Medical Surveillance. JOSEPH J. SCHWERHA MD MPH PROFESSOR OF OCCUPATIONAL AND ENVIRONMENTAL MEDICINE DIRECTOR OF THE OCCUPATIONAL AND ENVIRONMENTAL RESIDENCY PROGRAM GRADUATE SCHOOL OF PUBLIC HEALTH UNIVERSITY OF PITTSBURGH.
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JOSEPH J. SCHWERHA
PROFESSOR OF OCCUPATIONAL
AND ENVIRONMENTAL MEDICINE
DIRECTOR OF THE
OCCUPATIONAL AND ENVIRONMENTAL
GRADUATE SCHOOL OF PUBLIC HEALTH
UNIVERSITY OF PITTSBURGH
Occupational Health surveillance entails the systematic monitoring of health events and exposures in working populations in order to prevent and control occupational hazards and their associated diseases and injuries.
Surveillancederives from the French word surveiller, “to watch over,” which encompasses the twin notions of careful observation and timely intervention.
The four essential components of Occupational Health surveillance are:
The type of occupational health programs needed by any business is directly dependent on the goals, activities, and operations of that organization.
The first stage of medical surveillance is needs assessment.
“Do certain workers need special tests?”
* disinfectants * cleaning agents * paint removers
* wax strippers * solvents * pesticides
* emissions from heating or cooling devices
* a wide variety of materials used in painting, ceramics, printmaking, sculpture and casting, welding, stained glass, woodworking, photography, and many forms of commercial art
1. Upon initial assignment or institution
of medical surveillance: a. General physical examination performed
b. Medical history taken, including the following topics:
(1) alcohol intake
(2) past history of hepatitis
(3) work history and past exposure to
(4) past history of blood transfusions
(5) past history of hospitalizations
c. A serumspecimen obtained, determinations made of:
(1) Total bilirubin
(2) Alkaline phosphatase
(3) Serum glutamate oxalacetic transaminase -SGOT
(4) Serum glutamate pyruvic transaminase - SGPT
(5) Gamma glutamyl transpeptidase
(6) Acute test necessary to maintain an exposure
2. Examinations provided shall be performed to least
a. Every 6 months for certain conditions
b. Annually or age related
c. Government regulated
d. On the physician’s discretion
3. Each employee exposed to an emergency shall be affordedappropriate medical surveillance.
4. A statement of each employee’s suitability for continued exposure, including use of protective equipment and respirators, shall be obtained from the examining physician promptly after each examination. A copy of the physician’s statement shall be provided each employee.
5. If any employee’s health would be materially impaired by continuous exposure, each employee shall be withdrawn from possible contact.
6. Laboratory analyses for all biologic specimens included in medical examinations shall be performed in laboratories licensed under 42 CFR Part 74.
OHS’s must have available for staff use, in writing, preferably in a manual, the following desiderata:
(1) the type of examination (complete or partial, general or specific)
(2) the interval history items to be reviewed
(3) the periodicity
(4) the organ system or organs to be given specialscrutiny
(5) the hematologic, urine, biochemical, fecal,radiographic, cytologic, or breath analytic procedures to be completed
(6) acceptable levels for each test result
(7) the interval between a test productive of an abnormal leave and the repetition of the test
(8) the time of specimen collection
(9) the persons to be notified in the event of abnormal findings
(10) other actions to be taken
Biological monitoringis the measurement of a chemical, its metabolite, or a nonadverse biochemical effect in a biological specimen for the purpose of assessing exposure.
1. It is an attempt to measure the parameter most directly related to potential health effects. Results can aid in formulating a more refined estimate of risk of illness secondary to exposure.
2. Nonoccupational exposures and individual variability are assessed.
3. Multiple exposures and other routes of exposure, such as dermal and ingestion, can be evaluated.
1. Effectiveness is dependent on adequate toxicologic data.
2. Test results can be affected by other factors such as alcohol and pregnancy. Cigarette smoking can also interfere with monitoring results. Workers who smoke cigarettes, for example, may have levels of cadmium higher than their nonsmoking counter parts.
3. For some substances, relatively short biologic half-lives affect the monitoring.
4. Monitoring is ineffective for surface-acting agents such as sulfur dioxide and ammonia.
Association of Occupational and Environmental Medicine Clinics (AOEC) found the following three questions essential:
1. Please describe your job
2. Have you ever worked with any health hazard, such as asbestos, chemicals, noise, or repetitive motion?
3. Do you have any health problems that you believe may be related to work?
Environmental medicine can be considered to be “the study of effects upon human beings of external physical, chemical, and biologic factors in the general environment”. Clinical environmental medicine, then, would be “the study of detectable human disease or adverse health outcomes from exposure to these environmental factors”. The discipline of environmental medicine “combines clinical epidemiologic, and toxicologic approaches. It uniquely seeks to understand external causation and then to adopt policy, engineering, or human factor interventions to prevent or mitigate the caused outcomes”.
1. Lack of specificity about the identity of hazards
2. Inadequate information about exposure level
3. Recall biases (greater attention to exposures that were at the time bothersome or otherwise are perceived as being casual)
4. Other biases, e.g., patients fearful of possible job loss may under-report exposures, and litigants may exaggerate the intensities of exposures and their apparent effects
This additional information serves several purposes:
1.To learn the true chemical or physical hazards to which the patient has been exposed
2. To establish information about the dose of exposure
3. To corroborate or modify the information that has been obtained directly from the patient.
The structure and content of exit examinations most closely mirrors that of the periodic medical examination. Exit examinations tend to be either target-organ or substance specific and frequently are used by employers to document that the employee has suffered no adverse health effects from employment or to establish the extent of any such effects.
1. Medical surveillance
a. Establish and maintain a medical record for each employee
b. The record shall include:
(1) Name, SSN, and description of employee duties
(2) Copy of medical examination results
(3) Copy of the physician’s written opinion
(4) Complaints related to exposure
(5) Protective devices worn and length of time worn
(6) Copy of the standard and its appendices
c. The employer must maintain the record for at least 30-50 yrs
Occupational and environmental histories and examinations serve two main purposes in occupational health practice. The first is to help place and maintain people in work that is commensurate with their physical and mental capabilities.
The second usage is to monitor individuals exposed to environmental hazards associated with work-related diseases.
To a greater or lesser extent, all occupational and environmental evaluations contain three basic components: the occupational environmental history, the medical history and review of systems, and the physical examination.