Occupational Health
Surveillance in
Health Care
Lyndsay O’Hara
From the University of British Columbia, Vancouver, CANADA
on behalf of the workshop organizing committee
lyndsay.dybka@ubc.ca
Outline
1- Introductory presentation (10 mins)
 Background
 Why surveillance in healthcare workers is important
 The current state of occupational health surveillance
 The objectives of the workshop and this document
 Synthesis of existing classifications
 Occupational classifications
 Occupational health indicators
2- General discussion (15 mins)
3- Detailed discussion of definition of indicators (20 mins)
4- Wrap Up and Next Steps- See you in Mexico! (10 mins)
Background
 Proceedings of a Workshop within the 8th International Conference on
Occupational Health for Health Care Workers in Casablanca, Morocco in
October 2010
 19 participants from 8 countries- from various organizations with a
common interest in this area.
 Organized by ICOH-HCW committee, the International HCW Safety
Center at the University of Virginia, NIOSH, University of British
Columbia, and WHO
 Formation of small working groups
Why is Surveillance for Healthcare
Workers Important?
 The health care workforce is central to advancing
health in all health systems.
 Occupational surveillance is necessary to help ensure
safe working environments.
The Current State of Occupational
Health Surveillance
 Classifications of occupational diseases have been
developed mainly for two purposes; notification for
labour safety and health surveillance and
compensation.
 Variations among countries exist in collection and
notification procedures, as well as in the coverage and
sources of statistics.
 The result is a diversity of situations in countries.
 The absence of unified diagnostic criteria, coding
systems and classifications reduce the compatibility
and comparability of national statistics on occupational
diseases both within and between countries.
The Objectives of the Workshop
(and this document)
 While there seems to be a growing consensus that
having a set of common indicators for occupational
health surveillance is a desirable goal, a path for
achieving this has not been established.
 The purpose of these Proceedings is to maintain
momentum on this initiative, with the hope that at the
ICOH meeting in Mexico in 2012, and subsequently at
the ICOH-HCW-led conference in Brazil in 2013, the
progress made in Morocco, as captured in these
Proceedings, can serve as a starting point for further
refinement and work towards our common vision.
Synthesis of Some Existing
Classifications
 ILO Code of practice on the recording and notification of
occupational accidents and diseases (1994)
 Resolution concerning statistics of occupational injuries (1998)
 International statistical classification of diseases and related health
problems (ICD-10) in occupational health (1999)
 WHO Family of international classifications: definition, scope and
purpose (2007)
 Health Level 7 (HL 7)
 European Union Health and Safety
 Others????
Workshop Reflections
 This section provides documents the main themes of
discussions that arose during the workshop
 Workshop participants shared experiences related to
occupational health from Japan, USA, Tunisia, South
Africa, Canada, Morocco, Switzerland and Germany
Occupational Classification
Specific to the Health Care Setting
Occupational Health Indicators
 Workshop participants decided to classify indicators as
leading and trailing.
 "Leading" occupational health and safety measures are
indicators of where the organization is headed; they are
measures of future performance.
 "Trailing" indicators, are indicators of past performance and
do not accurately indicate present and future safety
conditions.
 Leading safety measures are focused on improving safety
performance. Trailing indicators indicate progress toward
compliance with safety rules.
 Both are essential for workplace safety. A safety program
striving for excellent performance will use a mix of leading
and trailing indicators.
Occupational Health Indicators
LEADING:
1. OHS Policy – written and accessible on each unit (yes/no)
2. Trained person in charge of OHS (yes/no)
3. Health and Safety Committee – meeting at least quarterly, with
members trained, keeping minutes and addressing action items,
(yes/no), plus % of H&S committee recommendations implemented.
4. Training in safe practices - % of patient care staff (or all Staff) who
received training on safe practices during previous 12 months/ % of all
staff trained.
5. Workplace assessment conducted (# of workplace assessments
done/% with recommendations written (including need for equipment,
supplies, repairs, training, policies or procedures, improved
environment)
Occupational Health Indicators
LEADING (continued):
6. Return-to-Work Safely program - presence of a
program (yes/no)
7. Immunizations -- % of patient care staff immunized for
Hep B, MMR, and others; overall staff % of staff
immunized for Hep B, MMR, and others.
8. Worker Assessment (biological monitoring if needed)
annually or biannually (? Lifestyle indicators)
9. Availability of Personal Protective Equipment
Occupational Health Indicators
TRAILING
(Number, Rate, Duration plus Time Loss, and Cost -if possible for
the following)
10. Overall injuries (per full-time equivalent staff)
11. Overall time-loss injuries (per full-time equivalent staff)
12. Musculoskeletal injuries (per full-time equivalent staff)
13. Needlestick injuries (per full-time equivalent staff)
14. Violent incidents against staff (per full-time equivalent staff)
15. Occupational disease (e.g. cases of asthma or other
respiratory irritant or allergic reaction, systemic toxic reaction. as
well as well as cases of dermatitis – irritant or allergic.)
Occupational Health Indicators
TRAILING (continued):
16. Workers who had to be quarantined
17. New cases of TB among health workers
18. % of staff accepting HIV Counselling and Testing (HCT)
19. % of staff screened for TB
20. Deaths of health care workers (occupational AND nonoccupational?) and
21. Permanent disability/loss to workforce of health care
workers (noting from both occupational AND non-occupational)
22. Worker Retention
Discussion:
We welcome your valuable
input and comments!
1- Feedback overall
2- Anything missed? (such as existing surveillance
documents)
3- Feedback on occupational classifications
4- Other?
5- Detailed definitions of indicators (to follow)
1. OHS Policy – written and
accessible on each unit (yes/no)
 There should be a written policy at the national level that applies to
health workforce and evidence of the policy in the workplace.
 The policy/procedure at the workplace should include a list of all
the hazards specific to work categories/tasks.
 And measure to be taken to prevent and control the risk according
to the specific risk of worker category.
 If there is a national policy, “Does it do certain things?”
 Minimums must be customized according to the workplace.
 Policies must be applicable at the national level, but may also go
beyond this level.
 Policies should be multi-level and the responsibility varies from
country to country (i.e. at the provincial level in Canada).
2. Trained person in charge of OHS
(yes/no)
 There should be a person assigned responsibility for occupational health programme
with formal (structured) training in the field of occupational health
 Simply having someone assigned to this role is insufficient. Roles and
responsibilities must be monitored and evaluated routinely.
 Training in the field is also essential. This can be formal training or on the job
training.
 The employer is responsible for occupational health programs.
 It should be noted that occupational health programs and services are two different
things.
 The occupational health service of the healthcare facility should provide a service to
assess fitness to work for any HCW with illness or injury causing impairment in order
to provide safe and appropriate work.
 An Occupational Health & Safety (OHS) professional works to promote and maintain
the highest level of physical, mental and social well-being of workers in all
occupations.
 Training re: primary, secondary and tertiary prevention
3. Health and Safety Committee – meeting at least
quarterly, with members trained, keeping minutes and
addressing action items, (yes/no), plus % of H&S
committee recommendations implemented.
 A bipartite Health and safety committee made up of selected frontline
workers (non supervisory) staff, management and ex-officio trained OH
personnel (as in #1) that meets at least quarterly with written evidence
that the committee takes action on occupational health issues in the
workplace.
 Health and Safety Committees also work to promote and maintain the
highest level of physical, mental and social well-being of workers in all
occupations.
 This involves conducting activities that reinforce the principle that people
are the primary asset of any organization.
 Also, the example set by the Health and Safety Committee, both in terms
of safety and health practices and their collaborative role in resolving
issues that affect all staff, will establish high standards for everyone.
 Regular meetings of the Health and Safety Committee are a fundamental
requirement.
4. Training in safe practices - % of patient care staff (or
all health care workers) who received training on safe
practices during previous 12 months/ % of all health care
workers trained.
 All staff should receive annual training of staff according to
the specific hazards in their work environment.
 There should also be regular training (at least annually)
about the hazards, their health effects and methods to
prevent and control exposure to the hazards that the
workers face in their work setting.
 The word “training” should include some live training. Time
minimums should be established in accordance with local
standards.
 Mechanisms to ensure effectiveness of training should also
be established.
5. Workplace assessment conducted
(# of workplace assessments done/% with
recommendations written (including need for equipment,
supplies, repairs, training, policies or procedures,
improved environment)
 This indicator should be linked with #3 (H&S committee)
 Joint occupational health and safety committees can help
plan, conduct, report and monitor workplace assessments.
 Workplace assessments help prevent injuries and illnesses
through critical examination of the workplace. Workplace
assessments also identify and record hazards for corrective
action.
 Regular workplace assessments (at least bi-annually) are an
important part of the overall occupational health and safety
program.
6. Return-to-Work Safely program – presence of a
program in the workplace endorsed by all workplace
parties aimed at secondary prevention.

An appropriately trained occupational health or rehabilitation health professional should be
designated to lead this program.

Policies and procedures should be written, ensuring respect for privacy and guarding
confidentiality.

The program must comply with all contract, collective bargaining, and workers compensation
requirements – hence involvement of all stakeholders is needed for success, (e.g. union
representation, if applicable, should be provided on a program steering committee).

The focus of the program should be both on the individual needs of the ill or injured workers as
well as promoting an overall healthy and safe work environment for all – preferably linking
primary and secondary prevention.

Injured workers who incur time loss from work should be contacted as soon as possible after
the injury to ascertain if work modifications (to tasks, equipment, workplace layout, etc. may be
needed, and to begin to plan accordingly).

The injured worker should be encouraged to return to the workplace as soon as medically able,
in a meaningful modified work assignment if feasible.

Structure, process and outcome measures of the program should be monitored, with outcome
measures not restricted solely to duration of time-loss and re-injuries, but also subjective
measures of pain and disability as well as satisfaction of all parties.
7. Immunizations -- % of patient care staff immunized for
Hep B, MMR, and others; overall staff % of staff
immunized for Hep B, MMR, and others.
 Compliance of at least 70% should be the goal of an immunization
programme
 The OH service should routinely offer and ensure follow up of the
following immunizations:
 MMR
 Tetanus, diphtheria, pertussis
 Varicella
 Hepatitis B (offered, not mandated)
 Influenza (annual)
 Special cases for consideration include:
 meningococcal vaccine for micro lab techs with risk of exposure to
n. Meningitidis
 consider other vaccines (eg hepatitis A, typhoid, yellow fever)
based on public health recommendations for the geographic area
and worker exposure potential.
8. Worker Assessment (biological monitoring if needed)
annually or biannually (e.g. BMI, Smoking)

The inclusion of lifestyle indicators was controversial and garnered significant debate amongst
workshop participants.

All agreed that TB surveillance is perhaps the most important in a worker assessment (see
indicator #17).

All health care workers should be assessed at time of hire and on an ongoing basis (frequency
depending on risk factors).

Surveillance for hazards such as the following based on individual risk of exposure should
also be considered:
 Noise
 Lead
 Asthma
 Asbestos

Surveillance should be either annual or bi-annual depending on the risk of a particular job.

Some facilities assign a risk level at time of hire. “Risk” must be explicitly defined.

Geographic region may also influence frequency of surveillance.
9. Availability of Personal Protective Equipment

The participants decided not to propose the definition of adequate in terms of actual numbers or
suggested ratios per health care worker. This is needed for logistics and procurers of products to
determine the exact numbers.

Factors affecting Personal Protective Equipment (PPE) decisions include virus-related issues, workerrelated issues, environmental issues and patient-related issues.

Two of the most common and potentially situations include exposure to blood and body fluids as well as
TB bacilli and influenza virus.

Institutions should have adequate supply (including a range of sizes) of PPE for at-risk workers, and
should provide this equipment at no cost to the employee.

Such equipment includes, but is not limited to:











gloves (sterile/non-sterile and latex/non-latex),
gowns
surgical masks
respirators (N95)
eye protection
aprons
head coverings
shoe covers or boots
coats or jackets
face shields
mouthpieces
10. Overall injuries
(per full-time equivalent staff)
11. Overall time-loss injuries
(per full-time equivalent staff)
12. MSI -- # of musculoskeletal injuries (per
full-time equivalent staff)
 Musculoskeletal injuries are defined by WHO as: “health problems of
the locomotor apparatus, i.e. muscles, tendons, the skeleton,
cartilage, ligaments, and nerves. Musculoskeletal disorders include
all forms of ill-health ranging from light transitory disorders to
irreversible, disabling injuries”.
 ILO List of Occupational Diseases (2010)
 2.3. Musculoskeletal disorders
 World Health Organization. Available from:
http://www.who.int/occupational_health/publications/oehmsd3.pdf
 International Labour Organization. (2009) List of Occupational
Diseases. Available from: www.ilo.org/wcmsp5/groups/public/--ed.../wcms_125137.pdf
13. Needlestick injuries-- # of needlestick
injuries (per full-time equivalent staff)
 Safe Injection Global Network (SIGN) used the WHO research on the global
burden of disease from sharps injuries to health care workers to spur action to
protect health care workers and inclusion of health care worker protection in
the WHO Global Plan of Action on Workers Health and other policy initiatives.
 While from its inception, SIGN's defined a safe injection to be safe for the
patient, the health care worker, and the environment; initially, attention was
focused on patient safety and not preventable needlestick injuries. It took a
few years for the growing evidence of the burden of disease from sharps
injuries to stimulate action.
 The following are core data elements of surveillance in this area:







Job category
Where in the institution did the injury occur?
Was the sharp item contaminated?
What procedure was being performed/attempted?
When did the injury occur? (in the use/disposal cycle)
What type of device caused the injury?
If the injury was caused by a needle, was it a “safety design”? (if so, was the safety
mechanism activated?)
14. Violence-- # of violent incidents (per full-time
equivalent staff)
 There are a number of definitions of workplace violence, with
some defining it only in terms of actual or attempted physical
assault, and others defining it as any behaviour intended to harm
workers or their organization.
 Given that non-physical abuse, such as verbal abuse and threats,
can have severe psychological and career consequences, a broad
definition of workplace violence will be used in this document. We
use the WHO definition of workplace violence as, “The intentional
use of power, threatened or actual, against another person or
against a group, in work-related circumstances, that either results
in or has a high degree of likelihood of resulting in injury, death,
psychological harm, maldevelopment, or deprivation”.
 *The workshop participants agreed to use definitions from the ILO
document on occupational diseases (ILO 194) to define #10-14
15. Occupational disease (e.g. cases of asthma or other
respiratory irritant or allergic reaction, systemic toxic
reaction. as well as well as cases of dermatitis – irritant or
allergic.)
 This indicator follows the ILO Code of practice on the
recording and notification of occupational accidents
and diseases (1994)
 It should be noted that in some countries (such as
Japan), if you work 100 hours more in one week and
you have an ischemic heart disease it is considered
occupational. The same applies to mental health issues
and suicide attempts.
 Occupational contact dermatitis remains an important
cause of disability.
16. Number of workers quarantined
17. New cases of TB among health
care workers

The facility TST or IGRA conversion rate should be calculated every 12 months to
assess the level of occupational risk. The calculation is as follows:
Conversion Rate= (x100)
Total number of staff (except new hires) with newly positive TST or IGRA results/year
_________________________________________________________________________
____
Total number of staff (except new hires) who had TSTs applied and read/year or IGRAs
completed/year

The Global Plan to Stop TB 2011-2015 also recommends comparing the ratio of TB
notification rate among health care workers to notification rates among the general
population.

It should be noted that numerator and denominator figures must be in the same time
period.
18. % of staff accepting HIV
Counselling and Testing (HCT)
 Evidence suggests that providing access of health care workers to HIV and
TB prevention, diagnosis, treatment, care and support can best be done onsite at the workplace, provided that the other aspects of concern, particularly
confidentially, can be strictly maintained.
 Timely initiation of Antiretroviral (ARV) treatment for HIV positive health care
workers could help overcome the health human resource obstacle to
increasing delivery of ARV treatment in resource poor settings.
 The recently released WHO/ILO/UNAIDS endorsed Policy Guidelines on
Improving Health Worker Access to Prevention, Treatment and Care Services
for HIV and TB state the following:
 “In conjunction with health workers’ representatives, develop and implement
programmes for regular, free, voluntary, and confidential counselling and testing for
HIV and TB, including addressing sexual and reproductive health issues, as well as
intensified case finding in the families of health workers with TB. “
 “Provide free HIV and TB treatment for health workers in need facilitating the delivery
of these services in a non-stigmatizing, gender-sensitive, confidential, and
convenient setting when there is no staff clinic and/or their own facility does not offer
ART, or where health workers prefer services off-site. “
19. % of staff screened for TB
 The literature suggests that health care workers are at greater risk of infection
with M. tuberculosis than the general public .
 Regular monitoring of health care workers for TB is necessary to identify those
who may have latent TB infection and to offer them preventive therapy when
appropriate.
 Monitoring also allows for rapid detection of health care workers with active
TB and ensures that they receive necessary treatment in a timely manner.
 TB screening for latent TB is recommended in areas where TB is not endemic
whereas screening for active disease is recommended for endemic areas.
 The type of facility that an individual works in and their occupational risk
should also be considered when determining their risk of exposure to TB at
work.
 Any health care worker that frequently performs aerosol-generating
procedures, such as bronchoscopy, or who works in a tuberculosis
care/outreach clinic are also considered higher risk than their colleagues.
 The frequency and method of TB screening will depend on national policy.
20. Deaths of health care workers
(occupational AND non-occupational)
 Collecting all of the causes of death and disability is
important because deaths that were once considered
non-occupational may be considered occupational at a
later date.
 It is acknowledged that accessing data about nonoccupational deaths in many jurisdictions may be
challenging.
21. Permanent disability/loss to
workforce of health care workers
(occupational AND non-occupational?)
22. Worker Retention
30th International Congress on
Occupational Health
 March 18-23, 2012
 Cancun, Mexico
 Abstract submission deadline: June 30th, 2011
 Website for more information:
http://www.icohcongress2012cancun.org/