Occupational Health Surveillance in Health Care

1. 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

2. 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)

3. Background • Proceedings of aWorkshop within the 8thInternational 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

4. 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.

5. 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.

6. 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.

7. 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????

8. 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

9. Occupational Classification Specific to the Health Care Setting

10. 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.

11. 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)

12. 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

13. 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.)

14. 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 non-occupational?) and 21. Permanent disability/loss to workforce of health care workers (noting from both occupational AND non-occupational) 22. Worker Retention

15. Discussion:We welcome your valuable input and comments!1- Feedback overall2- Anything missed? (such as existing surveillance documents)3- Feedback on occupational classifications4- Other?5- Detailed definitions of indicators (to follow)

16. 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).

17. 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

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. 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.

24. 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, worker-related 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

25. 10. Overall injuries(per full-time equivalent staff)

26. 11. Overall time-loss injuries(per full-time equivalent staff)

27. 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

28. 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?)

29. 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

30. 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.

31. 16. Number of workers quarantined

32. 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.

33. 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 on-site 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. “

34. 19. % of staff screened forTB • 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.

35. 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 non-occupational deaths in many jurisdictions may be challenging.

36. 21. Permanent disability/loss to workforce of health care workers (occupational AND non-occupational?)

37. 22. Worker Retention

38. 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/