Common Exposures & Health Effects
Includes E-Cigarettes, Vaping & Hip Implants

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Cobalt Exposures

Includes Hip Replacements,
E-Cigarettes and Vaping

Measuring Cobalt Exposure

Cobalt is abbreviated as Co.There are several ways of establishing whether you have had an exposure to Cobalt. First, is an evidence-based hair analysis of heavy metals that is able to reveal low-dose long-term exposure above the norm (population average).

Second is a simple history - questioning you about your lifestyle, occupation and food intake.

And lastly are urine and blood tests. These are used medically and are usually only useful if you have an occupational exposure or have been poisoned in last few days or have had a accidental acute (high-dose) exposure in last few days.

However blood (and indeed hair and urine) levels of a toxic metal can change due to internal factors like a co-occurring medical condition, menopause or changes in blood protein binding capacity (as in clinically important hypoalbuminemia and/or severe ischemia modified albumin (IMA) elevations).

Note that all these methods are designed to work together, so as to get an optimal overall picture of potential exposure routes.

REF: A Review of the Health Hazards Posed by Cobalt, 2013, Dennis J Paustenbach et al
Supplements containing Cobalt

While Cobalt has a biologically necessary role as metal constituent of vitamin B12, over supplementation of Co or B12 supplements have been shown to induce various adverse health effects. Adequacy of Vitamin B12 (also called cyanocobalamin, methylcobalamin or cobalamin) levels in the body, can be easily assessed via a Medicare rebate-able blood test.

Note that B12 is an essential nutrient for humans and the human body can't make B12. It is mostly obtained through animal products like meat, dairy and offal.

Image of Vitamin B12 with arrow pointing to Co in the centre
Click Image to Enlarge

cobalt symptoms
From Wkipedia

The recommended daily intake (RDI) of vitamin B12 for adults is 2.4 μg/d, which contains 0.1 μg of cobalt. Note some energy drinks can contain high amounts of vitamin B12 and as a result may elevate body Cobalt levels.

Additionally, some post-menopausal woman may take or be prescribed doses of Cobalt Chloride (0.5 to 1.12 mg CoCl2/day), if their HRT therapy has not worked satisfactorily. The Cobalt Chloride is used to reduce estrogen excretion.

Finally, Cobalt can be misused as a blood doping agent by athletes to enhance aerobic performance (Cobalt increases red cell production).

Metal-on-metal Hip Implants

Internal exposure through metal-on-metal hip implants are responsible for high body levels of Co concentrations and have been shown to induce various adverse health effects.

Toxic reactions, even at lower than normal doses have been described in cases of malfunctioning metal-on-metal hip implants, which may be explained by certain underlying conditions that increase the individual susceptibility for Co-induced systemic toxicity. This may be associated with a decrease in Co bound to serum proteins and an increase in free ionic Cobalt (Co2+) and it is this form that is believed to be the primary toxic form.

Real world Example

A 59-year-old female with a history of multiple left hip arthroplasties presented to a clinic with bilateral visual loss. The year prior, she had failure of the hip implant necessitating revision surgery with placement of a chromium-cobalt head. A few months after surgery, she began experiencing blurred and “white, spotty” vision in both eyes in addition to hypothyroidism, cardiomyopathy and neuropathy. The possibility of the patient's symptoms being due to cobalt toxicity from her hip prosthesis was proposed and she was found to have a serum cobalt level >1000 μg/L (normal 0–0.9 ng/mL). Case reported in 2020.

REF: Cobalt toxic optic neuropathy and retinopathy: Case report and review of the literature, 2020, by Maria D. Garcia, Minjun Hur, John J.Chen and M.Tariq Bhattia
REF: Cobalt toxicity in humans : a review of the potential sources and systemic health effects, 2017, Laura Leyssens et al.

Image of Cobalt released during failed metal-on-metal Hip implants
Click Image to Enlarge

cobalt symptoms
Image from: Cobalt toxic optic neuropathy and retinopathy: Case report and review of the literature, 2020

Therefore, it appears that the greatest risk of systemic cobalt toxicity seems to result from accelerated wear of a cobalt-containing revision of a failed ceramic prosthesis, rather than from primary failure of a metal-on-metal prosthesis.

REF: Systemic Toxicity Related to Metal Hip Prostheses, 2014, S M Bradberry et al.

In another case study of a 66yr woman and through a chain of unfortunate circumstances, a mechanical orthopedic problem turned into a devastating visual loss. "Given the high prevalence of hip implants, every neuro-ophthalmologist should keep cobalt neurotoxicity in mind and ask patients with obscure visual loss about hip replacements. If cobalt intoxication is suspected, measurements of cobalt concentration should be prompted."

REF: Wear and Tear Vision, 2015, Weber, Konrad P. MD, et al.

REF: A Systematic Review of Systemic Cobaltism After Wear or Corrosion of Chrome-Cobalt Hip Implants, 2019, Bradford D. Gessner, MD et al

Occupational Exposures
Hard metal industry

Almost 15% of the worldwide production of Co is being used for hard metal production. The hard metal industry is believed to represent the main source of occupational Co exposure. Along with tungsten (W), Cobalt (Co) is a major constituent of hard metal alloys.

Exposure is both through inhalation of dust and contact through the skin. Inhalation and subsequent uptake of Co is determined by the airborne workplace concentration, the duration of the working shift, the breathing volume per minute, and the percent retention of dust in the airways. Additionally, smoking has been shown to increase the Co intake via the dust-hand cigarette-mouth path. Highest levels of Co in dust were measured in the powder production areas, sintering workshop and the pressing department within a hard-metal plant.

Construction industry

In the construction industry, cement workers have Co contact primarily through skin contact with the cement. Irritant and allergic contact dermatitis are considered the most frequent occupational health hazards in cement workers. These skin reactions are exacerbated when Chromium is also present (as the salt chromate), as is common in the construction industry.

This concomitant hypersensitivity to cobalt and chromate is the result of an actual simultaneous sensitization due to combined exposure, rather than a cross-reaction between both allergens.

E-waste recycling industry

Some electric and electronic devices have been reported to contain and release cobalt and as a result, workers in the waste recycling industry can be significantly exposed to cobalt either through inhalation, skin contact or oral ingestion. Exposure varies between countries. Europe and North America have more formal e-waste recycling, while Africa, Asia and South America are more informal and use cutting, acid bathing and open burning and workers may not be protected at all.

Diamond industry

Diamond polishers often use high-speed polishing disks of which the surface is composed of microdiamonds, cemented in ultrafine cobalt metal powder. During polishing activities, Co dust is formed and may be inhaled by the diamond polisher.

Pigment production and Paint industry

Cobalt facilitates the drying process in certain paints or inks. Cobalt blue dyes are used for painting porcelain pottery. Hence, skin contact and inhalation of paint fumes/dusts lead to Co exposure

REF: Cobalt toxicity in humans : a review of the potential sources and systemic health effects, 2017, Laura Leyssens et al.
Vaping and E-Cigarettes

Here we show Electronic Nicotine Delivery Systems (ENDS)—including e-cigarettes and vaporizers, vape and hookah pens, as well as tank systems and the exposure to heavy metals with there use.

Image of Vaping device
Click Image to Enlarge

cobalt symptoms
Image From Toxtest

Image of E-cigarette
Click Image to Enlarge

cobalt symptoms
Image From Toxtest

A recent study found that electronic cigarette (e-cigarette) users have higher detectable blood levels (higher than non e-cigarette smokers) of the metals - Selenium, Silver, Vanadium, Beryllium, Europium and Lanthanum with levels of Cerium and Erbium increasing as the duration of the use of e-cigarettes increased.

REF: Body burden of toxic metals and rare earth elements in non-smokers, cigarette smokers and electronic cigarette users, 2018, Mihaela Badea et al.

These devices, also known as electronic nicotine delivery systems (ENDS) use a battery to generate a weakly heated aerosol based on polyalcohols, such as propylene glycol and glycerol with a small amount of water, containing pharmaceutical-grade nicotine. The study found varying degrees of quality and contamination of the nicotine liquid amongst available products - high arsenic in one sample and detectable amounts of Cobalt, Nickel, Chromium and Cadmium in most samples.

REF: Analysis of Nicotine Alkaloids and Impurities in Liquids for e-Cigarettes by LC–MS, GC–MS, and ICP-MS, 2016, Claudio Medana et al.

A case of e-cigarette-induced polycythaemia (increased haemoglobin and red cell numbers) of a 70 yr man who had smoked about 25 cigarettes per day for 50 years until he was 70 years old and switched from conventional smoking to e-cigarettes (electronic nonnicotine delivery system, approximately 40 puffs per day) one year before being investigated. Note that some general and non-specific polycythaemia symptoms include: weakness, fatigue, headache, itching, bruising, joint pain, dizziness, or abdominal pain.

Cobalt and Nickel have been found in e-cigarettes and cobalt chloride and nickel chloride seem to stimulate erythropoietin production (leading to greater numbers of red blood cells) that can lead to polycythaemia. This has lead to the hypothesis that cobalt and nickel could be substituted for ferrous iron in the porphyrin ring (haemoglobin) and because of this, the substituted haemoglobin protein is locked in the deoxy conformation (unable to bind oxygen properly) with speculation that this can cause the polycythemia.

To date, there have been some reports of e-cigarette related respiratory disorders, including eosinophilic pneumonitis, organizing pneumonia, hypersensitive pneumonitis, and acute respiratory distress syndrome. Moreover, some researchers doubt the long- term safety of e-cigarettes.

REF: Case Report - The First Case of E-Cigarette-Induced Polycythaemia, 2019, Marika Okuni-Watanabe et al.
Cobalt in Food

Food as very small amounts of cobalt. The table next shows amounts of cobalt in micrograms(ug) of cobalt per kg of food.

Table showing trace amounts of Cobalt in food.
Click Image to Enlarge

cobalt symptoms
From "Dietary Estimated Intake of Trace Elements: Risk Assessment in an Italian Population, 2019, Tommaso Filippini et al"

Cobalt in Water, Soil and Dust

Average soil concentrations of Cobalt (in the US ) is 7.2mg Co/kg soil with a range of 1-40 mg/kg. Cobalt is rarely detected in drinking water and if so, it’s range is 0.1 - 5 μg/L. Average ocean levels of Cobalt are approximately 0.3 μg/L.

However, near factories, mines, council waste burning facilities, e-waste recycling centres, Cobalt can leach into ground water and contaminate surrounding soil.

In more heavily polluted areas, analysis has indicated that dietary Cobalt intake (vegetables, cereals and fish) and ingestion of contaminated dust are the main human exposure routes in these polluted areas, of which the latter is especially significant in children.

Cobalt release from Cosmetics, Jewellery & Leather

Cosmetic products like eye pencil, eye shadow, lipstick, skin cream and soap can be sources of Cobalt exposure.

Jewellery items can contain and release Cobalt and if so Nickel is often also present. This dual exposure leads to more severe forms of contact dermatitis, with inexpensive dark-coloured jewellery items often realeasing higher levels of cobalt than more expensive and lighter-coloured versions.

Lastly, some leather goods and tattoo ink can contain Cobalt and as such cause skin reactions.

"Although chromium has classically been associated with dermatitis due to leather goods, cobalt has recently been shown to be another cause. A patient with allergic contact dermatitis (ACD) reported symptoms after using a leather sofa and was positive on patch testing to cobalt but not chromium. No other exposure source was found, and the leather from the sofa was found to contain cobalt."

REF: Cobalt toxicity in humans : a review of the potential sources and systemic health effects, 2017, Laura Leyssens et al.
REF: CONTACT ALLERGEN OF THE YEAR - Cobalt, 2016, Joseph F. Fowler, Jr, MD, American Contact Dermatitis Society, University of Louisville, KY; DOI: 10.1097/DER.0000000000000154
In-depth Result Examples

See in-depth client result examples of human hair analysis over the past year. Includes an example of 51yr lady with extremely high Cobalt levels and investigations to establish the cause of the exposure.

Health Effects of Cobalt Exposure

cobalt exposure toxtest

Here we show possible health effects associated with Cobalt toxicity and exposure. This in part is designed to serve as a wake-up call so that you do something about a higher than normal exposure to this potentially harmful substance. Be aware, however, that although a substance is classified as toxic, mutagenic or carcinogenic, does not mean you will experience severe symptoms or get cancer from your level of exposure to the substance.

There are many unique factors at work in an individual’s life that determine toxicology end-points (severity of symptoms or cellular disfunction). These include; accumulative and combined dose of all toxicants, genetics and performance of immune system and detoxification pathways in your body.

Importantly, we have some control over these factors when we consider, adjust and optimise our; stress levels, level of exposure to other toxic chemicals, nutrition, adequate high quality water intake, walking, sleep, meaning, exposure to nature and episodes of stillness and joy/pleasure. (These positively influence stress and immune responses)

The over-arching message here is that if you have exposure to a toxic substance, first, do what you can to minimise exposure, and second, enhance factors mentioned above. Retest in 6 months time if symptoms still persist. In severe cases and under under professional supervision, it can be useful to embark on advanced detoxification or chelation therapy.

Note also, that if you are distressed, anxious, depressed or have severe cognitive/psychological issues, then one-on-one help from a professional is highly recommended and often needed. The body and mind intimately work together and profoundly affect each other.

Hearing loss, tinnitus, and imbalance are being investigated in relation to elevated levels of cobalt. Compromised auditory and vestibular function has been seen in patients with failed metal-on-metal (MoM) hip implants.

From The Ototoxic Potential of Cobalt From Metal-on-Metal Hip Implants: Objective Auditory and Vestibular Outcome, 2020, Leyssens, Laura et al.

Indeed, chronic exposure to several other heavy metals including Cobalt such as Manganese (Mn), Cadmium (Cd), Lead (Pb), and Mercury (Hg), has the potential to affect hearing in humans and experimental animals.

REF : Ototoxicity of Divalent Metals, 2016, Jerome A. Roth & Richard Salvi.

Co-exposure to cobalt (Co), chromium (Cr), and nickel (Ni) has been suggested to cause more severe instances of allergic contact dermatitis/hypersensitivity which ranges from 1 to 20% of the general population in many countries. It was found that these metal ions induced human serum albumin (HSA) aggregation, and this effect was significantly enhanced when a mixture of all three metal ions was present instead of any single type of ion.

REF: Synergistic effects of metal-induced aggregation of human serum albumin, 2019, T Yolanda S. Hedberg et al.

Possible whole body symptoms of Cobalt toxicity
Click Image to Enlarge

cobalt symptoms REF: Cobalt toxic optic neuropathy and retinopathy: Case report and review of the literature, 2020, by Maria D. Garcia, Minjun Hur, John J.Chen and M.Tariq Bhattia

Infographic from Toxno shows some of the issues associated with Cobalt
Click Image to Enlarge

cobalt symptoms From and
Cobalt and its compounds: update on genotoxic and carcinogenic activities, 2018 D. Lison, et al.

Cobalt and its compounds have been classified as carcinogenic since the 1970s, with a general International Agency for Research on Cancer (IARC) assessment of cobalt in 1991 (group 2B). In its Monograph 86, IARC rated cobalt metal with tungsten carbide as being probably carcinogenic to humans (group 2A). French and Swedish occupational cohort studies suggest that cobalt increased the risk of lung cancer—even more so in combination with tungsten carbide—in the hard metal industry.

REF: Dust and Cobalt Levels in the Austrian Tungsten Industry: Workplace and Human Biomonitoring Data, 2016, by Hans-Peter Hutter et al.

Testing of a personal vaping device used with cannabis found cobalt in the vapor it released, as well as other toxic metals – nickel, aluminium, manganese, lead, and chromium.

The metals are coming from the heating coils found in vaping devices, more pronounced in devices used by cannabis users as these devices use higher temperatures than nicotine based e-cigarettes.

In this referenced case study (see below) they found the first known case of a metal-induced toxicity in the lung that has followed from vaping and it has resulted in long-term, probably permanent, scarring of the patient’s lungs.

The thinking is that only a rare subset of people exposed to cobalt will have this reaction, but the problem is that the inflammation caused by hard metal would not be apparent to people using e-cigarettes until the scarring has become irreversible, as it did with this patient.

One of the researches in this study, Professor Jones commented: “People who vape are often looking for a safer alternative to smoking. But as lung physicians, it is our job to be concerned about the substances that are inhaled into the lung, particularly those substances that can bypass our usual defence mechanisms such as these ultra-fine mists."

"We believe it is likely not just that this will happen again, but that it has happened already but not been recognized. One of our major reasons for publishing this case history is to inform our colleagues about the possible risks involved with vaping.”

Ref: “Giant cell interstitial pneumonia secondary to cobalt exposure from e-cigarette use” by Daffolyn Rachael Fels Elliott, Rupal Shah, Catherine Ann Hess, Brett Elicker, Travis S. Henry, Ana Maria Rule, Rui Chen, Mehdi Golozar and Kirk D. Jones, European Respiratory Journal, 2019 54: 1901922. DOI: 10.1183/13993003.01922-2019
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Many carcinogens are found in small amounts in e-cigarette fluid, aerosol and exhaled air. The complete effects of e-cigarette products on cancer may not be known for many years.

Exhaled e-cigarette aerosol contains propylene glycol, ultrafine particles, nicotine, metals (Cobalt, Barium, Cadmium, Nickel + more) and other carcinogens which are added to indoor air (potentially affecting others).

Performance variation within and between brands results in variation in the amount of chemicals e-cigarette users and non-users will be exposed to.

REF: ELECTRONIC CIGARETTE LIQUIDS AND VAPORS: IS IT HARMLESS WATER VAPOR Monique Williams, Dr. Prue Talbot, et al, University of California, Riverside TRDRP Electronic Cigarette Webinar, 2013

Significant changes to gut microbiota composition were observed in response to high doses of chromium and cobalt, and significant dose-dependent changes were observed in response to arsenic, cadmium and nickel, in the research shown below.

cobalt exposure toxtest
Venn diagram showing genera of gut bacteria that are significantly different in abundance before and after metal exposure.

REF: Exposure to toxic metals triggers unique responses from the rat gut microbiota, 2018, Joshua B. Richardson et al, Scientific REPoRts | (2018) 8:6578 | DOI:10.1038/s41598-018-24931-w
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