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!!!