Medical Surveillance Dr. Christina Brown, Medical Consultant Housekeeping Emergency Exits Washrooms Break Cell Phones Evaluations The Workplace Health, Safety and Compensation Commission Getting to Know Us! Our Vision “The vision of the Commission is of safe and healthy workplaces within a viable and sustainable system which reduces the impact of workplace injuries by providing the highest level of service to workers and employers” Getting to Know Us! Our Mission “By December 31, 2016, the Commission will have improved client service to support the prevention and management of workplace injuries, illnesses and known occupational disease.” Workshop Objectives Health surveillance – What and Why What is silica? Why worry about it? Noise Lead Purpose of health surveillance Designed to detect illness at an early phase; removal from exposure and/or treatment would be effective Medical examinations maybe be pre-placement, periodic and post employment Analysis of health information can identify problems that may be occurring in the workplace that require targeted prevention Health Surveillance 43. (1) In accordance with subsection 42 (2), an employer shall assess the need for and extent of health surveillance of his or her workers. (2) Based on the results of the assessment under subsection (1), an employer shall establish and maintain a program for the surveillance of the health of workers, which shall be in accordance with the following guidelines (a) the International Code of Ethics for Occupational Health Professionals; and (b) the International Labour Organization’s Technical and Ethical Guidelines for Health Surveillance. . Health Surveillance 3) In addition, to subsections (1) and (2), the minister may (a) designate a workplace or class of workplaces as requiring an occupational health surveillance program; or (b) make requirements for modifications to an occupational health surveillance program. 4) An employer shall ensure that an occupational health surveillance program in a workplace is communicated to employees of that workplace. Health Surveillance 5) The minister may require a worker to undergo a medical examination as part of a health surveillance program where it may be necessary for the prevention of occupational disease. 6) A medical examination shall be performed during normal working hours without loss of pay to workers. . Health Surveillance 7) Where the minister has been advised by a physician that a worker has been adversely affected by a hazardous substance in the workplace and requires temporary removal or workplace accommodation from that workplace or hazard, the minister may require the employer to provide without loss of pay to the worker temporary alternative work for the time period required Health Surveillance (8) An employer shall keep records of a health surveillance program for a period of time specified by the minister, and these records shall be made available to: (a) an employee who requests information pertaining to his or her health surveillance records; and (b) where a physician is no longer able to keep medical records pertaining to an occupational exposure, the minister shall be notified in advance to make alternate arrangements that are in accordance with the guidelines of the College of Physicians and Surgeons of Newfoundland and Labrador regarding the retention and storage of medical records Initial Health Assessment Occupational history Selective body system history General medical history and physical exam Appropriate testing Reporting Occupational history Work processes (eg. tasks, tools used) Hazard exposure (chemical, physical, biological) Route of entry (inhalation, skin, ingestion, injection) Frequency, duration and intensity of exposure Use of PPE Use of engineering controls (ventilation) Work organization (hours of work, breaks, OT) Worker history Document! Current and past employers Jobs and tasks performed Medical history including family history Personal activities (eg. smoking habits) and hobbies Do co-workers have similar symptoms or suffer from any illnesses? Selective Body System History Examples Respiratory questionnaire Nickel sensitivity questionnaire Hearing loss questionnaire Appropriate testing Bloodwork for lead and for other causes of symptoms that could be related to lead Chest x-rays CAT scans Audiological assessment Pulmonary Function Test Reporting To the worker To the employer To legislative bodies SILICA THE GOOD THE BAD and THE UGLY Free Silica Silica/ Silica dust Respirable silica Crystalline silica Rock dust Silica Mineral naturally found in the earth’s crust Consists in two main forms: free and combined silica Free silica form is the most hazardous to health and includes: amorphous and crystalline silica (including quartz, cristobalite and tridymite) Where is silica found? Sand Granite Sandstone Slate Shale Clay Chaulk Limestone Who is affected? Hardrock mining Quarrying Fracking Foundries Construction (e.g. road construction, masonry) Asphalt plants Pottery manufacturing Shipbuilding and repair Cement products manufacturing Porcelain manufacturing Jewelry making Increased risk activities Crushing, drilling, chipping rock Blasting, loading, shovelling and dumping rock Abrasive blasting (sandblasting) Polishing stone Cutting, hammering, drilling concrete Excavation and moving rock or earth Demolition Silica Medical Surveillance 47. (1) An employer shall establish and maintain a system for the surveillance of the health of his or her employees arising from silica dust exposure in accordance with the silica health surveillance guidance document prescribed by the minister. Silica Medical Surveillance (2) An employee who requires silica related health surveillance is one who: (a) works in an industry where he or she is potentially affected by a silica process as defined in this subsection 46 (2); (b) is potentially exposed to silica levels in excess of the ACGIH TLV- TWA ; and (c) has been determined, through the company’s silica control program, to require silica health surveillance as prescribed in the general health surveillance section. Silica Medical Surveillance 3) An employer shall not regularly employ a worker in a silica process unless the employer has been assured by a medical practitioner by a written notification that the worker is medically fit for the work being undertaken. Silica Medical Surveillance (4) An employer shall keep at the place of employment to be readily available to an officer a log recording the name of every worker referred for medical examination. Initial Silica Medical Surveillance 5) Shall be carried out under the direction of a physician and shall include (a) an occupational history; (b) a respiratory questionnaire; (c) a pulmonary/lung function test; (d) a chest x-ray (Full size PA view); and (e) a medical history and physical examination emphasizing the respiratory system. Periodic health surveillance Annual Medical exam especially respiratory system Pulmonary function test annually Chest x-rays Less than 20 years of exposure – 3-5 years Greater than 20 years of exposure – 1-3 years X-ray evidence of silicosis – annually Termination of employment Silica Medical Surveillance Where an employee is undergoing silica health surveillance the physician shall ensure, as soon as practicable, that (a) the employee is notified of the results and what they mean (b) the employer is notified of the general outcome of a worker’s health surveillance and is advised on the need for remedial actions; and (c) the minister is notified of a prescribed adverse health effect that had been detected which is consistent with exposure to silica. Silica Medical Surveillance (8) Where an employer has been advised by the physician on the need for remedial action, the employer shall, as soon as practicable, re-evaluate the assessment of the employee’s exposure to silica and implement the control measures required Statistics Proportion of silica-related claims by claim type, 2007-2013 combined 60% 53.3% 50% 40% 33.3% 30% 20% 13.3% 10% 0% Fatality Lost time medical aid Proportion of silica-related claims by nature of injury, Newfoundland and Labrador, 2007-2013 (combined) Respiratory system diseases, unspecified 6.7% Silicosis 6.7% Other respiratory system diseases, n.e.c. 6.7% Emphysema 6.7% Scleroderma 6.7% Pneumoconioses, n.e.c. 13.3% Pulmonary fibrosis, n.e.c. 13.3% Other diseases of upper respiratory tract, unspecified 13.3% Malignant neoplasms and tumors of sites, n.e.c. 33.3% 0% 5% 10% 15% 20% 25% 30% 35% Proportion of silica-related claims by occupation, Newfoundland and Labrador, 2007-2013 combined Proportion of silica-related claims by industry class, Newfoundland and Labrador, 2007-2013 (combined) Health Effects of Silica Health effects Silicosis Lung cancer Chronic bronchitis Certain connective tissue disorders such as scleroderma Auto-immune diseases such as rheumatoid arthritis Kidney disease Silicosis A progressive disease caused by prolonged or repeated exposure to silica resulting in scarring of the lungs. Belongs to a group of lung disorders called Pneumoconiosis. Irreversible and no cure - often lead to lung impairment, disability, and premature death. Three different forms: Acute Accelerated Chronic Silicosis symptoms Early symptoms include coughing, shortness of breath and weakness Not usually detected until it has advanced May develop infections Can continue to develop after exposure Silicosis diagnosis Medical history Occupational history Physical exam Chest x-ray High Resolution CT scan Pulmonary lung function testing TB skin or blood test Silicosis treatment Avoid further exposure and respiratory irritants Linked to other diseases including lung cancer & TB Antibiotics for infections Cough medicine, bronchodilators, oxygen Quit smoking COPD COPD stands for Chronic Obstructive Pulmonary Disease. It is a long-term lung disease often caused by smoking. Chronic bronchitis and emphysema. COPD slowly damages your airways making them swollen and partly blocked by mucus. It also damages in the tiny air sacs at the tips of your airways. COPD COPD does not have a clinical subcategory that is clearly identified as occupational, largely because the condition develops slowly and, given that the airway obstruction is chronic does not reverse when exposure is discontinued. There are impressive studies of occupational exposures and COPD in miners, Tunnel workers, concrete manufacturing workers, and non-mining industrial workers which demonstrate that moderate smoking and occupational exposures had approximately comparable effects on COPD risk. COPD Diagnosis Health history What is your smoking history? Do you suffer from shortness of breath? What makes your shortness of breath worse? Do you cough? Do you bring up sputum (phlegm, mucus), and if so, what does it look like? What is your family history of lung disease? Spirometry and other lung function testing Chest x-ray Blood test for oxygen and carbon monoxide Clinical Case 1 52 year mechanic worked in mine in Alberta. Initial duties in the mine and later in garage. Worked 27 years. Presents to doctor with hands being intolerant to cold, dry eyes and mouth. Diagnosed with Raynaud’s phenomenon and Sjorgen’s Syndrome. Over next year had worsening heartburn and skin becoming stiff and tight. Diagnosed with Scleroderma 2 years later increasing shortness of breath especially with exercise. Lung biopsy showed pulmonary fibrosis and pieces of silica in his lung. Clinical Case 2 55 year old male who worked in mine 32 years. Regular screening with Chest x-rays. Changes suggestive of silicosis on recent film. Upon discussion he has noted increased cough and shortness of breath on exertion – thought it was because he smoked ½ pack of cigarettes daily. High resolution CT scan – interstitial lung disease suggestive of silicosis. Decreased lung function on pulmonary function tests. Lung Biopsy confirms silicosis. Evaluate the risk… Likelihood of exposure (probability), frequency, severity How do we measure? Sampling for silica Respirable silica is not visible Visible dust Bulk sampling Instantaneous sampling Personal sampling Area sampling Air monitoring Air monitoring Sampling plan Set goals! Shifts How many samples Areas/jobs Make a decision Compare results to guideline (ACGIH) TLV-TWA = 0.025mg/m3 Make a decision: Acceptable exposure Unacceptable exposure More information necessary Implement Control Measures Controls for silica Elimination Substitution Engineering controls Administrative controls PPE Health surveillance Elimination/Substitution Sandblasting/Abrasive blasting substitution of silica sand Engineering controls Mechanical ventilation Local exhaust ventilation Wet suppression Isolation of workers Dust suppression skirting Local exhaust ventilation Wet suppression Isolation of workers Dust suppression skirts Administrative controls Air monitoring Safe work practices and procedures Good hygiene practices No dry sweeping Preventative maintenance programs Personal protective equipment Selection based on air concentration Last line of defense Sometimes used as temporary measure Respiratory protection program Respiratory protection program Selection Use, care and maintenance Fit-testing Training Clean shaven Health surveillance Hearing Loss Why do we want to prevent noise related injuries/illnesses? Affects individual workers and their families greatly 50% of occupational disease claims to Commission are due to deafness, hearing loss and impairment The cost of hearing related claims in NL is approximately $2.4 million/year 9/10 hearing loss claims in NL are male Cost of hearing related claims Number of hearing related claims Types of Occupational Hearing Loss Traumatic the result of a single exposure to a sudden burst of sound such as an explosive blast Or may result from head injury that impacts the hearing sensors Less common Types of occupational Hearing Loss Noise-induced Hearing Loss Develops slowly over long period of exposure to continuous or intermittent hazardous noise levels Noise levels are hazardous where there is evidence of: • Continuous noise exposure for 2 years or more at 8 hours per day at 85 dB, or threshold limit value with a 3 dB exchange rate for levels other than 85 dB • Intermittent noise exposure for 5 year. It 8 hours per day at 85 dB or a threshold limit value with a 3 dB exchange rate for levels other than 85 dB Types of Occupational Hearing Loss Chemical and biological exposure rare Tinnitus A subjective experience to find is the perception of sound [such as ringing or hissing] in the absence of an acoustic stimulus. WHSCC claims considered where the claims been accepted for compensable noise induced hearing loss, a tinnitus has been confirmed by an audiologist, and a clear and adequate history of 2 or more years of persistent and severe tinnitus has been shown Hearing Conservation Program Requires a noise survey in the workplace to determine high noise levels Baseline testing for new employees and annual testing thereafter Mandatory training and education for all workers in the health hazards of noise and the fitting, maintenance, care and use of hearing protection Identify Noise Hazards Conduct a hazard assessment Identify the noise sources Informal methods: Workplace inspections Workers’ comments Accident/incident investigations New purchase assessment Identify Noise Hazards Comprehensive noise assessment Measure the noise levels Noise is measured in decibels (dB) Instantaneous Full shift noise dosimetry Noise Controls… Buy Quiet! Noise Controls Elimination/substitution Examples: Move air compressor out doors Substitute the noise producing machine for a machine that produces less noise Purchase quieter equipment and tools – Cost issue Belt drives produce less noise than gears Belt conveyors produce less noise than roller conveyors Engineering Noise Controls Examples: Enclosures (cabs, furnace enclosure) Reduce high velocity Silencers – Mufflers Sound absorption panels Administrative Controls Develop a “buy quiet” policy Scheduling o Limit worker’s time in noise o Conduct noisy activities when workers are not present Signage - Areas where noise regularly exceeds 85dB should post a visible warning sign Noise Controls Personal Protective Equipment Examples: Ear plugs (foam, fitted, custom moulded) Ear muffs Canal caps Hearing Protection Used as a last resort May be used a temporary measure Individual differences – proper fit, hearing ability, communication needs, personal preferences and other constraints posed by daily work activities How to know if hearing protection is appropriate? Are your controls for noise effective? Evaluation Follow up noise measurements Workplace inspections Investigations Worker comments and feedback Annual audiometry results Audiometry Audiometric testing is required on a regular basis for those workers overexposed to noise This ensures the controls in place are effective Detects any early sign of hearing loss Audiometric test Medical history and examination May be performed by in-house personnel May be performed in-house or at an external clinic Performed in a quiet area Worker must not have had noise exposure before audiogram Legislation Section 68(c) OHS Regulations: hearing tests to be conducted on an annual basis or where recommended by an audiologist or occupational physician Hearing tests conducted within 3 months of hire Section 43(5) OHS Regulations: A medical exam shall be performed during normal working hours without loss of pay to workers Treatment Hearing aid Continued use of personal protective equipment or other type of noise reduction in the workplace Hearing loss can worsen if the source of noise is not controlled Lead Exposure 1) An employer shall develop an exposure control plan for lead where (a) a worker at a work site may be exposed to airborne lead in excess of its occupational exposure limit for more than 30 days in a year; or (b) a worker’s exposure to lead at a work site could result in an elevated body burden of lead through a route of entry. Lead Exposure 2) The exposure control plan shall include (a) a statement of purpose and the responsibilities of individuals; (b) methods of hazard identification, assessment and control; (c) worker education and training; (d) safe work practices as required; (e) descriptions of personal and work site hygiene practices and decontamination practices; (f) processes of health monitoring, including biological testing; (g) methods of documentation and record keeping; and (h) procedures for maintenance of the plan, including annual reviews and updating. Lead Exposure 3) A worker shall follow the exposure control plan and practice the personal and work site hygiene practice established by the employer to minimize lead exposure at the work site. 4) Where there is potential for a worker to be exposed to lead in harmful amounts at a work site, an employer shall ensure that air monitoring and surface testing for lead is regularly conducted to confirm that the controls in place are effective. Lead Exposure 5) Where a worker at a work site could reasonably be expected to have an elevated body burden of lead, an employer shall establish a system for the surveillance of the health of their employees arising from lead exposure in accordance with the lead health surveillance guidance document as prescribed by the minister. 6) An employer shall ensure that a worker who has been exposed to lead is informed of the health surveillance requirements. Summary Health surveillance Can describe the health status of the population and identify any trend development Can lead to further research on occupational diseases Assesses the effectiveness of existing controls Should be linked to the exposure/sampling program in the workplace Questions? Please take the time to complete the evaluation form provided and pass it in at the end of the day! Your feedback is important to us! Thank You!!!