet bulb thermometer
[101].

C. MetaboIi c Heat

The total heat load imposed on the human body is the aggregate of
environmental and physical work factors. The energy cost of an activity as
measured by the metabolic heat (M) is a major element in the heat-exchange
balance between the human body and the environment. The metabolic heat
value can be measured or estimated. The energy cost of an activity is made
up of two parts: the energy expended in doing the work and the energy
transformed into heat. On the average, muscles may reach 20% efficiency in
performing heavy physical work. However, unless external physical work is

58
produced, the body heat load is approximately equal to the total metabolic
energy turnover. For practical purposes M is equated with total energy
turnover.

1. Measurements o f M etab o lic Heat

a. Measurement o f M etab o lic Heat by D ire c t C a lo rim etry

To determine the worker's heat production by direct calorimetry, the

subject is placed in a calorimeter, an enclosed chamber surrounded
by circulating water; the increase in the temperature of the
circulating water is used to determine the amount of heat liberated
from the human body. The direct procedure has limited practical use
in occupational heat-stress studies, because the procedure is
difficult and time consuming and the equipment and chambers are
expensive [1 0 2 ].

b. Measurements o f M etabolic Heat by In d ir e c t C a lo rim etry

Primary methods of measurements of metabolic heat by indirect

calorimetry are based on measuring oxygen consumption. Indirect
calorimetry utilizes the closed circuit procedure or the open
circuit procedure. Another even more indirect procedure for
measuring metabolic heat is based on the linear relationship between
heart rate and oxygen consumption. The linearity, however, usually
holds only at submaximal heart rates, because on approaching the
maximum, the pulse rate begins to level off while the oxygen intake
continues to rise. The linearity also holds only on an individual
basis because of the wide interindividual differences in the
responses [103,104].

(1 ) Closed C ir c u it

In the closed circuit procedure the subject inhales from a

spirometer, and the expired air returns to the spirometer after
passing through carbon dioxide and water vapor absorbents. The
depletion in the amount of oxygen in the spirometer represents
the oxygen consumed by the subject. Each liter of oxygen
consumed results in the production of approximately 4.8 kcal of
metabolic heat. The development of computerized techniques,
however, has revised the classical procedures so that equipment
and the evaluation can be automatically controlled by a computer
which results in prompt, precise, and simultaneous measurement
of the significant variables [105].

(2 ) Open C ir c u it

In the open circuit procedure the worker breathes atmospheric

air, and then the exhaled air is collected in a large container,
i.e., a Douglas bag or meteorological balloon. The volume of
the expired air can be accurately measured with a calibrated
gasometer. The concentration of oxygen in the expired air can
be measured by chemical or electronic methods. The oxygen and

59
 carbon dioxide in the atmospheric air usually averages 20.90%
and 0.03%, respectively, or they can be measured so that the
amount of oxygen consumed, and consequently the metabolic heat
production for the performed activities, can be determined.
Each liter of oxygen consumed represents 4.8 kcai of metabolism.

Another open circuit procedure, the Max Planck respiration

gasometer, eliminates the need for an expired air collection bag
and a calibrated gasometer [105]. The subject breathes
atmospheric air and exhales into the gasometer where the volume
and temperature of the expired air are immediately measured. An
aliquot sample of the expired air is collected in a rubber
bladder for later analysis for oxygen and carbon dioxide
concentrations. Both the Douglas bag and the respiration
gasometer are portable and thus appropriate for collecting
expired air of workers atdifferent industrial or laboratory
sites [105].

2. E stim ation o f M etabolic Heat

The procedures for direct or indirect measurement of metabolic heat are

limited to relatively short duration activities and require equipment
for collecting and measuring the volume of the expired air and for
measuring the oxygen and carbon dioxide concentrations. On the other
hand, metabolic heat estimates, using tables of energy expenditure or
task analysis, although less accurate and reproducible, can be applied
for short and long duration activities and require no special
equipment. However, the accuracy of the estimates made by a trained
observer may vary by about + 10-15%. A training program consisting of
supervised practice in using the tables of energy expenditure in an
industrial situation will usually result in an increased accuracy of the
estimates of metabolic heat production [106,107].

a. Tables o f Energy Expenditures

Estimates of metabolic heat for use in assessing muscular work load

and human heat regulation are commonly obtained from tabulated
descriptions of energy cost for typical work tasks and activities
[108,109]. Errors in estimating metabolic rate from energy
expenditure tables are reported to be as high as 30% [110].

The International Organization for Standardization (ISO) [110]

recommends that the metabolic rate could be estimated by adding
values of the following groups: (1 ) basal metabolic rate,
(2) metabolic rate for body position or body motion, (3) metabolic
rate for type of work, and (4) metabolic rate related to work
speed. The basal metabolic rate averages 44 and 41 W/m2 for the
"standard" man and woman, respectively. Metabolic rate values for
body position and body motion, type of work, and those related to
work speed are given [ 1 1 0 ].

60
b. Task Ana Iys i s

In order to evaluate the average energy requirements over an

extended period of time for industrial tasks including both the work
and rest activities, it is necessary to divide the task into its
basic activities and subactivities. The metabolic heat of each
activity or subactivity is then measured or estimated and a
time-weighted average for the energy required for the task can be
obtained.

It is common in such analyses to estimate the metabolic rate for the

different activities by utilizing tabulated energy values from
tables which specify incremental metabolic heat resulting from the
movement of different body parts, i.e., arm work, leg work,
standing, and walking [2]. The metabolic heat of the activity can
then be estimated by summing the component M values based on the
actual body movements. The task analysis procedure recommended by
ACGIH is summarized in Table V-3.

61
 TABLE V-3.— Estimating energy cost of work by task analysis

A. Body position and movement kcaI/min*

Si tt ing 0.3
Standing 0.6
Walking 2.0-3.0
Walking uphi11 add 0.8 per meter rise

B. Type of work Average Range

kcaI/m in kcaI/m in

Hand work
I ight 0.4 0 .2 - 1.2
heavy 0.9
Work one arm
I ight 1.0 0.7-2.5
heavy 1.8
Work both arms
I ight 1.5 1.0-3.5
heavy 2.5
Work whole body
Iight 3.5 2.5-9.0
moderate 5.0
heavy 7.0
very heavy 9.0

C. Basal metabolism 1.0

D. Sample calculation** Average

kcaI/m in

Assembling work with

heavy hand tools
1. Standing 0.6
2. Two-arm work 3.5
3. Basal metabolism 1.0

Total 5.1 kcaI/min

* For standard worker of 70 kg body weight (154 lbs.) and 1.8 m^

body surface (19.4 ft^).
**Example of measuring metabolic heat production of a worker when
performing initial screening.
Adapted from References 2,108,111,112.

62
 VI. CONTROL OF HEAT STRESS

From a review of the heat balance equation [H=(M-W)+C+R-E], described in

Chapter III, Section A, total heat stress can be reduced only by modifying
one or more of the following factors: metabolic heat production, heat
exchange by convection, heat exchange by radiation, or heat exchange by
evaporation. Environmental heat load (C, R, and E) can be modified by
engineering controls (e.g., ventilation, air conditioning, screening,
insulation, and modification of process or operation) and protective
clothing and equipment; whereas metabolic heat production can be modified by
work practices and application of labor-reducing devices. Each of these
alternative control strategies will be discussed separately. Actions that
can be taken to control heat stress and strain are listed in Table VI-1
[113].

63
 TABLE VI-1.— Checklist for controlling heat
stress and strain

Item Actions for consideration

I. Controls

M, body heat production of task reduce physical demands of the work;

powered assistance for heavy tasks

R, radiative load interpose Iine-of-sight barrier;

furnace wall insulation,
metallic reflecting screen,
heat reflective clothing,
cover exposed parts of body

C, convective load if air temperature is above 35°C (95°F);

reduce air temperature,
reduce air speed across skin,
wear clothing
if air temperature is below 35°C (95°F);
increase air speed across skin and
reduce clothing

Em a x , maximum evaporative increase by:

cooling by sweat ing decreasing humidi t y ,
increasing ai r speed

decrease clothing

II. Work pract ices shorten duration of each exposure;

more frequent short exposures better
than fewer long exposures
schedule very hot jobs in cooler part of
day when possible

exposure limit self-Iimiting, based on formal in­

doctrination of workers and super­
visors on signs and symptoms of
overst rai n

recovery air-conditioned space nearby

(cont inued)

64
 TABLE VI-1.— Checklist for controlling heat
stress and strain

III. Personal protection cooled air, cooled fluid, or ice cooled

R , C , and Emax condi t ioned clothing
reflective clothing or aprons

IV. Other considerations determine by medical evaluation,

primarily of cardiovascular status
careful break-in of unacclimatized
workers
water intake at frequent intervals
to prevent hypohydration
fat igue or mild iI Iness
not related to the job may
temporarily contraindicate
exposure (e.g., low grade
infection, diarrhea, sleepless
night, alcohol ingestion)

V. Heat wave introduce heat alert program

Adapted from Reference 113.

65
A. Engineering Controls

The environmental factors that can be modified by engineering procedures are

those involved in convective, radiative, and evaporative heat exchange.

1. Convective Heat Control

As discussed earlier, the environmental variables concerned with

convective heat exchange between the worker and the ambient environment
are dry bulb air temperature (ta ) and the speed of air movement
(Va ). When air temperature is higher than the mean skin temperature
(Tsk of 35°C or 95°F), heat is gained by convection. The_rate of heat
gain is dependent on temperature_differential (ta - Ts k ) and air
velocity (Va ). Where ta is below 7 ^ , heat is lost from the body;
the rate of loss is dependent on ta - Tsk and air velocity.

Engineering approaches to enhancing convective heat exchange are limited

to modifying air temperature and air movement. When ta is less than
ts k , increasing air movement across the skin by increasing either
general or local ventilation will increase the rate of body heat loss.
When ta exceeds tsk (convective heat gain), ta should be reduced
by bringing in cooler outside air or by evaporative or refrigerative
cooling of the air, and as long as ta exceeds tsk, air speed should
be reduced to levels which will still permit sweat to evaporate freely
but will reduce convective heat gain (see Table VI-1). The effect of
air speed on convective heat exchange is a 0 . 6 root function of air
speed. Spot cooling (ta less than ts k ) of the individual worker can
be an effective approach to controlling convective heat exchange,
especially in large workshops where the cost of cooling the entire space
would be prohibitive. However, spot coolers or blowers may interfere
with the ventilating systems required to control toxic chemical agents.

2. Radiant Heat Control

Radiant heat exchange between the worker and the hot equipment,
processes, and walls that surround the worker is a fourth power function
of the difference between skin temperature (ts k ) and the temperature
of hot objects that "see" the worker (tr). Obviously, the only
engineering approach to controlling radiant heat gain is to reduce tr
or to shield the worker from the radiant heat source.

To reduce tr would require ( 1 ) lowering the process temperature which

is usually not compatible with the temperature requirements of the
manufacturing processes; (2 ) relocating, insulating, or cooling the heat
source;(3) placing Iine-of-sightradiant reflective shielding between
the heat source and the worker; or (4) changing the emissivity of the
hot surface by coating the material. Of the alternatives, radiant
reflective shielding is generally the easiest to install and the least
expensive. Radiant reflective shielding can reduce the radiant heat
load by as much as 80-85%. Some ingenuity may be required in placing
the shielding so that it doesn't interfere with the worker performing

66
 the work. Remotely operated tongs, metal chain screens, or air or
hydrauIicaIly activated doors which are opened only as needed are some
of the approaches.

3. Evaporative Heat Control

Heat is lost from the body when sweat is evaporated from the skin
surface. The rate and amount of evaporation is a function of the speed
of air movement over the skin and the difference between the water vapor
pressure of the air (pa ) at ambient temperature and the water vapor
pressure of the wetted skin assuming a skin temperature of 34°-35°C
(93.2°-95°F). At any air-to-skin vapor pressure gradient, the
evaporation increases as a 0 . 6 root function of increased air movement.
Evaporative heat loss at low air velocities can be greatly increased by
improving ventilation (increasing air velocity). At high air velocities
(2.5 m/sec or 500 fpm), an additional increase will be ineffective
except when the clothing worn interferes with air movement over the skin.

Engineering controls of evaporative cooling can therefore assume two

forms: ( 1 ) increase air movement or (2 ) decrease ambient water vapor
pressure. Of these, increased air movement by the use of fans or
blowers is often the simplest and usually the cheapest approach to
increasing the rate of evaporative heat loss. Ambient water vapor
pressure reduction usually requires air-conditioning equipment (cooling
compressors). In some cases the installation of air conditioning,
particularly spot air conditioning, may be less expensive than the
installation of increased ventilation because of the lower airflow
involved. The vapor pressure of the worksite air is usually at least
equal to that of the outside ambient air, except when all incoming and
recirculated air is humidity controlled by absorbing or condensing the
moisture from the air (e.g., by air conditioning). In addition to the
ambient air as a source of water vapor, water vapor may be added from
the manufacturing processes as steam, leaks from steam valves and steam
lines, and evaporation of water from wet floors. Eliminating these
additional sources of water vapor can help reduce the overall vapor
pressure in the air and thereby increase evaporative heat loss by
facilitating the rate of evaporation of sweat from the skin [114].

B. Work and Hygienic P ra c tic e s and A d m in is tra tiv e Controls

Situations exist in industries where the complete control of heat stress by

the application of engineering controls may be technologically impossible or
impractical, where thelevel of environmental heat stress may be
unpredictable and variable (as seasonal heat waves), and where the exposure
time may vary with the task and with unforeseen critical events. Where
engineering controls of the heat stress are not practical or complete, other
solutions must be sought to keep the level of total heat stress on the
worker within limits which will not be accompanied by an increased risk of
heat illnesses.

The application of preventive practices frequently can be an alternative or

complementary approach to engineering techniques for controlling heat
stress. Preventive practices are mainly of five types: (1) limiting or

67
modifying the duration of exposure time; (2 ) reducing the metabolic
component of the total heat load; (3) enhancing the heat tolerance of the
worker by heat acclimatization, physical conditioning, etc.; (4) training
the workers in safety and health procedures for work in hot environments;
and (5) medical screening of workers to eliminate individuals with low heat
tolerance and/or physical fitness.

1. L im itin g Exposure Time and /or Temperature

There are several ways to control the daily length of time and
temperature to which a worker is exposed in heat stress conditions.

• When possible, schedule hot jobs for the cooler part of the day
(early morning, late afternoon, or night shift).

• Schedule routine maintenance and repair work in hot areas for the
cooler seasons of the year.

• Alter rest-work regimen to permit more rest time.

• Provide cool areas for rest and recovery.

• Add extra personnel to reduce exposure time for each member of the
crew.

• Permit freedom to interrupt work when a worker feels extreme heat

d iscomfort.

• Increase water intake of workers on the job.

• Adjust schedule when possible so that hot operations are not

performed at the same time and place as other operations that require
the presence of workers, e.g., maintenance and cleanup while tapping
a furnace.

2. Reducing M etab o lic Heat Load

In most industrial work situations, metabol ic heat is not the major part
of the total heat load. However, because it represents an extra load on
the circulatory system, it can be a critical component in high heat
exposures. A design for rest-work cycles has been developed by Kamon
[115]. Metabolic heat production can be reduced usually by not more
than 200 kcal/h (800 Btu/h) by:

• Mechanization of the physical components of the job,

• Reduction of work time (reduce work day, increase rest time, restrict
double shi fting),

• Increase of the work force.

68
3. Enhancing Tolerance to Heat

Stimulating the human heat adaptive mechanisms can significantly

increase the capacity to tolerate work in heat. There is, however, a
wide difference in the ability of people to adapt to heat which must be
kept in mind when considering any group of workers.

a. A properly designed and applied heat-accIimatization program

will dramatically increase the ability of workers to work at a hot
job and will decrease the risk of heat-related illnesses and unsafe
acts. Heat acclimatization can usually be induced in 5 to 7 days of
exposure at the hot job. For workers who have had previous
experience with the job, the acclimatization regimen should be
exposure for 50% on day 1, 60% on day 2, 80% on day 3, and 100% on
day 4. For new workers the schedule should be 20% on day 1 and a
20 % increase on each additional day.

b. Being physically fit for the job will enhance (but not replace
heat acclimatization) heat tolerance for both heat-acclimatized and
unacclimatized workers. The time required to develop heat
acclimatization in unfit individuals is about 50% greater than in
the physically fit.

c. To ensure that water lost in the sweat and urine is replaced (at
least hourly) by hour during the work day, anadequate water supply
and intake are essential for heat tolerance and prevention of heat
induced illnesses.

d. Electrolyte balance in the body fluids must be maintained to

prevent some of the heat-induced illnesses. For heat-unacclimatized
workers who may be on a restricted salt diet, additional salting of
the food, with a physician's concurrence, during the first 2 days of
heat exposure may be required to replace the salt lost in the
sweat. The acclimatized worker loses relatively little salt in the
sweat; therefore, salt supplementation of the normal U.S. diet is
usually not requi red.

4. H ealth and S a fe ty T ra in in g

Prevention of serious sequelae from heat-induced illnesses is dependent

on early recognition of the signs and symptoms of impending heat
illnesses and the initiation of first aid and/or corrective procedures
at the earliest possible moment.

a. Supervisors and other personnel should be trained in recognizing

the signsand symptoms of the various typesof heat-induced
illnesses, e.g.,heat cramps, heat exhaustion, heat rash, and
heatstroke, and in administering first-aidprocedures (see
Table IV-1).

69
 b. All personnel exposed to heat should receive basic instruction
on the causes and recognition of the various heat illnesses and
personal care procedures that should be exercised to minimize the
risk of their occurrence.

c. All personnel who use heat protective clothing and equipment

should be instructed in their proper care and use.

d. A M personnel working in hot areas should be instructed on the

effects of nonoccupational factors (drugs, alcohol, obesity, etc.)
on tolerance to occupational heat stress.

e. A buddy system which depends on the instruction of workers on

hot jobs to recognize the early signs and symptoms of heat illnesses
should be initiated. Each worker and supervisor who has received
the instructions is assigned the responsibility for observing, at
periodic intervals, one or more fellow workers to determine whether
any of the early symptoms of a developing heat illness are present.
If a worker exhibits signs and symptoms which may be indicative of
an impending heat illness, the worker should be sent to the
dispensary or first-aid station for more complete evaluation of the
situation and to initiate the medical or first-aid treatment
procedures. Workers on hot jobs where the heat stress exceeds the
RAL or REL (for unacclimatized and acclimatized workers,
respectively) should be observed by a fellow worker or supervisor.
Contingency plans for treatment, e.g., cool rest area and
transportation to hospital, should be in place.

5. Screening fo r Heat In to le ra n c e

The ability to tolerate heat stress varies widely even between

individuals within a group of normal healthy individuals with similar
heat exposure experiences [5,6,116]. One way to reduce the risk of
incurring heat illnesses and disorders within a heat-exposed workforce
is to reduce or eliminate the exposure to heat stress of the
heat-intolerant individuals. Identification of heat-intolerant
individuals without the need for performing a strenuous, time-consuming
heat-tolerance test would be basic to any such screening process.

Data from laboratory and field studies indicate that individuals with
low physical work capacity are more likely to develop higher body
temperatures than are individuals with high physical work capacity when
exposed to equally hard work in high temperatures. None of the
individuals with a maximum work capacity of 2.5 liters of oxygen per
minute (L/min) or above were heat intolerant, while 63% of those with
M ^ m a x below 2.5 L/min were heat intolerant. It has also been shown
that heat-acclimatized individuals with a V0 2 max less than 2.5 L/min
had a 5% risk of reaching heatstroke levels of body temperature (40°C or
104°F) while those with a V 0 2 max above 2.5 L/min had only a 0.05% risk
[5,6].

Because tolerance to physical work in a hot environment is related to

physical work capacity, heat tolerance might be predictable from

70
 physical fitness tests. A simple physical fitness test which could be
administered in a physician's office or a plant first-aid room has been
suggested [116,117]. However, such tests have not as yet been proven to
have predictive validity for use in hot industries.

Medical screening for heat intolerance in otherwise healthy normal

workers should include a history of any previous incident of heat
illness. Workers who have experienced a heat illness may be less heat
tolerant [43.

C. H e a t-A le rt Program - Preventing Emergencies

In some plants where heat illnesses and disorders occurred mainly during hot
spells in the summer, a Heat-Alert Program (HAP) has been established for
preventive purposes. Although such programs differ in detail from one plant
to another, the main idea behind them is identical, i.e., to take advantage
of the weather forecast of the National Weather Service. If a hot spell is
predicted for the next day or days, a state of Heat Alert is declared to
make sure that measures to prevent heat casualties will be strictly
observed. Although this sounds quite simple and straightforward, in
practical application it requires the cooperation of the administrative
staff; the maintenance and operative workforce; and the medical, industrial
hygiene, and safety departments. An effective HAP is described below [77].

1. Each year, early in the spring, establish a Heat-Alert Committee

consisting of an industrial physician or nurse, industrial hygienist,
safety engineer, operation engineer, and a high ranking manager. Once
established, this committee takes care of the following options:

a. Arrange a training course for all involved in the HAP, dealing

with procedures to follow in the event a Heat Alert is declared. In
the course, special emphasis is given to the prevention and early
recognition of heat illnesses and first-aid procedures when a heat
i I Iness occurs.

b. By memorandum, instruct the supervisors to:

(1) Reverse winterization of the plant, i.e., oplen windows,

doors, skylights, and vents according to instructions for
greatest ventilating efficiency at places where high air
movement is needed;

(2) Check drinking fountains, fans, and \air conditioners to

make sure that they are functional, that the necessary
maintenance and repair is performed, that these facilities are
regularly rechecked, and that workers know how to use them;

c. Ascertain that in themedical department, as well as at the job

sites, all facilities required to give first aid in case of a heat
illness are in a state of readiness;

71
 d. Establish criteria for the declaration of a Heat Alert; for
instance, a Heat Alert would be declared if the area weather
forecast for the next day predicts a maximum air temperature of 35°C
(95°F) or above or a maximum of 32°C (90°F) if the predicted maximum
is 5°C (9°F) above the maximum reached in any of the preceding 3
days.

2. Procedures to be followed during the state of Heat Alert are as

follows:

a. Postpone tasks which are not urgent (e.g., preventive

maintenance involving high activity or heat exposure) until the hot
speII is over.

b. Increase the number of workers in each team in order to reduce

each worker's heat exposure. Introduce new workers gradually to
allow acclimatization (follow heat-acclimatization procedure).

c. Increase rest allowances. Let workers recover in

air-conditioned rest places.

d. Turn off heat sources which are not absolutely necessary.

e. Remind workers to drink water in small amounts frequently to

prevent excessive dehydration, to weigh themselves before and after
the shift, and to be sure to drink enough water to maintain body
weight.

f. Monitor the environmental heat at the job sites and resting

places.

g. Check workers' oral temperature during their most severe

heat-exposure period.

h. Exercise additional caution on the first day of a shift change

to make sure that workers are not overexposed to heat, because they
may have lost some of their acclimatization over the weekend and
during days o f f .

i. Send workers who show signs of a heat disorder, even a minor

one, to the medical department. The physician's permission to
return to work must be given in writing.

j. Restrict overtime work.

D. A u x ilia ry Body Cooling and P ro te c tiv e C lothing

When unacceptable levels of heat-stress occur, there are generally only four
approaches to a solution: (1 ) modify the worker by heat acclimatization;
(2) modify the clothing or equipment; (3) modify the work; or (4) modify the
environment. To do everything possible to improve human tolerance would
require that the individuals should be fully heat acclimated, should have
good training in the use of and practice in wearing the protective clothing,

72
should be in good physical condition, and should be encouraged to drink as
much water as necessary to compensate for sweat water loss.

If these modifications of the individual (heat acclimatization and physical

fitness enhancement) are not enough to alleviate the heat stress and reduce
the risk of heat illnesses, only the latter three solutions are left to deal
with the problem. It may be possible to redesign ventilation systems for
occupied spaces to avoid interior humidity and temperature buildup. These
may not completely solve the heat stress problem. When air temperature is
above 35°C (95°F) with an rh of 75-85% or when there is an intense radiant
heat source, a suitable, and in some ways more functional, approach is to
modify the clothing to include some form of auxiliary body cooling. Even
mobile individuals afoot can be provided some form of auxiliary cooling for
limited periods of time. A properly designed system will reduce heat
stress, conserve large amounts of drinking water which would otherwise be
required, and allow unimpaired performance across a wide range of climatic
factors. A seated individual will rarely require more than 100 W (86 kcal/h
or 344 Btu/h) of auxiliary cooling and the most active individuals not more
than 400 W (345 kcal/h or 1380 Btu/h) unless working at a level where
physical exhaustion per se would limit the duration of work. Some form of
heat-protective clothing or equipment should be provided for exposures at
heat-stress levels that exceed the Ceiling Limit in Figures 1 and 2.

Auxiliary cooling systems can range from such simple approaches as an ice
vest, prefrozen and worn under the clothing, to more complex systems;
however, cost of logistics and maintenance are considerations of varying
magnitude in all of these systems. In all, four auxiliary cooling
approaches have been evaluated: (1 ) water-cooled garments, (2 ) an
air-cooled vest, (3) an ice packet vest, and (4) a wettable cover. Each of
these cooling approaches might be applied in alleviating risk of severe heat
stress in a specific industrial setting [14,26].

1. W ater-cooled Garments

Water-cooled garments include (1) a water-cooled hood which provides

cooling to the head,(2 ) a water-cooled vest which provides cooling to
the head and torso,(3) a short, water-cooled undergarment which
provides cooling to the torso, arms, and legs, and (4) a long,
water-cooled undergarment which provides cooling to the head, torso,
arms, and legs. None of these water-cooled systems provide cooling to
the hands and feet.

Water-cooled garments and headgear require a battery driven circulating

pump and container where the circulating fluid is cooled by the ice.
The weight of the batteries, container, and pump will limit the amount
of ice that can be carried. The amount of ice available will determine
the effective use time of the water-cooled garment.

The range of cooling provided by each of the water-cooled garments

versus the cooling water inlet temperature has been studied. The rate
of increase in cooling, with decrease in cooling water inlet

73
temperature, is 3.1 W/°C for the water-cooled cap with water-cooled
vest, 17.6 W/°C for the short water-cooled undergarment, and 25.8 W/°C
for the long water-cooled undergarments. A "comfortable" cooling water
inlet temperature of 20°C (6 8 °F) should provide 46 W of cooling using
the water-cooled cap; 66 W using the water-cooled vest; 112 W using the
water-cooled cap with water-cooled vest; 264 W using the short
water-cooled undergarment; and 387 W using the long water-cooled
undergarment.

2. A ir-c o o le d Garments

Air-cooled suits and/or hoods which distribute cooling air next to the
skin are available. The total heat exchange from a completely sweat
wetted skin when cooling air is supplied to the air-cooled suit is a
function of cooling air temperature and cooling airflow rate. Both the
total heat exchanges and the cooling power increase with cooling airflow
rate and decrease with increasing cooling air inlet temperature.

For an air inlet temperature of 10°C (50°F) at 20% rh and a flow rate of
10 ft^/min (0.28 nvVmin), the total heat exchanges over the body
surface would be 233 W in a 29.4°C (84.9°F) 85% rh environment and 180 W
in a 51.7°C (125.1°F) at 25% rh environment. Increasing the cooling air
inlet temperature to 21°C (69.8°F) at 10% rh would reduce the total heat
exchanges to 148 W and 211 W, respectively. Either air inlet
temperature easily provides 100 W of cooling.

The use of a vortex tube as a source of cooled air for body cooling is
applicable in many hot industrial situations. The vortex tube, which is
attached to the worker, requires a constant source of compressed air
supplied through an air hose. The hose connecting the vortex tube to
the compressed air source limits the area within which the worker can
operate. However,unless mobility of the worker is required, the vortex
tube, even though noisy, should be considered as a simple cooled air
source.

3. Ice Packet Vest

The available ice packet vests may contain as many as 72 ice packets;
each packet has a surface area of approximately 64 cm^ and contains
about 46 grams of water. These ice packets are generally secured to the
vest by tape. The cooling provided by each individual ice packet will
vary with time and with its contact pressure with the body surface, plus
any heating effect of the clothing and hot environment; thus, the
environmental conditions have an effect on both the cooling provided and
the duration of time this cooling is provided. Solid carbon dioxide in
plastic packets can be used instead of ice packets in some models.

In environments of 29.4°C (84.9°F) at 85% rh and 35.0°C (95°F) at

62% rh, an ice packet vest can still provide some cooling up to 4 hours
of operation (about 2 to 3 hours of effective cooling is usually the
case). However, in an environment of 51.7°C (125.1°F) at 25% rh, any
benefit is negligible after about 3 hours of operation. With 60% of the
ice packets in place in the vest, the cooling provided may be negligible

74
 after 2 hours of operation. Since the ice packet vest does not provide
continuous and regulated cooling over an indefinite time period,
exposure to a hot environment would require redressing with backup
frozen vests every 2 to 4 hours. Replacing an ice packet vest would
obviously have to be accomplished when an individual is not in a work
situation. However, the cooling is supplied noise-free and independent
of any energy source or umbilical cord that would limit a worker's
mobility. The greatest potential for the ice packet vest appears to be
for work where other conditions limit the length of exposure, e.g.,
short duration tasks and emergency repairs. The ice packet vest is also
relatively cheaper than other cooling approaches.

4. Wetted Overgarments

A wetted cotton terry cloth coverall or a two-piece cotton cover which

extends from just above the boots and from the wrists to a V-neck when
used with impermeable protective clothing can be a simple and effective
auxiliary cooling garment.

Predicted values of supplementary cooling and of the minimal water

requirements to maintain the cover wet in various combinations of air
temperature, relative humidity, and wind speed can be calculated. Under
environmental conditions of low humidity and high temperatures where
evaporation of moisture from the wet cover garment is not restricted,
this approach to auxiliary cooling can be effective, relatively simple,
and inexpensive to use.

E. Performance Degradation

A variety of options for auxiliary cooling to reduce the level of heat

stress, if not totally eliminate it under most environmental conditions both
indoors and outdoors, have been prescribed. However, the elimination of
serious heat-stress problems will not totally resolve the degradation in
performance associated with wearing protective clothing systems.
Performance decrements are associated with wearing encapsulating protective
ensembles even in the absence of any heat stress [78]. The majority of the
decrements result from mechanical barriers to sensory inputs to the wearer
and from barriers to communication between individuals. Overall, it is
clear that elimination of heat stress, while it will allow work to continue,
will not totally eliminate the constraints imposed by encapsulating
protective clothing systems [78].

75
 VII. PREVENTIVE MED ICAL PRACTICES

With proper attention to health and safety considerations, a hot work

environment can be a safe place within which to work. A primary
responsibility for preventing heat illness resides with the engineer and/or
industrial hygienist who recommends procedures for heat-stress controls and
monitors workplace environmental conditions. Continuous industrial hygiene
characterization of environmental conditions, obtained via either continuous
monitoring of the environment or algorithms that relate workplace
temperature and humidity to ambient climatic conditions and to the work
activity itself, must be available to these personnel. However, because of
thecomplexities of anticipating andpreventing heat illness in the
individual worker, the physician must be intimately involved in efforts to
protect workers exposed to potentially hazardous levels of heat stress in
the workplace.

Since an environment that exceeds the Recommended Alert Limit (RAL) for an
unacclimatized or the Recommended Exposure Limit (REL) for an acclimatized
worker poses a potential threat to workers, the supervising health
professional must possess a clear understanding of the peculiar complexities
of heat stress. In particular, the physician must be aware of the following:

• The REL represents the most extreme heat-stress condition to which

even the healthiest and most acclimatized worker may be safely
exposed for prolonged periods of time.

• Among workers who do not have medical conditions that impair heat
tolerance, some may be at risk of developing heat illness when
exposed to levels below the RAL. In addition, some workers cannot
acclimatize to heat-stress levels above the RAL. Empirical data
suggest that fewer than 5% of the workers cannot adequately
acclimatize to heat stress (see Chapter IV).

• The RAL and REL are TWA values with permissible short-term excursions
above the levels; however, the frequency and extent to which such
brief excursions may be safely permitted are no-t known.

Thus, sound judgment and vigilance by the physician, the workers, and their
supervisors are essential to the prevention and early recognition of adverse
heat-induced health effects.

The physician's role in protecting workers in a hot environment should

include the following:

• Work environment not exceeding the RAL In a work environment in

which the heat stress experienced by the worker approaches but is
kept below the RAL by engineering controls, work practices, and/or
personal protective equipment, the physician's primary
responsibilities are (1 ) preplacement evaluation (detection of a
worker with a medical condition that would warrant exclusion of the
worker from the work setting), (2 ) supervision during initial days of
exposure of the worker to the hot environment (detection of
apparently "healthy" workers who cannot tolerate heat stress), and

76
 (3) detection of evidence of heat-induced illness (a sentinel health
event [SHE]) in one or more workers that would indicate a failure of
control measures to prevent heat-induced illness and related injuries
at levels below the RAL).

• Work environment that exceeds the RAL In a work environment in which

only acclimatized individuals can work safely because the level of
heat stress exceeds the RAL, the physician bears a more direct
responsibility for ensuring the health and safety of the workers.
Through the preplacement evaluation and the supervision of heat
acclimatization, the physician may detect a worker who is incapable
of heat acclimatization or who has another medical condition that
precludes placing that worker in a hot environment. While a single
incident of heat illness may be a SHE indicating a failure of control
measures, it may also signify a transient or long-term loss of heat
tolerance or a change in the health status of that worker. The onset
of heat-induced illness in more than one worker in a
heat-acclimatized workforce is a SHE that indicates a failure of
control measures. The physician must be cognizant of each of these
poss ibi Ii t ies.

Thefollowing discussion is directed toward the protection of workers in

environments exceeding the RAL. However, it also provides the core of
information required to protect all workers in hot environments.

A. P ro te c tio n o f Workers Exposed to Heat in Excess o f the RAL

The medical component of a program which protects workers who are exposed to
heat stress in excess of the RAL is complex. In order to ascertain a
worker's fitness for placement and/or continued work in a particular
environment, numerous characteristics of the individual worker (e.g., age,
gender, weight, social habits, chronic or irreversible health
characteristics, and acute medical conditions) must be assessed in the
context of the extent of heat stress imposed in a given work setting. Thus,
while many potential causes of impaired heat tolerance may be regarded as
"relative contraindications" to work in a hot environment, the physician
must assess the fitness of the worker for the specific job and should not
interpret potential causes of impaired heat tolerance as "absolute
contraindications" to job placement.

A preplacement medical evaluation followed by proper acclimatization

training will reduce the likelihood that a worker assigned to a job that
exceeds the RAL will incur heat injury. However, substantial differences
exist between individuals in their abilities to tolerate and adapt to heat;
such differences cannot necessarily be predicted prior to actual trial
exposures of suitably screened and trained individuals.

Heat acclimatization signifies a dynamic state of conditioning rather than a

permanent change in the worker's innate physiology. The phenomenon of heat
acclimatization is well established, but for an individual worker, it can be
documented only by demonstrating that, after completion of an
acclimatization regimen, the worker can indeed work without excessive
physiologic heat strain in an environment that an unacclimatized worker

77
could not withstand. The ability of such a worker to tolerate elevated heat
stress requires integrity of cardiac, pulmonary, and renal function; the
sweating mechanism; the body's fluid and electrolyte balances; and the
central nervous system's heat-regulatory mechanism. Impairment or
diminution of any of these functions may interfere with the worker's
capacity to acclimatize to the heat or to perform strenuous work in the heat
once acclimatized. Chronic illness, the use or misuse of pharmacologic
agents, a suboptima I nutritional state, or a disturbed water and electrolyte
balance may reduce the worker's capacity to acclimatize. In addition, an
acute episode of mild illness, especially if it entails fever, vomiting,
respiratory impairment, or diarrhea, may cause abrupt transient loss of
acclimatization. Not being exposed to heat stress for a period of a few
days, as may occur during a vacation or an alternate job assignment away
from heat, may also disrupt the worker's state of heat acclimatization.
Finally, a worker who is acclimatized at one level of heat stress may
require further acclimatization if the total heat load is increased by the
imposition of more strenuous work, increased heat and/or humidity, a
requirement to carry and use respiratory protection equipment, or a
requirement to.wear clothing that compromises heat elimination.

A physician who is responsible for workers in hot jobs (whose jobs exceed
the RAL) must be aware that each worker is confronted each day by workplace
conditions that may pose actual (as opposed to potential) risks if that
worker's capacity to withstand heat is acutely reduced or if the degree of
heat stress increases beyond the heat-acclimatized tolerance capacity of
that worker. Furthermore, a physician who will not be continuously present
at the worksite bears a responsibility to ensure the education of workers,
industrial hygienists, medical and health professionals, and on-site
management personnel about the early signs and symptoms of heat intolerance
and injury. Biologic monitoring of exposed workers may assist the physician
in assuring protection of workers (biologic monitoring is discussed in
Chapter IV).

B. Medical Examinations

The purpose of preplacement and periodic medical examinations of persons

applying for or working ata particular hot job is to determine if the
person can meet the total demands and stresses of the hot job with
reasonable assurance that the safety and health of the individual and/or
fellow workers will not be placed in jeopardy. Examinations should be
performed that assess the physical, mental, psychomotor, emotional, and
clinical qualifications of such individuals. These examinations entail two
parts which relate, respectively, to overall health promotion (regardless of
workplace or job placement) and to workplace-specific medical issues. This
section focuses only on the latter and only with specific regard to heat
stress. However, because tolerance to heat stress depends upon the
integrity of multiple organ systems and can be jeopardized by the insidious
onset of common medical conditions such as hypertension, coronary artery
disease, decreased pulmonary function, diabetes, and impaired renal
function, workers exposed to heat stress require a comprehensive medical
evaluat ion.

78
Prior to the preplacement examination, the physician should obtain a
description of the job itself, a description of chemical and other
environmental hazards that may be encountered at the worksite, the
anticipated level of environmental heat stress, an estimate of the physical
and mental demands of the job, and a list of the protective equipment and
clothing that is worn. This information will provide the examining
physician a guide for determining the scope and comprehensiveness of the
physical examination. Specific factors important in determining the
individual's level of heat tolerance, the abilities to perform work in hot
environments, and the medical problems associated with a failure to meet the
demands of the work in hot jobs have been discussed in Chapter IV. A
discussion of health factors and medications that affect heat tolerance in a
nonworker population can be found in Ki Ibourne et al. [62].

The use of information from the medical evaluation should be directed toward
understanding the potential maximum total heat stress likely to be
experienced by the worker on the job, i . e . , the sum of the metabolic demands
of the work and of using respirators and other personal protective equipment
or clothing; the environmental heat load; and the consequences of
impediments to heat elimination, such as high humidity, low air movement
(enclosed spaces or unventilated buildings), or protective clothing that
impedes the evaporation of sweat. The envi ronmlntal heat load and the
physical demands of the job can be measured, calculated, or estimated by the
procedures described previously in Chapters III and V. For such
measurements the expertise of an industrial hygienist may be required;
however, the physician must be able to interpret the data in terms of the
stresses of the job and the worker's physical, sensory, psychomotor, and
mental performance capabilities to meet the demands [73,118,119].

1. Preplacement Physical Examination

The preplacement physical examination is usually designed for new

workers or workers who are transferring from jobs that do not involve
exposure to heat. Unless demonstrated otherwise, it should be assumed
that such individuals are not acclimatized to work in hot environments.

a. The physician should obtain:

(1) A medical history that addresses the cardiac, vascular,

respiratory, neurologic, renal, hematologic, gastrointestinal,
and reproductive systems and includes information on specific
dermatologic, endocrine, connective tissue, and metabolic
conditions that might affect heat acclimatization or the ability
to eliminate heat [ 1 2 0 ,1 2 1 ].

(2) A complete occupational history, including years of work in

each job, the physical and chemical hazards encountered, the
physical demands of these jobs, intensity and duration of heat
exposure, and nonoccupational exposures to heat and strenuous
activities. This history should identify episodes of
heat-related disorders and evidence of successful adaptation to
work in heat in previous jobs or in nonoccupat ional activities
[120 ].

79
 (3) A list of all prescribed and over-the-counter medications
used by the worker. In particular, the physician should
consider the possible impact of medications that potentially can
affect cardiac output, electrolyte balance, renal function,
sweating capacity, or autonomic nervous system function
including: diuretics, antihypertensive drugs, sedatives,
antispasmodics, anticoagulants, psychotropics, anticholinergics,
and drugs that may alter the thirst (haloperidol) or sweating
mechanism (phenothiazines and antihistamines).

(4) Information about personal habits, including the use of

alcohol and other social drugs.

(5) Data on height, weight, gender, and age (see discussion in

Chapter IV).

b. The direct evaluation of the worker should include the following:

(1) Physical examination, with special attention to the

cardiovascular, respiratory, nervous, and musculoskeletal
systems, and the skin.

(2) Clinical chemistry values needed for clinical assessment,

such as fasting blood glucose, blood urea nitrogen, serum
creatinine, serum electrolytes (sodium, potassium, chloride,
bicarbonate), hemoglobin, and urinary sugar and protein.

(3) Blood pressure evaluation.

(4) Assessment of the ability of the worker to understand the

health and safety hazards of the job, understand the required
preventive measures, communicate with fellow workers, and have
mobility and orientation capacities to respond properly to
emergency situations.

c. More detailed medical evaluation . may be warranted.

Communication between the physician performing the preplacement
evaluation and the worker's own physician may be appropriate and
should be encouraged. For instance:

(1) History of myocardial infarction, congestive heart failure,

coronary artery disease, obstructive or restrictive pulmonary
disease, or current use of certain antihypertensive medications
indicates the possibility of reduced maximum cardiac output.

(2) For a worker who uses prescribed medications that might

interfere with heat tolerance or acclimatization, an alternate
therapeutic regimen may be available that would be less likely
to compromise the worker's ability to work in a hot environment.

(3) Hypertension per se is not to be an "absolute"

contraindication to working under heat stress (see Vli-B-3).
However, the physician should consider the possible effects of

80
 ant¡hypertensive medications on heat tolerance. In particular,
for workers who follow a salt-restricted diet or who take
diuretic medications that affect serum electrolyte levels, it
may be prudent to monitor blood electrolyte values, especially
during the initial phase of acclimatization to heat stress.

(4) For workers who must wear respiratory protection or other

personal protective equipment, pulmonary function testing and/or
a submaxima I stress electrocardiogram may be appropriate.
Furthermore, the physician must assess the worker's ability to
tolerate the total heat stress of a job, which will include the
metabolic burdens of wearing and using protective equipment.

(5) For workers with a history of skin disease, an injury to a

large area of the skin, or an impairment of the sweating
mechanism that might impair heat elimination via sweat
evaporation from the skin, specific evaluation may be advisable.

(6 ) Insofar as obesity can interfere with heat tolerance (see

Chapter IV), a specific measurement of percent body fat may be
warranted for an individual worker. An individual should not be
disqualified from a job solely on this basis, but such a worker
may merit special supervision during the acclimatization period.

(7) Women having childbearing potential (or who are pregnant)

and workers with a history of impaired reproductive capacity
(male or female) should be apprised of the overall uncertainties
regarding the effects on reproduction of working in a hot
environment (see VII-B-4).

2. Ongoing Medical E valu ation

a. Medical supervision of workers following job placement involves

two primary sets of responsibilities:

(1) The monitoring of individual workers for changes in

individual health that might affect heat tolerance or for
evidence suggesting failure to maintain a safe working
environment. The evaluation of these data in aggregate form
permits surveillance of the work population as a whole for
evidence of heat-related injury that is suggestive of failure to
maintain a safe working environment.

(2) The ability to respond to heat injuries that do occur

within the workforce.

b. On an annual basis, the physician should update the information

gathered in the preplacement examination (see Chapter V11 —B— 1—a and
b) for all persons working in a hot environment. In addition, the
physician should ensure that workers who may have been transferred
into a hot environment have been examined and are heat
acclimatized. A more complete exsun ¡nation may be advisable if
indicated by the updated medical history and laboratory data.

81
 Special attention should be directed to the cardiovascular,
respiratory, nervous, and musculoskeletal systems and the skin.

3. Hypertension

Limited human data are available that relate to the relationship of

hypertension to heat strain. The capacity to tolerate exercise in heat
was compared in a group of workers with essential hypertension (resting
arterial pressure 150/97 mmHg) with a group of normotensives of equal
age, V0 2 max, weight, body fat content, and surface area (resting
arterial pressure 115/73 mmHg). During exercise in heat (38°C (91.4°F)
ta and 28°C (82.4°F) twb at work rates of 85-90 W J , there was no
significant intergroup difference in tre, ts k , calculated
heat-exchange variables, heart rate, or sweat rate. The blood pressure
difference between the two groups was maintained [122]. The study of
mortality of steelworkers employed in hot jobs conducted by Redmond et
a l . on a cohort of 59,000 steelworkers showed no increase in relative
risk of death from all cardiovascular diseases or from hypertensive
heart disease as a function of the level of the heat stress; however,
for workers who had worked for 6 months or less at the hot jobs, the
relative risk of death from arteriosclerotic heart disease was 1.78 as
compared to those who worked at the hot jobs longer than 6 months [123].

4. Considerations Regarding Reproduction

a. Pregnancy

The medical literature provides little data on potential risks for

pregnant women or for fertile men and fertile noncontracepting women
with heavy work and/or added heat stress within the permissible
limits, e.g., where tre does not exceed 38°C (100.4°F) (see
Chapter IV). However, because the human data are limited and
because research data from animal experimentation indicate the
possibility of heat-induced infertility and teratogenicity, a woman
who is pregnant or who may potentially become pregnant should be
informed that absolute assurances of safety during the entire period
of pregnancy cannot be provided. The worker should be advised to
discuss this matter with her own physician.

b. In fe r tility

Heat exposure has been associated with temporary infertility in both

females and males, with the effects being more pronounced in the
male [124,125]. Available data are insufficient to assure that the
REL protect against such effects. Thus, the examining physician
should question workers exposed to high heat loads about their
reproductive histories, whether they use contraceptive methods, type
of contraceptive methods used, whether they have ever tried to have
children, and whether female workers have ever been pregnant. In
addition, the worker should be questioned about any history of
infertility, including possible heat-related infertility. Because
the heat-related infertility is usually temporary, reduction in heat
exposure or job transfer should result in recovery.

82
 c. T e ra to g e n ic ity and Heat-induced A bortion

The body of experimental evidence reviewed by Lary [126] indicates

that in the nine species of warm-blooded animals studied, prenatal
exposure of the pregnant females to hyperthermia may result in a
high incidence of embryo deaths and in gross structural defects,
especially of the head and central nervous system (CNS). An
elevation of the body temperature of the pregnant female to
39.5°-43°C (103.1°-109.4°F) during the first week or two of
gestation (depending on the animal species) resulted in structural
and functional maturation defects, especially of the central nervous
system, although other embryonic developmental defects were also
found. It appears that some basic developmental processes may be
involved, but selective cell death and inhibition of mitosis at
critical developmental periods may be primary factors. The
hyperthermia in these experimental studies did not appear to have an
adverse effect on the pregnant female but only on the developing
embryo. The length of hyperthermia in the studies varied from
10 minutes a day over a 2- to 3-week period to 24 hours a day for 1
or 2 days.

The evidence for teratogenic effects of hyperthermia in humans is

less convincing, in part, because it is based mainly on
self-reported data obtained months or years after a pregnancy in
which increased body temperature occurred during pathologic
processes (e.g., acute infection during early pregnancy). However,
recent retrospective epidemiologic studies have associated
hyperthermia of a day or less, to a week or more, during the first
trimester of pregnancy with birth defects, especially defects in CNS
development (e.g., anencephaly) [126]. Based on the animal
experimental data and the human retrospective studies, it appears
prudent to monitor the body temperature of a pregnant worker exposed
to total heat loads above the REL, every hour or so to ensure that
the body temperature does not exceed 39°-39.5°C (102°-103°F) during
the first trimester of pregnancy.

C. S u rv e iI lance

To ensure that the control practices provide adequate protection toworkers

in hot areas, the plant physician or nurse can utilize workplace medical
surveillance data, the periodic examination, and an interval history to note
any significant within- or between-worker events since the individual
worker's previous examination. Such events may include repeated accidents
on thejob, episodes of heat-related disorders, or frequent health-related
absences. These events may lead the physician to suspect overexposure of
the worker population (from surveillance data), possible heat intolerance of
thé individual worker, or the possibility of an aggravating stress in
combination with heat, such as exposure to hazardous chemicals or other
physical agents. Job-specific clustering ofheat-related illnesses or
injuries should be followed up by industrial hygiene and medical evaluations
of the worksite and workers.

83
D. B io lo g ic M onitoring o f Workers Exposed to Heat S tress

To assess the capacity of the workforce and individual workers to continue

working on a particular hot job, physiologic monitoring of each worker or
randomly selected workers while they are working in the heat should be
considered as an adjunct to environmental and metabolic monitoring. A
recovery heart rate, taken during the third minute of seated rest following
a normal work cycle, of 90 beats per minute (b/min) or higher, and recovery
heart rate taken during the first minute of seated rest minus the third
minute recovery heart rate of 10 b/min or fewer, and/or an oral temperature
of 38°C (100.4°F) or above indicate excessive heat strain [127,128]. Both
oral temperature and pulse rate should be measured again at the end of the
rest period before the worker returns to work to determine whether the rest
time has been sufficient for recovery to occur. Measurements should be
taken at appropriate intervals covering a full 2 -hour period for the hottest
part of the day and again at the end of the workday. Baseline oral
temperatures and pulse rates taken before the workers begin the first task
in the morning can be used as a basis for deciding whether individual
workers are fit to continue work that day. If excessive heat strain is
indicated, the work situation will require reexamination, preferably by the
physician and industrial hygienist to determine whether it is a case of
worker intolerance or excessive job-related heat stress.

84
 VIII. BASIS FOR THE RECOMMENDED STANDARD

The research data and industry experience information upon which the
recommendations for this standard are based were derived from (a) an
analysis of the published scientific literature; (b) the many techniques for
assessing heat stress and strain that are currently available; (c) suggested
procedures for predicting risk of incurring heat-related disorders, of
potentially unsafe acts, and of deterioration of performance; (d) accepted
methods for preventing and controlling heat stress; and (e) domestic and
international standards and recommendations for establishing permissible
heat-exposure limits.

The scientific basis for the recommendations has been discussed in

Chapters III through VII. In Chapter VIII some special considerations which
heavily influenced the form and emphasis of the final recommended criteria
for this standard for work in hot environments are discussed.

A. Estim ation o f Risks

The ultimate objective of a recommended heat-stress standard is to limit the

level of health risk (level of strain and the danger of incurring
heat-related illnesses or injuries) associated with the total heat load
(environmental and metabolic) imposed on a worker in a hot environment. The
level of sophistication of risk estimation has improved during the past few
years but still lacks a high level of accuracy. The earlier estimation
techniques were usually qualitative or at best only semiquantitative.

One of the earlier semiquantitative procedures for estimating the risk of

adverse health effects under conditions of heat exposure was designed by Lee
and Henschel [129]. The procedure was based on the known laws of
thermodynamics and heat exchange. Although designed for the "standard man"
under a standard set of environmental and metabolic conditions, it
incorporated correction factors for environmental, metabolic, and worker
conditions that differed from standard conditions. A series of graphs was
presented that could be used to semiquantitatively predict the percentage of
exposed individuals of different levels of physical fitness and age likely
to experience health or performance consequences under each of 15 different
levels of total stress. Part of the difficulty with the earlier attempts to
develop procedures for estimating risk was the lack of sufficient reliable
industry experience data to validate the estimates.

A large amount of empirical data on the relationship between heat stress and
strain (including death from heatstroke) has accumulated over the past
40 years in the South African deep hot mines. From data derived from
laboratory studies, a series of curves has been prepared topredict the
probability of a worker's body temperature reaching dangerous levels when
working under various levels of heat stress [130,131]. Based on these data
and on epidemiologic data on heatstroke from miners, estimates of
probabilities of reaching dangerously high rectal temperatures were made.
If a body temperature of 40°C (104°F) is accepted as the threshold
temperature at which the worker is in imminent danger of fatal or
irreversible heatstroke, the estimated probability of reaching this body
temperature is 10~6 for workers exposed to an effective temperature (ET)

85
of 34.6°C (94.3°F), 10~ 4 at 35.3°C (95.5°F), 10" 2 at 35.8°C (96.4°F),
and 10 “0 - 5 a t 36.6°C (97.9°F). If a body temperature of 38.5°-39.0°C
(101.3°-102.2°F) is accepted as the critical temperature, the ET at which
the probability of the body temperature reaching these values can also be
derived for 10" 1 to 10~® probabilities. These ET correlates were
established for conditions with relative humidity near 100 %; whether they
are equally valid for these same ET values for low humidities has not been
proven. Probabilities of body temperature reaching designated levels at
various ET values are also presented for unacclimatized men [5,130,131].
Although these estimates have proven to be useful in preventing heat
casualties under the conditions of work and heat found in the South African
mines, their direct application to industrial environments in general may
not be warranted.

A World Health Organization (WHO) scientific group on health factors

involved in working under conditions of heat stress concluded that "it is
inadvisable for deep body temperature to exceed 38°C (100.4°F) in prolonged
daily exposure to heavy work. In closely controlled conditions the deep
body temperature may be allowed to rise to 39°C (102.2°F)" [48]. This does
not mean that when a worker's tre reaches 38°C (100.4°F) or even 39°C
(102.2°F), the worker will necessarily become a heat casualty. If, however,
the tre exceeds 38°C (100.4°F), the risk of heat casualties occurring
increases. The 38°C (100.4°F) tre, therefore, has a modest safety margin
which is required because of the degree of accuracy with which the actual
environmental and metabolic heat load are assessed.

Some safety margin is also justified by the recent finding that the number
of unsafe acts committed by a worker increases with an increase in heat
stress [70]. The data derived by using safety sampling techniques to
measure unsafe behavior during work showed an increase in unsafe behavioral
acts with an increase in environmental temperature. The incidence was
lowest at WBGT's of 17°-23°C (62.6°-73.4°F). Unsafe behavior also increased
as the level of physical work of the job increased [70].

B. C o rre la tio n Between Exposure and E ffe c ts

The large amount of published data obtained during controlled laboratory

studies and from industrial heat-stress studies upholds the generality that
the level of physiologic strain increases with increasing total heat stress
(environmental and metabolic) and the length of exposure. All
heat-stress/heat-strain indices are based on this relationship. This
generality holds for heat-acclimatized and heat-unacclimatized individuals,
for women and men, for all age groups, and for individuals with different
levels of physical performance capacity and heat tolerance. In each case,
differences between individuals or between population groups in the extent
of physiologic strain resulting from a given heat stress relates to the
level of heat acclimatization and of physical work capacity. The individual
variability may be large; however, with extreme heat stress, the variability
decreases as the limits on the body's systems for physiologic regulation are
reached. This constancy of the heat-stress/heat-strain relationship has
provided the basic logic for predicting heat-induced strain using computer
programs encompassing the many variables.

86
Sophisticated models designed to predict physiologic strain as a function of
heat load and as modified by a variety of confounding factors are
available. These models range from graphic presentations of relationships
to programs for handheld and desk calculators and computers [132,133]. The
strain factors that can be predicted for the average worker are heart rate,
body and skin temperature, sweat production and evaporation, skin
wettedness, tolerance time, productivity, and required rest allowance.
Confounding factors include amount, fit, insulation, and moisture vapor
permeability characteristics of the clothing worn, physical work capacity,
body hydration, and heat acclimatization. From some of these models, it is
possible to predict when and under what conditions the physiologic strain
factors will reach or exceed values which are considered acceptable from the
standpoint of health.

These models are useful in industry to predict when any combination of

stress factors is likely to result in unacceptable levels of strain which
then would require introduction of control and correction procedures to
reduce the stress. The regression of heat-strain on heat-stress is
applicable to population groups, and with the use of a 95% confidence
interval can be applied as a modified form of risk prediction. However,
they do not, as presently designed, provide information on the level of heat
stress when one worker in 1 0 , or in 1 ,0 0 0 , or in 1 0 ,0 0 0 , will incur heat
exhaustion, heat cramps, or heatstroke.

C. Ph ysiolog ic M onitoring o f Heat S tra in

When the first NIOSH Criteria for a Recommended Standard....Occupational

Exposure to Hot Environments document was prepared in 1972, physiologic
monitoring was not considered a viable adjunct to the WBGT index,
engineering controls, and work practices for the assessment and control of
industrial heat stress. However, recently it has been proposed that
monitoring body temperature and/or work and recovery heart rate of workers
exposed to work environment conditions in excess of the ACGIH TLV could be a
safe and relatively simple approach [117,127,128]. All the heat-stress
indices assume that, providing the worker population is not exposed to
heat-work conditions that exceed the permissible value, most workers will
not incur heat-induced illnesses or injuries. Inherent in this is the
assumption that a small proportion of the workers may become heat
casualties. The ACGIH TLV assumes that nearly all healthy heat-acclimatized
workers will be protected at heat-stress levels that do not exceed the TLV.

Physiologic monitoring (heart rate and/or oral temperature) of heat strain

could help protect all workers, including the heat-intolerant worker exposed
at hot worksites. In one field study, the recovery heart rate was taken
with the worker seated at the end of a cycle of work from 30 seconds to
1 minute (P-|), 1 - 1/2 to 2 minutes (P2 ), and 2-1/2 to 3 minutes (P3 ).
Oral temperature was measured with a clinical thermometer inserted under the
tongue for 4 minutes. The data indicate that 95% of the time the oral
temperature was below 37.5°C (99.5°F) when the P-j recovery heart rate was
124 b/min or less, and 50% of the time the oral temperature was below 37.5°C
(99.5°F) when the P-| was less than 145 b/min. From these relationships, a
table for assessing heat strain and suggested remedial actions was

87
developed. If the P3 heart rate is lower than 90 b/min the
work-heat-stress conditions are satisfactory; if the P3 approximates
90 b/min and/or the P 1 -P 3 recovery is approximately 10 b/min, it
indicates that the work level is high but there is little increase in body
temperature; if P 3 is greater than 90 b/min and/or P 1 -P 3 is less than
10 b/min, it indicates a no-recovery pattern and the heat-work stress
exceeds acceptable levels; corrective actions should be taken to prevent
heat injury or illness [127,128]. The corrective actions may be of several
types (engineering, work practices, etc.).

In practice, obtaining recovery heart rates at 1- or 2-hour intervals or at

the end of several workcycles during the hottest part of the workday of the
summer season may present logistical problems, but available technology may
allow these problems to be overcome. The pulse rate recording wristwatch
that is used by some joggers, if proved sufficiently accurate and reliable,
may permit automated heart rate measurements. With the advent of the single
use disposable oral thermometer, measuring oral temperatures of workers at
hourly intervals should be possible under most industrial situations without
interfering with the normal work pattern. It would not be necessary to
interrupt work to insert the thermometer under the tongue and to remove it
at the end of 4 to 5 minutes. However, ingestion of fluids and mouth
breathing would have to be controlled for about 15 minutes before an oral
temperature is taken.

Assessment of heat strain by monitored physiologic responses of heart rate

and/or body temperature using radiotelemetry has been advocated. Such
monitoring systems can be assembled from off-the-shelf electronic components
and transducers and have been used in research in fire fighting and steel
mills and are routinely used in the space flight program [134,135].
However, at present they are not applicable to routine industrial situations.

The obvious advantage of such an automated system would be that data could
be immediately observed and trends established from which actions can be
initiated to prevent excessive heat strain. The obvious disadvantages are
that it requires time to attach the transducers to the worker at the start
and remove them from the worker at the end of each workday; the transducers
for rectal or ear temperature, as well as stick-on electrodes or
thermistors, are not acceptable for routine use by some people; electronic
components require careful maintenance for proper operations. Also, the
telemetric signals are often disturbed by the electromagnetic fields that
may be generated by the manufacturing process.

D. Recommendations o f U.S. O rg anizations and Agencies

1. The American Conference of Governmental In d u s tria l H yg ie n is ts

(ACGIH)

The American Conference of Governmental Industrial Hygienists (ACGIH)

TLVs for heat-stress refers "to heat stress conditions under which it is
believed that nearly all workers may be repeatedly exposed without
adverse health effects" [2]. The TLVs are based on the assumptions that
the ( 1 ) workers are acclimatized to the work-associated heat stress
present at the workplace, (2 ) workers are clothed in usual work

88
clothing, (3) workers have adequate water and salt intake, (4) workers
should be capable of functioning effectively, and (5) the TWA deep body
temperature will not exceed 38°C (100.4°F). Those workers who are more
tolerant to work in the heat than the average and are under medical
supervision may work under heat-stress conditions that exceed the TLV,
but in no instance should the deep body temperature exceed the 38°C
(100.4°F) limit for an extended period. The TLV permissible
heat-exposure values consider both the environmental heat factors and
the metabolic heat production. The environmental factors are expressed
as the WBGT and are measured with the dry bulb, natural wet bulb, and
black globe thermometers. The metabolic heat production is expressed as
work-load category: light work = <200 kcal/h (<800 Btu/h or 230 W);
moderate work = 200-350 kcal/h (800-1400 Btu/h or 230-405 W); and heavy
work = >350 kcal/h (>1400 Btu/h or 405 W). The ranking of the job may
be measured directly by the worker's metabolic rate while doing the job
or estimated by the use of the work-load assessment procedure where both
body position and movement and type of work are taken into
consideration. For continuous work and exposure, a WBGT limit value is
set for each level of physical work with a decreasing permissible WBGT
for increasing levels of metabolic heat production.

The TLV permissible heat-exposure values range from a WBGT of 30°C

(8 6 °F) for light work, 26.7°C (80°F) for moderate work, to 25°C (77°F)
for heavy work for continuous exposure based on a 1-hour TWA for WBGT
and work load. These values are comparable to those in the ISO Standard
7243 [3]. In addition to the permissible heat-exposure threshold limit
values for continuous work, the ACGIH Heat Stress TLV contains values
for various rest-work regimens: 75% work, 25% rest each hour; 50% work,
50% rest each hour; and 25% work, 75% rest each hour for light,
moderate, and heavy work, respectively. These TLVs assume that the rest
environment is approximately the same as that at work. Appendix B of
the ISO 7243 contains a simi lar set of values for rest-work regimens
where the rest environment is similar to the work environment.

The ACGIH TLVs for heat stress which were adopted in 1974 forms the
basis for the ISO standard on Heat Stress of 1982 (discussed in Chapter
VI 11-E).

2. Occupational S a fety and H ealth A d m in is tra tio n (OSHA)

Standards Advisory Committee on Heat S tress (SACHS)

In January 1973, the Assistant Secretary of Labor for Occupational

Safety and Health (OSHA) appointed a Standards Advisory Committee on
Heat Stress (SACHS) to conduct an in-depth review and evaluation of the
NIOSH Criteria for a Recommended Standard....OccupationaI Exposure to
Hot Environments and to develop a proposed standard that "would
establish work practices to minimize the effects of hot environmental
conditions on working employees" [7]. The purpose of the standard was
to minimize the risk of heat disorders and illnesses of workers exposed
to hot environments so that the worker's well-being and health would not
be impaired. The 15 committee members represented worker, employer,
state, federal, and professional groups.

89
The recommendations for a heat-stress standard were derived by the SACHS
by majority vote on each statement. Any statement which was disapproved
by an "overwhelming majority" of the members was no longer considered
for inclusion in the recommendations. The recommendations establish the
threshold WBGT values for continuous exposure at the three levels of
physical work: light <200 kcal/h (<800 Btu/h), 30°C (8 6 °F); moderate
200-300 kcal/h (804-1200 Btu/h), 27.8°C (82°F); and heavy >300 kcal/h
(>1200 Btu/h), 26.1°C (79°F) with low air velocities up to 300 fpm.
These values are similar to theACGIH TLVs. When the air velocity
exceeds 300 fpm, the threshold WBGT values are increased 2.2°C (4°F) for
light work and 2.8°C (5°F) for moderate and heavy work. The logic
behind this recommendation was that the instruments used for measuring
the WBGT index do not satisfactorily reflect the advantage gained by the
worker when air velocity is increased beyond 300 fpm. Data presented by
Kamon et al. [136], however, questioned the assumption, because the
clothing worn by the worker reduced the cooling effect of increased air
velocity. However, under conditions where heavy protective clothing or
clothing with reduced air and/or vapor permeability is worn, higher air
velocities may to a limited extent facilitate air penetration of the
clothing and enhance convective and evaporative heat transfer.

The recommendations of the SACHS contain a list of work practices that

are to be initiated whenever the environmental conditions and work load
exceed the threshold WBGT values. The threshold WBGT values and work
levels are based on a 120-minute TWA. Also included are directions for
medical surveillance, training of workers, and workplace monitoring.

The threshold WBGT values recommended by the OSHA SACHS are in

substantial agreement with the ACGIH TLVs and the ISO standard. The
OSHA SACHS recommendations have not, however, been promulgated into an
OSHA heat-stress standard. Following any one of the three procedures
would provide equally reliable guidance for ensuring worker health and
well-being in hot occupational environments [137].

3. American In d u s tria l Hygiene A ssociation (AI HA)

The American Industrial Hygiene Association (AIHA) publication Heat inq

and Cooling for Man in Industry, Chapter 2, "Heat Exchange and Human
Tolerance Limits" contains a table of "Industrial Heat Exposure Limits"
for industrial application [138]. The limits of heat exposure are
expressed as WBGT values for light, moderate, and heavy work when the
exposure is continuous for 50 minutes of each hour for an 8 -hour day and
for intermittent work-rest when each work period of 3 hours, 2 hours,
1 hour, 30 minutes, or 20 minutes is followed by 1 hour of rest. In
establishing the heat-exposure limits for intermittent work-rest, it was
assumed that the worker would rest in an environment that was cooler
than the work area. It is also emphasized in the report that under
conditions of severe heat where the work periods are limited to 20 or
30 minutes, experienced workers set their own schedules and work rate so
that individual tolerances are not exceeded.

90
The maximum heat exposure limits for each of the work categories are,
for continuous work, comparable to the TLVs and the ISO standard
described in Chapter Vlll-E.

For intermittent work, direct comparisons are difficult because of the

differences in assumed rest area temperatures. However, when
corrections for these differences are attempted, the ISO and the ACGIH
TLV values for 75/25 and 50/50 work-rest regimens are not very different
from the AIHA values. These limits support the generalizations that
workable heat-stress exposure limits, based on the WBGT and metabolic
heat-production levels, are logical and practical for use for industrial
guidance [137].

4. The Armed S ervices

The 1980 publication (TBMED 507, NAVMED P-5052-5 and AFP 160-1) of the
Armed Services, "Occupational and Environmental Health, Prevention,
Treatment, and Control of Heat Injury" [139], addresses in detail the
procedures for the assessment, measurement, evaluation, and control of
heat stress and the recognition, prevention, and treatment of heat
illnesses and injuries. Except for the part in which problems specific
to military operations are discussed, the document is applicable to
industrial-type settings.

The WBGT index is used for the measurement and assessment of the
environmental heat load. It is emphasized that the measurements must be
taken as close as possible to the location where the personnel are
exposed. The threshold levels of WBGT for instituting proper hot
weather practices are given for the various intensities of physical work
(metabolic heat production). The WBGT and metabolic rates are
calculated for a 2-hour TWA. The threshold WBGT values of 30°C (8 6 °F)
for light work, 28°C (82.4°F) for moderate work, and 25°C (77°F) for
heavy work are about the same as those of the ISO standard and the ACGIH
TLVs. However, these are the thresholds for instituting hot weather
practices rather than limiting values. The mean metabolic rates (kcal/h
or W) for light, moderate, and heavy work cited in this Armed Services
document are expressed as TWA mean metabolic rates and are lower than
the values generally used for each of the work categories.

Except for the problem of the metabolic rates, this document is an

excellent, accurate, and easily used presentation. Engineering controls
and the use of protective clothing and equipment are not extensively
discussed; however, on balance it serves as a useful guide for the
prevention, treatment, and control of heat-induced injuries and
illnesses. In addition, it is in general conformity with the ISO
standard, the ACGIH TLVs, and most other recommended heat-stress indices
based on the WBGT.

5. American C ollege o f Sports M edicine (ACSM)

In July 1984, the American College of Sports Medicine (ACSM) published a

position statement on "Prevention of Heat Injuries During Distance
Running" [140]. To be competitive, the long distance runner must be in

91
 excellent physical condition, exceeding the physical fitness of most
industrial workers. For long distance races such as the marathon, the
fastest competitors run at 12 to 15 miles per hour, which must be
classified as extremely hard physical work. When the thermal
environment reaches even moderate levels, overheating can be a problem.

To reduce the risk of heat-induced injuries and illnesses, the ACSM has
prepared a list of recommendations which would serve as advisory
guidelines to be followed during distance running when the environmental
heat load exceeds specific values. These recommendations include
(1) races of 10 km or longer should not be conducted when the WBGT
exceeds 28°C (82.4°F); (2) all summer events should be scheduled for
early morning, ideally before 8 a.m. or after 6 p.m.; (3) race sponsors
must provide fluids; (4) runners should be encouraged to drink
300-360 mL of fluids 10 to 15 minutes before the race; (5) fluid
ingestion at frequent intervals during the race should be permitted with
water stations at 2-3 km intervals for races 10 km or longer, and
runners should be encouraged to drink 100-200 mL at each water station;
(6 ) runners should be instructed on recognition of early signs and
symptoms of developing heat illness; and (7) provision should be made
for the care of heat-illness cases.

In these recommendations the WBGT is the heat-stress index of choice.

The "red flag" high risk WBGT index value of 23°-28°C (73.4°-82.4°F)
would indicate all runners must be aware that heat injury is possible,
and any person particularly sensitive to heat or humidity should
probably not run. An "amber flag" is moderate risk with a WBGT of
18°-23°C (64.4°-73.4°F). It is assumed that the air temperature and
humidity and solar radiation are likely to increase during the day.

E. In te rn a tio n a l Standards and Recommendations

1. The In te rn a tio n a l O rg an izatio n fo r S ta n d a rd iza tio n (IS O )

In 1982 the International Organization for Standardization (ISO) adopted

and published an international standard on’ "Hot Environments
Estimation of the Heat Stress on Working Man Based on the WBGT Index
(Wet Bulb Globe Temperature)" [3]. The standard, as published, was
approved by the member bodies of 18 of the 25 countries who responded to
the request for review of the document. Only two member bodies
disapproved. Several of the member bodies who approved the documents
have official or unofficial heat-stress standards in their own
countries, i.e., France, Republic of South Africa, Germany, and Sweden.
The member bodies of the United States and the U.S.S.R. were among those
who neither approved nor disapproved the document. The vote of each
member body is supposedly based on a consensus of the membership of its
Technical Advisory Group. Although the U.S. group did not reach a
consensus, several of the guidelines in the ISO standard were
recommended by the NIOSH workshop [141] to be included in an updated
criteria document.

The ISO heat-stress standard in general resembles the ACGIH TLV for heat
stress adopted in 1974. The basic premise upon which both are

92
 based is that no worker should be exposed to any combination of
environmental heat and physical work which would cause the worker's body
core temperature to exceed 38°C (100.4°F). The 38°C is based on the
recommendations of the World Health Organization's report of 1969 on
health factors involved in working under conditions of heat stress
[48]. In addition, the ISO standard is based on the WBGT index for
i expressing the combination of environmental factors and on reference
tables (or direct oxygen consumption measurements) for estimating the
metabolic heat load. The ISO standard includes a table for the
classification of metabolic heat with examples of activities
characteristic of each of the five metabolic rates (rest, low metabolic
rate, moderate metabolic rate, high metabolic rate, and very high
metabolic rate). The upper permissible WBGT value for each of these
work categories is presented for both the heat-acclimatized and for the
heat-unacclimatized worker. For the heavy and very heavy work
categories, the WBGT values are further subdivided into "no sensible air
movement" and for "sensible air movement" categories.

The ISO standard index values, as do most other recommended heat-stress

limit values, assume that the worker is a normal healthy individual,
physically fit for the level of activity being done, and wearing
standard summer weight workclothing with a thermal insulation value of
about 0 . 6 clo (not including the still air layer insulation).
Deviations in health status, physical fitness, and type and
characteristics of clothing worn will require a modification of the
permissible WBGT index values. The ISO WBGT index values are also based
on the hypothesis that the environment in which any rest periods are
taken is essentially the same as the worksite environment, and that the
worker spends most of the workday in this environment.

The environmental measurements specified in the ISO standard for the

calculation of the WBGT are (1) air temperature, (2) natural wet bulb
temperature, and (3) black globe temperature. From these, WBGT index
values can be calculated or can be obtained as a direct integrated
reading with some types of environmental measuring instruments. The
measurements must, of course, be made at the place and time of the
worker's exposure.

The ISO standard brings together, on an international level, heat-stress

guidelines which are component parts of the many official and unofficial
standards and guidelines set forth nationally. Basically a general
conformity between the many proposed standards.

A disturbing aspect of the ISO standard is that the "reference values

correspond to exposures to which almost all individuals can be
ordinarily exposed without harmful effect, provided that there is no
preexisting pathological condition." This statement implies that in the
specified nonpathologic population exposed to the standard index values
of heat stress, some individuals could incur heat illnesses. What
proportion of the population is "almost all?" How many heat illnesses
are acceptable before corrective actions are taken? How are these less
tolerant workers identified?

93
The problem of how to identify those few individuals whose low heat
tolerance places them at high risk before their health and safety are
jeopardized in a hot work environment is not addressed. The ISO
standard does not address the problem of using biologic monitoring as an
adjunct approach to reducing the risk of heat-induced illnesses.

The ISO standard includes one condition that is not addressed in some of
the other standards or recommendations. A correction factor for air
velocity during high metabolic heat production is introduced to
compensate for the effect of air velocity on sweat evaporation rate.
When there is no perceptible air movement, the WBGT index value is 1°C
(1.8°F) lower than where there is a perceptible air movement for high
metabolic rate (200-260 W/m2 ) and 2°C (3.6°F) lower for very high
metabolic rate (>260 W/m2 ). This appears to be a reasonable
correction; however, rarely in industrial situations does a "no sensible
air movement" occur except possibly in confined enclosures. The
movement of the torso and the limbs, especially during hard work, in
itself will create an effective air movement. Consequently, it may be
questioned whether an air movement correction is really necessary.

2. ISO Proposed A n a ly tic a l Method

The ISO Working Group for the Thermal Environment has prepared a draft
document "Analytical Determination of Thermal Stress" which, if adopted,
would provide an alternative procedure for assessing the stressfulness
of a hot industrial environment [142]. The method is based on a
comparison between the required sweat production as a result of the
working conditions and the maximum physiologically achievable skin
wettedness and sweat production. The standard requires (1) calculating
the sweat evaporation rate required to maintain body thermal balance,
(2 ) calculating the maximum sweat evaporation rate permitted to the
ambient environment, and (3) calculating the sweat rate required to
achieve the needed skin wettedness. The cooling efficiency of sweat as
modified by the clothing worn is included in the calculation of required
skin wettedness.

The data required for making the calculations include dry bulb air
temperature, wet bulb temperature, radiant temperature, air velocity,
metabolic heat production, vapor and wind permeability, and insulation
value of the clothing worn. From these, the convective, radiative, and
evaporative heat exchange can be calculated using the thermodynamic
constants. Finally, E reg/Emax can be expressed as sweat production
required to wet the skin to the extent necessary (skin wettedness
required). This approach basically is similar to the new effective
temperature (ET*) proposed by the scientists at the Pierce Foundation
Laboratories [143].

The computer program for calculating the required sweat rate and the
allowable exposure time is written in BASIC computer language. It may
require adaptation of the program to fit a particular user computer
system. The major disadvantages with this proposed approach to a
standard are essentially the same as those of other suggested approaches
based on detailed calculations of heat exchange. The separate

94
environmental factors, especially effective air velocity, are difficult
to measure with required accuracy under conditions of actual industrial
work situations. Air velocity, in particular, may vary widely from time
to time at a workplace and at any time between short distances at a
workplace. For routine industrial use, this proposed procedure appears
to be too complicated. Furthermore, a number of assumptions must be
made for the variables needed to solve the equation, because the
variables cannot or are not easily measured directly, e.g., mean skin
temperature is assumed to be 35°C (95°F) but may be lower or higher, and
the convective and radiant heat transfer coefficients, which are assumed
to be constant, vary with body posture. These and other assumed values
detract from the usefulness of the predictions of heat strain.

On the positive side, the equations are well suited for deciding on the
most efficient approach to reducing total heat load (e.g., environmental
vs. metabolic heat). The ISO draft standard recommends limits in terms
of hourly TWA values and 8 hours of exposure. The criterion for the
8 -hour exposure is the amount of body water that can be lost by sweating
and can be replaced without excessive hypohydration. These 8 -hour
values, expressed as total sweat production, are 3,250 mL for
unacclimatized and 5,200 mL for acclimatized workers. An 8 -hour sweat
production of 2,500 mL and 3,900 mL, respectively, for the
unacclimatized and the acclimatized workers are considered to represent
a level of heat stress at which some countermeasures should be
initiated. Hourly limits based on these 8 -hour recommended action
limits would be reduced by about 35%. If workers were exposed to heat
each hour at the maximum hourly level in terms of the required sweat
index, they would reach the 8 -hour sweating limit after about 5 hours of
exposure. These recommendations are supported by data from several
western and eastern countries and from the United States, including the
NIOSH studies.

The suggested physiologic strain criteria for thermal exposure limits

based on average values are summarized in Table V I 1 1- 1 .

95
 TABLE VI11-1.— Criteria for thermal limits based on average values

Heat (nonaccIi mat ized) Heat (accIimat ized)

Alert Danger Alert Danger

Heat storage kcal 58 70 58 70

Rectal temp increase °C (°F ) 0.8 (1.4) 1 ( 1 .8 ) 0.8 (1.4) 1 (1.8)
Skin temp increase °C (°F) 2.4 (4.3) 3 (5.4) 2.4 (4.3) 3 (5.4)
Sweat rate, max rest g/h 260 390 520 780
Sweat rate, max work g/h 520 650 780 1040
Max 8 h sweat production to
prevent excessive
dehydrat ion 2.60 3.25 3.90 5.20
Skin wettedness, rest 0.85 1.0
Skin wettedness, work 0.50 0.85

Adapted from Reference 16.

F. Foreign Standards and Recommendations

Several nations have developed and published standards, recommendations, and

guidelines for limiting the exposure of workers to potentially harmful
levels of occupational heat stress. These documents range from official
national position standards to unofficial suggested practices and procedures
and to unofficially sanctioned guidelines proposed by institutions, research
groups, or individuals concerned with the health and safety of workers under
conditions of high heat load. Most of these documents have in common the
use of (1) the WBGT as the index for expressing the environmental heat load
and (2 ) some method for estimating and expressing the metabolic heat
production. The permissible total heat load is then expressed as a WBGT
value for all levels of physical work ranging from resting to very heavy
work.

1. F i nI and

A heat-stress limits guide has been recommended which is not, however,

an official national standard for Finland. The guide conforms to the
ACGIH TLV for heat stress [144]. To evaluate the heat exposure, the
WBGT method was used, because it was considered to be the best
internationally documented procedure, and because it is simple and
suitable for use in the field.

The limits presented in the Finnish guidelines are (as are the ACGIH
TLV) based on the assumption that the worker is healthy, heat
acclimatized, properly clothed, and provided with adequate water and
salt. Higher levels of heat exposure are permitted for workers who show
unusually high heat tolerance.

96
2. Sweden

The Department of Occupational Safety, General Bureau TAA 3, Collection

of Reports AFS 198X, Report No. 4, 1981-09-11, Ventilation of Work Rooms
[145], although mainly concerned with workroom heating, cooling, and
ventilation to achieve thermal comfort and no health hazards, does
specify "highest permissible heat exposure" which should not be
exceeded. The maximum heat exposure is based on an hourly TWA for each
of the various levels of physical activity: sitting, light, medium
heavy, and heavy. For each activity level, the maximum environmental
heat load is expressed in WBGT units: 28°, 25°, and 23°C (82°, 77°, and
73°F) for the light, medium heavy, andheavy activity levels,
respectively. The activity levels in watts or kcal/h are not given.
Consequently, it is difficult to compare exactly the presented maximum
heat exposure levels with those of the ISO or ACGIH TLV.

If it is assumed that the activity levels are comparable to those of the

ISO and ACGIH TLV, then the Swedish maximum heat-stress levels are about
2°C (3.6°F) lower for each activity. The Swedish WBGT (SWBGT) for air
velocities less than 0.5 m/sec is calculated from the formula
SWBGT = 0.7twb+0.3ta+2. The added 2 is a correction factor when the
psychrometric wet bulb temperature is used instead of the natural wet
bulb temperature.

3. Roman i a

Chapter X, "Microclimate, Ventilation and Heating" of the Occupational

Health Protection Standards of the Romanian Republic [146] provides data
on air movement requirement and average maximum acceptable air
temperature (ta ) for various levels of physical work
(light = 150 kcal/h, average = 151-300 kcal/h, heavy = >300 kcal/h) and
various levels of radiant heat load (600, 1 2 0 0 , 1800 kcal/h); relative
humidity should not exceed 60%. In addition, several engineering
controls, work practices, and types of personal protective equipment are
listed. These control procedures are comparable to those provided in
other heat-stress standards and recommendations. The maximum listed air
temperatures and required wind speeds range from 28°C (82.4°F) and
1 m/sec for light work and low radiant heat to 22°C (71.6°F) and 3 m/sec
for heavy physical work and high radiant heat. To convert the ta ,
Va , and the various levels of radiant heat and the metabolic heat load
into WBGT, CET or comparable indices for direct comparison with other
standards and recommendations would require considerable manipulation.
The standard specifies that the microclimatic conditions at the worksite
must be such that the worker can maintain thermal equilibrium while
performing normal work duties. The body temperature accepted for
thermal equilibrium is not specified. No mention was made of state of
acclimatization, health status, clothing worn, etc., as factors to be
considered in setting the heat stress values.

4. U .S .S .R .

The U.S.S.R. heat-stress standard CH245-68, 1963 [147] defines

acceptable combinations of air temperature, humidity, air speed, and

97
radiant temperatures for light, medium heavy, and heavy work loads. In
general format, the U.S.S.R. and Romanian standards are comparable.
They differ, however, in several points: (1) for medium heavy work the
U.S.S.R. uses 150-245 kcal/h while Romania uses 150-300 kcal/h; (2) for
heavy work the values are >250 kcal/h for the U.S.S.R. and >300 kcal/h
for Romania; (3) for light work and radiant heat <600 kcal/m2/h the
U.S.S.R. ta is 22°-24°C (71,6°-75.2°F) at air velocity of 0.5-1 m/sec
while the Romanian ta is 28°C (82.4°F) at air velocity of 1 m/sec;
(4) for the heavy work and radiant heat >1200 kcal/h the U.S.S.R. ta
is 16°C (60.8°F) with air velocity of 3 m/sec while the Romanian ta is
22°C (71.6°F) at air velocity of 3 m/sec; and (5) for all combinations
of work and radiant heat loads in between these extremes the U.S.S.R.
ta is consistently 2°C (3.6°F) or more below the Romanian ta at
comparable air velocities. The U.S.S.R. standard suggests that for high
heat and work load occupations, the rest area for the workers be kept at
"optimum conditions." For radiant heat sources above 45°C (113°F),
radiation shielding must be provided. State of acclimatization,
physical fitness, health status, clothing worn, provision of water,
etc., are not addressed as factors that were considered in establishing
the heat-stress limits.

5. Be Ig i um

The Belgium Royal Decree [148] concerning workplace environments

contains a section on maximum permissible temperature in indoor
workplaces acceptable for very light (90 kcal/h), light (150 kcal/h),
semi heavy (250 kcal/h), and heavy work (350 kcal/h). The work category
energies are comparable to those used in the ISO standard. It is
specified that if the workers are exposed to radiant heat, the
environmental heat load should be measured with a wet globe thermometer
or any other method that will give similar effective temperature
values. The maximum temperatures established for the various work
intensities are the same as those of the ISO and the ACGIH TLV, but the
values are stated in terms of ET.

Based on the advice of an industrial physician and agreement of the

workers' representative to the Committee of Safety, Health and
Improvement of the Workplace, the maximum permissible temperature may be
exceeded if (1 ) exposure is intermittent, (2 ) a cool rest area is
available, and (3) adequate means of protection against excessive heat
are provided. The decree also provides that for outside work in the
sun, the workers should be protected from solar radiation by an adequate
device.

The industrial physician is given the responsibility for ensuring heat

acclimatization of the worker, selection and use of protective devices,
establishing rest times, and informing workers of the need for an
adequate fluid intake. The employer is responsible for providing
engineering controls for convective heat by ventilation and radiant heat
by shielding, reflective protective clothing, or clothing with
incorporated cooling.

98
If engineering controls are not adequate, a reduction in exposure time
to the excessive heat is recommended. This reduction in exposure is
accomplished by varying the work-rest cycle. The rest area temperature
must be below 30°C (8 6 °F). A table is provided for work-rest cycles for
various environmental heat loadsat each of the levels of physical
work. For 10 minutes of rest in each 2-hour work period, the maximum
effective temperatures are 30.1°,26.8°, and 25.1°C (86.1°, 80.23°, and
77.2°F) for light, semi heavy, and heavy work, respectively. At the
other extreme, only 5 minutes of work is permitted when the effective
temperature is 33°, 32°, and 31.5°C (91.9°, 89.6°, and 88.7°F) for
light, semi heavy, and heavy work, respectively. These values are
relatively comparable to the WBGT values listed in the ACGIH TLVs for
similar work loads.

6. A u s tra lia

Rule 1 of the Factories (Health and Safety) Regulations, Factories and

Shops Act of 1960-1973, as revised by order of Council, November 1973,
sections (8 )(b ) through (8 )(d), (9), and (10) [149] contain general
statements pertaining to temperature, air movement, and humidity for hot
working areas in factories. In thoise factories that are not air
conditioned, the inside globe temperature shall not exceed 25°C (77°F)
when the outside temperature is 22.2°C (72°F) or below, or the inside
globe temperature shall not exceed the outside temperature by more than
2.8°C (5°F) when the outside temperature is above 22.2°C (72°F).

Minimum air movement is specified only for dressing and dining areas,
and humidities are specified only for areas that are air conditioned.
These Australian rules are very general but do contain a provision that
if in the opinion of an inspector "the temperature and humidity is
likely to be injurious to the health of a worker, the inspector may
require that remedial measures shall be taken." These remedial measures
include plant alterations and engineering controls. Recently, however,
the Australian member body of ISO voted for the adoption of the ISO
standard. Recently, the Victorian Trade Hall Council published
guidelines on working in heat [150]. The suggested guidelines which
closely follow the ACGIH TLVs for heat stress [2] included a summary of
(1) what is heat stress, (2) effects of heat stress, (3) heat illnesses,
(4) measurement of heat stress, (5) protective measurements against heat
stress, (6 ) medical requirements under heat-stress conditions,
(7) acclimatization to heat, and (8 ) regulations governing hot work.
The Australian Health and Medical Research Council also adopted these
guidelines. An unusual feature is the recommendation that "hazard
money" should not be an acceptable policy but that "a first priority is
the elimination of the workplace hazards or dangers and the refusal to
accept payment for hazardous or unsafe work."

7. Japan

The Recommendations on Maximum Allowable Concentrations of Toxic

Substances and Others in the Work Environment, 1982 published by the
Japanese Association of Industrial Health contains a section on "Maximum
Allowable Standards for High Temperatures" [151]. These recommendations

99
are designed as guidelines for protecting the worker from health hazards
in the hot work environment but do not have official governmental
endorsement. In this way they are comparable to the ACGIH TLVs.

The section on maximum allowable standards for high temperatures sets

the environmental heat-stress limits in WBGT and Corrected Effective
Temperature (CET) units for five intensities of physical work ranging
from extremely light (130 kcal/h) to heavy (370 kcal/h). When the
permissible maximum allowable WBGT values are compared to the ACGIH TLVs
for similar levels of physical work, they are essentially equal and are
also comparable to the ISO recommended heat-stress limits.

100
 IX. INDICES FOR ASSESSING HEAT STRESS AND STRAIN

During the past half century several schemes have been devised for assessing
and/or predicting the level of heat stress and/or strain that a worker might
experience when working at hot industrial jobs. Some are based on the
measurements of a single environmental factor (wet bulb), while others
incorporate all of the important environmental factors (dry bulb, wet bulb,
and mean radiant temperatures and air velocity). For all of the indices,
either the level of metabolic heat production is directly incorporated into
the index or the acceptable level of indexvalues varies as a function of
metabolic heat production.

To have industrial application, an index must, at a minimum, meet the

following cri teria:

• Feasibility and accuracy must be proven with use.

• All important factors (environmental, metabolic, clothing, physical

condition, etc.) must be considered.

• Required measurements and calculations must be simple.

• The measuring instruments and techniques applied should result in

data which truly reflect the worker's exposure but do not interfere
with the worker's performance.

• Index exposure limits must be supported by corresponding physiologic

and/or psychologic responses which reflect an increased risk to
safety and health.

• It must be applicable for setting limits under a wide range of

environmental and metabolic conditions.

The measurements required, advantages and disadvantages, and applicability

to routine industrial use of some of the more frequently used
heat-stress/heat-strain indices will be discussed under the following
categories: (1) Direct Indices, (2) Rational Indices, (3) Empirical
Indices, and (4) Physiological Monitoring.

A. D ire c t Indices

1. Dry Bulb Temperature

The dry bulb temperature (ta ) is commonly used for estimating comfort
conditions for sedentary people wearing conventional indoor clothing
(1.4 clo including the surface air layer). With light air movement and
relative humidity of 20 to 60%, air temperatures of 22°-25.5°C
(71.6°-77.9°F) are considered comfortable by most people. If work
intensity is increased to moderate or heavy work, the comfort air
temperature is decreased about 1.7°C (3°F) for each 25 kcal (100 Btu or
29 W) increase in the hourly metabolic heat production. Conversely, if

101
 the air temperature and/or the metabolic heat production are
progressively increased above the comfort zone, the level of heat stress
and heat strain will increase.

Dry bulb temperature is easily measured, but its use when the
temperature above the comfort zone is not justified except for work
situations where the worker is wearing completely vapor- and
ai r-impermeable encapsulating protective clothing. Even under these
conditions, appropriate adjustments must be made when significant solar
and long wave radiation are present [14].

2. Wet Bulb Temperature

The psychrometric wet bulb temperature (tw|j) may be an appropriate

index for assessing heat stress and predicting heat strain under
conditions where radiant temperature and air velocity are not large
factors and where twb approximates ta (high humidities). For
normally clothed individuals at low air velocities, a wet bulb
temperature of about 30°C (8 6 °F) is the upper limit for unimpaired
performance on sedentary tasks and 28°C (82.4°F is the upper limit) for
moderate levels of physical work. As twb increases above these
threshold values,performance deteriorates and accidents increase. The
wet bulb temperatures under these hot, humid conditions have been used
to predict risk of heatstroke occurring in South African and German
mines [130].

Wet bulb temperature is easy to measure in industry with a sling or

aspirated psychrometer, and it should be applicable in any hot, humid
situation where twb approaches skin temperature, radiant heat load is
minimal, and air velocity is light.

B. Rational Indices

1. O perative Temperature

The operative temperature (t0 ) expresses the heat exchange between a

worker and the environment by radiation and convection in a uniform
environment as it would occur in an actual industrial environment. The
t0 can be derived from the heat-balance equation where the combined
convection and radiation coefficient is defined as the weighted sum of
the radiation and convection heat-transfer coefficients, and it can be
used directly to calculate heat exchange by radiation and convection.
The t0 considers the intrinsic thermal efficiency of the clothing.
Skin temperature must be measured or assumed. The t0 presents several
difficulties. For convective heat exchange, a measure of air velocity
is necessary. Not included are the important factors of humidity and
metabolic heat production. These omissions make its applicability to
routine industrial use somewhat limited.

2. Belding-Hatch H e at-S tress Index

The Belding and Hatch Heat-Stress Index (HSI) [152] has had wide use in
laboratory and field studies of heat stress. One of its most useful

102
features is the table of physiologic and psychologic consequences of an
8 -hour exposure at a range of HSI values. The HSI is essentially a
derivation of the heat-balance equation that includes the environmental
and metabolic factors. It is the ratio (times 100) of the amount of
body heat that is required to be lost to the environment by evaporation
for thermal equilibrium ( E reg) divided by the maximum amount of sweat
evaporation allowed through tne clothing system that can be accepted by
the environment (Emax). It assumes that a sweat rate of about 1 liter
per hour over an 8 -hour day can be achieved by the average, healthy
worker without harmful effects. This assumption, however, lacks
epidemiologic proof. In fact, there are data that indicate that a
permissible 8 liters per 8 -hour day of sweat production is too high, and
as the 8 -hour sweat production exceeds 5 liters, more and more workers
will dehydrate more than 1.5% of the body weight, thereby increasing the
risk of heat illness and accidents. The graphic solution of the HSI
which has been developed assumes a 35°C (95°F) skin temperature and a
conventional long-sleeved shirt and trouser ensemble. The worker is
assumed to be in good health and acclimatized to the average level of
dai ly heat exposure.

The HSI is not applicable at very high heat-stress conditions. It also

does not identify correctly the heat-stress differences resulting from
hot, dryand hot, humid conditions. The strain resulting from metabolic
vs.environmental heat is not differentiated. Because E req/Emax is
a ratio, the absolute values of the two factors are not addressed, i.e.,
the ratio for an E req and Emax of 300 or 500 or 1,000 each would be
the same (1 0 0 ); yet the strain would be expected to be greater at the
higher E req and Emax values.

The environmental measurements require data on air velocity which at

best is an approximation under industrial work situations; in addition,
ta > twb, and *r must be measured. Metabolic heat production must
also bemeasured or estimated. The measurements are, therefore,
difficult and/or time-consuming which limits the application of the HSI
as a field monitoring technique.

The heat transfer coefficients used in the original HSI have been
revised as a result of observations on clothed subjects, by McKarns and
Brief [153]. Their modification of the HSI nomograph facilitates the
practical use of the index, particularly for the analysis of factors
contributing to the heat stress. The McKarns and Brief modification
also permits the calculation of allowable exposure time and rest
allowances at different combinations of environmental and metabolic heat
loads; however, the accuracy of these calculations is affected by the
limitations of the index mentioned above. HSI programs for a
programmable handheld calculator are available.

3. Skin Wettedness (%SWA)

Several of the rational heat-stress indices are based on the concept

that in addition to the sweat production required for temperature
equilibrium ( E req) and the maximum amount of sweat that can be
evaporated (Emax;, the efficiency of sweat evaporation will also

103
 affect heat strain. The less efficient the evaporation, the greater
will be the body surface area that has to be wetted with sweat to
maintain the required evaporative heat transfer; the ratio of
wetted to nonwetted skin area times 100% (SWA = E req/Emax).
This concept of wettedness gives new meaning to the E req/Emax ratio
as an indicator of strain under conditions of high humidity and low air
movement where evaporation is restricted [16,22,26,136,143,154].

The skin wettedness indices consider the variables basic to heat balance
(air temperature, humidity, air movement, radiative heat, metabolic
heat, and clothing characteristics) and require that these variables be
measured or calculated for each industrial situation where an index will
be applied. These measurement requirements introduce exacting and
time-consuming procedures. In addition, wind speed at the worksite is
difficult to measure with any degree of reliability; at best it can
generally be only an approximation. These indices are satisfactory as a
basis for calculating the magnitude of thermal stress and strain and for
recommending engineering and work practice controls; however, as
procedures for routine environmental monitoring, they are too
complicated, require considerable recording equipment, and are
t ime-consumi n g .

C. Emp i r i caI Ind i ces

Some of the earlier and most widely used heat-stress indices are those based
upon objective and subjective strain response data obtained on individuals
and groups of individuals exposed to various levels and combinations of
environmental and metabolic heat-stress factors.

1. The E ffe c tiv e Temperature (ET, CET, and ET*)

The effective temperature (ET) index is the first and until recently,
the most widely used of the heat-stress indices. The ET combines dry
bulb and wet bulb temperatures and air velocity. In a later version of
the ET, the Corrected Effective Temperature (CET), the black globe
temperature (tg ) is used instead of ta to take- the heating effect of
radiant heat inio account. The index values for both the ET and the CET
were derived from subjective impressions of equivalent heat loads
between a reference chamber at 100 % humidity and low air motion and an
exposure chamber where the temperature and air motion were higher and
the humidity lower. The recently developed new effective temperature
(ET*) uses 50% reference relative humidity in place of the 100%
reference rh for the ET and CET. The ET* has all the liabilities of the
rational heat-stress indices mentioned previously; however, it is useful
for calculating ventilation or air-conditioning requirements for
maintaining acceptable conditions in buildings.

The ET and CET have been used in studies of physical, psychomotor, and
mental performance changes as a result of heat stress. In general,
performance and productivity decrease as the ET or CET exceed about 30°C
(8 6 °F). The World Health Organization has recommended as unacceptable
for heat-unacclimatized individuals values that exceed 30°C (8 6 °F) for

104
sedentary activities, 28°C (82.4°F) for moderate work, and 26.5°C
(79.7°F) for hard work. For the fully heat-acclimatized individuals,
the tolerable limits are increased about 2°C (3.6°F).

The data on which the original ET was based came from studies on
sedentary subjects exposed to several combinations of ta , tw b , and
Va all of which approximated or slightly exceeded comfort conditions.
The responses measured were subjective impressions of comfort or equal
sensations of heat which may or may not be directly related to values of
physiologic or psychologic strain. In addition, the sensations were the
responses to transient changes. The extrapolation of the data to
various amounts of metabolic heat production has been based on
industrial experience. The ET and CET have been criticized on the basis
that they seem to overestimate the effects of high humidity and
underestimate the effects of air motion and thus tendto overestimate
the heat stress.

In the hot, humid mines of South Africa, heat-acclimatized workers doing

hard physical work showed a decrease in productivity beginning at ET of
27.7°C (81.9°F) (at 100% rh with minimal airmotion) which is
approximately the reported threshold for the onset of fatal heatstroke
during hard work [5,6]. These observations lend credence to the
usefulness of the ET or CET as a heat-stress index in mines and other
places where the humidity is high and the radiant heat load is low.

2. The Wet Bulb Globe Temperature (WBGT)

The Wet Bulb Globe Temperature (WBGT) index was developed in 1957 as a
basis for environmental heat-stress monitoring to control heat
casualties at military training camps. It has the advantages that the
measurements are few and easy to make; the instrumentation is simple,
relatively inexpensive, and rugged; and the calculations of the index
are straightforward. For indoor use only two measurements are needed:
natural wet bulb and black globe temperatures. For outdoors in
sunshine, the air temperature also must be measured. The calculation of
the WBGT for indoors is:

WBGT=0.7tnwb+0.3tg

for outdoors:

WBGT=0.7tnwb+0.2tg+0.1ta

The WBGT combines the effect of humidity and air movement (in tnwb),
air temperature and radiation (in t g ) , and air temperature ( t a ) as a
factor in outdoor situations in the presence of sunshine. If there is a
radiant heat load (no sunshine), the t„ reflects the effects of air
velocity and air temperature. WBGT measuring instruments are
commercially available which give ta , tn w b , and tg separately or
as an integrated WBGT in a form for digital readouts. A printer can be
attached to provide tape printouts at selected time intervals for WBGT,
ta> tnwb- va> and tg values.

105
The application of the WBGT index for determining training schedules for
military recruits during the summer season has resulted in a striking
reduction in heat casualties [155]. This dramatic control of heat
casualty incidence stimulated its application to hot industrial
si tuat ions.

In 1972 the first NIOSH Criteria for a Recommended Standard. ...

Occupational Exposure to Hot Environments [9] recommended the use of the
WBGT index for monitoring industrial heat stress. The rationale for
choosing the WBGT and the basis for the recommended guideline values was
described in 1973 [156]. The WBGT was used as the index for expressing
environmental heat load in the ACGIH TLVs - Heat Stress adopted in 1974
[2]. Since then, the WBGT has become the index most frequently used and
recommended for use throughout the world including its use in the
International Standards Organization document Hot Environments—
Estimation of the Heat Stress on Working Man Based on the WBGT Index
(Wet Bulb Globe Temperature) 1982 [3] (see Chapter VIII Basis for the
Recommended Standard for further discussion of the adoption of the WBGT
as the recommended heat stress index). However, when impermeable
clothing is worn, the WBGT will not be a relevant index, because
evaporative cooling (wet bulb temperature) will be limited. The air
temperature or adjusted dry bulb temperature is the pertinent factor.

The WBGT index meets the criteria of a heat-stress index that are listed
earlier in this chapter. In addition to the WBGT TLVs for continuous
work in a hot environment, recommendations have also been made for
limiting WBGT heat stress when 25, 50, and 75% of eachworking hour is
at rest (ACGIH-TLVs, OSHA-SACHS, AIHA). Regulating worktime in the heat
(allowable exposure time) is a viable alternative technique for
permitting necessary work to continue under heat-stress conditions that
would be intolerable for continuous exposure.

3. Wet Globe Temperature (WGT)

Next to the ta and twb, the wet globe thermometer (Botsball) is the
simplest, most easily read, and most portable of the environmental
measuring devices. The wet globe thermometer consists of a hollow
3-inch copper sphere covered by a black cloth which is kept at 100%
wettedness from a water reservoir. The sensing element of a thermometer
is located at the inside center of the copper sphere, and the
temperature inside the sphere is read on a dial on the end of the stem.
Presumably, the wet sphere exchanges heat with the environment by the
same mechanisms that a nude man with a totally wetted skin would in the
same environment; that is, heat exchange by convection, radiation, and
evaporation are integrated into a single instrument reading [157]. The
stabilization time of the instrument ranges from about 5 to 15 minutes
depending on the magnitude of the heat-load differential (5minutes for
5°C (9°F) and 15 minutes for >15°C (59°F)).

During the past few years, the WGT has been used in many laboratory
studies and field situations where it has been compared with the WBGT
[158,159,160,161,162]. In general, the correlation between the two is
high (r=0.91-0.98); however, the relationship between the two is not

106
 constant for all combinations of environmental factors. Correction
factors ranging between 1°C (1.8°F) and 7°C (12.6°F) have been
suggested. A simple approximation of the relationship is WBGT=WGT+2°C
for conditions of moderate radiant heat and humidity. These
approximations are probably adequate for general monitoring in
industry. If the WGT shows high values, it should be followed with WBGT
or other detailed measurements. The WGT, although good for screening
and monitoring, does not yield data for solving the equations for heat
exchange between the worker and the industrial environment, but a
color-coded WGT display dial provides a simple and rapid indicator of
the level of heat stress.

D. P h ysiolog ic M onitoring

The objectives of a heat-stress index are twofold: (1) to provide an

indication of whether a specific total heat stress will result in an
unacceptably high risk of heat illness or accidents and (2 ) to provide a
basis for recommending control procedures. The physiologic responses to an
increasing heat load include-an increase in heart rate, an increase in body
temperature, an increase in skin temperature, and an increase in sweat
production. In a specific situation any one or all of these responses may
be elicited. The magnitude of the response(s) will in general reflect the
total heat load. The individual integrates the stress of the heat load from
all sources, and the physiologic responses (strain) to the heat load are the
biological corrective actions designed to counteract the stress and thus
permit the body to maintain an optimal internal temperature. Acceptable
increases in physiologic responses to heat stress have been recommended by
several investigators [48,127,128]. It, therefore, appears that monitoring
the physiologic strain directly under regular working conditions would be a
logical and viable procedure for ensuring that the heat strain did not
exceed predesignated values. Measuring one or more of the physiologic
responses (heart rate and/or oral temperature) during work has been
recommended and is, in some industries, used to ensure that the heat stress
to which the worker is exposed does not result in unacceptable strain
[127,128]. However, several of the physiologic strain monitoring procedures
are either invasive (radio pill) or socially unacceptable (rectal catheter)
or interfere with communication (ear thermometer). Physiologic monitoring
requires medical supervision and the consent of the worker.

1. Work and Recovery Heart Rate

One of the earliest procedures for evaluating work and heat strain is
that introduced by Brouha in which the body temperature and pulse rate
are measured during recovery following a workcycle or at specified times
during the workday [29]. At the end of a workcycle, the worker sits on
a stool, an oral thermometer is placed under the tongue, and the pulse
rate is counted from 30 seconds to 1 minute (P -|), from 1-1/2 to
2 minutes (P2 ). and from 2-1/2 to 3 minutes (P 3 ) of seated
recovery. If the oral temperature exceeds 37.5°C (99.5°F), the P-|
exceeds 110 beats per minutes (b/min), and/or the P 1-P 3 is fewer
than 10 b/min, the heat and work stress is assumed to be above
acceptable values. These values are for group averages and may or may

107
not be applicable to an individual worker or specific work situation.
However, these values should alert the observer that further review of
the job is desi rable.

A modified Brouha approach is being used for monitoring heat stress in

some hot industries. An oral temperature and a recovery heart rate
pattern have been suggested by Fuller and Smith [127,128] as a basis for
monitoring the strain of working at hot jobs. The ultimate criterion of
high heat strain is an oral temperature exceeding 37.5°C (99.5°F). The
heart rate recovery pattern is used to assist in the evaluation. If the
P 3 is 90 b/min or fewer, the job situation is satisfactory; if the
P 3 is about 90 b/min and the P 1 -P3 is about 10 b/min, the pattern
indicates that the physical work intensity is high but there is little
if any increase in body temperature; if the P 3 is greater than
90 b/min and the P 1 -P 3 is fewer than 10 b/min, the stress (heat +
work) is too high for the individual and corrective actions should be
introduced. These individuals should be examined by a physician, and
the work schedule and work environment should be evaluated.

The field data reported by Jensen and Dukes-Dobos [163] corroborate the
concept that the P-| recovery heart rate and/or oral temperature is
more likely to exceed acceptable values when the environmental plus
metabolic heat load exceeds the ACGIH TLVs for continuous work. The
recovery heart rate can be easily measured in industrial situations
where being seated for about 5 minutes will not seriously interfere with
the work sequence; in addition, the instrumentation required (a
stopwatch at a minimum) canbe simple and inexpensive. Certainly the
recovery and work heart rate can be used on some jobs as early
indicators of the strain resulting from heat exposure in hot industrial
jobs. The relatively inexpensive, non invasive electronic devices now
available (and used by joggers and others) should make self-monitoring
of work and recovery pulse rates practical.

2. Body Temperature

The WHO scientific group on Health Factors Involved in Working Under

Conditions of Heat Stress recommended that the deep body temperature
should not, under conditions of prolonged daily work and heat, be
permitted to exceed 38°C (100.4°F) or oral temperature of 37.5°C
(99.5°F). The limit has generally been accepted by the experts working
in the area of industrial heat stress and strain.

Monitoring the body temperature (internal or oral) would, therefore,

appear to be a direct, objective, and reliable approach. Measuring
internal body temperature (rectal, esophageal, or aural) although not a
complicated procedure does present the serious problem of being
generally socially unacceptable to the workers.

Oral temperatures, on the other hand, are easy to obtain especially now
that inexpensive disposable oral thermometers are available. However,
to obtain reliable oral temperatures requires a strictly controlled
procedure. The thermometer must be correctly placed under the tongue
for 3 to 5 minutes before the reading is made, mouth breathing is not

108
permitted during this period, no hot or cold liquids should be consumed
for at least 15 minutes before the oral temperature is measured, and the
thermometer must not be exposed to an air temperature higher than the
oral temperature either before the thermometer has been placed under the
tongue or until after the thermometer reading has been taken. In hot
environments this may require that the thermometers be kept in a cool
insulated container or immersed in alcohol except when in the worker's
mouth. Oral temperature is usually lower than deep body temperature by
about 0.55°C (0.8°F). There is no reason why, with worker permission,
monitoring body temperature cannot be applied in many hot industrial
jobs. Evaluation of the significance of any oral temperature must
follow established medical and occupational hygiene guidelines.

3. Skin Temperature

The use of skin temperature as a basis for assessing the severity of

heat strain and estimating tolerance can be supported by
thermodynamically and field derived data. To move body heat from the
deep tissues (core) to the skin (shell) where it is dissipated to the
ambient environment requires an adequate heat gradient. As the skin
temperature rises and approaches the core temperature, this temperature
gradient is decreased and the rate (and amount) of heat moved from the
core to the shell is decreased and the rate of core heat loss is
reduced. To restore the rate of heat loss or core-shell heat gradient,
the body temperature would have to increase. An increased skin
temperature, therefore, drives the core temperature to higher levels in
order to reestablish the required rate of heat exchange. As the core
temperature is increased above 38°C (100.4°F), the risk of an ensuing
heat illness is increased.

From these observations it has been suggested that a reasonable estimate

of tolerance time for hot work could be made from the equilibrium
lateral thigh or chest skin temperature [14,15,20,22,164,165]. Under
environmental conditions where evaporative heat exchange is not
restricted, skin temperature would not be expected to increase much if
at all. Also in such situations, the maintenance of an acceptable deep
body temperature should not be seriously jeopardized except under very
high metabolic loads or restricted heat transfer. However, when
convective and evaporative heat loss is restricted (e.g., when wearing
impermeable protective clothing), an estimate of the time requiredfor
skin temperature to converge with deep body temperature should provide
an acceptable approach for assessing heat strain as well as for
predicting tolerance time.

4. Hypohydration

Under heat-stress conditions where sweat production may reach 6 to

8 liters in a workday, voluntary replacement of the water lost in the
sweat is usually incomplete. The normal thirst mechanism is not
sensitive enough to urge us to drink enough water to prevent
hypohydration. If hypohydration exceeds 1.5-2% of the body weight,
tolerance to heat stress begins to deteriorate, heart rate and body
temperature increase, and work capacity decreases [32]. When

109
hypohydration exceeds 5%, it may lead to collapse and to hypohydration
heat illness. Since the feeling of thirst is not an adequate guide for
water replacement, workers in hot jobs should be encouraged to take a
drink of water every 15 to 20 minutes. The water should be cool
10°-15°C (50°-59°F), but neither warm nor cold. Drinking from
disposable drinking cups is preferable to using drinking fountains. The
amount of hypohydration can be estimated by measuring body weight at
intervals during the day or at least at the beginning and end of the
workshift. The worker should drink enough water to prevent a loss in
body weight. However, as this may not be a feasible approach in all
situations, following a water drinking schedule is usually satisfactory.

110
 X. RESEARCH NEEDS

The past decade has brought an enormous increase in our knowledge of heat
stress and strain, of their relation to health and productivity, of
techniques and procedures for assessing heat stress and strain, and for
predicting the heat-related health risks associated with various amounts of
heat stress. In spite of this, there are several areas where further
research is required before occupational heat-induced health and safety
problems can be completely prevented.

A. Exposure Times and Patterns

In some hot industries the workers are exposed to heat most of the day;
other workers may be exposed only part of the time. Although there is
general agreement on the heat-stress/strain relation with resultant health
and safety risks for continuous exposure (8 -hour workday), controversy
continues on acceptable levels of heat stress for intermittent exposure
where the worker may spend only part of the working day in the heat. Is a
1-hour, a 2-hour, or an 8 -hour TWA required for calculating risk of health
effects? How long are acceptable exposure times for various total heat
loads? Are the health effects (heat illnesses) and risks the same for
intermittent as for continuous heat exposure? Do workers exposed
intermittently each day to various lengths and amount of heat stress develop
heat acclimatization similar to that achieved by continuously exposed
workers? Are the electrolyte and water balance problems the same for
intermittently as for continuously heat-exposed workers?

B. Deep Body Temperature

The WHO Scientific Group recommended that "it is considered inadvisable for
a deep body temperature to exceed 38°C (100.4°F) for prolonged dai ly
exposures (to heat) in heavy work" [48], and that a deep body temperature of
39°C (102.2°F) should be considered reason to terminate exposure even when
deep body temperature is being monitored. Are these values equally
realistic for short-term acute heat exposures as for long-term chronic heat
exposures? Are these values strongly correlated with increased risk of
incurring heat-induced illnesses? Are these values considered maximal which
are not to be exceeded, mean population levels, or 95th percentile levels?
Is the rate at which deep body temperature rises to 38° or 39°C important in
the health-related significance of the increased body temperature? Does a
38° or 39°C deep body temperature have the same health significance if
reached after 1 hour of exposure as when reached after more than 1 hour of
exposure?

C. E le c tro ly te and Water Balance

The health effects of severe acute negative electrolyte and water balance
during heat exposure are well documented. However, the health effects of
the imbalances when derived slowly over periods of months or years are not
known; nor are the effects known for long term electrolyte loading with and
without hyper or hypohydration. An appropriate electrolyte and water
regimen for long-term work in the heat requires more data derived from
further laboratory and epidemiologic studies.

111
D. identifying Heat Intolerant Workers

Most humans when exposed to heat stress will develop, by the processes of
heat acclimatization, a remarkable ability to tolerate the heat. In any
worker population, some will be able to tolerate heat better than others,
and a few, for a variety of reasons, will be relatively heat intolerant. At
present, the heat-tolerant individual cannot be easily distinguished from
the heat-intolerant individual except by the physiojogic responses to
exposure to high heat loads or on the basis of V 0 2 max (<2.5 L/m).
However, waiting until an individual becomes a heat casualty to determine
heat intolerance is anunacceptable procedure. A short and easily
administered screening test which will reliably predict degree of heat
tolerance would be very useful.

E. E ffects of Chronic Heat Exposure

All of the experimental and most of the epidemiologic studies of the health
effects of heat stress have been directed toward short exposures of days or
weeks in length and toward the acute heat illnesses. Little is known about
the health consequences of living and working in a hot environment for a
working lifetime. Dosuch long exposures to heat have any morbidity or
mortality implications? Does experiencing an acute heat illness have any
effects on future health and longevity? It is known that individuals with
certain healthdisorders (e.g. diabetes, cardiovascular disease) are less
heat tolerant. There is some evidence that the reverse may also be true;
e.g., chronic heat exposure may render an individual more susceptible to
both acute and chronic diseases and disorders [77], The chronic effect of
heat exposure on blood pressure is a particularly sensitive problem, because
hypertensive workers may be under treatment with diuretics and on restricted
salt diets. Such treatment may be in conflict with the usual emphasis on
increased water and salt intake during heat exposure.

F. Circadian Rhythm of Heat Tolerance

The normal daily variation in body temperature from the high point in the
early afternoon to the low point in the early morning hours is about 1°C
(1.8°F). Superimposed on this normal variation in body temperature would,
supposedly, be the increasedue to heat exposure. In addition, the WHO
report recommends that the 8 -hour TWA body temperature of workers in hot
industries should notexceed 38°C (100.4°F) [48]. The question remains: Is
this normal daily increase in body temperature additive to the increase
resulting from heat stress? Does tolerance to increased body temperature
and the connected health risk follow a similar diurnal pattern? Would it be
necessary to establish different permissible heat exposure limits for day
and night shift workers in hot industries?

G. H eat-S train Monitoring

The heat-stress indices andstrain prediction techniques are useful for

estimating what the level of strain is likely to be for a given heat-stress
situation and a given worker population, but they do not permit a prediction
of which individual or individuals will become heat casualties. Because of
the wide interindividual tolerance to heat stress, predictions of when and

112
under what circumstances an individual may reach unacceptable levels of
physiologic and psychologic strain cannot be made with a high degree of
accuracy. One solution to this dilemma might be an individual heat-load
dosimeter or a physiologic strain monitor (e.g., body or skin temperature or
heart rate). A physiologic strain monitor would remove the necessity for
measuring and monitoring the thermal environment and estimating the
metabolic heat production. Monitoring the body temperature of a worker on a
hot job once an hour and removing the worker from the heat if the body
temperature reaches a previously agreed upon level would eliminate the risk
of incurring a heat-related illness or injury. A small worker-worn packet
containing a sensor, signal converter, display, and alarm to monitor body
temperature and/or heart rate is technically feasible. The problem,
however, is worker acceptance of the sensors.

H. Accidents and Heat Stress

Are accidents more prevalent in hot industries and in the hotter months of
the year? There are data [70,71] that show a relationship between
industrial accidents and heat stress, but there are not enough data to
establish heat stress limits for accident prevention in hot industries.
Field evaluations, as well as laboratory studies, are required to correlate
accident probability or frequency with environmental and job heat-stress
values in order to determine with statistical validity the role of heat
stress in industrial accidents.

I. E ffects of Heat on Reproduction

It is a we 11-documented phenomenon in mammals that spermatogenesis is very

sensitive to testicular temperature [125]. Raising testicular temperature
to deep body temperature inhibits spermatogenesis and results in relative
infertility. A recent study of male foundry workers suggests that
infertility is higher among couples where the male member is a foundry
worker exposed to high temperatures than it is among the general population
[124], There are many industrial situations, including jobs where
impermeable or semipermeable protective clothing must be worn, in which the
testicular temperature would be expected to approximate body temperature.
If a degree of male infertility is associated with heat exposure, data are
required to prove the relationship, and remedial or preventive methods must
be devised.Whether heat acts as a teratogenic agent in humans, as it
apparently does in animals, is another problem that requires more research.

J. Heat Tolerance and S h ift Work

It has been estimated that about 30% of workers are on some type of work
schedule other thanthe customary day work (9 a.m.-5 p.m.). Shift work,
long days-short week, and double shifts alter the usual living patterns of
the worker and result in some degree of sleep deprivation. What effect
these changes in living patterns have on heat tolerance is mostly
undocumented. Before these changes in work patterns are accepted, it is
prudent that their health and safety implications in conjunction with other
stress be known.

113
K. Effects of Clothing and Benefits of Cooling Garments

There are several versions of effective cooling clothing and equipment

commercially available. All versions, although very useful in specialhot
situations, have one or more of the following disadvantages: (1 ) limited
operating time, (2 ) restrictions of free movement of the worker,
(3) additional weight that must be carried, (4) limited dexterity and
movement of the hands, arms, head, and legs, (5) increased minimal space
within which the individual can work, and (6 ) use with other protective
clothing and equipment (e.g., for protection against chemical hazards). The
maximum efficiency and usability of such systems have not been achieved.
Research on systems that will minimize the disadvantages while maximizing
the efficiency of the cooling- and heat-exchange capacities is needed.

L. Medical Screening and B iologic Monitoring Procedures

Data to substantiate the degree of effectiveness of medical screening and

biologic monitoring in reducing the risk of heat-induced illnesses among
workers in hot industries are, at present, not systematically recorded nor
are they readily available in the open literature. Such data, however, must
be made available in sufficient quantity and detail to permit an
epidemiologic and medical assessment of their health and safety, as well as
economic feasibility for health and safety control procedures in hot
industries. Standardized procedures for reporting incidences of
heat-related health and safety problems, as well as environmental and
work-heat loads, assessment of control procedures in use, medical screening
practices, and biologic monitoring procedures, if routinely followed and
reported, would provide an objective basis for assessing the usefulness of
medical screening and biologic monitoring as preventive approaches to health.

114
 XI. REFERENCES

1. Rutstein DD, Mullan RJ, Frazier TM, Halperin WE, Melius JM,
Sestito, JP. Sentinel health events (occupational): A basis for
physician recognition and public health surveillance. Am J Public
Health 1983;73:1054-62.

2. American Conference of Governmental Industrial Hygienists. Threshold

limit values for chemical substances and physical agents in the work
environment with intended changes for 1985-86. Cincinnati: ACGIH,
1985.

3. International Standards Organization (ISO). Hot

environments— estimation of heat stress on working man based on the
WBGT index (Wet Bulb Globe Temperature). 1982;ISO 7243-1982.

4. Leithead CS, Lind AR. Heat stress and heat disorders. London:
Cassell, 1964, FA Davis Company, Philadelphia.

5. Strydom NB. Physical work and heat stress. In: Zenz C, ed.
Occupational Medicine. Chicago: Year Book 1975;469-92.

6. Wyndham CH. Research in the human sciences in the gold mining

industry. Am Ind Hyg Assoc J 1974;35:113-36.

7. Ramsey JD. Heat stress standard: OSHA's Advisory Committee

recommendations. Natl Saf News 1975;89-95.

8. Spaul WA, Green leaf JE. Heat Stress Field Study. US Nav Med
1984;75:25-33.

9. Criteria for a recommended standard....occupational exposure to hot

environments. U.S. Department of Health, Education, and Welfare,
Health Services and Mental Health Administration, National Institute
for Occupational Safety and Health, 1972;pub Iicat ion no. HSM-10269.

10. Statistical Abstracts of the United States. 105th ed. National data
book and guide sources. U.S. Department of Commerce, Bureau of
Census, 1985.

11. Nishi Y. Measurement of thermal balance of man. In: Cena K, Clark

JA, eds. Bioengineering, thermal physiology and comfort. New York:
Elsevier, 1981;29-39.

12. Grayson J, Kuehn LA. Heat transfer and heat loss. In: Lomax P,
Schonbaum E, eds. Body temperature. New York: Marcell Decker, Inc.,
1979;72.

13. Belding HS. Evaluation of stresses of exposure to heat. University

of Pittsburgh, 1971;Grant No. EC 00202-16, Section IV:5-7.

115
14. Goldman RF. Evaluating the effects of clothing on the wearer. In:
Cena K, Clark JA, eds. Bioengineering, thermal physiology and
comfort. New York: Elsevier Scientific Publishing Co., 1981;41—55.

15. Goldman RF. Personal protective equipment. In: Levine S, Martin W,

eds. Protecting personnel at hazardous waste sites. Butterworth
Pub Iishing C o . , 1985.

16. International Standards Organization (ISO): Thermal environments—

analytical determination of thermal stress, 1982;IS0/DP7933.

17. Goelzer B. Evaluation of heat stress in the work environment.

Geneva: World Health Organization, OCH/77.1.

18. Lind AR. Human tolerance to hot climates. In: Lee DHK, ed.
Handbook of physiology— reactions to environmental agents. Amer
Physiol Soc, Bethesda, Maryland, 1977;9:93-109.

19. Horvath SM. Hot and cold environments. In: Cralley and Cralley ed.
Patty's industrial hygiene and toxicology, 2nd ed. 1985;3B.

20. Goldman RF. Heat stress in industrial protective encapsulating

garments. In: Levine SP, Martin WF, e d . Protecting personnel at
hazardous waste sites, Butterworth Publishing Co., 1985;10:215-66.

21. DiBenedetto JP, Worobec SM. Exposure to hot environments can cause
dermatological problems. Occup Health Saf 1985;54:35-8.

22. Goldman RF. Prediction of human heat tolerance. In: Folinsbee LJ,
Wagner JA, Borgia JA, Drinkwater BL, Gliner JA, Bedi JF, eds.
Environmental stress. New York: Academic Press, Inc., 1978;53-69.

23. Vogt JJ, Candas V, Libert JP. Graphical determination of heat

tolerance limits. Ergonomics 1982;25:285-94.

24. McCullough EA, Arpin E J , Jones B, Konz SA, Rohles FH. Heat transfer
characteristics of clothing worn in hot industrial environments.
ASHRAE Trans 1982;88:1077-94.

25. American Society of Heating, Refrigeration, and Air Conditioning

Engineers. Physiological principles, comfort, and health, 1981
fundamentals handbook, 1981 ;8 .1-8.34.

26. Goldman RF. Clothing, its physiological effects, adequacy in extreme

thermal environments, and possibility of future improvements. Arch
Sei Physiol 1973;27:A137-47.

27. Drinkwater BL, Horvath SM. Heat tolerance and aging. Med Sei Sports
1979;11:49-55.

28. Helion RF, Lind AR. The influence of age on peripheral vasodilation
in a hot environment. J Physiol 1958;141:262-72.

116
29. Brouha L. Physiology in industry. New York: Pergamon Press, 1960.

30. Cooper KE, Veale WL, Kasting NW. Temperature regulation, fever and
antipyreics. In: Barnett HJM Jr, ed. New uses for old drugs. New
York: Rirsch & Mustard, Raven Press, 1982.

31. Greenleaf JE. Hyperthermia and exercise. In: Robertshaw D, ed.

Environmental physiology III, vol 20. Baltimore: University Park
Press, 1979;157-208.

32. Greenleaf JE, Harrison MH. Water and electrolytes. In: Layman DK,
ed. Exercise, nutrition and health. American Chemical Society, 1985.

33. Lind AR. Limits of exposure to work in hot climates without a rise in
body temperature. In proc. sympo. standards for occupational
exposures to hot environments, SM Horvath, RC Jensen, eds. U.S.
Department of Health, Education, and Welfare, National Institute for
Occupational Safety and Health, SM Horvath and RC Jensen, eds.
Publication no. 76-100, 1976;3:9-16.

34. Astrand PO, Rodahl K. Textbook of work physiology, 22nd ed. New
York: McGraw-Hill Book Co, 1977.

35. Henschel A. The environment and performance. In: Simonson E, ed.

Physiology of work capacity and fatigue. CC Thomas, Springfield,
Illinois, publisher, 1971;14:325-47.

36. Rowell LR. Competition between skin and muscle for blood flow during
exercise. In: Nadel ER, ed. Problems with temperature regulation
during exercise. New York: Academic Press, Inc., 1977, pp. 49-76.

37. Hancock PA. Heat stress impairment of mental performance: a revision

of tolerance limits. Aviat Space Environ Med March 1981;177-80.

38. Ramsey JD, Morrissey SJ. Isodecrement curves for task performance in
hot environments. Appl Ergonomics 1978;9:66-72.

39. Hancock PA. Task categorization and the limits of human performance
in extreme heat. Aviat Space Environ Med 1982;53:778-84.

40. Givoni B, Rim Y. Effect of the thermal environment and psychological

factors upon subjects' responses and performance of mental work.
Ergonomics 5:99-119, 1962.

41. Marg K. Evaporative cooling— heat stress and its effect on worker
productivity, quality, and safety. Plant Engineering 1983;73-4.

42. MacPherson RK. Physiological responses in hot environments. ed.

MacPherson: Med Res Council, Special Report 298, Her Majesty's
Stationery Office, London, 1960.

117
43. U.S. Department of Defense. Occupational and environmental health:
Prevention, treatment and control of heat injuries. Headquarters,
Departments of the Army, Navy and Air Force. 1980;TB MED 507, NAVMED
P-5052-5, AFP 160-1.

44. Kerslake. The stress of hot environments. Cambridge University

Press, London, 1972.

45. Strydom NB, Kotze H F , van der Walt WH, Rogers GG. Effect of ascorbic
acid on rate of heat acclimatization. J Appl Physiol 1976;41:202-5.

46. Knochel JP. Environmental heat illness. Arch Intern Med

1974;133:841-64.

47. Wyndham CH. The physiology of exercise under heat stress. Ann Rev
Physiol 1973;35:193-220.

48. World Health Organization. Technical Report Series No. 412, Health
factors involved in working under conditions of heat stress. Geneva:
WHO, 1969.

49. Lind AR, Bass D E . Optimal exposure time for development of WHO, 1969.
acclimatization to heat. Symposium on temperature acclimation. Fed
Proc 1963;22:704-8.

50. Pandolf KB, Burse RL, Goldman RF. Role of physical fitness in heat
acclimatization, decay and reinduction. Ergonomics 1977;20:399-408.

51. Lind AR, Humphreys PW, Collins KJ, Foster K, Sweetland KF. Influence
of age and daily duration of exposure on responses of men to work in
heat. J Appl Physiol 1970;28:50-6.

52. Strydom NB. Age as a causal factor in heat stroke. J of the South
African Institute of Mining and Metallurgy, 1971;72:112-4.

53. Ave Mini BA, Kamon E, Krajewski JT. Physiological responses of

physically fit men and women to acclimation to humid heat. J Appl
Physiol 1980;49:254-61.

54. Ave Mini BA, Shapiro Y, Pandolf KB, Pi mental NA, Goldman RF.
Physiological responses of men and women to prolonged dry heat
exposure. Aviat Space Environ Med 1980;51:1081-85.

55. Drinkwater BL, Denton JE, Kupprat IC, Talag S, Horvath SM. Aerobic
power as a factor in women's response to work in hot environments. J
Appl Physiol 1976;41:815-21.

56. Frye AJ, Kamon E. Responses to dry heat of men and women with similar
aerobic capacities. J Appl Physiol 1981;50:65-71.

57. Nunneley SA. Physiological responses of women to thermal stress: a

review. Med Sci Sports 1978;10:250-55.

118
58. Wells CL, Buskirk ER. Limb sweating rates overlying active and
nonactive muscle tissue. J Appl Physiol 1971;31:858-68.

59. Khagali M, Hayes JSR. Heatstroke and temperature regulation.

Sydney: Academic Press, 1983.

60. Henschel A, Burton LL, Margolies L, Smith JE. An analysis of heat

deaths in St. Louis during July, 1966. Am J Public Health
1969;59:2232-42.

61. Ellis FP. Mortality from heat illness and heat-aggravated illness in
the United States. Environ Res 1972;5:1-58.

62. Kilbourne EM, Choi K, Jones TS, Thacker SB. Risk factors for heat
stroke— a case-control study. JAMA 1982;247:3332-6.

63. Buskirk ER, Bass DE. Climate and exercise. In: Johnson WR, Buskirk
ER, eds. Structural and physiological aspects of exercise and sport.
Princeton: Princeton Book Company, 1980;190-205.

64. Jensen RC. Workers' compensation claims attributed to heat and cold
exposure. Prof Safety September 1983;19-24.

65. Dinman BD,Stephenson RR, Horvath SM, Colwell MO. Work in hot
environments: I. Field studies of work load, thermal stress and
physiologic response. J Occup Med 1974;16:785-91.

66. Minard D. Reports of heat cases from industries cooperating in an

evaluation of occupational heat stress, Summer of 1972. Proc
symposium; Standards for occupational exposure to hot environments, SM
Horvath and RC Jensen. U.S. Department of Health, Education, and
Welfare, National Institute for Occupational Safety and Health,
1976;publication no. 76-100.

67. Janous JA. An examination of heat injury experiences. In: Proc

symposium standards for occupational exposures to hot environments.
SM Horvath and RC Jensen, ed., U.S. Department of Health and Human
Services, Centers for Disease Control, National Institute for
Occupational Safety and Health, publication 78-100, 1976 (adapted from
Master's thesis and presented by FN Dukes-Dobos) at a conference.

68. Horvath SM. Heat Stress: American Experience in Health Protection in

Primary Aluminum Production. Proc of a Seminar, Montreal 1981, S
Hughes, ed. Int Primary Aluminum Institute, London.

69. Horvath SM, Colwell MO. Heat stress and the new standard. J Occup
Med 1973;15:524-528.

70. Ramsey JD, Burford CL, Beshir MY, Jensen RC. Effects of workplace
thermal conditions on safe work behavior. J Safety Research
1983;14:105-14.

119
71. Dukes-Dobos FN. Mortality and morbidity of occupational heat stress.
Proceedings of the American Industrial Hygiene Conference, May 25-29,
Portland, Oregon, 1981:12.

72. Dinman BD, Horvath SM. Heat disorders in industry: a réévaluation of

diagnostic criteria. J Occup Med 1984;26:489-95.

73. Minard D. Physiology of heat stress. In: The industrial

environment— its evaluation & control. U.S. Department of Health,
Education, and Welfare, Public Health Service, Center for Disease
Control, National Institute for Occupational Safety and Health.
1973:399-410.

74. Springer K. If you can't stand the heat. Ohio Monitor

May 1985;58:4-9.

75. Minard D, Copman L. Elevation of body temperature in disease. In:

Hardy JD, ed. Temperature: its measurement and control in science
and industry. New York: Reenhold Co. 1963;3(3):253.

76. Shibolet S, Lancaster MC, Danon Y. Heat stroke: a review. Aviat

Space Environ Med March 1976;47:280-301.

77. Dukes-Dobos FN. Hazards of heat exposure: a review. Scand J Work

Environ Health 1981;7:73-83.

78. Joy RJT, Goldman RF. A method of relating physiology and military
performance: a study of some effects of vapor barrier clothing in a
hot climate. Mi lit Med June 1968;133:458-70.

79. Pandolf KB, Griffin TB, Munro EH, Goldman R F . Persistence of impaired
heat tolerance from artificially induced miliaria rubra. Amer J
Physiol 1980;239:R226-32.

80. Pandolf KB, Griffin TB, Munro EH, Goldman R F . Heat intolerance as a
function of percent of body surface involved with miliaria rubra.
Amer J Physiol 1980;239-.R233-40.

81. Ramsey JD, Beshir MY. Thermal standards and measurement techniques.
In: Rentos PG, ed. The industrial environment: its evaluation and
control. 4th ed. NIOSH [Unpublished report, 1985].

82. Benedict RF. Fundamentals of temperature, pressure and flow

measurements. New York: John Wiley and Sons, 1977.

83. ASHRAE handbook, 1981 fundamentals. Atlanta: The Am Soc Heat Ref Air
Cond, 1981.

84. Kuehn LA. Response of the globe temperature. Department of National

Defense, OCIEM, N.859, Canada, 1973.

85. Kuehn LA, Machattie LE. A fast responding and direct reading WBGT
index meter. AIHA J 1975;36:325-31.

120
86. Cena K, Clark JA. Physics, physiology and psychology:
bioengineering, thermal physiology and comfort. Cana R, Clark JA,
e d s . New York: Elsevier Scientific Pub Co, 1981:274-82.

87. Gagge AP. Effects of radiant flux, an independent variable that

describes thermal radiation on man/physiological and behavioral
temperature regulation. Hardy JD, Gagge AP, Stolwijk JAJ, eds.
Springfield, Illinois: Charles C. Thomas, 1970:34-45.

88. Roller WL, Goldman RF. Estimation of solar radiation environment.

Int J Biometeorol 1967;11:329-36.

89. Garg AP. Treatise on solar energy. In: Fundamentals of solar

energy, vol 1. New York: John Wiley and Sons, 1982.

90. Allen RW, Ells MD, Hart AW. Industrial Hygiene. Englewood, New
Jersey: Prentice-HalI, Inc., 1976;87— 114.

91. Chang SX, Ge XS. Preliminary research in the measurement of the solar
radiation by transient technique. Solar Energy 1983;30:391-5.

92. Duffie JA, Beckman WA. Solar engineering of thermal process. New
York: John Wiley and Sons, 1980.

93. Gandhi OP. Microwave: engineering applications. New York: Pergamon

Press, 1981.

94. Michaelson SM. Microwave biological effects: an overview. Proc IEEE

1980;68:40-9.

95. McRae Dl. Soviet and Eastern European research on biological effects
of microwave radiation. Proc IEEE 6 8 , 1980:84-91.

96. Goldman RF. Acclimation to heat and suggestions, by inference, for

microwave radiation. In: Microwaves and thermoregulation. Academic
Press, Inc., 1983:275-82.

97. Adair, E. ed. Microwaves and Thermoregulation, Academic Press, 1983.

98. Baranski S, Czerski P. Biological effects of microwaves.

Stroudsburg, Pennsylvania: Dowden, Hutchinson, and Ross, Inc., 1976.

99. Djordjevic Z, Kolak A, Djokovic V, Ristic P, Kelecevic Z. Results of

our 15-year study into the biological effects of microwave exposure.
Aviat Space Envrion Med 1983;54:539-42.

100. Jones TS, Liang AP, Kilbourne EM, et al. Morbidity and mortality
associated with the July 1980 heat wave in St. Louis and Kansas City,
Mo. JAMA 1982;247:3327-31.

121
101. Mutchler JE, Malzahn DD, Vecchio JL, Soule RD. An improved method for
monitoring heat stress levels in the workplace. Cincinnati: U.S.
Department of Health, Education, and Welfare, Public Health Service,
Center for Disease Control, National Institute for Occupational Safety
and Health. (NIOSH) 1975 publication no. 75-161.

102. Banister EW, Brown SR. The relative energy requirements of physical
activity, exercise physiology. e d . H.B. Fells. New York: Academic
Press, 1968:267-322.

103. Berger RA. Applied exercise physiology. Philadelphia, Pennsylvania:

Lea and Febiger, 1982.

104. Karpovich PV, Sinning WE. Physiology of muscular activity.

W. B. Saunders Co., Pennsylvania: 1971.

105. Stegman J. Exercise physiology. Chicago, Illinois: Year Book

Medical Publisher, Inc., 1981.

106. American Industrial Hygiene Association Technical Committee on

Ergonomics. Ergonomics guide to assessment of metabolic and cardiac
costs of physical work. Am Ind Hyg Assoc J 1971;31:560-4.

107. Garg A, Chaffin DB, Herrin GD. Prediction of metabolic rates for
manual materials handling jobs. Am Ind Hyg Assoc J 1978;39:661-74.

108. Durnin WGA, Passmore R. Energy, work and leisure. London: Heinemann
Educational Books Ltd., 1967.

109. Smith Jl , Ramsey JD. Designing physically demand tasks to minimize

levels of worker stress. Industr Engineering 1980;14:44-50.

110. International Organization for Standardization (ISO). Determination

of Metabolic Rate. ISO/TC 159/SC 5 N & E, Geneva, 1983.

111. Energy requirements for physical work. Research Progress Report

No. 30. Purdue Farm Cardiac Project, Agricultural Experiment Station,
West Lafayette, Indiana, 1961.

112. Lehmann GEA, Muller A, Spitzer M. Der Kalorienbedarf bie Gewerblicher

Arbeit. Arbeitsphysiol 1950;14:166.

113. Belding HS. Control of exposures to heat and cold. In: The
industrial environment — its evaluation and control. U.S. Department
of Health and Human Services, Public Health Service, Center for
Disease Control, National Institute for Occupational Safety and
Health, 1973:563-572.

114. Dasler AR. Heat stress, work function and physiological heat exposure
limits in man. In: Mangum BW, Hill JE, eds. Proceedings of a
Symposium held at the National Bureau of Standards, Gaithersburg,
Maryland. Thermal analysis— human comfort— indoor environments. NBS
special publication 491, 1977:65-92.

122
115. Kamon E. Design of work-rest schedule for hot jobs. In: Proc NIOSH
Workshop on Recommended Heat Stress Standard, ed. FN Dukes-Dobos and
A Henschel, U.S. Department of Health and Human Services, Centers for
Disease Control, National Institute for Occupational Safety and
Health, publication no. 81-108;17:71-95.

116. Shvartz E. Heat stress tolerance testing. In: Dukes-Dobos FN,

Henschel A, eds. Proceedings of a NIOSH workshop on recommended heat
stress standards. Cincinnati: U.S. Department of Health and Human
Services, Public Health Service, Centers for Disease Control, National
Institute for Occupational Safety and Health. 1980;DHHS (NIOSH)
publication no. 81-108:46-60.

117. Siconolfi SF, Garber CE, Lasater TM, Carleton RA. A simple, valid
step test for estimating maximal oxygen uptake in epidemiologic
studies. Am J Epidemiol 1985;121:382-390.

118. Minard D. Pre-employment and periodic medical examinations for

workers on hot jobs. Proceedings of a NIOSH Workshop on Recommended
heat stress standard., DHHS (NIOSH) publication no. 81-108:61-70.

119. Zenz C. A physician's guide for preplacement and periodic

examinations for workers in hot jobs. U.S. Department of Health,
Education, and Welfare, National Institute for Occupational Safety and
Health, 1983, NIOSH order no. 81-3248.

120. Goldman RF, Peters JM. The occupational and environmental health
history. JAMA 1981;246:2831-7.

121. American Lung Association of San Diego and Imperial Counties. Taking
the occupational history. Ann Intern Med 1983;99:641-51.

122. Kenney WL, Kamon E. Comparative physiological responses of

normotensive and essential hypertensive men to exercise in the heat.
Eur J Applied Physiol 1984;52:196-201.

123. Redmond LK, Ernes JJ, Mazumdar S, Magee PC, Kamon E. Mortality of
steelworkers employed in hot jobs. J Environ Pathol and Toxicol
1979;2:75-96.

124. Rachootin P, Olsen J. The risk of infertility and delayed conception

associated with exposures in the Danish workplace. J Occup Med May
1983;25:394-402.

125. Levine RJ. Male fertility in hot environments. [letter to the

editor] JAMA 1984,252:3250.

126. Lary JM. Hyperthermia and teratogenicity. In: Anghileri L, Robert

J, eds. Hyperthermia in cancer treatment. Boca Raton: CRC Press,
1984.

123
127. Fuller FH, Smith PE. The effectiveness of preventive work practices
in a hot work shop. In: Dukes-Dobos FN, Henschel A, eds.
Proceedings of a NIOSH workshop on recommended heat stress standards.
Cincinnati: U.S. Department of Health and Human Services, Public
Health Service, Centers for Disease Control, National Institute for
Occupational Safety and Health. 1980;DHHS (NIOSH) publication no.
81-108:32-45.

128. Fuller FH, Smith PE. Evaluation of heat stress in a hot workshop by
physiological measurements. Am Ind Hyg Assoc J 1981;42:32-7.

129. Lee DHK, Henschel A. Evaluation of thermal environment in shelters.

U.S. Department of Health, Education, and Welfare, Public Health
Service, Division of Occupational Health. 1963;Report no. TR- 8 .

130. Stewart JM. The use of heat transfer and limiting physiological
criteria as a basis for setting heat stress limits. Second
International Mine Ventilation Congress. Reno, Nevada: November 4-8,
1979.

131. Wyndham CH, Heyns AJ. The probability of heat stroke developing at
different levels of heat stress. Arch Sci Physiol 1973;27:A545-562.

132. Witten L. Comments on mathematical models for thermoregulatory

behavior. In: Dukes-Dobos FN, Henschel A, eds. Proceedings of a
NIOSH workshop on recommended heat stress standards. Cincinnati:
U.S. Department of Health and Human Services, Public Health Service,
Centers for Disease Control, National Institute for Occupational
Safety and Health. 1980;DHHS (NIOSH) publication no. 81-108:129-39.

133. Kamon E, Ryan C. Effective heat strain index using pocket computer.
Am Ind Hyg Assoc J 1981;42:611-5. (Errata: Am Ind Hyg Assoc
J;43:A-43, 1982).

134. Reischl U. Personal heat stress monitoring. In: Dukes-Dobos FN,

Henschel A, eds. Proceedings of a NIOSH workshop on recommended heat
stress standards. Cincinnati: U.S. Department of Health and Human
Services, Public Health Service, Centers for Disease Control, National
Institute for Occupational Safety and Health. 1980;DHHS (NIOSH)
publication no. 81-108:110-28.

135. Reischl U, MarschalI DM, Reischl P. Radiotelemetry-based study of

occupational heat stress in a steel factory. U. Reischl, D.M.
MarschalI, P. Reischl, Biotelemetry 1977;115-30.

136. Kamon E, Ave Mini BD. Wind speed limits to work under hot
environments for clothed men. J Appl Physiol 1979;46:340-349.

137. Henschel A. Comparison of heat stress action levels. U.S. Department

of Health, Education, and Welfare, Centers for Disease Control,
National Institute for Occupational Safety and Health, publication no.
81-108. In: Proceedings NIOSH workshop on recommended heat stress
standards. FN Dukes-Dobos and A. Henschel, eds. 1980:21-31.

124
138. American Industrial Hygiene Association. In: Heat exchange and human
tolerance limits, heating and cooling for man in industry. 2 nd ed.
1975:5-28.

139. Occupational and environmental health: prevention, treatment, and

control of heat injury. TB MED 507, NAVMED P-5052-5, AFP 160-1,
Headquarters, Departments of Army, Navy and Air Force, 1980.

140. American College of Sports Medicine. Prevention of heat injuries

during distance running— ACSM position statement. Med Sci Sports Exer
1984;16:1X-XIV.

141. Dukes-Dobos FN, Henschel A, eds. Proceedings of a NIOSH workshop on

recommended heat stress standards. Cincinnati: U.S. Department of
Health and Human Services, Public Health Service, Centers for Disease
Control, National Institute for Occupational Safety and Health.
1980;DHHS (NIOSH) publication no. 81-108.

142. International Standards Organization (ISO). Analytical determination

of thermal stress. IS0/TC159/SC5/WG1 82/36699. 1982:1-32.

143. Gonzalez RR, Berglund LG, Gagge AP. Indices of thermoregulatory

strain for moderate exercise in the heat. J Appl Physiol
1978;44:889-99.

144. Si Ilanpaa J, Niemela R. Evaluation measurements of thermal

conditions. Tyo Terveys TurvalIisuus. 1977;3:17-9.

145. Sundell J, Ersson C. Ventilation of work rooms. Department of

Occupational Safety, General Bureau TAA 3, Collection of Reports AFS
Report no. 4, 1981;09-11.

146. Socialist Republic of Romania. Occupational Health Protection

Standards of the Romanian Republic. Microclimate, ventilation and
heating. Occupational Hygiene Standards.

147. U.S.S.R. Heat Stress Standard. Moscow. 1963;48-50.

148. Belgium Royal Decree Relating to the Environments of Workplaces and

Modifying Title II, Chapter II, Section I, as well as Chapter III,
Section II, of the general regulations for labor protection (1).
Belgisch Staatsblad, 1975:1-10.

149. Australia Proposed Uniform Standard for Control of Atmospheric

Conditions in Working Interiors, Department of Labour, 1974.

150. Mathews J, Calabrese N, eds. Guidelines on Working in heat.

ACTU-VTHC Occupational Health and Safety Unit Health and Safety
Bui let in no.15, 1982.

151. Japan Association of Industrial Health. Recommendations on maximum

allowable concentrations of toxic substances and others in the work
environment. 1982:1-28.

125
152. Belding HS, Hatch TF. Index for evaluating heat stress in terms of
resulting physiological strain. Heat Pip Air Condit 1955;27:129-35.

153. McKarns JS, Brief RS. Nomographs give refined estimate of heat stress
index. Heat Pip Air Condit. 1966;38:113-6.

154. Candas V, Libert JP, Vogt JJ. Influence of air velocity and heat
acclimation on human skin wettedness and sweating efficiency. J Appl
Physiol 1979;47:1194-200.

155. Minard D. Prevention of heat casualties in Marine recruits. Mi Iit

Med 1961;126:261-72.

156. Dukes-Dobos FN, Henschel A. Development of permissible heat exposure

limits for occupational work. ASHRAE J 1973:57-62.

157. Botsford JH. A wet globe thermometer for environmental heat

measurement. Am Ind Hyg Assoc J 1971;32:1-10.

158. Ciricello VM, Snook SH. The prediction of WBGT from the Botsball. Am
Ind Hyg Assoc J 1977;38:264-71.

159. Johnson AT, Kirk GD. Correlation of WBGT and Botsball sensors. Am
Ind Hyg Assoc J 1980;41:361-6.

160. Beshir MY, Ramsey JD, Bur ford CL. Threshold values for the Botsball:
a field study of ergonomics. Ergonomics 1982;25:247-54.

161. Beshir MY. A comprehensive comparison between WBGT and Botsball. Am

Ind Hyg Assoc J 1981;42:81-7.

162. Parker RD R, Pierce FD. Comparison of heat stress measuring

techniques in a steel mill. Am Ind Hyg Assoc J 1984;45:405-15.

163. Jensen RC, Dukes-Dobos FN. Validation of proposed limits for exposure
to industrial heat. In: Horvath SM, Jensen RC. Standards of
occupational exposure to hot environments— proceedings of symposium.
U.S. Department of Health, Education, and Welfare, Public Health
Service, Center for Disease Control, National Institute for
Occupational Safety and Health. 1976;DHEW (NIOSH) publication no.
76-100:169-178.

164. lampietro PF. Use of skin temperature to predict tolerance to thermal

environments. Aerospace Med 1971;42:396-9.

165. Shvartz E, Benor D. Heat strain in hot and humid environments.

Aerospace Med 1972;43:852-5.

166. American Physiological Society. Proposed standard system of symbols

for thermal physiology. J Appl Physiol 1969;27:439-40.

167. Bligh J, Johnson KG. Glossary of terms for thermal physiology. J

Appl Physiol 1973;35:941-61.

126
168. Heat Stress Management Program for the Nuclear Power Industry -
Interim Report. [Report prepared for the Electric Power Research
Institute, Palo Alto, California]. Westinghouse Electric Corporation,
Research and Development Center, EPRI NP-4453; 1986.

169. Occupational Safety and Health Guidance Manual for Hazardous Waste
Site Activities. Cincinnati, Ohio: National Institute for
Occupational Safety and Health (NIOSH), Occupational Safety and Health
Administration (OSHA), U.S. Coast Guard (USCG), and the U.S.
Environmental Protection Agency (EPA), 1985; DHHS publication no.
85-115.

127
 XII. APPENDIX A
GLOSSARY OF TERMS AND SYMBOLS
ADAPTED IN PART FROM REFERENCES 166 and 167

ACCLIMATIZATION: The physiologic changes which occur in response to a

succession of days of exposure to environmental heat stress that reduce
the strain caused by the heat stress of the environment.

AREA, DUBOIS (Aj)u) : Total nude body surface area in square meters (m2 )
calculated from the OuBois formula based on body weight (kg) and height
(m) .

AREA, EFFECTIVE RADIATING (Ar) : Surface area of the body in square meters
(m2 ) that exchanges radiant energy with a radiant source.

AREA, SOLAR RADIATION (As ) : Surface area of the body in square meters (m2 )
that is projected normal to the sun.

AREA, WETTED (Aw ) : Square meters (m2 ) of skin area covered by sweat.

BODY HEAT BALANCE: Steady state equilibrium between body heat production
and heat loss to the environment.

BODY HEAT BALANCE EQUATION: Mathematical expression of relation between heat

gain and heat loss expressed as (H=M+C+R-E).

BODY HEAT STORAGE (S): The change in heat content (either + or -) of the
body.

CIRCADIAN RHYTHM: Synchronized rhythmic biological phenomena which occurs on

approximately a 24-hour cycle.

CLO: A unit expression of the insulation value of clothing, clo = 5.55

expressed as kcal/m 2 /h°C.

CONVECTIVE HEAT TRANSFER ( C ) : The net heat exchange by convection between an

individual and the environment.

CONVECTIVE HEAT TRANSFER COEFFICIENT (hc ) : The rate of heat transfer between
the body surface and the ambient air per square meters (m2 ) skin
surface expressed as kc a l , Btu, or W.

EVAPORATIVE HEAT LOSS (-E): Body heat loss by evaporation ofwater (sweat)
from the skin expressed as kcal, Btu, or W.

EVAPORATIVE HEAT TRANSFER ( E ) : Rate of heat loss by evaporation of water

from the skin or gain from condensation of water on the skin expressed
as kcal, Btu, or W.

EVAPORATIVE HEAT TRANSFER COEFFICIENT (he ): Therate of heat exchange by

evaporation between the body surface and theambient air as a function of
the vapor pressure difference between the two and air velocity.

128
HEAT CAPACITY: Mass times specific heat of a body.

HEAT CONTENT OF BODY: Body mass times average specific heat and absolute
mean body temperature.

HEAT CRAMP: A heat-related illness characterized by spastic contractions

of the voluntary muscles (mainly arms, hands, legs, and feet) usually
associated with a restricted salt intake and profuse sweating without
significant body dehydration.

HEAT EXHAUSTION: A heat-related illness characterized by muscular weak­

ness, distress, nausea, vomiting, dizziness, pale clammy skin, and
fainting; usually associated with lack of heat acclimatization and
physical fitness, low health status, and an inadequate water intake.

HEATSTROKE: An acute medical emergency arising during exposure to heat

from an excessive rise in body temperature and failure of the
temperature regulating mechanism. It is characterized by a sudden and
sustained loss of consciousness preceded by vertigo, nausea, headache,
cerebral dysfunction, bizarre behavior, and body temperatures usually in
excess of 41.1°C (106°F).

HEAT SYNCOPE: Collapse and/or loss of consciousness during heat exposure

without an increase in body temperature or cessation of sweating,
similar to vasovagal fainting except heat induced.

HUMIDITY, RELATIVE (0 or r h ) : The ratio of the water vapor present in the

ambient air to the water vapor present in saturated air at the same
temperature and pressure.

HYPERPYREXIA: A body core temperature exceeding 40°C (104°F).

HYPERTHERMIA: A condition where the core temperature of an individual is

higher than one standard deviation above the mean for species.

INSENSIBLE PERSPIRATION: Water that passes through the skin by diffusion.

MAXIMUM OXYGEN CONSUMPTION (Vft^max): The maximum amount of oxygen that

can be utilized by the body.

METABOLIC RATE (MR): Chemical energy transfer into free energy per unit
t ime.

METABOLISM (M): Transformation of chemical energy into energy which is

used for performing work and producing heat.

PRESCRIPTIVE ZONE: That range of environmental heat stress below which the
physiologic strain (heart rate and body temperature) is independent of
the level of environmental heat stress.

PRESSURE, ATMOSPHERIC (pa ) : Pressure exerted by the weight of the air

which is 760 mmHg at sea level and decreases with altitude.

129
PRESSURE, WATER VAPOR (pa ) : The pressure exerted by the water vapor in the
air.

RADIANT HEAT EXCHANGE (R): Heat exchange by radiation between two radiant
surfaces of different temperatures.

RADIATIVE HEAT TRANSFER COEFFICIENT (hr) : Rate of heat transfer between two
black surfaces per unit temperature difference.

STANDARD MAN: A representative human with a body weight of 70 kg (154 lb)

and a body surface area of 1.8 m 2 (19.4 ft2 ).

SWEATING, THERMAL: Response of the sweat glands to thermal stimuli.

TEMPERATURE, AMBIENT (ta ): The temperature of theairsurrounding a body.

Also called air temperature or dry bulb temperature.

TEMPERATURE, AMBIENT, MEAN (ta ) : The mean value of several dry bulb
temperature readings taken at various locations or at various times.

TEMPERATURE, CORE (tcr): Temperature of the tissues and organs of the

body. Also called Deep Body Temperature.

TEMPERATURE, DEW-POINT (t^p): The temperature at which the water vapor in

the air first starts to condense.

TEMPERATURE, EFFECTIVE (ET): Index for estimating the effect of temperature,

humidity, and air movement on the subjective sensation of warmth.

TEMPERATURE, GLOBE (tg): The temperature inside a blackened, hollow, thin

copper globe measured by a thermometer whose sensing element is in the
center of the sphere.

TEMPERATURE, MEAN BODY (tjj): The mean value of temperature readings taken at
several sites within the body and on the skin surface. It can be
approximated from skin and core temperatures.

TEMPERATURE, RADIANT (tr): The point temperature of the surface of a

material or an object.

TEMPERATURE, MEAN RADIANT (tr) : The mean surface temperature of the

material and objects totally surrounding the individual.

TEMPERATURE, RECTAL (tre): Temperature measured 10 centimeters (cm) in the

rectal canal.

TEMPERATURE, MEAN SKIN (is|<): The mean of temperatures taken at several

locations on the skin weighted for skin area.

TEMPERATURE, SKIN (tg^): Temperature measured by placing the sensing element

on the skin.

130
TEMPERATURE, ORAL (tor) : Temperature measured by placing the sensing element
under the tongue for a period of 3 to 5 minutes.

TEMPERATURE, TYMPANIC (tty ): Temperature measured by placing the sensing

element in the ear canal close to the tympanic membrane.

TEMPERATURE REGULATI O N : The maintenance of body temperature within a

restricted range under conditions of positive heat loads (environmental
and metabolic) by physiologic and behavioral mechanisms.

TEMPERATURE, OPERATIVE (t0 ): The temperature of a uniform black enclosure

within which an individual would exchange heat by convection and
radiation at the same rate as in a nonuniform environment being
evaluated.

TEMPERATURE, PSYCHROMETRIC WET BULB (tw b ) : The lowest temperature to which

the ambient air can be cooled by evaporation of water from the wet
temperature sensing element with forced air movement.

TEMPERATURE, Natural Wet Bulb (tnwb): The wet bulb temperature under condi­
tions of the prevailing air movement.

THERMAL INSULATION, Clothing O c |): The insulation value of a clothing

ensemble.

THERMAL INSULATION, Effective (lcl+,a ) ; The insulation value of the

clothing plus the still air layer.

THERMAL STRAIN: The sum of physiologic responses of the individual to

thermal stress.

THERMAL STRESS: The sum of the environmental and metabolic heat load im­
posed on the individual.

WETTEDNESS, SKIN (w): The amount of skin that is wet with sweat.

WETTEDNESS, Percent of Skin (Aw /SWA q u x 10 0 ) : The percent of the total body
skin surface that is covered with sweat.

131
 SYMBOLS

Symbo1 Terra Units

Ab Body surface area m2

ADu Body surface area, DuBois m2

Ar Skin area exposed to radiation m2

Aw Wetted area of skin m2

Btu British thermal units Btu/h

C Heat exchange by convection W, kcal/h;Btu/h

CO Cardiac output of blood per minute I/m

Emax Maximum water vapor uptake by the

air at prevailing meterologic
condi t ions kg/h

Amount of sweat that must be

m
CD
-O

evaporated to maintain body heat

balance kg/h

Fcl Reduction factor for loss of convective

heat exchange due to clothing di mens ion Iess

H Body heat content kcal, Btu, w

he Convective heat transfer coefficient Wirr2 /°C - 1 ;

k c a l / h ~ V m 2 °C~1
Btu/h" V f t~2 °F~

be Evaporative heat transfer coefficient Wm- 2 /°C-1 ;

kcal/h~ 1 /m 2 °C -1
B t u / h " V f t_ 2 °F~

HR Heart rate b/min

hr Radiative heat transfer coefficient Wtrr2 /°C - 1 ;

kcal/h- V m 2 °C- 1
B t u / h - V f t - 2 °F-

^r+c Radiative + convective heat transfer Wm- 2 /°C-1 ;

coeff icient kcal/h-V m _2 °C-
B t u / h ' V f t- 2 oF -

'a Thermal insulation of still air layer clo

'cl Thermal insulation of clothing layer cio

132
 SYMBOLS

Symbol Term Uni ts

im Moisture permeability index of clothing dimensionless

im/clo Permeability index-insulation ratio dimensionless

K Heat exchanged by conduction W, kcal/h,Btu/h

kcal Ki Ioca lories kcal/h

Met Unit of metabolism. met

1 met = 50 k c a l / n w h

mmHg Pressure in millimeters of mercury mmHg

ms- 1 Meters per second m/sec

pa Water vapor pressure of ambient air m m H g , kPa

psk Water vapor pressure of wetted skin mmHg, kPa

Psk,s Water vapor pressure at skin temperature m m H g , kPa

rh Relat ive humidi ty percent

R Heat exchange by radiation Wm-2/°C-1 ;

kcal m - 2 / h ~ V ° C - 1 ;
Btu/h-Vft-2°F-1

S Sweat produced I ,g,kg

SR Sweat produced per unit time g/mi n,g/h,kg/m in,kg/h

SV Stroke volume - amount of blood pumped

by the heart per beat mI

SWA Area of skin wet with sweat m2

%SWA SWA/Aqux100 = % of body surface wet

wi th sweat percent

T Absolute temperature (t+273) °K,TR

ta Ambient air dry bulb temperature °C, °F

*adb Ambient dry bulb temperature adjusted

for solar radiation °C, °F

tcr Body core temperature °C, °F

tg Black globe temperature °C, °F

133
 SYMBOLS

Symbol Term Units

0
O
0
LL
*nwb Natural wet bulb temperature

*0 Operative temperature °C, °F

O
o

u.
0
*r Radiant temperature

O
0

U.
0
*r Mean radiant temperature

o
o

u.
0
*re Rectal temperature

o
Tl
0
Skin temperature

O
*sk

U.
0

0
*sk Mean skin temperature

*wb Psyehrometric wet bulb temperature °C, °F

LL
o

0
*wg Wet globe temperature

va Air veloci ty m s , fpm

V0 2 max Maximum aerobic capacity mL/m in, I/h

W Mechanical efficiency of work %, percent

U) Skin wettedness dimens ion Iess

6 Stefan-Bolzmann constant Wm~ 2 K4

c Emittance coefficient dimensionless

134
 APPENDIX B
HEAT-EXCHANGE EQUATION UTILIZING THE SI UNITS

1. Convection (C ) SI U n its

The rate of heat exchange between a person and the ambient air can be
stated algebraically:

C=hc (tg-tgk)

where:

hc is the mean heat transfer coefficient,

ta = air temperature

T sk = mean weighted skin temperature

The value of hp is different for the different parts of the body [11]
depending mainly on the diameter of the part, e.g., at the torso the
value of hc is about half of what it is at the thighs. The value used
for hc is generally the average of the hc values for the head,
chest, back, upper arms, hands, thighs, and legs. The value of hc
varies between 2 and 12 depending on body position and activity.

Other factors which influence the vajue of hc are air speed and
direction and clothing. The value of Tsk can also vary depending on
the method used for the measurements, the number and location of the
measuring points over the body, and the values used for weighting the
temperatures measured at the different location.

Numerous investigators have tried to simplify the calculation of

convective heat exchange. Most recently the ISO Working Group on the
Thermal Environment (ISO-WGTE) developed a draft standard for the
Analytical Determination of Heat Stress [16]. One of the
simplifications they adopted is to use only the following three values
for hc which are expressed in units of Wm~ 2 °c - 1 , corresponding to
the SI system.

a. When air speed is very low and is due only to natural convection

hc=2.38(tsk-ta ) 0 2 5

b. In forced convection, when relative air speed (Va r ) is less

than 1ms~1 hc=3.5+5.2Var

c. In forced convection, when Var is greater than 1ms~1

hc=8.7Var 0.6

The expression Var is defined as the ratio of the air velocity

relative to the ground and the speed of the body or parts of the body
relative to the ground. If the body movement is due to muscular work,
Var can be calculated by the following equation:

135
 Var=Va+0.0052(M-58)

where:

Va = air velocity in ms -1 and

M = metabolic heat production (Wm~2)

For simplicity, however, it is recommended to add to Va 0.7 ms- ^ as

a correction for the effect of physical work.

The ISO-WGTE recommends also to include in the equation for calculating

the convective heat exchange a separate coefficient for clothing, called
reduction factor for loss of sensible heat exchange due to the wearing
of clothes (Fc |) which can be calculated by the following equation:

Fc |=1/1 + (hc+hr)lcl (dimens ion Iess)

where:

h r = the heat transfer coefficient for radiant heat exchange

lc l = the thermal insulation of clothing

Both h r and lg| will be explained later in this appendix in more

detail. The ISO-WGTE recommended the use of 36°C (96.8°F) for tsk on
the assumption that most workers engaged in industrial hot jobs would
have a tsk very close to this temperature, thus any error resulting
due to this simplification will be small. They also assumed that most
work is done in an upright body position, thus hc does not have to be
corrected for different body positions when calculating the convective
heat exchange of workers.

The final equation for C to be used according to the ISO-WGTE is:

C=hcFc |(ta-36)(Wm-2)

2. Radiation (R) SI Units

The rate of radiant heat exchange between a person and the surrounding
solid objects can be stated algebraically:

R-MVTsk)4
where:

h r = the coefficient for radiant heat exchange

T r = the mean radiant temperature in °K
Tsk = the mean weighted skin temperature in °K

The value of h r depends on the body position of the exposed worker and
on the emissivity of the skin and clothing, as well as on the insulation
of clothing. The body position will determine how much of the total
body surface will be actually exposed to radiation, and the emissivity

136
of the skin and clothing will determine how much of theradiant heat
energy will be absorbed on those surfaces. The insulation of clothing
determines how much of the radiant heat absorbed at the surface of the
garments will actually be transferred to the skin.

The ISO-WGTE recommended a linearized equation for calculating the value

of R using SI uni t s :

R=hr Fc |(tr-ts k ) (Wm-2/°C-1)

The effect of insulation and emissivity of the clothing material on

radiant heat exchange is covered by the addition of the clothing
coefficient Fr i which is also used in the equation for C as described
above.

They also recommend a simplified equation for calculating an approximate

value for h r :

h r= 4Es k .Ar/AQu t(tr+tsk)/2+273]3

= is the universal radiation constant

= (5.67x10-8 )Wm-2°K-4

The effect of the emissivity of the skin on radiant heat exchange is

covered by the expression Esk which has the value of 0.97 in the
infrared range. The effect of body position is covered by the
expression A r/ADU , which is the ratio of the skin surface area
exposed to radiation and the total skin surface area, as estimated by
DuBois' formula.

ADu= 0 .00718 xWeight®•425 / Height0-725

In this equation body weight must be expressed in kg, height in cm, and
the value of A d u is then obtained in m2. Some values given for the
ratio A r/Aou by the ISO-WGTE are:

Standing 0.77
Seated 0.70
Crouched 0.67

The value of tr (mean radiant temperature) can be calculated by the

foI lowing equat ion:

t r = t g + 1 . S V a 0 -5 ( t g - t a )

For further simplification, the value of tsk can be assumed to be

36°C, just as it was in the equation for convection.

3. Evaporation (E) Si Units

E req is the amount of heat which must be eliminated from the body by
evaporation of sweat from the skin in order to maintain thermal

137
equilibrium. However, major limitations to the maximum amount of sweat
which can be evaporated from the skin (Em a x ) are:

a. The human sweating capacity,

b. The maximum vapor uptake capacity of the ambient air,

c. The resistance of the clothing to evaporation.

As described in Chapter IV, the sweating capacity of healthy individuals

is influenced by age, sex, state of hydration, and acclimatization.

The draft ISO-WGTE [16] standard recommends that an hourly sweat rate of
650 grams for an unacclimatized person and 1,040 grams for an
acclimatized one is the maximum which can be considered permissible for
the average worker while performing physical work in heat. However,
these limits should not be considered as maximum sweating capacities but
related to levels of heat strain at which the risk of heat illnesses is
m in im a I .

In the same vein, for a full workshift the total sweat output should not
exceed 3,250 grams for an unacclimatized person and 5,200 grams for an
acclimatized one if deterioration in performance due to dehydration is
to be prevented. It follows from the foregoing that if heat exposure is
evenly distributed over an 8 -hour shift, the maximum acceptable hourly
sweat rate is about 400 grams for an unacclimatized person and 650 grams
for an acclimatized person.

Thus, if the worker's heat exposure remains within the limits of the
recommended standard, the maximum sweating capacity will not be
exceeded, and the limitation of evaporation will be due only to the
maximum vapor uptake capacity of the ambient air. The Emax can be
described with the equation recommended by the ISO-WGTE:

Emax= (P s k ,s-P a )^ e

where:

Emax = maximum water vapor uptake capacity (Wm- 2 )

Psk.s = saturated water vapor pressure at 36°C

skin temperature (5.9 kPa )

Pa = partial water vapor pressure at ambient air temperature

(kPa )

Ro = total evaporative resistance of the limiting layer of air and

clothing (m2 kPa W- 1). This can be calculated by the following
equat ion:

Re=1/16.7 /hc/Fp c |

138
where:

hc = convective heat exchange coefficient (Wnr2/C_1)

F p d = reduction factor for loss in latent heat exchange due to

clothing (dimensionless). This factor can be calculated by the
following equat ion:

^ pcI=1/1+0-92hc/1c |

where:

lc l = Thermal insulation of clothing (m2 °C W- "*)

What this means is that the maximum vapor uptake capacity of the air
depends on the temperature, humidity, and velocity of the ambient air
and the clothing worn. However, the relationship of these variables in
respect to human heat tolerance is quite complex. Further complications
are caused by the fact that in order to be able to evaporate a certain
amount of sweat from the skin, it is necessary to sweat more than that
amount, because some of the sweat will drip off the skin or will be
picked up by the clothing. To calculate the additional amount of sweat
required due to dripping the ISO-WGTE recommended the following
equat ions:

Sreq=Ereq

where:

S req = Required Sweat (Wm- 2 ). This quantity can also be

expressed as (g h ~ 1 m -2 )x0.68

Ereq = Required Evaporation (Wm-2) can be calculated by the

equation E req = M+C+R

i| = £vaporative efficiency of sweating of a nude person. It can be

calculated by the following equation:

r|= 1 -0 . 5 /e - 6 .6 ( 1 -w)

where:

e = the base of natural logarithm

w = ^ r e q ^ m a x ’ also cal led the "Wettedness Index"

There are not enough experimental data available to calculate the loss
of evaporative efficiency of sweat due to the wicking effect of
clothing. However, if the workers wear thin knitted cotton underwear,
this can actually enhance the cooling efficiency of sweat, because after
wicking the sweat off the skin, it spreads it more evenly over a larger
area, thus enhancing evaporation and preventing dripping. Since the
thin knitted material clings to the skin, the evaporative cooling will
affect the skin without much loss to the environment. If a loosely

139
fitting garment wicks up the sweat, there may be a substantial loss in
evaporative cooling efficiency. However, if the heat exposure (M+C+R)
remains below the human sweating capacity, the exposed worker will be
able to increase the sweat excretion to compensate for the loss of its
cooling efficiency. A compensatory increase of sweating does not add
much to the physiologic strain if water and electrolytes are replaced
satisfactorily and if the water vapor uptake capacity of the ambient air
is not exhausted.

In order to make sure that in the S req index the wettedness modifies
the value of S req only to the extent to which it increases physiologic
strain, the E req/Emax ratio affects the value of S req in an
exponential manner.

The closer the value of E req comes to Emax, the greater will be the
impact of w on S req. This is in accord with the physiologic strain as
well as the subjective feeling of discomfort.

In this manner, the S req index is an improvement over other rational

heat-stress indices, but at the same time the calculations involved are
more complex. With the availability of pocket-sized programmable
calculators, the problem of calculations required is greatly reduced.
However, it is questionable whether it is worthwhile to perform a
complex calculation with variables which cannot be measured accurately.
These variables include: the mean weighted skin temperature, the
velocity and direction of the air, the body position and exposed surface
area, the insulation and vapor permeability of the clothing, and the
metabolic heat generated by the work.

For practical purposes, simplicity of the calculations may be preferable

to all-inclusiveness. Also, the utilization of familiar units (the
British units or metric units instead of SI suggested, e.g., kcal, Btu,
and W to express energy in heat production) may assist in wider
application of the calculations. They can be useful in analysis of a
hot job for determining the optimal method of stress reduction and for
prediction of the magnitude of heat stress so that proper preventive
work practices and engineering controls can be planned in advance.

* U .S . G O V E R N M E N T P R IN T IN G O FFIC E : 1994: 5 5 0 -1 4 7 /0 0 0 2 0

140