Medical Surveillance

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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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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.
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Surveillance derives from the French word
surveiller, to watch over, which encompasses
the twin notions of careful observation and
timely intervention.
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• The four essential components of Occupational
  Health surveillance are
• To gather information on cases of occupational
  diseases and injuries and on workplace exposures
• To distill and analyze data
• To disseminate organized data to necessary
  parties, including workers, unions, employers,
  governmental agencies, and the public and
• To intervene on the basis of data to alter the
  factors that produced these health events and
  hazards

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Current Occupational Health Surveillance
Activities in the U.S.A.

• Death Certificates
• Hospital Discharge Data
• Physicians Reports A sentinel provider is a
  physician or other health provider (or facility)
  who, due to their specialty or geographic
  location, is likely to provide care for workers
  with occupational disorders. As a part of SENSOR
  at present, NIOSH provides support to 14 states
  to develop surveillance systems for 12
  occupational conditions, including silicosis,
  amputations, asthma, burns, cadmium poisoning,
  carbon monoxide poisoning, carpal tunnel
  syndrome, childhood injuries, dermatitis,
  noise-induced hearing loss, pesticide poisoning,
  and tuberculosis.

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Surveillance Activities continued

• Laboratory Reports
• Workers Compensation Reports
• National Surveys
• Employer Surveillance Programs
• Occupational Health Clinics

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Occupational Hazard Surveillance Activities in
the United States

• OSHA Integrated Management Information System
• NIOSH National Hazard Surveys

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Evaluations for Specific Occupational
Exposures and Diseases
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Assessment
The type of occupational health programs needed
by any business is directly dependent on the
goals, activities, and operations of that
organization.
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Needs Assessment
The first stage of medical surveillance is needs
assessment. Do certain workers need special
tests?
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Assessment of Factors Outside the Workplace
disinfectants cleaning agents paint
removers wax strippers solvents
pesticides emissions from heating or cooling
devices sunlamps a wide variety of
materials used in painting, ceramics,
printmaking, sculpture and casting, welding,
stained glass, woodworking, photography, and many
forms of commercial art
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Medical Surveillance
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 hepatotoxic
agents (4) past history of blood
transfusions (5) past history of
hospitalizations
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Medical Surveillance continued

• 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

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Medical Surveillance continued
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 physicians
discretion 3. Each employee exposed to an
emergency shall be afforded appropriate medical
surveillance.
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Medical Surveillance continued

• 4. A statement of each employees 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
  physicians statement shall be provided each
  employee.

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Medical Surveillance continued
5. If any employees 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.
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Medical Surveillance continued
OHSs 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 special
scrutiny (5) the hematologic, urine, biochemical,
fecal, radiographic, cytologic, or breath
analytic procedures to be completed
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Medical Surveillance continued

• (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

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Objectives of Occupational Health Services

• To protect the health and well-being of workers
  against the stressors and potential health
  hazards of the work environment.
• To place job applicants or current employees in
  work commensurate with their physical and
  emotional capacities, work that can be performed
  without endangering the worker or fellow
  employees and without damaging property.
• To provide emergency medical care for injured or
  ill workers and definitive care and
  rehabilitation for those with work-generated
  injuries or illnesses, in keeping with the
  medical, surgical, or psychotherapeutic expertise
  of the staff, medical department policy,
  managerial policy, and the availability of
  community resources.

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Objectives of Occupational Health Services
continued

• To maintain or improve the health of the worker
  through promotional, educational, counseling, or
  informational activities, preventive health
  measures including fitness or wellness programs,
  and periodic clinical reviews of health status.
• To promote improved health among family members.

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Biological monitoring is the measurement of a
chemical, its metabolite, or a nonadverse
biochemical effect in a biological specimen for
the purpose of assessing exposure.
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Advantages of Biologic Monitoring
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.
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Limitations of Biologic Monitoring
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.
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(No Transcript)
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Variety of Periodic Medical Examinations continued
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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?
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Work and Exposure History

• Focus on the job when the patient first began
  having symptoms
• Patients job title (or occupation) it is
  important to know the nature of the job
• Tell me what you do on your job?
• Is there anything you do now that is different
  from past jobs where youve been an
  electrician?
• Specific exposures the exposure history requires
  further study to identify specific constituents
  of products and exposure levels.
• Assessment of relative levels of exposure (i.e.,
  low, medium, high) for specific agents can be
  valuable

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Work History

• Change in symptoms during the work day.
• Change in symptoms over the work week.
• Change in symptoms on weekends and on vacations.
• Onset of symptoms away from work.
• Other experiences with work-related events.

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Clinical Environmental Medicine
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.
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Principles of Occupational and Environmental
Disease

• The clinical and pathologic expression of most
  environmentally caused diseases are
  indistinguishable from those of nonenvironmental
  origins.
• Many diseases of occupational or environmental
  cause are multifactorial, with nonenvironmental
  factors playing a role.
• The effects of occupational and environmental
  exposures occur after a biologically predictable
  latent interval following exposure.

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Principles of Occupational and Environmental
Disease continued

• The dose of an exposure to a noxious agent is a
  strong predictor of the likelihood and type of
  effect
• People differ substantially in their responses to
  noxious exposures.

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The Environmental Evaluation
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
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The Environmental Evaluation continued
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.
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The Environmental Evaluation

• Issues about confidentiality should always be
  considered
• Prior medical records
• Exposure records from an employer
• Health and regulatory agencies
• Unions and community groups
• Direct site visit

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Exit Examinations
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.
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Record Keeping
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
physicians 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
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Summary of Occupational and Environmental History
and Examinations
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.