2.
4 MEDICAL SURVEILLANCE
Upon completion of the module, the learner will be able to:
1) Discuss medical surveillance and biological monitoring as strategies in
examining health conditions of workers;
2) Explain the role of these strategies in preventing occupational illnesses; and
3) Describe the different steps in conducting medical surveillance
An important facet in Occupational Health is Medical Surveillance. Medical
Surveillance isthe systematic assessment of employees exposed or potentially
exposed to occupational hazards. This assessment monitors individuals for
adverse health effects and determines the effectiveness of exposure
prevention strategies.
To appreciate the role of medical surveillance in Occupational Health, one
must understand the parameters of how an occupational or work-related
disease develops. It is often mistakenly thought that an exposure to the health
hazards in the workplace will always cause adverse health effects. But this is
not specifically true, there are factors that influence development of a work-
related/ occupational disease. These are the (1) Workplace Factors and
(2) Worker’s Susceptibility.
Workplace Factors
Workplace Factors Description
Exposure duration • length of time of being vulnerable
to work hazards; low level exposure
to the hazard over extended period
of time increases the risk of disease
Magnitude • level or dose of exposure:as the
concentration of a hazard is
increased the likely it can do more
harm
Timing of Exposure • this is related to exposure duration,
a worker who is continuously
exposed to the hazard for several
periods in a day is more at risk
Multiplicity of exposure • Exposures to mixtures of hazards or
several chemicals at the same time
can cause synergistic or cumulative
effects
(Occupational Safety and Health Center, 2019)
Despitehaving similar exposure to workplace hazard, workers may be
affecteddifferently due to non-occupational factors/ Worker’s Susceptibility.
Worker’s Susceptibility Factors Description
Age • an important factor since elderly
and young workers have altered
metabolic processes, which allow a
buildup of toxic substances in which
a normal adult can easily neutralize
Sex • some agents may have a target
toxicity. Some may be toxic to female
workers and not toxic to male workers
or vice versa.
Genetic • refers to the inherent genetic make-
up of an individual such as allergies,
sensitization
Medical History • is important to identify previous
illnesses, which may be aggravated by
substances, or agents found in the
workplace
Lifestyle • smoking, alcohol consumption,
physical inactivity, unhealthy diet,
drug abuse, among others can alter a
worker’s natural defense mechanisms
and increase the chance of developing
ill-effects
(Occupational Safety and Health Center, 2019)
Weighing in the workplace factors and the worker’s susceptibility is our guide
and reference to carefully monitor any development of occupational disease/
illness from the vulnerable/ susceptible work force and also maintaining the
level of health status of the healthy work force from the start and end of their
employment.
2.4.1 Workplace monitoring and its different strategies
The challenge of Occupational health lies on the difficulty of recognizing the
development of the work-related diseases and occupational disease clinically
of the workers. Aside from the non-specificity of clinical and pathological
characteristics of these diseases, the long latency period before the worker
exhibits the symptoms is also a major difficulty.
A good example of this is the latency period of the harmful effects of asbestos,
a naturally occurring silicate mineral used in some industries. It takes more
than 15 years for the exposed workers to develop asbestosis (lung disease
caused by asbestos) and an even longer period of 10-45 years for workers to
develop lung cancer/ mesothelioma.
Now the question lies on, how can we protect our worker’s health before it is
too late? This is where our workplace monitoring and its strategies come in.
A. Monitoring in the workplace
In this context, Monitoring is referred to as systematic, continuous and
repetitive health-related activities that should lead to corrective action. These
are monitoring activities done systematically and periodically monitored.
Example in chemical exposure, employers should monitor and record the
exposure of workers to hazardous chemicals to ensure their safety and health.
They should ensure that workers are not exposed to chemicals to an extent
which exceeds exposure limits or other exposure criteria for the evaluation and
control of the working environment. Based on the monitoring data, employers
should assess the exposure of workers to hazardous chemicals.
Types of Monitoring:
? Ambient/ Environmental
? Biologic Monitoring
? Medical Surveillance
The Ambient or Environmental Monitoring is already discussed in Topic 2.3.
Work Environment Measurement. Airborne concentrations of hazardous
chemicals measured by the accredited service providers is monitored to
ensure the safety and health of workers against inhalation risks. These must be
weighed against the standards given and must not exceed the prescribed
values. These must be done as frequently as deemed necessary but not to
exceed more than a year.
All of the results of these three types of monitoring cannot be used as a
stand-alone reference and must be compared collectively to determine
effectivity of controls and monitoring worker’s exposure.
2.4.2 Role of biological monitoring and medical surveillance as part of
workplace monitoring
Another type of monitoring is the Biological monitoring and Medical
Surveillance. While Environmental monitoring measures the working
conditions, biological monitoring and medical surveillance indicates the
biological response of the exposed workers, whether it has a positive healthy
response or to a negative response which can lead to illness. A good indicator
of effectivity of health hazard control is monitoring the health of the exposed
workers and its biological parameters. In general, the role of the latter is:
? To check that control measures are working;
? To have an early detection of job-related health problems; and
? To check that health and safety proceduresare understood and followed
(HSE Science and Research Centre, n.d.)
These data will provide trends or emerging patterns in workplace hazards and
illnesses.
2.4.3 Biological monitoring
Biological monitoring was defined in a 1980 seminar, jointly sponsored by the
European Economic Community (EEC), National Institute for Occupational
Safety and Health (NIOSH) and Occupational Safety and Health Association
(OSHA) (Berlin, Yodaiken and Henman 1984) in Luxembourg as “the
measurement and assessment of agents or their metabolites either in
tissues, secreta, excreta, expired air or any combination of these to
evaluate exposure and health risk compared to an appropriate reference”.
Monitoring is a repetitive, regular and preventive activity designed to lead, if
necessary, to corrective actions; it should not be confused with diagnostic
procedures.
Biological monitoring is one of the three important tools in the prevention of
diseases due to toxic agents in the general or occupational environment, the
other two being environmental monitoring and health surveillance.
The sequence in the possible development of such disease may be
schematically represented as follows: source-exposed chemical agent—
internal dose—biochemical or cellular effect (reversible) —health effects—
disease. The relationships among environmental, biological, and exposure
monitoring, and health surveillance, are shown in Figure 2?20
Figure 2?21The relationship between environmental, biological and exposure
monitoring, and health surveillance
When a toxic substance (an industrial chemical, for example) is present in the
environment, it contaminates air, water, food, or surfaces in contact with the
skin; the amount of toxic agent in these media is evaluated via environmental
monitoring.
As a result of absorption, distribution, metabolism, and excretion, a certain
internal dose of the toxic agent (the net amount of a pollutant absorbed in or
passed through the organism over a specific time interval) is effectively
delivered to the body, and becomes detectable in body fluids. As a result of its
interaction with a receptor in the critical organ (the organ which, under
specific conditions of exposure, exhibits the first or the most important
adverse effect), biochemical and cellular events occur. Both the internal dose
and the elicited biochemical and cellular effects may be measured through
biological monitoring.
Health surveillance was defined at the above-mentioned 1980
EEC/NIOSH/OSHA seminar as “the periodic medico-physiological examination
of exposed workers with the objective of protecting health and preventing
disease”.
Biological monitoring and health surveillance are parts of a continuum that
can range from the measurement of agents or their metabolites in the body
via evaluation of biochemical and cellular effects, to the detection of signs of
early reversible impairment of the critical organ. The detection of established
disease is outside the scope of these evaluations.
A. Goals of Biological Monitoring
Biological monitoring can be divided into (a) monitoring of exposure, and (b)
monitoring of effect, for which indicators of internal dose and of effect are
used respectively.
The purpose of biological monitoring of exposure is to assess health risk
through the evaluation of internal dose, achieving an estimate of the
biologically active body burden of the chemical in question. Its rationale is to
ensure that worker exposure does not reach levels capable of eliciting adverse
effects. An effect is termed “adverse” if there is an impairment of functional
capacity, a decreased ability to compensate for additional stress, a decreased
ability to maintain homeostasis (a stable state of equilibrium), or an enhanced
susceptibility to other environmental influences.
Depending on the chemical and the analysed biological parameter, the term
internal dose may have different meanings (Bernard and Lauwerys 1987). First,
it may mean the amount of a chemical recently absorbed, for example, during
a single workshift. A determination of the pollutant’s concentration in alveolar
air or in the blood may be made during the workshift itself, or as late as the
next day (samples of blood or alveolar air may be taken up to 16 hours after
the end of the exposure period). Second, in the case that the chemical has a
long biological half-life—for example, metals in the bloodstream—the internal
dose could reflect the amount absorbed over a period of a few months.
Third, the term may also mean the amount of chemical stored. In this case it
represents an indicator of accumulation which can provide an estimate of the
concentration of the chemical in organs and/or tissues from which, once
deposited, it is only slowly released. For example, measurements of DDT or
PCB in blood could provide such an estimate.
Finally, an internal dose value may indicate the quantity of the chemical at the
site where it exerts its effects, thus providing information about the
biologically effective dose. One of the most promising and important uses of
this capability, for example, is the determination of adducts formed by toxic
chemicals with protein in haemoglobin or with DNA.
Biological monitoring of effects is aimed at identifying early and reversible
alterations which develop in the critical organ, and which, at the same time,
can identify individuals with signs of adverse health effects. In this sense,
biological monitoring of effects represents the principal tool for the health
surveillance of workers. (Encylopedia of Occupatinal Safety and Health, n.d.)
2.4.4 Medical surveillance
A. Definition of medical surveillance
Medical surveillance, as required by the Occupational Safety and Health
Standard, it is a program of medical examinations and tests designed to
detect and monitor potential health effects from hazardous chemical or
physical exposures in the workplace to enable early treatment or other steps
to protect employee health. Medical surveillance is conducted in conjunction
with other employer measures – such as workplace practices and engineering
controls – to prevent occupational injury and illness.
B. Purpose of medical surveillance
Medical surveillance is the analysis of health information to look for problems
that may be occurring in the workplace that require targeted prevention. Thus,
surveillance serves as a feedback loop to the employer. Surveillance may be
based on a single case or sentinel event, but more typically uses screening
results from the group of employees being evaluated to look for abnormal
trends in health status. Surveillance can also be conducted on a single
employee over time. Review of group results helps to identify potential
problem areas and the effectiveness of existing worksite preventive strategies.
The following resources contain medical surveillance information including
specific hazards and surveillance guidelines (Occupational Safety and Health
Administration, n.d.)
C. Steps in conducting medical surveillance
Medical Surveillance is useful when:
? Diseases in question are associated with particular exposure or industry; and
? Workers are among high-risk groups such as:
? workers who are new toa hazardous job
? workers returning after injury or illness
? workers with concurrent condition or illness which can be adversely affected
by the workplace hazard
? workers exposed to very hazardous substances or work processes
(Occupational Safety and Health Center, 2017)
The Medical Surveillance of Occupational Diseases are done through these
steps:
? Hazard and Exposure Assessment
There must be an assessment of hazards and the worker’s assessment which
considers the following:
? Types of substances;
? Process involved;
? Exposure pathways;
? Exposed population; and
? Estimate intensity, frequency and duration of exposure to toxic agent.
? Identification of Target Organ Toxicities for Each Hazard
After determining the hazard exposure, the known specific target organ
toxicities must be identified. One sources of this is the SDS of the chemical
used.
EXAMPLE
Causative agent Industry/process Diseases
Inorganic dusts Mining, sandblasting, Pheumococoniosis
construction, Silicosis
manufacturing Asbestosis
Molds Agriculture Framers lungs
? SELECTING MEDICAL SCREENING TEST
After determining the target organ systems that the hazards will be affecting,
medical examinations shall be performed for screening and detecting early
pathological processes.
? INTERVAL OF SCREENING TEST
1. Pre-placement or baseline
This is the time of the first hire or first exposure. Under Rule 1960 of the OSHS,
this is the Entrance Health examination. Pre-employment Physical examination
shall be conducted to determine the physical condition of the prospective
employee at the time of hiring and to prevent the placement of a worker on a
job where, through some physical or mental defects, may be dangerous to his
fellow workers or to property.
2. Periodical Examination
This is required by regulation or as recommended by the physician. The
Annual Medical Examination under Rule 1967.03 of the OSHS is done
periodically to follow-up previous findings, to allow early detection of
occupational and non-occupational diseases, and determine the effect of
exposure of employees to health hazards.
3. Separation from employment/ End of Exposure
Under Rule 1967.09 of the OSHS, an employee leaving the
company, if necessary, be examined by the occupational health physician:
- to determine if the employee is suffering from any occupational
disease;
- to determine whether he is suffering from any injury or
illness which has not completely healed; and
- to determine whether he has sustained an injury.
4. Special/ Transfer Examination
After accident or unanticipated exposure, medical examination are required
such as when exposed to lead, mercury, hydrogen sulfide and other
chemicals.
(Department of Labor and Employment, 2019)
In occupations where there is a risk to the health of the worker either due to
toxic substances they handle or of the environment in which they work, only
persons who are pronounced medically fit shall be employed.
When occupational disease have been detected in workers and continued
employment might jeopardize their health, their employment shall be
discontinued until after their complete or satisfactory recovery. If
circumstances permit, such workers shall meanwhile be given some other job
consistent with their state of health and which shall not impede or retard their
recovery.
A return to work examination shall be conducted for workers who came from
absences due to illnesses/ diseases for the following reasons:
(1) to detect if illness of the worker is still contagious;
(2) to determine whether the worker is fit to return to work, and
(3) After prolonged absence for health reasons, for the purpose of
determining its possible occupational causes.
(Department of Labor and Employment, 2019)
? INTERPRETATION OF DATA AND RECOMMENDATION
This is determined whether there is an individual pattern or a group pattern
according to the medical results or tests.
? Individual
This requires individual action. If an individual tests are abnormal,
recommendations can be removal of the exposure or referral for further tests.
? Group pattern
This is a more complicated case. If a group of workers come up with poorer
lab results. This requires further investigation and study. Was there
overexposure? Are the control measures ineffective? Determne the relation
between hazard exposure and test results.
(Occupational Safety and Health Center, 2017)
? COMMUNICATION OF RESULTS
The communication of results must be handled delicately such as in
preserving confidentiality of the workers and at the same time, handled
urgently especially if it involves a group. All information must communicated
properly according to protocol so effective measures can be immediately
planned and implemented. Other guidelines are as follows:
? Ensure of confidentiality (uses job code, job titles or other exposure
surrogates instead of the names of individual employees.
? Over all findings and trends must lead to sound recommendation for
prevention
? Communicate to the Safety and Health Committee for them to continuously
initiate, facilitate, and review new/ existing preventive OSH programs
? RECORDKEEPING
There must be organized keeping of records so that information will be readily
available anytime. These data are also important reference to evaluating
effectivity of the controls implemented or to any of the OSH programs aimed
for workers’ health and safety.
? Medical recordkeeping – test results, interpretations, records of notifications
? Requirements, procedures, and interpretations of findings for health
surveillance as specified by national legislation.
? Physical Examination
? Complete system review
? Occupational History
? Descriptions of all jobs held
? Work exposure
? Symptoms or illness at previous at previous jobs
? Personal protective equipment uses
? Medical History of workers
? Personal Illness
? Family health problems
? Lifestyle (e.g. smoking, drugs use etc.)
(Occupational Safety and Health Center, 2017)
? EVALUATION OF CONTROL MEASURES
As we had established, these monitoring must result to corrective actions. It
will not be enough the control measures be implemented. It should always be
followed by evaluation through studying the fluctuations/ trends of the data
(e.g medical cases) being monitored as a predicted response to the control
measures for the addressed health hazard.
Occupational Health Program
In response to the monitoring activities, the employer shall organize and
maintain an occupational health program to achieve the following objective:
(1) Assess the worker’s physical, emotional and psychological assets as well as
his liabilities in order to facilitate his proper placement and ensure the
suitability of individuals according to their physical capacities, mental abilities
and emotional make-up in work which they can perform with an acceptable
degree of efficiency without endangering their own health and safety and that
of their co-workers;
(2) Protect employees against health hazards in their working environment in
order to prevent occupational as well as non-occupational diseases;
(3) Maintenance of a healthful work environment by requiring occupational
health personnel to conduct regular appraisal of sanitation conditions,
periodic inspection of premises, including all facilities therein, and evaluate the
working environment in order to detect and appraise occupational health
hazards and environmental conditions affecting comfort and job efficiency.
(Department of Labor and Employment, 2019)
Difficult and challenging as it may seem, monitoring the workplaces is an
important facet towards a safe and healthy workplace. In attaining this, it will
need a participatory approach from the workers, management and stake
holders. It requires coordinated interventions based on knowledge from
standards, guidelines, scientific data and best practices (Occupational Safety
and Health Center, 2017).
D. Standards, Policies and Guidelines for Medical Surveillance And
Biological Monitoring
OSHS RULE 1050 – Notifications and Keeping record of accidents and/or
Occupational Illness
? Employers work accident/illness report IP6
? Annual work accident report exposure data report IP6-B
? Annual Medical Report Form-47-A
OSHS RULE 1070 – Occupational Health and Environmental Control
? Threshold Limit Values (TLVS)
? Permissible exposure
? Work Environment Measurement
OSHS Rule 1960 – Occupational Health Services
