that are more dependent on worker involvement, with PPE being used only as a last resort. According to this principle, engineering controls should be used when there is a high level of inhalation exposure or when there is no, or very little, toxicological information available. In the absence of appropriate engineering controls PPE should be used, especially respiratory protection, as part of a respiratory protection programme that includes fit-testing (strong recommendation, moderate-quality evidence). WHO suggests preventing dermal exposure by occupational hygiene measures such as surface cleaning, and the use of appropriate gloves (conditional recommendation, low quality evidence). When assessment and measurement by a workplace safety expert is not available, WHO suggests using control banding for nanomaterials to select exposure control measures in the workplace. Owing to a lack of studies, WHO cannot recommend one method of control banding over another (conditional recommendation, very low-quality evidence). For health surveillance WHO could not make a recommendation for targeted MNM-specific health surveillance programmes over existing health surveillance programmes that are already in use owing to the lack of evidence. WHO considers training of workers and worker involvement in health and safety issues to be best practice but could not recommend one form of training of workers over another, or one form of worker involvement over another, owing to the lack of studies available. It is expected that there will be considerable progress in validated measurement methods and risk assessment and WHO expects to update these guidelines in five years' time, in 2022. Other guidance Because nanotechnology is a recent development, the health and safety effects of exposures to nanomaterials, and what levels of exposure may be acceptable, are subjects of ongoing research. Of the possible hazards, inhalation exposure appears to present the most concern. Animal studies indicate that carbon nanotubes and carbon nanofibers can cause pulmonary effects including inflammation, granulomas, and pulmonary fibrosis, which were of similar or greater potency when compared with other known fibrogenic materials such as silica, asbestos, and ultrafine carbon black. Acute inhalation exposure of healthy animals to biodegradable inorganic nanomaterials have not demonstrated significant toxicity effects. Although the extent to which animal data may predict clinically significant lung effects in workers is not known, the toxicity seen in the short-term animal studies indicate a need for protective action for workers exposed to these nanomaterials, although no reports of actual adverse health effects in workers using or producing these