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Guidelines for tanning salon operators

COMMUNICABLE DISEASE CONTROL
HEALTH PROTECTION AND SAFETY

Guidelines for
Tanning Salon Operators

Ministry of Health and
Ministry of Health Services
Ministry Responsible for Seniors
Health Protection Planning Division British Columbia Ministry of Health Services March 1997 (revised March 2004) Canadian Cataloguing in Publication Data British Columbia. Public and Preventive Health Division Guidelines for Tattooing ISBN 0-7726-3643-5 1. Tanning salons - Health aspects - British Columbia.
2. Ultraviolet radiation - British Columbia - Safety measures.
I. British Columbia. Public and Preventive Health Division RL89.G84 1998 363.72ʼ9 C98-960227-3 (revised January 2000) TABLE OF CONTENTS
APPENDIX D: PRODUCTS THAT INCREASE THE RISK . . . . . . . . . . . . . . . . . . . . . 14
APPENDIX E: RADIATION EMITTING DEVICES ACT REGULATIONS . . . . . . . . 17
TANNING OPERATOR KNOWLEDGE QUESTIONNAIRE . . . . . . . . . . . . . . . . . . 23
GLOSSARY OF TERMS
Corium
- lowest (innermost) layer of cells in the skin.
Delayed tanning - tanning process resulting in an increase in the amount of
melanin pigment produced in the skin.
Epidermis - outer layers of skin in which melanin is found, and where
tanning occurs.
Erythema - the medical term for inflammatory redness of the skin. It can be
produced by exposure to UVR, particularly UVB radiation. When this happens, it is commonly called "sunburn".
Immediate pigment darkening - tanning process that darkens only the melanin
pigment already present in the skin.
Melanin - pigment in the skin which becomes darker when exposed to
ultraviolet radiation.
Melanoma - most serious form of skin cancer.
Photokeratitis and photoconjunctivitis - painful injuries to the unprotected
eye caused by overexposure to UVR
Stratum corneum - tough outer layer of dying skin cells.
UVA - ultraviolet radiation (sometimes called "long wave" radiation - 320 to
400 nanometres) most common in commercial tanning equipment
UVB - ultraviolet radiation (sometimes called "short wave" radiation - 280 to
320 nanometres) responsible for most sunburns as well as long lasting tans. UVB is found at varying levels in all commercial tanning devices.
UVR - ultraviolet radiation - includes the entire spectrum (100 to 400
nanometres) of ultraviolet radiation, including UVC radiation (100 - 280 INTRODUCTION
Prolonged exposure to Ultraviolet (UV) A and B radiation can cause sunburns,
premature skin aging, skin cancers, cataracts and other eye and skin diseases. It has been shown that UV can affect the immune system of the skin.
The rate of skin cancer in the British Columbia population has doubled over the last 20 years. In Canada this year about 65,000 Canadians are expected to develop skin cancer. One in seven of today's children is expected to develop some form of skin cancer in his or her lifetime. Evidence indicates that 85 per cent or more of all skin cancers are caused by exposure to UV radiation.
When a person chooses to acquire or enhance a tan using a tanning salon facility, it is important for that person to be aware of the hazards involved, so they can make an informed decision about the amount of exposure they receive. This booklet is designed to give owners and staff of tanning salons a fundamental knowledge of ultraviolet radiation, and its effects on people exposed to the various types of UV radiation. It discusses the risks of tanning, provides information on certain products that increase that risk, and provides a list of general guidelines for tanning salon personnel to help reduce health risks both to their clients and to themselves. The final section contains a series of questions and answers for tanning salon personnel which lets them test their knowledge and understanding of the information in this booklet. Public Health Officials may refer to this document and to the Ministry of Health's Guidelines for Personal Services Establishments* when assessing whether a tanning salon is being operated in accordance with the Personal Services Establishment Regulation. However, following the guidelines listed in this document does not relieve the operator from the obligation to take any additional measures necessary to prevent health hazards from occurring in the establishment. Operators are also responsible for ensuring that they are carrying on business in compliance with municipal and other regulatory requirements, and for obtaining business licences and/or operating permits from the appropriate licensing authorities.
*Note: These Guidelines for Tanning Salon Operators, and the Guidelines for Personal Services Establishments, can both be viewed on the internet, at: RISKS OF TANNING
Sunburn
Sunburn (or erythema) is an inflammatory redness of the skin, caused by too
much exposure to UV radiation, particularly UVB radiation. When the skin can't produce enough melanin or isn't thick enough to protect itself from UV radiation, the skin begins to burn. The small blood vessels in the skin dilate and increase the blood flow to the skin's surface, making it red and sore. This reaction can be almost immediate in severe cases, or may develop up to 24 hours later in less severe cases of overexposure. People with fair skin who always burn and never tan are genetically incapable of producing sufficient melanin in their bodies to allow tanning. They will always burn, whether in the sun or when using tanning equipment.
Premature Aging
UVR causes premature aging effects such as skin thickening, wrinkling and
hardening. Overexposure to UVR can also make the skin more fragile and vulnerable to damage. Skin Cancer
Skin cancer is the most common form of cancer in Canada. In 1999, an
estimated 64,000 new cases of this increasingly prevalent skin disease are expected. If current trends continue, one in seven of today's children will develop skin cancer during their lifetime. Squamous and basal cell cancers are the most common, but rarely fatal, forms of skin cancer. Exposure to UV radiation causes these forms of cancer. Malignant melanoma is a less common, but potentially deadly, type of skin cancer. Melanoma has been linked to intense intermittent and long-term exposure to ultraviolet radiation during childhood or the teenage years.
Other risk factors for melanoma include a family history of melanoma, and physical attributes such as having lots of moles, and/or red or blond hair. Melanoma usually affects people from 25 to 50 years of age. (Source: Canadian Dermatology Association.)The risk of developing skin cancer increases as total exposure to UVR increases. People with fair skin who burn easily are also most at risk of developing skin cancer.
Eye Problems
Ultraviolet radiation may cause painful temporary injuries to the cornea and
conjunctiva, called photokeratitis and photoconjunctivitis. These injuries — normally caused by too much UVB or UVC radiation — are more commonly known as ‘welder's flash' or ‘snow blindness'. These conditions may develop from 2 to 24 hours after exposure, but usually occurs within 6 to 12 hours. UVA radiation may cause eye aging effects, such as browning of the lens and loss of elasticity. Overexposure to UVB can cause cataracts in the lens. Some people have also reported retina damage due to too much UVR.
RISKS ASSOCIATED WITH TANNING SALONS
Risks of overexposure to UV radiation
A serious, although rarely occurring health risk associated with tanning salons
is that of extreme overexposure to UV radiation during a single session which results in a serious case of erythema, or "sunburn". These cases, although relatively rare, have caused serious harm to affected tanning salon clients. These incidents have usual y been attributed to operator error in under-estimating the strength of the UV radiation being emitted from the equipment and/or over-estimating the maximum time that an artificial tanning session should last. Maximum exposure times for different skin types depend on the strength and type of ultraviolet emissions from the ultraviolet light bulbs used in each individual piece of tanning equipment. There are many different models and brands of ultraviolet light bulbs available on the market, producing varying intensities and emitting different amounts of UVA and UVB radiation. While all pieces of tanning equipment are required to carry specific information about maximum exposure times and minimum intervals between exposures, this information is based on the bulbs provided with the original equipment, when it was first manufactured. It is not uncommon, however, for replacement bulbs installed in tanning equipment by operators as part of their routine maintenance program to have different — and often higher — levels of ultraviolet emissions than the original manufacturer's bulbs. Cases of overexposure to UV radiation have occurred as a result of clients being exposed to tanning equipment which has had its original bulbs replaced with newer, more powerful bulbs which have shorter maximum exposure times than those times which may be shown on the equipment. For this reason, it is essential that operators ensure that clients are informed as to the maximum exposure time (in minutes) and the minimum time interval needed between consecutive exposures for the particular make and model of bulbs that are actually installed in each separate tanning machine. The best way to determine how much UVA a bulb (or bulbs) is emitting is to measure it. Checking the bulb UVA output from time to time will assist operators in adjusting the recommended tanning times for first time users as the bulbs age and when new bulbs are purchased. Small, portable UVA meters commercially available from this purpose.
Operators should not rely on the manufacturer's information on the exterior of the tanning device if there is any possibility that the bulbs may not be the same type as those installed with the original equipment. That information will only be correct if the original bulbs are still in place, or if bulbs identical to the originals have been used as replacements. Operators should also note that: (a) Maximum exposure time cannot be increased to compensate for decreasing UV intensity as bulbs age; and (b) Different beds have different maximum exposure times. A client accustomed to tanning on a bed with a high proportion of UVA radiation must be advised that they cannot have a similar exposure time on a UVA tanning bed with a higher proportion of UVB radiation.
Risks of infection
There is also a risk of transmission of infectious diseases (e.g. Pink Eye) from
sharing of protective eyewear equipment. It is therefore recommended in these guidelines that customers of tanning salons be encouraged to purchase their own personal protective eyewear equipment for their own personal and exclusive use. If protective eyewear equipment is provided by the tanning salon, it should either be single-use and disposed of after use on a single client, or else such equipment must be disinfected after each use in accordance with the requirements for "Semi-Critical Items" as defined in the Ministry of Health's Guidelines for Personal Service Establishments (Section 4.A ii).
Risk of overhead bulbs breaking
Another risk from tanning salons is the danger of the client getting injuries as
a result of the overhead bulbs in two part or hinged tanning beds breaking and showering the client with broken glass. This may result from the client accidentally bumping against the overhead bulbs. It has also happened when an improperly installed bulb has simply fallen out of its socket and fallen onto the client. In either case, this danger can be minimized by ensuring that some form of physicial barrier (i.e. a clear UV-transmitting acrylic cover) is in place between the lamps and the person being exposed to UV radiation, over the top section of two part or hinged tanning beds as well as over the bottom section. This barrier will prevent injury to the user of the equipment in case of accidental lamp breakage. It will also guard against burns from too close contact with the bulbs.
HEALTH & SAFETY GUIDELINES
Owners/operators of tanning salons should refer to the Ministry of Health
publication: "Guidelines for Personal Service Establishments", available from the Environmental Health office of your local Health Unit or Department. These guidelines describe the minimum standards necessary to prevent health hazards from occurring in Personal Service Establishments as required under the Personal Service Establishments Regulation of the Health Act. In addition, operators should follow the guidelines listed below, which have been developed specifically for tanning salon operations.
A. — GENERAL GUIDELINES:
1. Informed consent:
Operators of tanning salons must consider the issue of informed consent by their customers, in addition to taking measures to prevent disease transmission and injury. It is recommended that operators seek legal advice on the development and use of a declaration of health risks and a consent to being exposed to UV radiation, which should be completed and signed by each customer prior to their using tanning equipment. Operators should satisfy themselves that their customers are aware of the health risks associated with exposure to UV radiation. It is recommended that tanning clients be advised to consider discussing the risks of artificial tanning with their family physicians. In order to give their informed consent, minors must have the maturity to and must understand all the implications of exposure to UV radiation. It is recommended that operators require minors to obtain written parental consent.
2. Children, teens are most vulnerable
People normally get the majority of their total, lifetime exposure to UV radiation when they are young, as children and teenagers. Research shows that the risk of getting skin cancer increases as exposure to UV radiation increases. Research also shows that a person's chance of getting the less common but more deadly form of skin cancer — malignant melanoma — as an adult is twice as high if they had one or more serious sunburns when they were young. For these reasons it is particularly important to make sure that children and teenagers are protected from overexposure to UV radiation, and that they understand the increased long term health risks as a result of increased exposure to ultraviolet radiation.
While minors are not prohibited from using tanning salons, the use of tanning salons — particularly by minors — is not recommended for the health reasons described in these guidelines.
3. Evaluate your customers
People who always burn and never tan should be advised not to use tanning units. People who do not tan easily (for example, fair-skinned adults with red or blond hair and freckles) should not use tanning units for as long a time as adult customers with dark skin and hair. While minors are not prohibited from using tanning salons, the use of tanning salons — particularly by minors — is not recommended for the health reasons described in these guidelines. Anyone who has a skin infection, rash or other skin condition should not use a tanning salon until the problem is resolved or a doctor has been consulted.
4. Inform your customers
Make sure that your clients are informed about factors which could adversely affect their tolerances to ultraviolet radiation exposure. This should include information about both oral and topical medications, and cosmetics or lotions applied to the skin. See Appendix D.
5. Delayed or adverse reactions
Clients should be advised that they may have a delayed, adverse reaction to UV exposure (i.e. red, irritated and watering eyes, or an itching skin rash or sunburn) after they leave the tanning salon. This delayed reaction
can take anywhere from less than an hour to as long as a day and a half to develop. If such adverse reaction is serious, they should be advised to consider seeing their doctor. They should also be asked to notify the tanning salon operator of their reaction.
B. — EQUIPMENT GUIDELINES:
1. Compliance with federal Regulations
All sunlamps, including tanning beds, must comply with the regulations specified for sunlamps under the Federal government's Radiation Emitting Devices (RED) Act (Appendix E). Operators should check with their equipment supplier to ensure that their sunlamps and tanning beds comply with this Act before purchasing any new, used or replacement equipment.
2. Staff attendance, knowedge and testing
You should make sure that an operator or staff member who can inform and assist the public in the safe use of the tanning devices is always available during business hours. Staff should be familiar with these guidelines, and have completed the questionnaire at the back of this booklet to evaluate their knowledge.
3. Exposure times must be based on current, installed bulbs.
Operators must ensure that clients are informed as to the maximum exposure time (in minutes) and the minimum time interval needed between consecutive exposures for the particular make and model of bulbs that are actually installed in each separate tanning machine. 4. Regular testing of bulbs
It is recommended that operators check the intensity of the bulbs' UVA output when new bulbs are installed, and from time to time afterwards, to make sure the operator is able to determine the correct recommended maximum exposure times based on the actual output of the bulbs. Small, portable UVA meters are commercially available for this purpose.
5. Loss of intensity in aging bulbs
Maximum exposure time for clients can not be increased to compensate for
decreasing UV intensity as bulbs age.
6. Different equipment used by same client
Different beds have different maximum exposure times. A client accustomed to tanning on a bed with a high proportion of UVA radiation must be advised that they cannot have a similar exposure time on a UVA tanning bed with a higher proportion of UVB radiation.
7. Accessible "on - off" switch
Make sure that each tanning device can be easily turned off by the person who is being exposed, without their having to disconnect the electrical plug or remove the ultraviolet lamp (a requirement of the Federal Radiation Emitting Devices Act (RED )regulations).
8. Protective eye wear must be provided
Make sure that each client/customer is provided with — and instructed on how to wear — ultraviolet radiation safety eyewear which covers the 9. Eyewear must meet certain criteria
Protective eyewear used with sunlamps or tanning beds must meet two criteria (derived from the RED Regulations): (a) the user must be able to see through them clearly enough to read the labels and operate the controls on the tanning equipment.
(b) the eyewear must attenuate the shortwave ultraviolet radiation (200-320 nm) by a factor of at least 1,000, and attenuate the longwave ultraviolet radiation (320-400 nm) by a factor of at least 100.
A list of eyewear which has met these specifications is reproduced in Appendix C. Eyewear may also be tested by the office of the Ministry of Health's Radiation Protection Branch (#210 - 4940 Canada Way, Burnaby B.C. (604) 660-6633 for 10. Eyewear use
It is recommended that customers of tanning salons be encouraged to purchase their own personal protective eyewear equipment for their own personal and exclusive use. 11. Prevention of eye infection
If protective eyewear equipment is provided by the tanning salon, it should either be single-use and disposed of after use on a single client, or else such equipment must be disinfected after each use in accordance with the requirements for "Semi-Critical Items" as defined in the Ministry of Health's Guidelines for Personal Service Establishments (Section 4.A ii).
C. — FACILITY GUIDELINES:
1. Warning Signs
Make sure that ultraviolet radiation warning signs, approved by the local Medical Health Officer, are posted in plain view and easily readable at all tanning locations within the facility, and in the client reception area as well. The local health authority will supply the necessary signs to be posted. 2. Protection against lamp breakage
Ensure that a physical barrier (i.e. a clear UV-transmitting acrylic cover) is in place between the lamps and the person being exposed to UV radiation, over the top section of two part or hinged tanning beds as well as over the bottom section. This barrier will prevent injury to the user of the equipment in case of accidental lamp breakage. It will also guard against burns from too close contact with the bulbs.
3. Employee protection during maintenance
Whenever maintenance is being performed on any of the tanning equipment (i.e. changing UV bulbs, cleaning equipment, etc.) ensure that employees either turn off all the tanning bulbs while working on or around the equipment, or else wear protective eyewear and clothing to minimize their exposure and protect against potential damage to their eyes and skin. 4. Adequate Ventilation
Ensure that adequate ventilation is provided in such a way that the tanning booth/room does not exceed 30°C.
5. General Infection control:
Ensure that common contact surfaces are disinfected between each use with a low level disinfectant. Refer to the Ministry of Health's "Guidelines for Personal Service Establishments", Section 4, regarding the importance of proper handwashing, and the use and care of critical items, including sterilization of equipment and disposal of wastes.
The Ministry of Health Services welcomes written comments and/or suggestions on these guidelines, and will take any such feedback into consideration for future revisions. Comments should be addressed to Health Protection Planning, Ministry of Health Services, 1515 Blanshard Street, Victoria, BC V8W 3C8.


APPENDIX A - THE TANNING PROCESS
Skin
is made up of basically two sections, the epidermis (outer layer) and the
corium (dermis or inner layer). The innermost section or corium is formed of tissues containing nerves, blood vessels, lymphatics and fatty tissue. The outer section or epidermis is made up of a series of layers. Cel s are created in the bottom or innermost layer of the epidermis. As they age, they travel from the innermost layer of the epidermis, through the middle layers, out toward the surface of the skin where they die. This surface layer (or stratum corneum) forms a tough outer protective covering. As the cells move outward, they lose moisture, flatten and eventually flake off the surface of the skin. This process takes about 28 days.
Tough outer layer of dying skin cells (stratum SECTION OF
(cells capable of producing melanin) Tissue below skin: muscle, fat, bone, etc.
Tanning: There are two effects that occur in the skin following exposure to UV
radiation. When the skin is exposed to ultraviolet radiation a slight, immediate pigment darkening or immediate tanning is sometimes observable. It is believed to result from darkening of the melanin pigment that is already present in the epidermis as it absorbs and filters out some of the damaging UV radiation. This tan is only temporary, and fades within 3 to 36 hours after exposure. This type of tan is strongly stimulated by UVA radiation.
A second process known as "delayed tanning" occurs in some individuals when the skin is exposed to ultraviolet radiation. This process causes two responses. a) more melanocytes (skin cel s capable of producing melanin pigment) are produced at the base of the epidermis, and each melanocyte produces more melanin pigment. These melanin-containing cells begin to distribute themselves throughout the layers of the skin, as they work their way toward the surface of the skin. This greater presence of melanin-containing cells causes the skin to appear darker in colour. b) the tough outer or surface layer of dying skin cel s thickens and absorbs more of the hazardous shortwave UVB radiation, thereby increasing protection to the inner living skin tissue from the harmful rays. This second, two-part process takes one or more days to happen, and produces a noticeable tan within a few days that can last for weeks or even months.
APPENDIX B
Forms of radiation
Ultraviolet Radiation (UVR)
is a form of electromagnetic energy with
wavelengths ranging from 100 to 400 nanometres. These wavelengths can be divided into UVA (wavelength 320 to 400 nanometres), UVB (wavelength 280 to 320 nanometres) and UVC radiation (100 to 280 nanometres).
UVA (wavelength 320 to 400 nanometres, sometimes known as "black light" or
"longwave" radiation) carries less energy than UVB and UVC, although UVA penetrates more deeply into the skin and underlying tissues. UVA is about 1,000 times more effective than UVB in producing an immediate tanning effect, by causing the melanin in the epidermis to darken immediately (i.e. as soon as the skin is exposed). Intense, prolonged exposure to UVA can burn sensitive skin. Prolonged UVA exposure can damage underlying structures in the corium and causes premature aging of the skin.
UVB (wavelength 280 to 320 nanometres, sometimes called "shortwave"
radiation) carries much more energy than the longer waved UVA radiation, although it does not penetrate as deeply into the skin as UVA. UVB is 1,000 times more likely to cause sunburn (erythema) than UVA. Exposure to UVB causes a delayed tanning effect — that is, it takes two or three days for the tan to appear. Repeated exposure to UVB radiation also causes skin thickening and a longer lasting tan. Various factors may influence how a person will react to exposure to UV radiation, including skin type, length of exposure, and genetic background. To help you remember that UVB is 1,000 times more able to cause sunburn than UVA, remember: "B is for Burn".
UVC radiation from the sun is completely absorbed by the earth's atmosphere,
and does not reach the surface of the earth. This is fortunate since UVC radiation is very dangerous to all forms of life, even with only very short exposures. Modern tanning equipment does not emit significant levels of UVC radiation.
Most tanning beds produce from 7 to 20 m/W cm2 (milliwatts per square centimetre) of UVA. That's three to eight times more UVA than the sun produces at midday during summer in B.C. Face tanners generally emit much more UVA than tanning beds. NOTE: Some newer, non-fluorescent technology tanning beds can emit more than 60 m/W cm2 — which is 25 times more than the UVA produced by the sun at midday.
All tanning beds also emit varying amounts of UVB. The amount of UVB emitted varies with each lamp. Even tanning lamps labelled ‘Only UVA' still emit some UVB. Some lamps may emit ten times more UVB than others, producing significant sunburn in a short time, even to people who have previously used tanning lamps. Radiation that may cause skin cancers.UVB in particular can cause sever Used for sterilizing water Higher energyradiation, such as x-rays and gamma rays. Also a health risk.
APPENDIX C
Protective eyewear for sunlamps
Protective eyewear used with sunlamps or tanning beds must meet the
following two criteria: 1) the user must be able to see through them, clearly enough to read the labels and operate the controls.
2) the eyewear must attenuate the shortwave ultraviolet radiation by a factor of at least 1,000 and attenuate the longwave ultraviolet radiation by a factor of at least 100.
To date the following eyewear products have been tested by the Radiation Protection Branch and found to meet both criteria above: a) Super Sunnies, Lucas Products Corporation, U.S.A.
b) Le String, Irex100, by Bolle, France c) Eurotan Blinkers, Eye Pro Inc., U.S.A.
f) Ten Stück Sonnan Clip g) Peepers, 1992 California SunCare, Inc.
h) Hytique EyeLids i) Sun-clipse, Apollo's St. Louis, Missouri j) Australian Gold EZ Eyes, distributed by ETS, Inc.
k) SunGlobes, World SunCare Products Corp.
The following do not meet the criteria above: a) Cool Eyes Inc. (does not meet criterium #1) APPENDIX D
Products that increase the risk
Many products, including prescribed medications, over-the-counter patent
medicines, and a wide range of personal care products can increase the skin's sensitivity to UVR. This can result in photosensitivity, an intense reaction of the skin to UVR which can cause burning (or erythema) in a much shorter time period than would normally be expected. Photosensitivity can be caused by products applied directly to the skin (contact photosensitizing agents) or from medications or other substances that have been ingested. The article below, which lists a number of agents that may cause photosensitivity reactions, is reproduced with permission of the Marshall University School of Medicine, Huntington, WV, USA.
The URL is: http://meb.marshall.edu/chh/DrugInfo/Review/Drug-sun.htm Because there are literally hundreds of known photosensitizing agents under these general categories, clients taking any medications or using any of the other products listed below should consult a physician or pharmacist before DRUG-INDUCED PHOTOSENSITIVITY
Many drugs can cause skin to become very sensitive to the sun or the
type of light used in tanning booths. This reaction is called ‘Drug-Induced
Photosensitivity'. Drugs which you take by mouth and drugs which you apply on
the skin can cause this reaction.
Photosensitivity reactions can be divided into two groups: • Phototoxic reactions • Photoallergic Reactions Phototoxic reactions are dose related and can be seen to a slight degree in most people taking these medications who are exposed to enough sunlight. Photoallergic reactions involve the immune system and may be similar to other allergic reactions, swelling, rashes, and hives.
The drugs cause this reaction by absorbing ultraviolet light or visible light. Therefore, it may surprise you to learn that agents which are used in sunscreens can also cause photosensitivity reactions. The ability to absorb light is normally part of the physical chemical activity of the drug as opposed to its clinical effect.
Types of photosensitivity reactions include: • Abnormal and extreme sunburn • Stinging and Burning • Vesicles • Hives • Swelling Some of the drugs which are well known to cause photosensitivity reactions include Nalidixic Acid (NegGram), Doxycycline (Vibramycin, Vibratabs), and Hydrochlorothiazide (HCTZ, Hydrodiuril, Oretic, others). Other less known drugs which cause photosensitivity reactions include estrogens (for example, birth control pills and Premarin) and oral medications for diabetes to name a few. However, there is great differences in the frequency and severity of reactions from patient to patient. Some patients may develop blisters after a brief exposure to sunlight while others will have no reaction at all. Most will have a slight, probably unnoticeable, reaction.
Lists of Drugs Which Can Cause Photosensitivity Reactions
Antibiotics which commonly cause photosensitivity reactions
• Doxycycline (Vibramycin, Vibratabs) • Demeclocycline (Declomycin) - High Incidence. Reactions to fingernails and skin usual manifestation. • Tetracycline (Achromycin and others) • Nalidixic Acid (NegGram) • Lomefloxacin (Maxaquin) ** Especially noted for severe reactions when they occur. Blood Pressure and Heart Medications which commonly cause
photosensitivity reactions

• Hydrochlorothiazide (Hydrodiuril, Oretic and other names) **Many, many drugs contain HCTZ as one of the ingredients • Chlorothiazide (Diuril and other names) • Furosemide (Lasix) • Amiodarone (Cordarone) - high incidence of drug-induced photosensitivity reactions. Other Drugs which commonly cause photosensitivity reactions
• Chlorpromazine (Thorazine) • PABA and/or PABA esters ** commonly used in sunscreens. Reactions may occur after repeated use and are in the form of rashes and hives (an immune reactions), not sunburn. Other drugs which less commonly cause photosensitivity reactions
• Alprazolam (Xanax) • Amitriptyline (Elavil, Endep and other names) • Benzocaine (Sensorcaine and many other numbing products) • Captopril (Capoten) • Chlordiazepoxide (Librium) • Chloroquine • Chlortetracycline • Ciprofloxacin (Cipro) • Co-trimoxazole (Bactrim,Septra) • Dapsone • Diltiazem (Cardizem, and other names) • Diphenhydramine (Benadryl, Benylin, and other names) • Enoxacin (Penetrex) • Estrogens (Birth Control Pills, Premarin, and more) • Fluorouracil (5-FU) • Glyburide (Diabeta, Micronase, Glynase, and other names) • Griseofulvin (GrisPeg, Fulvicin, and other Names) • Haloperidol (Haldol)-uncommon • Hydralazine (Apresoline) • Ibuprofen (Advil, Motrin, and other names) • Isoniazid (INH) • Isotretinoin (Accutane) • Methotrexate • Minoxidil (Loniten, Rogaine) • Naproxen (Naprosen, Alleve, other names) • Nifedipine (Procardia, Adalat) • Norfloxacin (Noroxin) • Nortriptyline (Aventyl, and other names) • Ofloxacin (Floxin) • Oral Contraceptives • Oxytetracycline (Terramycin) • Perfenazine (Trilafon) • Phenylbutazone (Butazolidin) • Phenytoin (Dilantin) • Piroxicam (Feldene) - Not rare for a photosensitivity reaction to occur. • Prochlorperazine (Compazine) • Promethazine (Phenergan) • Protriptyline (Vivactil) • Quinidine (Quinidex, Quinaglute, Cardioquin, other names) • Quinine (Quinamm) • Sulfonamide antibiotics (Bactrim, Septra, Gantrisin, and others) • Thioridiazine (Mellaril) • Thiothixene (Navane) • Tolbutamide (Tolinase) • Tretinoin (Retin-A) • Trifluroperazine (Stellazine) • Vitamin A APPENDIX E
Radiation Emitting Devices Act
Note: these regulations have been reproduced from the Department of
Justice Canada website (http://canada.justice.gc.ca/FTP/EN/Regs/Chap/R/R-1/
index.html).
The Department of Justice Canada assumes no responsibility for the accuracy or reliability of any reproduction derived from legal materials on this site. The legal materials on this site have been prepared for convenience of reference only and have no official sanction. For all purposes of interpreting and applying the law, users should consult the Acts as passed by Parliament, which are published in the "Assented to" Acts service, Part III of the Canada Gazette and the annual Statutes of Canada, and the regulations, as registered by the Clerk of the Privy Council and published in part II of the Canada Gazette.
The above-mentioned publications are available at most public libraries.
Radiation Emitting Devices Regulations
Regulations Respecting Radiation Emitting Devices
2. In these Regulations, "Act" means the Radiation Emitting Devices Act; (Loi) "device" means a radiation emitting device that is within a class of radiation emitting devices prescribed in these Regulations; (dispositif) "Minister" means the Minister of National Health and Welfare. (ministre) 11. Sunlamps, being devices that are (a) equipped, or intended to be equipped, with one or more ultraviolet (b) designed to induce skin tanning or other cosmetic effects and are represented as inducing such effects but not including any such device represented for use in the production therapeutic effects for medical purposes.
PART XI SUNLAMPS
1. In this Part and in item 11 of Schedule I, "double-contact medium screw lampholder" means a lampholder described in Double-Contact Medium Screw Lampholder (ANSI) C81.10-1976, Standard Sheet 2-13-1, a standard published by the American National Standards Institute Inc.; (douille à vis moyenne (contact double)) "exposure position" means any location, orientation, place or distance relative to the ultraviolet radiating surfaces of the sunlamp at which it is recommended by the manufacturer that the user be exposed; (position pendant l'exposition) "irradiance" means radiant power incident per unit area expressed as watts per square centimetre (W/cm2); (éclairement énergétique) "maximum exposure time" means the longest time interval for continuous exposure recommended by the manufacturer of a sunlamp; (durée maximale d'exposition) "maximum timer interval" means the longest time interval setting on the timer of a sunlamp; (intervalle maximal de la minuterie) "minimum distance for use" [Revoked, SOR/85-757, s. 1] "minimum interval between consecutive exposures" means the shortest time interval between two consecutive exposures recommended by the manufacturer of a sunlamp; (intervalle minimal entre des expositions consécutives) "protective eyewear" means any device designed to be worn by the user of a sunlamp to reduce the radiation reaching the eyes either directly or indirectly; (dispositif de protection des yeux) "single-contact medium screw lampholder" means a lampholder described in Single-Contact Medium Screw Lampholder (ANSI) C81.10-1976, Standard Sheet 2-11-1, a standard published by the American National Standards Institute Inc.; (douille à vis moyenne (contact unique)) "spectral irradiance" means the irradiance resulting from radiation within an infinitesimally small wavelength range, expressed as watts per squarecentimetre per nanometre (W/cm2/nm); (éclairement énergétique spectral) "spectral transmittance" means the spectral irradiance transmitted through protective eyewear divided by the spectral irradiance incident on the protective eyewear; (transmittance spectrale) "timer" means any device that is incorporated into a sunlamp and is capable of terminating the emission of ultraviolet radiation from the sunlamp at the end of a preset time interval; (minuterie) "ultraviolet lamp" means any device that is designed to produce ultraviolet radiation in the wavelength range from 200 nm to 400 nm; (lampe à rayonnements ultraviolets) "wavelength" means a wavelength as measured in air. (longueur d'onde) STANDARDS OF DESIGN AND CONSTRUCTION
2. (1) Every sunlamp shall be designed and constructed in such a manner that, under the conditions of use specified by the manufacturer, it functions in accordance with the standards of functioning described in section 4 for as long as the sunlamp has its original components or replacement components recommended by the manufacturer.
(2) Every sunlamp shall be designed and constructed in such a manner that (a) all marks, labels and signs are permanently affixed to and clearly visible on the external surface when the sunlamp is assembled for use; and (b) all controls, meters, lights or other indicators are readily discernible and clearly labelled to indicate their function.
(3) Every sunlamp shal have, on its external surface, the fol owing information clearly legible and readily accessible to view by the user immediately before using the sunlamp: (a) the name and address of the manufacturer;(b) the model designation, the serial number and the month and year (c) the recommended exposure positions and the directions for determining the recommended exposure positions; (d) a warning that the use of exposure positions other than the recommended exposure positions may result in overexposure; (e) the maximum exposure time in minutes;(f) the minimum interval between consecutive exposures;(g) the type and model designation of each ultraviolet lamp intended to be used in the sunlamp unless the sunlamp is manufactured, maintained and serviced by the same manufacturer; and (h) an electro-optical radiation warning sign designed in accordance with section 5 of this Schedule.
(4) Every sunlamp shall be designed and constructed to include the following safety features: (a) a control by which the sunlamp may be easily turned off by the person being exposed at any time without disconnecting theelectrical plug or removing the ultraviolet lamp or lamps; and (b) a timer that satisfies the standards of functioning specified in subsection 4(2).
(5) Every ultraviolet lamp intended for use in a sunlamp shall be designed and constructed in such a manner that it cannot be inserted andoperated in a single-contact medium screw lampholder or a double-contact medium screw lampholder.
(6) Every sunlamp shall be designed and constructed in such a manner that failure or malfunction of any component of the sunlamp does not result in non-compliance of the sunlamp with the standards offunctioning specified in section 4.
(7) Every sunlamp shall be accompanied by sufficient sets of protective eyewear that meet the standards of functioning specified in subsection 4(3) to at least equal the maximum number of persons who may, at the same time, be exposed to ultraviolet radiation from the sunlamp, as recommended by the manufacturer of the sunlamp.
(8) Every sunlamp shall have the electro-optical radiation warning sign described in section 5 permanently affixed to and clearly visible on the external surface of the sunlamp.
(9) Every ultraviolet lamp intended for use in a sunlamp or any packaging uniquely associated with an ultraviolet lamp shall have a label that contains (a) the words "DANGER-Ultraviolet radiation. Follow instructions.
Use only in fixture equipped with a timer. DANGER-Rayonnements ultraviolets. Veuillez suivre les instructions. À n'utiliser qu'avec un dispositif pourvu d'une minuterie"; and (b) the model designation.
(10) Subsection (9) does not apply to an ultraviolet lamp that is designed and manufactured for use in a sunlamp that is maintained andserviced by the same manufacturer.
3. Every sunlamp shall be equipped with (a) instructions for the operation and safe use of the sunlamp that includes statements respecting (i) the exposure positions and directions for determining them,(ii) the maximum exposure time,(iii) the minimum interval between consecutive exposures,(iv) the maximum number of persons who may, at the same time, be exposed to ultraviolet radiation from the sunlamp, asrecommended by the manufacturer of the sunlamp, and (v) an electro-optical radiation warning sign designed in accordance with section 5 of this Part; (b) instructions for obtaining repairs and recommended replacement components and accessories that are compatible with the sunlamp, including protective eyewear, ultraviolet lamps, timers, reflectors and filters, in order that, if installed or used as directed the sunlamp continues to comply with the provisions of this Part; and (c) a warning that the instructions accompanying the sunlamp should always be followed to avoid or minimize potential injury.
STANDARDS OF FUNCTIONING
4. (1) Every ultraviolet lamp intended for use in a sunlamp shall function in such a manner that, at any distance in any direction from the sunlamp, the irradiance within the wavelength range from 200 nm to not more than 260 nm does not exceed 0.003 of the irradiance within the wavelength range from 260 nm to not more than 320 nm.
(2) The timer required by paragraph 2(4)(b) of this Part shall be so (a) be adjustable to preset times and have a maximum timer interval not exceeding the maximum exposure time; (b) have a margin of error not greater than 10 per cent of the maximum timer interval of the sunlamp;- (c) not automatically reset and therefore cause radiation emission to resume when the sunlamp emissions have been terminated by the timer; and (d) not preclude a user of a sunlamp from resetting the timer before the end of the preset timer interval.
(3) The protective eyewear required by subsection 2(7) of this Part shall have a spectral transmittance not exceeding a value of 0.001 over the wavelength range from 200 nm to not more than 320 nm and a value of 0.01 over the wavelength range from 320 nm to not more than 400 nm and shal be sufficient over wavelengths greater than 400 nm to enable the user to see clearly enough to read the labels and reset the timer. WARNING SIGN SPECIFICATIONS
5. The electro-optical radiation warning sign required by paragraph 2(3)(h) and subparagraph 3(a)(v) of this Part is a sign that (a) is shown in two contrasting colours;(b) is clearly visible and identifiable from the exposure position;(c) bears the words "WARNING-ULTRAVIOLET RADIATION- FOLLOW INSTRUCTIONS-FAILURE TO USE PROTECTIVE EYEWEAR MAY RESULT IN SEVERE BURNS OR OTHER EYE INJURY-IF DISCOMFORT DEVELOPS, DISCONTINUE USE AND CONSULT A PHYSICIAN.
-ATTENTION-RAYONNEMENTS ULTRAVIOLETS-VEUILLEZ SUIVRE LES INSTRUCTIONS-SANS DISPOSITIF DE PROTECTION DES YEUX, CE PRODUIT PEUT CAUSER DES BRÛLURES OU LÉSIONS OCULAIRES GRAVES-SI VOUS SENTEZ UN MALAISE, EN DISCONTINUER L'USAGE ET CONSULTER UN MEDECIN"; (d) incorporates a statement, in English and French, to indicate that (i) as with natural sunlight, overexposure can cause eye injury (ii) repeated exposure may cause premature aging of the skin


(iii) medications or cosmetics applied to the skin may increase sensitivity to ultraviolet light, (iv) a person who does not tan in the sun most likely will not tan from the use of this device, (v) a person having a history of skin problems or having a skin that is specially sensitive to sunlight should consult a physician before use, and (vi) overexposure should be avoided; (e) has no outer dimensions less than two centimetres; and(f) is designed in accordance with the following diagram: TANNING OPERATOR
KNOWLEDGE QUESTIONNAIRE
The owner or manager of the facility should ensure that each operator completes
the questionnaire on the following two pages to evaluate their knowledge about UV radiation. (Please photocopy)It is recommended that the owner or manager retain copies of the completed questionnaire for review by Environmental Health Officers. It is also recommended that operators not be permitted to work with clients until they can answer all of the questions in the questionnaire correctly.
TANNING OPERATOR KNOWLEDGE QUESTIONNAIRE
Operator's name: Date completed: 1. Name the three wavelength regions that ultraviolet radiation may be divided into.
2. Which of these three wavelength regions of ultraviolet radiation are now most prevalent in commercial tanning equipment emissions? 3. What is the correct term for skin reddening or sunburn? 4. Briefly, what is the skin's reaction that causes erythema? 5. Of UVA and UVB, which penetrates most deeply into the layers of the skin? 6. Of UVA and UVB, which is responsible for long term or long lasting tans? 7. List one painful eye injury resulting from ultraviolet radiation exposure to the unprotected eye.
8. List two common categories of drugs or medications which may increase sensitivity to ultraviolet exposure.
9. The sun produces about 2.5 mW/ cm2 of UVA in summer around noon in BC. How much UVA does a typical tanning bed produce?
True or False
10. Most conventional commercial tanning devices emit some UVB radiation.
11. The risk of developing skin cancer will increase as total ultraviolet exposure is increased.
12. Cataracts can be a long term chronic effect of ultraviolet radiation exposure of unprotected eyes.
13. After using a commercial tanning facility, if a customer complains of red irritated and watering eyes, or an itching skin rash causing discomfort, the customer should be told that the cause may be related to ultraviolet 14. The customer doesn't have to wear protective eye-wear while using a tanning device at a commercial tanning facility if he or she doesn't want to.
15. A fair-skinned person with red or blond hair and freckles should be allowed to use a tanning unit for as long as a dark haired, dark skinned, brown eyed individual.
16. Ultraviolet radiation is responsible for premature skin aging effects such as wrinkling and skin hardening.
17. UVA radiation exposure causes the skin to produce more melanin- producing cells, thus creating a longer lasting tan.
18. It is the customer's responsibility to ask the owner or operator for instructions on the proper use of tanning equipment.
Results: Correct Answers Incorrect AnswersComments: Owner's or manager's signature Date TANNING OPERATOR
KNOWLEDGE ANSWER KEY

Core Questions
1. UVA, UVB and UVC are the three ultraviolet radiation wavelength regions.
2. UVA and UVB: Commercial tanning equipment all emit primarily UVA
radiation, with either a small amount of UVB or else UVA with a considerable amount of UVB.
3. Erythema is the medical term for inflammatory redness of the skin. It can be produced by exposure to UV Radiation. When this happens, Erythema is commonly called "sunburn".
4. Erythema occurs when the small blood vessels in the skin dilate and increase the flow of blood to the skin's surface.
5. UVA is the wavelength which penetrates most deeply into the skin.
6. UVB causes long lasting tans by increasing the production of the melanin pigment in the skin.
7. Photokeratitis or photoconjunctivitis (also known as welder's flash or snow blindness) are two painful eye injuries that can result from exposure of unprotected eyes to UVR.
8. Antibiotics, blood pressure and heart medications, and birth control pills are some of the common classes of drugs which can increase the skin's sensitivity to UVR. (See Appendix D for full list).
9. Tanning beds typically produce between 7 to 20 m/W cm2 of UVA, which is as much as three to eight times the UVA the sun produces at noon in BC in the summer. Some newer, non-fluorescent technology tanning beds can emit more than 60 m/W cm2 — which is 25 times more than the UVA produced by the sun at midday. True or False
10. True
All tanning lamps emit some UVB radiation, the form of ultraviolet radiation with the greatest capability of causing sunburns. All operators must be aware of the maximum exposure times for their clients,
depending on their skin type and the intensity of the lamps used in their tanning equipment.
The risk of developing skin cancer increases as total exposure to ultraviolet rays increases.
Ultraviolet radiation exposure to unprotected eyes can cause cataracts, photokeratitis and other painful eye injuries.
Operators should tell customers that exposure to ultraviolet radiation at a tanning salon can cause watering eyes, an itching skin rash or sunburn.
14. False
All customers must wear protective eye-wear while using tanning
15. False
Fair-skinned people with red or blond hair and freckles should not use a tanning device for as long as people with dark hair, dark skin and brown eyes. Fair-skinned people are most at risk of burning and skin cancer. Children, the elderly and those who always burn or don't tan well should not use tanning units at all. Ultraviolet radiation causes premature skin aging effects such as wrinkling and hardening.
17. False
Although UVA radiation penetrates more deeply into the skin, it is mainly the UVB exposure that causes the skin to produce more melanin, creating a long lasting tan. UVB radiation is 1,000 times more likely to cause sunburn than the same intensity of UVA radiation.
18. False
Operators must provide customers with clear instructions on how to use tanning equipment, including maximum exposure times (based on their skin type) and the need to wear protective eye wear while tanning.

Source: http://www.health.gov.bc.ca/library/publications/year/2004/PHI080.pdf

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FASEL-C.JO.FN.MLL.CF.JDE.2.CF2.JUSTINFORMAT.FINAL.DOC (DO NOT DELETE)1/9/2008 5:10:40 PM PATENT TERM LIMITS, ANTI-TRUST LAW, AND THE HATCH-WAXMAN ACT: WHY DEFENSE OF A LEGALLY GRANTED PATENT MONOPOLY DOES NOT VIOLATE ANTI- Christopher Fasel∗ I. INTRODUCTION In the interest of increasing public availability of prescription medication,

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