Accident Prevention Manual

for Business & Industry:

Engineering & Technology
13th edition
National Safety Council

Compiled by
Dr. S.D. Allen Iske, Associate Professor
University of Central Missouri
 CHAPTER 9
OCCUPATIONAL MEDICAL SURVEILLANCE
 What is Occupational Surveillance?
• Epidemiological surveillance is the systematic collection
and analysis of health data for planning, implementing,
and evaluating public health programs
• The ultimate goal of surveillance is prevention of illness or
injury.
• Focus is on monitoring the health of working populations
and the exposure to hazards in the workplace.
 The Four Components of an
Occupational Surveillance System
1. Gathering information on adverse health events and
exposure circumstances
2. Distill and analyze the data
3. Disseminating data to interested parties
4. Intervening on the basis of the evidence provided by
the data to alter the factors that produced the hazards
and adverse health outcomes
 Occupational Surveillance
• How can occupational surveillance be applied?
• Working populations as well as individuals workers
• Federal, state, and local officials may use the results to monitor
and set policy to mitigate workplace risk.
• In individual workplaces, employers may use surveillance to
establish and monitor prevention programs specific to processes
and conditions.
 Combined Effects of Exposure
• OSHA has medical screening requirements for certain
chemical exposures and working populations.
• Hazardous waste workers, noise-exposed workers, those who
wear respiratory protection
• Healthcare professionals generally consider the effects of
a chemical independently, but exposure to a single
chemical rarely occurs.
• Many chemical exposures occur as part of a hazardous
mixture.
• As chemicals or substances combine in the body the
potential for injury or disease increases significantly.
Combined Effects of Exposure (Cont.)
• OSHA permissible exposure levels (PELs) and ACGIH
threshold limit values (TLVs) were developed under the
assumption that workers are exposed to one chemical at a
time.
• To determine overexposure for a mixture:
• Add concentrations of substances as a fraction of their respective
TLV
• If the total exceeds one, an overexposure has been detected
• This is known as the mixture rule published by ACGIH.
• The underlying assumption is that “combined” chemicals act on the
same end-organ.
Combined Effects of Exposure (Cont.)
Example:
If an employee is exposed to air that contains 400 ppm of acetone
(TLV, 750 ppm), 150 ppm of sec-butyl acetate (TLV 200 ppm) and 100
ppm of methyl ethyl ketone (TLV 200 ppm) during an 8-hour workday,
has the exposure exceeded the threshold limit?
The formula for additive effects is:
C1 + C2 + C3 + … = 1
T1 + T2 + T3 +…

Where C = the observed atmospheric concentration, and T = the

corresponding TLV. If the sum of the fractions is greater than 1, then
the TLV has been exceeded.
400 + 150 + 100 = 0.53 + 0.75 + 0.5 = 1.78
750 200 200
Surveillance of Working Populations
• Data collection systems for occupational surveillance:
• What illness and injuries are occurring (occupational sentinels)
• Why they are occurring (workplace conditions)
• How they are occurring (mechanism of injury)
• Where they are occurring (industry type, economic sector,
establishment size)
• When they are occurring (day of the week, time of day, seasonal
variations, changes over time)
Occupational Surveillance Data Sources
 What: Occupational Sentinel
Health Events
• An occupational sentinel health event is a disease,
disability, or untimely death which is occupationally
related and whose occurrence may:
• provide the impetus for epidemiologic or industrial hygiene studies
• serve as a warning signal that materials substitution, engineering
control, personal protection, or medical care may be required

• It is useful for managers, healthcare workers, and public

health personnel to review health data for individuals or
populations to look for patterns that may be related to
occupational exposure.
 Why/How: Occupational
Sentinel Exposures
• Hazard surveillance and remediation is a more
effective approach to prevention of illness and injury.
• Characterization of chemical, physical, biological,
biomechanical, and psychosocial hazards associated
with work is essential to protect workers from harm.
• Hazards may be evaluated on an industry-wide scale
or in an individual company.
• In addition to exposure hazards that lead to illness,
injury mechanisms may be coded in certain health
surveillance systems to that mechanisms and
circumstances of injury may be determined.
 Where: Economic Sector,
Industry Type, Job Titles
• The Standard Industrial Classification (SIC) codes are
used in most workers’ compensation reporting systems.
• The North American Industrial Classification System is
being used more frequently today.
• It breaks down industry and job tasks more finely.
• Gives a clearer picture of the work tasks leading to injury.
 When: Day, Date, Time of Injury

• Systems that record information on when an injury

occurred may give clues to reasons for certain types of
injuries and provide a focus for preventive activities.
• Example: Outdoor construction and agricultural work take
place during warmer seasons, and injuries in those
sectors are more likely to occur in the summer.
• The time of day that injuries occur can give clues about
the impact of shiftwork on workplace health and safety.
 Types of Surveillance Systems
• Active—An agency selects a sample of workplaces,
surveys the workplaces, analyzes the data, and
extrapolates the results to the U.S. industry as a whole.
• OSHA 300 logs and National Health Interview Survey
• Passive—Data that are collected for purposes other than
occupational surveillance may be used to inform
understanding of occupational illness and injury.
• Clinics and hospital records, emergency room visits, and workers’
compensation reports
 Occupational Medical Screening
• Screening—performance of medical testing for the
purpose of detecting organ dysfunction or disease before
an employee would seek medical care
• The main goal of screening is to benefit the individual
worker.
• May provide surveillance information on populations and identify
sentinel cases
• OSHA has screening requirements for employees
exposed to specific hazards.
• Medical screening programs require a systematic
approach to data collection and require an understanding
of many disciplines in order to be accurate informative
and preventive.
Occupational Medical Screening
OSHA Requirements
Occupational Medical Screening OSHA
Requirements (Cont.)
 Occupational Medical Screening
• Prevention
• Optimally, the workplace should be monitored for hazardous
conditions on an ongoing basis.
• Industrial hygiene hierarchy of controls
• It is most effective to implement engineering controls or substitute
hazardous agents with less hazardous agents.
• Removing hazards before exposure occurs is an example of
primary prevention.
• Medical surveillance can be used for primary prevention if it entails
detecting hazardous agents in the tissues of workers before
irreversible clinical effects occur.
• Example: An employee exposed to lead has elevated blood levels, but
he is removed from work before he becomes ill.
 Occupational Medical
Screening (Cont.)
• Prevention (cont.)
• Clinical testing may be done for secondary prevention as well:
• Example: Workers exposed to solvents, detection of abnormal
elevations in liver enzymes in the blood stream, signaling adverse
effect of solvents on the liver
• Tertiary prevention is undertaken when an irreversible injury or
illness has occurred
• Goal is to limit damage
• Example: An individual who developed asthma as a result of an
occupational exposure can be removed from the exposure and treated
to prevent exacerbations and limit disease progression.
Model for Prevention of
Occupational Diseases
 Occupational Medical
Screening (Cont.)
• Biomarkers
• Biological markers are substances, structures, or processes than
can be measured in human tissues that may predict disease.
• Biomarkers of exposure measure internal dose.
• Blood lead level is one of more than 100 such laboratory tests.
• Biomarkers may also be used to determine
susceptibility to disease.
• DNA tests, immunological response, or specific gene sequences
associated with certain diseases
 Occupational Medical
Screening (Cont.)
• Biological monitoring limitations
• difficulty correlating a health risk with exposure once the
exposure information is known
• short biological half-lives of some substances
• ineffective monitoring for surface active agents
• interference of tobacco, alcohol, and other agents with some test
results
• measurement that may reflect multiple exposure sources (air,
food, water, soil, and skin contact), preventing accurate
determination of occupational exposure
 Occupational Medical
Screening (Cont.)
• Ethical and legal issues
• Markers of susceptibility involving genetic screening in the
worksite provoked serious debate over who has a right to the
information and for what purpose.
• Concerns: potential for discrimination against workers on the
basis of racial or cultural characteristics and acquired or inherited
genetic susceptibility
• Central legal issues address the rights of those monitored and
the use of monitoring as a primary control strategy.
• Before companies approve the use of biomarkers in health
surveillance, they must carefully consider how they will handle
and communicate personal health data beyond the physician-
patient relationship.
• Occupational medical surveillance raises difficult issues related
to labor-management relations, labor law, and discrimination.
 Medical Screening Programs
• 13 steps to design and conduct a screening program
1. Assess the hazards: evaluate routes of absorption and exposure
levels, quantitatively or qualitatively
2. Identify target organ toxicity: review toxicology literature
3. Select tests: those which detect disease at an early stage to limit
or prevent disease/injury
4. Develop action criteria: plan for how to interpret data and act on
results
5. Standardize the testing process: a quality-control protocol and
standardization of testing to ensure reliability and comparability
6. Perform the test: informed consent should be obtained from
workers and results kept confidential
7. Interpret the results: utilize predetermined action criteria
Medical Screening Programs (Cont.)
8. Confirm results: abnormal tests should be confirmed by performing a
second test before rendering a decision about removal from work.
9. Determine work fitness: appropriate tests should be used before
recommending removal from the job; retention of salary and benefits
may be of concern
10. Notify workers: notification of results of screening tests should be
delivered to the worker promptly and in strict confidence, with an
interpretation by a health professional
11. Diagnostic evaluation: abnormal results should result in a sound,
medical evaluation
12. Evaluate and control exposure: if an occupational health sentinel is
detected, the work environment should be evaluated and hazardous
exposures controlled
13. Record keeping: medical records should contain all testing results,
interpretation, and copies of employee/employer notification