Occupational Medicine 2014;64:113–119

Advance Access publication 31 December 2013 doi:10.1093/occmed/kqt158

Work-related chemical exposures presenting to an

emergency department in Singapore
H. H. Tan1, S. Teo1,2 and H. C. Tseng3
1
Department of Emergency Medicine, Clinical Toxicology Consultation Service, Changi General Hospital, Singapore 529889,
Republic of Singapore, 2OSH Specialist Department, Occupational Health Division, Ministry of Manpower, MOM Services
Centre, 1500 Bendemeer Road, #03-02, Singapore 339946, Republic of Singapore, 3Department of General Medicine, Changi
General Hospital, Singapore 529889, Republic of Singapore.
Correspondence to: H. H. Tan, Department of Emergency Medicine, Clinical Toxicology Consultation Service, Changi General
Hospital, 2 Simei Street 3, Singapore 529889, Republic of Singapore. Tel: +65 6850 1687; fax: +65 6260 3756;
e-mail: hock_heng_tan@cgh.com.sg

Background Singapore is a small industrialized island state with a low accident rate and few hazardous chemical-
related injuries reported. However, the use of chemicals continues to increase and pose hazards in
the workplace.
Aims To study workplace chemical injuries and exposures to improve worksite safety.
Methods Work-related chemical exposure cases were identified from emergency department (ED) computer-
ized records from 2007 to 2010.
Results A total of 239 cases were identified. Most of the patients were male (92%) and young adults (73%
aged between 21 and 40 years). Fifty per cent of the workers were foreign workers. Most of them
were cleaners, labourers and technicians (53%) and worked mainly in the construction and manu-
facturing industries (47%). All the exposures were acute and presented within 4 h of the exposure
incident (52%). Most of the chemical exposures were to the eye (55%) and skin (32%). The chemi-
cals involved included corrosives (41%), hydrocarbons (18%) and cleaning solutions (9%). Pre-
hospital decontamination (eye and skin irrigation) was performed for 54% of the workers. Antidote
treatment with calcium gluconate for hydrofluoric acid exposure was used for five patients in the
ED. Only 11% of patients were admitted. Four patients had surgical procedures and five patients
had long-term complications. Forty-five incidents were notified to the Ministry of Manpower. The
under-reporting rate for cases with >3 days of medical leave was 66%.
Conclusions Work-related chemical exposures that present to the ED had low morbidity. Most of the workers
did well with immediate decontamination and supportive treatment but antidotes were required for
some exposures.
Key words Chemical exposure; chemicals; hazard; injury; occupational disease; occupational; poisoning; safety;
work; workplace.

Introduction with excessive absorption of chemical and 141 cases with

Singapore is a small industrialized island state with a work
force of ~3.1 million [1] out of a population of 5 million
people in 2010 [2]. Industries in Singapore are distributed
throughout the island except for the energy and chemi-
cal manufacturing industries, which are concentrated in
Jurong Island [3] on the west of Singapore. The morbidity
and mortality from industrial accidents and diseases have
been reported as low with an accident frequency rate of 1.7
per million man-hours in 2010 [4]. There were 15 cases
harmful substance exposure and contact reported in 2010
[4,5]. However, there is a risk of under-reporting from an
official surveillance system [6]. The use of chemicals in the
workplace has increased globally and will continue to pose
hazards at the workplace [7,8]. Locally, both Ngo and Leo
[9] and Woo and Sundar [10] reported that ~10% of indus-
trial eye cases were due to chemical injuries. Chemical
burns constitute 8% [11] and 6% [12] of all burns cases
who were admitted to the National Burns Centre in
Singapore, of which occupational burns comprised 33 and

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114  OCCUPATIONAL MEDICINE
41%, respectively, as reported in these two studies. The
study done by Ponampalam et al. [13] showed that toxic
exposures comprised 0.94% of emergency department
(ED) visits out of which 8% were work related.
The effective management of chemical exposures and
injuries requires not only adequate treatment with the use
of decontamination and special antidotes but also pre-
vention and control of chemical hazards. In Singapore,
the Management of Hazardous Chemical Programme
(MHCP) [14] was introduced by the Ministry of Manpower
(MOM) as a targeted intervention and enforced at the
national level with the aim to protect all workers from
chemical-related diseases, injuries and fatalities. The com-
prehensive in-plant programme covers the selection and
procurement of chemicals, to risk management and safe
work procedures and ends with waste disposal. Workers
need to be educated and have the correct competency and
capability on proper handling and usage of chemicals.
Surveillance of work-related injuries is tracked by
MOM and reported in their annual reports [4,5].
Notification of occupational diseases and injuries to
MOM is mandatory in Singapore under the WSH
(Incident Reporting) Regulations and the Work Injury
Compensation Act except for certain civil service occu-
pations [15]. Employers are required to notify any acci-
dent at the workplace if the injured worker is given
medical leave of >3  days or requires in-patient admis-
sion of >1 day. Doctors and employers are also required
to notify occupational diseases listed in the Second
Schedule of Workplace Safety and Health Act (WSHA).
The aim of this paper was to describe the epidemiol-
ogy of chemical poisonings and exposures from the work-
place that presented to an ED in the east of Singapore.
Methods
This was a retrospective review of 4 years of ED records
from January 2007 to December 2010. All cases seen at
the ED and classified as occupational or work-related
injuries (occurring during work) were identified and
formed the base pool of cases for this study. We scoped
the review to specifically focus on patients with chemical
exposures. In addition to chemical exposures, some of
these patients also sustained injuries from other mecha-
nisms like heat, cold or mechanical means.
The following cases were not included in this study:
burns primarily due to scalding from hot water, hot food
and hot cooking oil; burns from contact with hot objects,
flame burns from fires and explosions as well as electri-
cal injuries. In addition, all bites and stings and exposure
to bodily fluids where the main risk is infectious disease
transmission were also excluded.
The ED case records were traced together with rel-
evant in-patient records and the parameters collected
were compiled into standard data sheets. The collected
data included age, gender, race, occupation and type
of industry involved. The cases were also evaluated on
the type and nature of chemical exposures, pre-hospital
treatment, time of presentation from time of exposure,
management in the ED and final disposition of patients.
For mixtures, the chemicals were classified according to
the main constituent. The cases were compared against
the MOM database as to the reporting status for work
injury compensation or incident report.
Training was given for data abstraction to ensure con-
sistency and accuracy of data collection. The abstracted
data were checked by another investigator and uncertain-
ties regarding data collected were resolved after reviewing
the records. The data were analysed with SPSS software
version 19. Data were reported in average and percent-
ages and no statistical analysis was performed. This study
was granted ethical approval by the institution review
board and was supported by the hospital research grant.
Results
A total of 19 303 cases of work-related injuries were
reported over the 4-year period of our review, of which
239 cases (1.2%) had chemical exposure and were
included in the study. There were 69, 54, 59 and 57 cases,
respectively, from 2007 to 2010 with an average of about
60 cases per year. In addition to chemical exposures, 11
patients also had another mechanism of injury: 9 from
heat, 1 from cold injury and 1 from mechanical means.
The demographic characteristics of the work-related
chemical exposure cases are shown in Table 1. Most of the
patients were male (92%) with 73% of them aged between
21 and 40  years. The youngest patient in the study was
18 years old and the oldest was 66. About half of the patients
were foreign workers and the other half Singaporeans
or permanent residents. The ‘others’ race category con-
sisted of Caucasians and other nationalities like Filipinos,
Myanmese, Thais and Bangladeshis, etc. The most com-
mon job category was cleaners and labourers (34%). The
industry with the highest proportion of chemical-related
injuries was construction and ship building (28%).
Table  2 describes the type and nature of chemical
exposures as well as the pre-hospital management. Most
of the cases presented within 4 h of exposure (52%). All
the cases were from acute exposures (one time exposure
<24 h duration). The most common route of exposure
was to the eye. Ten cases ingested the chemical (nine
from accidental ingestion and the other case was splashed
with the chemical and ingested some). The accidental
ingestions occurred because they had mistaken the liq-
uid chemical for drinkable water in six cases while no
reason was available in the other three cases. The chemi-
cals were kept in mineral water (two cases), cola (one
case) and other (two cases) bottles. In all these cases,
only a small amount from 1 to 2 mouthfuls to a cupful
of chemical was ingested. One case had an intramuscular
injection from an auto-injector containing pralidoxime.
 H. H. TAN ET AL.: WORK-RELATED CHEMICAL EXPOSURES  115

Table 1.  Demographic characteristics of chemical exposure cases Table 2.  Type and nature of chemical exposure and pre-hospital
management
Number of cases
(n = 239) (%) Number of cases
(n = 239) (%)
Age
 ≤20 10 (4) Time from exposure to presentation at ED
 21–30 95 (40)   <1 h 41 (17)
 31–40 80 (33)   1–4 h 82 (35)
 41–50 35 (15)   >4–24 h 53 (22)
 51–60 15 (6)   >24 h 55 (23)
 >60 4 (2) Unknown 8 (3)
Race Routes of exposure
 Chinese 105 (44)  Eye 125 (53)
 Indian 52 (22)  Dermal 71 (30)
 Malay 44 (18)   Dermal and eye 5 (2)
 Others 38 (16)  Inhalation 26 (11)
Nationality   Inhalation and eye 1 (0)
  Non-resident workers 118 (50)  Ingestion 10 (4)
Singapore citizens and permanent 110 (46)  Injection 1 (0)
residents Class of chemicals
 Unknown 11 (5)  Corrosive 98 (41)
Job description  Hydrocarbon 42 (18)
  Cleaners, labourers 81 (34)   Cleaning agents 22 (9)
 Technician 46 (19)  Gases/vapour 17 (7)
  Plant, machine operators, assemblers 11 (5)  Paints 7 (3)
  Craftsman and related trades 2 (1)  Pesticide 4 (2)
 Managerial/professional 9 (4)  Others 29 (12)
 Others 10 (4)  Unknown 20 (8)
 Unknown 80 (33) State of chemical
Type of industries  Liquid 200 (84)
  Manufacture chemical 6 (3)  Gases/vapour/aerosol 32 (13)
  Manufacture others 39 (16)  Solids 5 (2)
  Construction, ship building 66 (28)  Unknown 2 (1)
  Hotels, restaurant 6 (3) Mechanism of injury
  Transport, store, communications 21 (9)  Mixing 8 (3)
 Others 29 (12)  Splash 130 (55)
 Unknown 72 (30)  Leakage/spillage 31 (13)
 Explosion 5 (2)
  Exposure in confined space 13 (5)
The most common class of chemical reported was   Accidental ingestion 9 (4)
corrosives (41%). There were 30 cases with hydrofluo-  Others 17 (7)
ric acid (HFA) exposure over the 4  years. Most of the  Unknown 26 (11)
cases were exposed to dilute HFA but there were five PPE worn
cases with exposure to >40% HFA. Aside from the his-  Goggles 15 (6)
tory from the patient, information about the chemicals   Face mask or face shield 4 (2)
 Gloves 16 (7)
involved was available from safety data sheets (SDS) in
 Boots 1 (0)
five cases and from supervisors or other co-workers of   Chemical suits 4 (2)
the patient in 23 cases.  Others 3 (1)
The majority of cases (93%) arrived at the hos-   None reported 201 (84)
pital by their own transport while the remaining 8% Pre-hospital treatment received
arrived by ambulance. Only a small percentage of   Eye irrigation 94 (40)
patients were documented to be wearing some form of   Dermal irrigation 33 (14)
personal protective equipment (PPE) when the injury   Seen own doctor 75 (32)
  Medications given 17 (7)
and exposure occurred. The majority of the patients
  Induce vomiting 5 (2)
(84%) did not have any PPE usage documented.   Applied antidote for HFA 8 (3)
The most significant pre-hospital management car-  Others 3 (1)
ried out was eye irrigation (40%) and skin irrigation/   None of above reported 67 (28)
shower (14%).
116  OCCUPATIONAL MEDICINE

We also identified six incidents (3% of all incidents) Table 3.  Clinical features and presentation of patients
where two or more patients were exposed and came to the
Number of cases
ED for the same incident. The first incident involved 16 (n = 239) (%)
patients who were suspected of being exposed by dermal
contact to HFA that had leaked from a container. Most of Eye
the patients were well and asymptomatic. Of the other five Any redness, pain, swelling, blurred 129 (54)
incidents, three of them involved inhalational exposure to vision, etc.
chemicals—sewage gas inhalation (three patients), chlorine Skin
gas inhalation (three patients) and cleaning solution vapour  Burns 59 (25)
inhalation (two patients). For the remaining two incidents,  Dermatitis/rash 1 (0)
one of them involved cement being splashed into the eyes  Cellulitis 3 (1)
Respiratory
of two patients when a pipe exploded. The last incident was
  Shortness of breath 17 (7)
that of two workers exposed to HFA by dermal contact.  Cough 9 (4)
The majority of the clinical presentations were eye- Neurological
related injuries (54%) and skin burns (25%) from chem-  Drowsy 1 (0)
ical exposures. Some patients presented with more than  Giddy 10 (4)
one symptom or injury. The clinical features and pre­   Nausea and vomiting 11 (5)
sentations are described in Table 3.  Headache 3 (1)
The most frequent decontamination procedure per- Gastrointestinal
  Oral mucosal pain/sore throat 7 (3)
formed in the ED was eye irrigation (46%). Only one
  Abdominal pain 3 (1)
patient received activated charcoal for gastric decon-
tamination. Standard supportive management includ-
ing wound care was administered to the patients when
required in the ED. Only five patients received antidotes
for HFA exposure in the ED: three of these patients Table 4.  Outcome and disposition of cases
received topical calcium gluconate gel, one patient
Number of cases
received calcium gluconate gel and intravenous (IV) cal- (n = 239) (%)
cium gluconate 2.5% via IV regional block (Bier’s block)
while the last patient received 10% calcium gluconate via
Disposition of patients
the IV route. The patient who received IV calcium gluco-   Admitted to our hospital 22 (9)
nate via Bier’s block was exposed to 49% HFA because   Discharged with follow-up 164 (69)
of a defect in his glove. He presented >4 h after exposure   Discharged with no follow-up 43 (18)
with pain in his fingertips. Despite topical application of   Transferred to other hospital 7 (3)
calcium gluconate gel and IV morphine, his pain con- Discharged against medical advice 2 (1)
tinued. After the IV calcium gluconate via Bier’s block  Others 1 (0)
administration, his pain subsided significantly and he Follow-up referrals
 Eye 119 (50)
was discharged with out-patient follow-up.
 Burns 29 (12)
There were seven cases where the Drug and Poison  Toxicology 6 (3)
Information Centre or the hospital toxicology service  Medical 4 (2)
was consulted. Toxicology specific tests were performed  Dermatology 2 (1)
for only seven cases and they included blood tests for car-  Orthopaedics 2 (1)
bon monoxide exposure (three cases) and screening tests  Otolaryngology 1 (0)
(blood and/or urine) for poisoning agents (four cases).   General practitioners 15 (6)
The outcome and disposal of the cases are described Admission discipline (27 cases)
 Medical 14 (6)
in Table 4. The majority of patients were discharged with
 Eye 7 (3)
out-patient specialist follow-up. Altogether, 27 patients  Ortho 1 (0)
(11%) were admitted, of which 22 patients were admit- Burns (transferred to another hospital) 5 (2)
ted to our hospital. Seven patients were transferred to Length of admission (27 cases)
a neighbouring hospital with a burns department and   1 night stay 16 (7)
five of these patients were admitted there. All the 27   2 nights stay 3 (1)
patients were admitted to the general ward. Four of these   >2 nights stay 8 (3)
patients required surgical interventions that were related Length of medical leave
 1–3 days 111 (46)
to their injuries. Most of these patients (59%) were admit-
 >3 days 109 (46)
ted for a one night stay in the hospital.  Nil 17 (7)
The patients who were discharged with no follow-  Unknown 2 (1)
up appointments were presumed to have made a good
 H. H. TAN ET AL.: WORK-RELATED CHEMICAL EXPOSURES  117
recovery as they did not re-attend for similar problems
(only one patient re-attended and was again discharged
without follow-up). However, there were five patients who
developed long-term complications from the injuries and
required prolonged follow-up (at least 6 months). Two of
these patients had eye (exposure to wet cement) and fin-
ger (exposure to unknown liquid) surgery and required
follow-up for 1 year and 6 months, respectively. The other
three patients had eye injuries (from sodium hydroxide),
skin burns (from nitric acid) and reactive airways dysfunc-
tion from inhalational exposure (to chlorine) and required
follow-up for 15 months, 3 years and 1 year, respectively.
The number of cases notified to MOM as work-
related injuries or diseases from their database compared
with the number of cases for each year were 15/64, 7/51,
9/54 and 14/54 from 2007 to 2010, respectively, averag-
ing ~20% (45/223) a year. Of the cases notified, only one
case was reported as an occupational disease. This case
was signed off absent for 1–3 days and was not admit-
ted. Altogether, 223 cases were included in this analy-
sis because 11 cases did not have proper identification
numbers and so could not be tracked in the MOM data-
base and five cases belonged to uniformed civil service
occupations, which were exempted from the regulation
on notification. The cases were further analysed accord-
ing to the number of days of absence advised initially
when they were seen at the ED as well as the length of
admission where applicable. Cases with absence >3 days
or were admitted for >1 day met the criteria for the case
to be notified. There were 101 cases (range: 22–28 cases
a year) who had absence >3 days or were admitted for
>1  day. All those who were admitted for >1  day also
had absence >3 days. Eight cases were excluded for the
two reasons stated above. Out of these 101 cases, 34%
(34) were reported in the MOM database. Of the 67
cases not reported, the occupation of 18 of them could
not be determined from the records.
Discussion
In this study, we found a low rate of work-related
chemical exposures presenting to the ED. However, the
demographic data from this study regarding the nation-
alities, types of industries and occupations of the work-
ers exposed are helpful for the development of targeted
prevention strategies. Our study also explored possible
deficiencies in the use of PPE, decontamination and sur-
veillance of occupational exposure incidents. Addressing
these issues could improve the prevention and manage-
ment of chemical exposure at the workplace.
Our hospital is one of the six public general hospitals
in Singapore with a yearly ED attendance of ~150 000
patients. This contributes to 17% of the public hospital
ED load [16]. From our study, the incident of chemi-
cal-related industrial accidents per year is ~0.04% of ED
attendance and 1.2% of all work-related injuries. Similar
studies done locally on work-related injuries seen in the
ED [17] also showed a low rate (<4%) of ‘other’ type
of injury after excluding blunt and penetrating trauma.
Compared with the study by Ponampalam et  al. [13],
which showed a work-related toxic exposure rate of
~0.076% of ED attendance, we had a lower rate. We pos-
tulate that this is because our study had strict inclusion
criteria while the earlier study was based on toxic expo-
sures in general.
We found a large proportion of ‘others’ race in our
study, which reflected the composition of foreign work-
ers with many different ethnic groups and nationalities.
This is different from the Singapore citizens and per-
manent residents ‘others’ race proportion, which only
accounts for 3.3% [2]. Foreign workers comprise 35%
of the working population [1]. In our study, most of the
workers were in the construction and manufacturing
industry and they worked mainly as cleaners, labourers
and technicians. The high proportion of foreign work-
ers may pose a language barrier in terms of instructions
regarding chemical safety and training in use of PPE.
Preventive efforts in educating safe practices at the work-
place could be targeted at these workers.
The number of cases reporting wearing PPE during
the exposure was low possibly because this was a ret-
rospective study and most of this information was not
well documented. The study on eye injury by Woo and
Sundar [10] and Ngo and Leo [9] reported a low rate of
wearing PPE (29 and 21%, respectively), compliance to
PPE provided (39 and 45%, respectively) and being pro-
vided with PPE (32 and 34%, respectively). Even if the
workers were wearing PPE, the PPE may not be properly
fitted or even appropriate. As most of the workers were
in the construction and cleaning industry, the hot and
humid environment they work in may not be conducive
for prolonged use of PPE. A prospective study would be
needed to further explore this issue.
From our study, only 17% of the cases arrived within
1 h of exposure. As decontamination is most effective
soon after chemical exposure [18], emphasis should be
placed on pre-hospital decontamination. The proportion
of casualties who had pre-hospital eye irrigation for eye
injuries (72%) and dermal irrigation for skin burn (56%)
was relatively low. Data from other reports [19] also
showed that decontamination was not performed for the
majority of casualties (72%). Provision of adequate clean
running water for decontamination purposes should be
available at worksites where exposure is possible.
Industrial chemical accidents have caused several
large scale mass casualty disasters in history [20]. This is
because potent chemicals in the form of gases or ­aerosols
could disperse over a large area in a short duration.
In our study, there were only six incidents with two or
more casualties and three of them involved inhalational
exposure. This is low compared with Agency for Toxic
Substances and Disease Registry (ATSDR) data where
118  OCCUPATIONAL MEDICINE
41% of the incidents had two or more casualties per inci-
dent [19]. This could be because there was less inhalation
exposure in our cohort (11%) while injuries from vapour
accounted for 46.5% of cases [19] and inhalational expo-
sure made up 43% of cases [6] in other reports. EDs
should be prepared for chemical incidents with a large
number of casualties. Most of these casualties are also
likely to arrive by their own transport [21].
We also found that 66% of reportable cases from our
study were not reported. We recognize that under-report-
ing may be due to a lack of awareness or recognition of
occupational diseases. But it is also the result of each
country’s differing legal reporting criteria used. There
could also be other reasons why the cases were not noti-
fied, for example, the medical leave that was issued may
not be taken or submitted by the worker. This highlights
the importance and advantage of having multiagency
sources of information [6] and close collaboration with
the ED of the various hospitals as it would aid us in bet-
ter targeted national chemical prevention programmes.
Our study has various limitations. It is a retrospective
study from one centre. Most of the casualties did not
bring along the SDS and hence the exact chemical com-
position could not be precisely determined. There was
also inadequate documentation about PPE worn and
precise reasons for the exposure. However, this study
gives a realistic picture of the management of cases in
the ED where the focus is on acute treatment rather than
accident prevention. Lastly, our case mix includes mainly
those with acute exposure while those with chronic or
sub-acute exposures were not identified.
In conclusion, although we did not find a high rate
of work-related chemical exposure from our study, we
identified at risk groups where preventive efforts could
be targeted. Our results also highlighted issues on PPE,
decontamination and surveillance, which could be
strengthened to prevent and improve management of
chemical injuries at the workplace.
Key points
•• Our study did not find a high rate of work-related
chemical exposure, but the demographic informa-
tion obtained could be used for targeted preven-
tive efforts among specific worker population who
are at higher risk of exposure.
•• We also found that injuries from work-related
chemical exposure were under-reported and
multiagency collaboration is required to improve
surveillance.
•• Management of chemical-related incidents involve
access to chemical information, use of personal
protective equipment, early decontamination, use
of appropriate antidotes as well as preparedness
for possible mass casualty events.
Funding
Changi General Hospital’s research grant (Reference:
CGHRF2009.1).
Acknowledgements
We would like to thank the research assistants who participated
in data abstraction.
Conflicts of interest
None declared.
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