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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: Pocket Consultant
- Sprache: Englisch
Offering a balance of theory and practice, with guides for further reading, this is a clinical guide for the practitioner in the widest sense: physicians, nurses, occupational hygienists, safety officers, environmental, health officers and personnel managers. With coverage of both medicine and hygiene, and including sections on OH law, it is a primer for appropriate courses and provides all that the interested medical student would need to know.
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Seitenzahl: 573
Veröffentlichungsjahr: 2013
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Contents
Acknowledgements
Foreword
1 Introduction
1.1 What is occupational health?
1.2 Who is involved in occupational health?
1.3 The world of work
1.4 The world of people at work
1.5 The roles of the occupational health professional
1.6 Industrial processes and health outcomes
1.7 Summary
1.8 The future
2 Occupational Health Services—an International Perspective
2.1 Delivery of occupational health services
2.2 Developing countries
2.3 Rapidly industrialising countries
2.4 Developed countries
2.5 From clinical care to health promotion
2.6 Occupational health services
3 Occupational Diseases
3.1 Historical perspective
3.2 The toll of occupational injuries and disease
3.3 Target organs
3.4 Prescribed diseases in the UK
4 Occupational Infections
4.1 Introduction
4.2 Blood-borne infections
4.3 Vector-borne infections
4.4 Food- and water-borne infections
4.5 Infections spread by droplets and close contact
4.6 Zoonotic infections
4.7 Other infections
5 Occupational Toxicology
5.1 General principles of toxicology
5.2 Inorganic chemicals
5.3 Organic chemicals
5.4 Occupational cancer
6 Occupational Hygiene—Gases, Vapours, Dusts and Fibres
6.1 Introduction
6.2 Monitoring of the workplace environment
6.3 Toxic gases
6.4 Dusts and particles
7 Physical Hazards—Light, Heat, Noise, Vibration, Pressure and Radiation
7.1 Light
7.2 Heat
7.3 Noise
7.4 Vibration
7.5 Pressure
7.6 Radiation
8 Musculoskeletal Disorders
8.1 Introduction
8.2 Low back pain
8.3 Repetitive strain injury (RSI)
9 Psychosocial Aspects of the Workplace
9.1 Introduction
9.2 Occupational stress
9.3 Special problems
9.4 The role of personality
9.5 Psychological assessment of stress
10 Risk Assessment
10.1 Introduction to risk assessment
10.2 Walk-through surveys
10.3 Sampling strategies
10.4 The Control of Substances Hazardous to Health (Amendment) Regulations 2004
10.5 Health assessment
10.6 Biological monitoring and biological effect monitoring
10.7 Medical records
10.8 Principles of epidemiology
11 Control of Air-borne Contaminants
11.1 Introduction
11.2 Extract ventilation design
11.3 Dilution ventilation
11.4 Choice of fan
11.5 Air cleaning and discharges to the atmosphere
11.6 Energy and cost implications of ventilation systems
12 Personal Protection of the Worker
12.1 Introduction
12.2 Eye and face protection
12.3 Skin and body protection
12.4 Respiratory protection
12.5 Hearing protection
13 Special Issues in Occupational Health
13.1 Introduction
13.2 Working hours
13.3 Workplace injury incidents
13.4 Occupational health for health-care workers
13.5 Audit and quality improvement in occupational health
13.6 Occupational health and public health
14 Legal Aspects of Occupational Health
14.1 Introduction
14.2 Statute
14.3 Common law
14.4 The regulations
14.5 Employment protection legislation
14.6 Pre-employment medical examinations
14.7 Medical records and the duty of confidentiality
14.8 European Union law
14.9 Disability Discrimination Act 1995 (as amended by the Disability Discrimination Act 2005 and the Disability Discrimination Amendment Regulations 2003)
15 Sources of Information
15.1 Introduction
15.2 Organisations and associations
15.3 Further reading
15.4 Useful addresses
Index
© 2007 T.C. Aw, K. Gardiner, J.M. Harrington
Published by Blackwell Publishing Ltd
Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USA
Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK
Blackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia
The right of the Author to be identified as the Author of this Work has been asserted in accordance with the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.
First published 2007
Library of Congress Cataloging-in-Publication Data
Aw, T.C.
Pocket consultant : occupational health / T.C. Aw, K. Gardiner, J.M. Harrington; 5th ed.
p. ; cm. – (Pocket consultant)
Rev. ed. of: Occupational health / J.M. Harrington… [et al.]; 4th ed. 1998.
Includes bibliographical references and index.
ISBN-13: 978-1-4051-2221-4
ISBN-10: 1-4051-2221-8
1. Industrial hygiene–Handbooks, manuals, etc. 2. Occupational diseases–Handbooks, manuals, etc. I. Gardiner, K. II. Harrington, J.M. III. Occupational health.
IV. Title. V. Title: Occupational health. VI. Series.
RC967 .H33 2006
613.6′2–dc22
2006000955
ISBN-13: 978-1-4051-22214
ISBN-10: 1-4051-22218
A catalogue record for this title is available from the British Library
Commissioning Editor: Alison Brown
Editorial Assistant: Jennifer Seward
Development Editor: Elisabeth Dodds
Production Controller: Kate Charman
For further information on Blackwell Publishing, visit our website:
http://www.blackwellpublishing.com
Acknowledgements
Acknowledgements to colleagues and students for reviewing and advising on the various chapters. Our special thanks to Dipti Patel, FFOM, LLM, Melody Greenwood and Rhiannon Cox.
Foreword
This pocket consultant started out as what was often referred to popularly as ‘Harrington and Gill’. Since then, it has undergone several revisions, and it has become the best selling compact primer for occupational health in the UK. It is used by many multidisciplinary groups of occupational health practitioners (including nurses, doctors, safety professionals), and as a standard text for several occupational health courses.
We are delighted to present the 5th edition. The concise nature of the presentation, with short sections and bullet points has been retained. We have created a new chapter on occupational toxicology, updated the chapters on occupational health law and on sources of information, and added new material on emerging infections relevant to occupational health practice. The section on psychosocial aspects has been expanded, and the section on vibration rewritten to take on board new HSE (Health and Safety Executive) information on the subject. The findings of recent evidence-based reviews on several topics including vibration and low back pain have been included.
We would especially like to thank our readers, students, and colleagues from within and outside the UK, for taking the time to make useful suggestions, to clarify some points, to correct a few errors, and to improve the text. Our thanks also to those who contributed material for this new edition, and to those who reviewed the sections. We hope the book continues to be a ready, quick reference for occupational health practitioners.
Tar-Ching Aw, Kerry Gardiner and Malcolm Harrington
Canterbury, 2006
1
Introduction
1.1 What is occupational health?
Occupational health is a multifaceted and multidisciplinary activity concerned with the prevention of ill health in employed populations. This involves a consideration of the two-way relationship between work and health. It is as much related to the effects of the working environment on the health of workers as to the influence of the workers’ state of health on their ability to perform the tasks for which they were employed. Its main aim is to prevent, rather than cure, ill health from wherever it arises in the workplace.
A joint International Labour Organization/World Health Organization (ILO/ WHO) Committee defined the subject back in 1950 as: ‘the promotion and maintenance of the highest degree of physical, mental and social wellbeing of workers in all occupations’.
The relationship between the worker and the world of work is, necessarily, complex (Fig. 1.1). The worker brings to the place of work a pre-existent health status influenced by many factors—only some of which are under the workers’ direct control. Any illness that occurs in the employed worker has to be viewed in this context. The health outcome could be caused by work, modulated by work or unrelated to it. Such a view of occupational health is, however, predominantly a medical model. The situation is much more complex nowadays.
1.2 Who is involved in occupational health?
Traditionally, occupational health has been viewed as a clinical subject, implying that the dominant roles in prevention should be played by the physician and the nurse. The ILO/WHO definition from nearly half a century ago suggests that a broader view is necessary.
Thus, the list of relevant professionals is extensive and includes:
physicians;
nurses;
occupational hygienists;
sociologists;
toxicologists;
psychologists;
health physicists;
microbiologists;
epidemiologists;
ergonomists;
Fig. 1.1 The problems facing the practitioner attempting to establish a link between work and health. The new employee brings a legacy of genetic, social, dietary and environmental factors affecting health to the new workplace, which may influence his or her response to workplace hazards.
Fig. 1.2 The occupational health stakeholders.
safety engineers;
work organisation experts;
lawyers.
Yet, the ultimate responsibility for maintaining the health of the workforce rests with the employer, and, to a lesser extent, with the employee. This is the way most health and safety law is formulated. On the basis of this model, one can begin to view those involved as an even broader group. The ‘stakeholders’ would thus include a number of groups who, although they may not be professionally responsible for ensuring the wellbeing of the workers, do have a crucial interest in the outcome (Fig. 1.2).
1.3 The world of work
The changing patterns of employment in world industry will have important implications for the future style and thrust of occupational health, as well as for the competence needed to deliver the goods. Across the world, the days of full-time, long-term employment in one industry for a worker with one set of skills are rapidly disappearing. The main features for the future seem to be:
fragmented industry;
smaller workforces;
more mobile employees;
multi-skilled workers;
greater use of subcontracted tasks;
less job stability;
less job security;
more part-time work;
more flexible hours of work;
more mechanised (and therefore possibly more dehumanised) workplaces.
1.4 The world of people at work
Today, certainly in the developing world, occupational physicians see more illness but less disease. Whilst musculoskeletal disorders and stress-related complaints dominate the scene, they too are interrelated and both are subject to ‘somatising tendencies’ (presenting as physical symptoms related to different target organ systems). Thus, the new ‘age of existentialism’ is dominated by such conditions as:
stress;
non-specific effect modifiers;
post-traumatic stress disorder;
chronic fatigue syndrome;
multiple chemical sensitivity;
diffuse pain syndromes;
a combination of psychological, neurological, and immunological issues.
1.5 The roles of the occupational health professional
In developed countries, many of the older occupational diseases have been controlled—or, at least, the means for controlling them are known. In such settings, the delivery of an effective occupational health service to employed people will become more complex and more difficult in the future—although with greater emphasis on control, there should be less to do in dealing with the injured or sick. These, after all, represent the ‘failings’ of an effective preventive programme.
Moreover, the influences of the stakeholder and the complexities of the employment scene have shifted the traditional emphasis away from the structure of ‘see the health effect, diagnose the illness, find the cause’ to the more proactive stance of ‘control the exposure and monitor the effects’. In this model, the roles of the safety engineer and the occupational hygienist become more central, and now sit alongside the clinical aspects rather than being secondary to them. One further aspect of occupational health services is worth mentioning: in the market economies, there has been a shift towards demonstrating to employers the economic value to them of such a service. A UK Faculty of Occupational Medicine brochure listed the ways in which occupational physicians can help the employer to ‘meet their obligations’ under European health and safety legislation. These included:
helping with company compliance with the law;
advising on health and safety policy;
assisting in the control of sickness absence;
reviewing the fitness of employees’ post-sickness absence;
managing rehabilitation;
advising on fitness to work;
managing access to first aid services;
organising health promotion initiatives;
designing and managing substance abuse programmes at work;
advising on the management and alleviation of stress;
advising employees about overseas travel on company business;
assessing employees’ eligibility for long-term disability benefits or retirement on health grounds.
The order of these functions is probably not random, and many might dispute the contents of this list and certainly the order. Nevertheless, it demonstrates the move towards delivering an economically attractive package to the employer. Whether this is what the employee needs is another matter. Indeed, one can dispute whether this medical model has real validity for the twenty-first century.
In developing countries, an occupational health service often starts with the provision of medical care for the workforce (akin to a general practice at the worksite, and often with provision for the workers’ dependants) (see Chapter 2). In the newly emerging countries of Eastern Europe, the ‘prophylactic’ medical examination remains at the heart of the health-care system in the workplace. Even in Poland, which is among the more advanced of this group of countries, their 1997 Occupational Health Services Act places medical examinations at the core of service activities. Recent updates of the legislation have tended, however, to stress the importance of the preventive role of the medical input.
Many of these functions are often performed by an occupational health nurse, who frequently works in isolation from any form of direct medical advice. Both physicians and nurses, however, have to be aware of their clinical limitations (either by training or by the fact that the employee is another physician’s patient), and both also must see the workplace in the context of what goes on at the worksite (see Section 1.6).
Such a knowledge of the workplace activity and process is a central feature of the work of the occupational hygienist, the ergonomist, and the expert in work organisation. These professionals are in short supply, and few businesses employ their own. Yet, their role is to recognise and understand the complexities of the work process, the nature of the materials used, produced, and disposed of and the methods of production. In addition, the hygienist is an expert in identifying the sources and measuring the concentrations and emissions of workplace contaminants to ensure that appropriate controls can be put in place.
The investigation of a putative link between a hazard and health effect requires a study of the populations exposed (a task for the epidemiologist), as well as a knowledge of the toxicological effects (a task for the toxicologist) with the necessary accompaniment of a risk assessment (a task for the occupational health and safety professional with experience in risk management).
Safety is often considered separately from health. This is inappropriate and counterproductive to the development and execution of an integrated health and safety strategy to protect health in the workplace. The key functions of safety management are:
policy and planning—determining safety goals and a plan of work to achieve these goals;
the provision of a clear basis of responsibility and communication to achieve control;
the identification and assessment of risks and the control measures necessary to counter such risks;
the monitoring and review of these policies and practices.
While safety engineers tend to concentrate on the mechanical aspects of the workplace process, a similar structure of activity and function could be established for all occupational health professionals.
Who does what then comes down to the resources available to the employer, as well as the hazards and risks inherent in the process. As industry becomes more fragmented, the large, company-financed, multidisciplinary teams will disappear as well. The role of independent consultant advisers will then come to the fore, but the integrated activity of several professional groups working together to achieve long-term goals could be lost. In this context, the corporate control of the company may need to take the coordinating role.
Every professional providing occupational health advice and service must ensure that they have had the relevant training by the professional bodies of their specialty which are responsible for overseeing competence. Training and education schemes are available for the main groups listed in Section 1.2 above. Furthermore, many of these bodies now insist upon programmes of continuing professional development for the career lifetime after successful completion of the examinations for competence.
1.6 Industrial processes and health outcomes
Although there has been a dramatic rise in service industries in most developed countries, manufacturing industries remain a vital part of the economy. These industries, together with the extractive process and power generation enterprises, remain the main source of concern regarding workplace exposures leading to ill health and injury.
The main industries and their health effects are summarised in Table 1.1.
Whatever the workplace activity and whoever is responsible for managing health and safety, the means of protecting the workforce can be summarised as:
hazard identification;
risk assessment;
management intervention;
control procedures;
review and audit effectiveness.
1.7 Summary
The health of the employee at a place of work is the concern of many professional groups. There is a need to identify hazards be they physical, chemical, biological or psychosocial. Once identified, the risks to the workforce must be assessed and measures to control these risks must be instituted. Measuring the effectiveness of this process involves the monitoring of the workplace environment and the health status of the employees. Auditing the effectiveness of these measures and improving the control are never-ending processes.
The bottom line remains the health of the worker. This is what both the workers and employers desire—a healthy workforce at work. It follows that the culture of good health and safety policy and practice must pass from the professionals—and the management—to the workforce. When everyone at the workplace believes that such policies and practice are part of their responsibility, occupational health can be considered to have achieved its main goal.
1.8 The future
Such an ideal of the total ‘ownership’ of health and safety by all, managers and managed alike, may be some time distant—if it is achieved at all. Nevertheless, occupational health professionals need to be looking for the newer emphases that will emerge in the next decade, as these will influence the content and style of their work. Apart from the shifts in workforce size, skills, and structure mentioned in Section 1.3, several other influences are now beginning to emerge, which could necessitate yet more shifts in the job content of the occupational health practitioner. These are some to start thinking about:
public safety/consumer protection;
public risk perceptions (and effective public risk communication);
environmental impact of workplace process;
leisure industry risks.
Table 1.1 Industrial processes and potential occupational health exposures. Industrial processes release hazardous substances and physical agents which can cause ill health to the operators if encountered in sufficiently large doses. Substances that can be inhaled will appear in the form of dusts, fibres, fumes, mists, micro-organisms, gases, and vapours. Those that come into contact with the skin will be liquid or particulate. Substances can also be ingested or inoculated. Hazardous agents take the form of emissions of noise, heat, barometric pressure, electromagnetic waves, and ionising particles which target one or more organs. The table lists some of these in relation to industry or occupation.
Finally, that which is probably destined to dominate our professional lives in the twenty-first century:
PSYCHOSOCIAL HEALTH.
2
Occupational Health Services—an International Perspective
2.1 Delivery of occupational health services
Different models exist for the provision of occupational health in various countries, with the differences lying in the mix of occupational health professionals that make up the occupational health team, the range of services that they provide, the legislative requirements and framework and the perceived needs by workers and their employers. Some of the legislative and preventive activities are performed by government departments, whereas the provision of occupational health services for groups of workers is often organised by employers. The training of occupational health professionals is usually offered by academic centres or training institutes.
An important difference between countries lies in the method used to pay for occupational health services. For those countries where there is an insurance based ‘workers’ compensation’ system in place, or national legislation that requires employers to ensure that workers have access to an occupational health service, the services are often not provided by an in-house service directly connected with the company, but provided by a commercial provider from a remote site. The range of services that can be provided in these systems is often clearly defined, but restricted to what the insurance system allows or national legislation requires the employer to provide. In these types of systems the occupational health services often enjoy a degree of independence from the employer, but may have more limited influence over workplace conditions than in other systems. In those countries where the occupational health services are paid for directly by the employer—either via an in-house service based on the company premises, or purchased from an external supplier—there is the potential for services to be provided that are restricted only to what the employer wishes to purchase for or provide to their staff. However, an in-house service working closely with the employer may be in the best position to identify workplace risks and influence the employer to improve working conditions in a more proactive manner.
2.2 Developing countries
In many developing countries, such as in parts of Africa, South America and Asia, occupational health is provided as part of the general medical care for the workforce. In-house medical services are usually only available for larger companies, especially those belonging to multinational organisations. Larger companies employ more workers, have the resources to provide medical facilities for their workforce and often have occupational health policies and standards which apply to all their member companies world-wide. For developing countries, this model often places emphasis on the treatment of illnesses, whether occupational or non-occupational in origin, with fewer resources for occupational health prevention. Some companies even have their own private clinics and hospitals to care for local workers and their families. These clinical facilities also cater for the medical needs of the overseas expatriate staff and their families. One reason why companies often concentrate on treatment services is the limited availability and access to medical facilities in these countries. Another is the importance attached to dealing with the immediate health problems as they present at that time, and the often longer term health problems that arise out of potentially hazardous occupational exposures.
Preventive occupational health functions are often organised as a separate safety (or health and safety) department, which increasingly includes environmental aspects in its remit. The model which relies on the availability of doctors, dentists, nurses, care assistants and other clinical staff has been described as providing ‘family medicine in industry’, rather than providing occupational health cover. Treatment-orientated medical services are the rule in countries such as Chile, where occupational physicians focus on the recognition and treatment of occupational disease, with less emphasis on workplace visits and assessments to identify potential hazards and to recommend corrective action.
2.3 Rapidly industrialising countries
In countries such as South Korea, Taiwan, Thailand and Malaysia (part of the group of countries often referred to as the ‘tiger economies’), there has been rapid economic and industrial development. In these countries, increasing attention is being paid to occupational and environmental health issues. In recent years, especially during 1996 and 1997, many parts of South-East Asia (particularly Malaysia, Singapore and Indonesia) were affected by episodes of environmental haze which enveloped the major cities. This haze was accompanied by an increase in respiratory, eye and other health effects. The source of this haze was thought to be primarily the burning of vegetation and trees during the clearing of tropical forest areas for shifting agriculture, forestry or land development. Other possible contributors include traffic exhaust fumes, industrial activity and the El Niño weather phenomenon. Occupational health professionals in these countries are increasingly involved in advising on such matters of environmental and health concern. Governmental and quasi-governmental organisations have been formed to coordinate activity on occupational and environmental health.
The developments in occupational health in Malaysia can be used as an example of how occupational health services may be provided in an industrialising country. In Malaysia, the Workers and Environmental Health Unit of the Ministry of Health is a central government source of advice and information, with satellite government occupational health clinics being planned for different parts of the country. The Department of Occupational Safety and Health of the Ministry of Human Resources enforces occupational health and safety legislation. Much of this legislation has been derived from similar UK laws. A National Institute of Occupational Safety and Health has been established to provide training. General practitioners with an interest in occupational health have been appointed by the Malaysian Social Security Organisation (SOCSO) to evaluate and forward claims for compensating occupational diseases. There are several avenues for training physicians in occupational medicine. These include local academic institutions and training establishments in other countries, such as Australia and Ireland. However, occupational health nursing and occupational hygiene training lag behind. In the private sector, some general practitioners provide clinical cover for factory workers through contracts with employers. The emphasis is on treatment, pre-employment assessments, sickness absence issues and return to work, with fewer opportunities for occupational hygiene assessments or preventive activities at the workplace. With the development of notification schemes for occupational diseases, and the agreement of uniform criteria for diagnosing such diseases, the preventive aspects of occupational health services will have greater emphasis in the future.
2.4 Developed countries
Many developed countries have a legal requirement for the provision of occupational health services. The situation in Europe varies from country to country, although there have been attempts by the administration of the European Union (EU) to harmonise occupational exposure standards and requirements for occupational health provisions. Its approach has been to specify minimum standards for compliance by EU member states, but to allow higher standards to be promulgated by individual states if they wish. The EU has also established a European Agency for Health and Safety in Bilbao, Spain. There is also a European Foundation for the Improvement of Living and Working Conditions based in Dublin, Ireland.
In Austria, there is a legal requirement to employ company physicians for companies with 100 or more workers. In The Netherlands, an official occupational health service is mandatory for companies employing more than 500 workers, or those in specifically defined hazardous industries, for example. the assembly of lead batteries or the manufacture of lead pigments. The occupational health services are mainly preventive in function. The activities are aimed at the early detection of occupational ill health, prevention of occupational disease, rehabilitation, reduction of sickness absence and health surveillance. The multidisciplinary staff employed includes occupational physicians, nurses, occupational hygienists and physicians’ assistants.
In Portugal, there has been a legal requirement since 1991 to provide occupational safety, hygiene and health services for private and public workplaces employing more than 250 workers. The services include safety officers, nurses, occupational physicians and worker representatives. Occupational hygienists are in short supply, and are rare as team members of these services in Portugal.
Greece has legislative provisions for occupational health services based on occupational health physicians and health visitors. The role and responsibilities of the health visitors are defined under statute. The focus of activity involves the health screening of workers. This includes pre-employment assessments and follow-up, as well as the investigation of workplace conditions.
In Italy, occupational health nursing is not as well developed a field as occupational medicine or occupational safety. The role of nurses in occupational health care is therefore limited. In occupational health services in Australia, physiotherapists are often part of the occupational health team.
In the UK, occupational health nurses and safety practitioners form one of the biggest professional groups in the provision of occupational health. The enforcement of health and safety legislation is the responsibility of a government agency—the Health and Safety Executive (HSE)—which is part of the Department of Work and Pensions. It has hygienists, engineers, nurses and physicians among its ranks of inspectors. There is no legal requirement for occupational health services, although first aid provisions are mandatory. Recent regulations have required employers to appoint ‘competent persons’ to assist them in their health and safety duties. Doctors have to be appointed by the HSE for companies with workers exposed to workplace hazards such as lead, asbestos, ionising radiation, compressed air and certain chemicals listed in the Control of Substances Hazardous to Health Regulations 1994. The availability of occupational health services for workers is patchy, and often limited to those employed by larger organisations. More than 90% of workplaces, especially those with small numbers of employees, do not have occupational health cover. Where provided, occupational health services may be an in-house facility, or employers may rely on external contracted providers of occupational health care. Independent group occupational health services are organised on a regional or national level. An area of recent expansion in occupational health services is the National Health Service (NHS). Almost all hospitals in the NHS have some form of occupational health cover, which may be separate from, or may encompass, safety and environmental functions. The occupational health departments for the health-care industry are led by specialist occupational physicians or occupational health nurses. The activities have still tended to be clinical, with considerable focus on biological hazards. Hygienists and ergonomists, employed as part of the occupational health team for health-care workers, are rare. However, manual handling trainers are increasingly joining the occupational health teams.
In France and Germany, the model used places emphasis on the requirement for the workforce to have periodic access to an occupational health service. The rationale is to allow a review of the health status of the workers, with the aim of early detection of ill health. If there is any indication that illness may be related to workplace factors, investigations and preventive action can follow. German law provides for preventive medical examinations for exposure to a variety of workplace hazards, including noise, ionising radiation and a list of chemical agents. Several million medical examinations are performed annually under these regulations.
The Scandinavian countries, for example Finland and Sweden, have systems for occupational health cover that are much admired. Finland has a National Institute for Occupational Health based in Helsinki, with satellite departments in other cities. The activities include research, training, clinical and investigative services. There are also active efforts by this institute to help in occupational health initiatives in developing countries in Africa and Asia. Finland has had an Occupational Health Care Act since 1979. This requires all employers to provide occupational health services for their employees.
In the USA, there is a variation between states in the provision of occupational health. In New York State, private occupational and environmental medicine services predominate, including mobile clinics, multispecialty clinics and other services, invariably paid for by employers. New York State’s occupational medicine clinics have been developed as centres for the diagnosis of occupational disease, some with industrial hygienists attached. The hygienists are in a position to investigate the workplace with the cooperation of the employer and the unions. The diagnosis of a case of occupational disease is treated as a sentinel health event, which indicates a need to assess other coworkers exposed to similar workplace factors. The main government agency for enforcing occupational health and safety legislation in the USA is the Occupational Health and Safety Administration (OSHA)—part of the Department of Labor. Responsibility for research and health hazard evaluations lies with the National Institute for Occupational Safety and Health (NIOSH). This is one of the centres within the Centers for Disease Control and Prevention (CDC)—a public health agency belonging to the Department of Health and Human Services. Occupational exposure standards are produced by several organisations, including NIOSH and OSHA. However, the best known standards are the threshold limit values and biological exposure indices produced by the American Conference of Governmental Industrial Hygienists (ACGIH)—a non-governmental independent professional organisation (despite its name). The standards are reviewed annually and revised as necessary. They have been adopted by many countries outside the USA.
2.5 From clinical care to health promotion
Successful measures have been introduced to reduce workplace exposures and prevent occupational disease in some industries. These have mainly occurred in developed countries, and have resulted in occupational health attention being directed at more difficult targets for prevention, for example the reduction of stress, health promotion and activities aimed at strengthening the health status of workers. Occupational health departments in these countries may also place emphasis on general health promotion measures in addition to workplace assessment and health surveillance. Health promotion activities include the provision of facilities for regular exercise at the workplace, campaigns to reduce cigarette smoking, and advice on the consumption of alcohol in moderation, safe driving and healthy diet. The rationale proposed for this approach is that, once traditional occupational diseases are prevented, the focus should shift to the improvement of the general health status of the workforce. Unfortunately, in some workplaces health promotion activities have been emphasised at the expense of efforts towards reduction and control of workplace hazards.
Thus, there are different systems available for the provision of occupational health care. Each system has its limitations and advantages, and what works in one industry or country may not be the best model for a different industry or country. The chosen model should be acceptable to both employees and employers, and should take into account the availability of trained occupational health professionals from different disciplines.
2.6 Occupational health services
The range of functions provided by occupational health services is given below.
Clinical occupational health activities
Pre-employment assessments
Pre-employment assessments vary from the use of a self-completed questionnaire to a full ‘hands-on’ clinical examination by a physician. The argument against the use of a questionnaire is that job applicants wanting to be employed may be somewhat economical with the truth when answering questions on the state of their health. This is especially the case when the denial of ever experiencing specific health problems is difficult to check and confirm. Full clinical examinations are, however, time consuming and have a low detection rate for relevant abnormalities. A compromise approach is to use an initial screening questionnaire, with a staged evaluation, first by an occupational health nurse, and then by an occupational physician where indicated (further details of health assessments are discussed in Chapter 10). With promulgation of legislation against disability discrimination in several countries, the whole issue of preemployment assessment and its use needs to be reviewed.
Periodic medical examinations (including health surveillance)
These may be performed because of statutory requirements, or where clinically indicated for groups of workers exposed to specific hazards. In many countries, examples of statutory medical examinations include clinical examination of professional drivers, and examination and blood lead determination for workers exposed to lead compounds. Periodic examinations have also been advocated in health surveillance schemes for workers exposed to respiratory sensitisers, such as isocyanates. The health surveillance of specific groups, for example executives, is often in demand from employers and the executives themselves. This is based on the following assumptions: executive staff are expensive to employ, they make critical decisions that can affect the success of the company, they are time consuming to train and difficult to replace, and therefore should be placed in a system where there is periodic confirmation that they are in good health. Despite this, executive medical examinations are of questionable value. They are costly to perform, with a low detection rate of significant clinical abnormalities. It has also been argued that, if there is clinical value in such periodic assessments, they should be made available to other categories of staff.
Post-sickness absence review
The rationale behind reviewing individuals with long-term sickness absence is to ensure that the cause of the illness has not affected their capacity to continue in their present job. It also allows any necessary adjustments to the workplace to be made to accommodate the individual on his/her return to work. For food industries, occupational health services often have the responsibility to ensure that workers are not still infectious before returning to handling food products, especially after a spell of diarrhoea and vomiting.
Key questions that are often asked of the clinician are:
Can you confirm that there is an underlying medical condition causing the absence and that the length of absence is consistent with that condition?
Can you estimate the length of time the employee is likely to be absent with this condition?
Can you indicate whether on return to work the employee is likely to be able to resume his or her normal duties?
Are there likely to be any significant implications for the health and safety of the employee, or others, on his or her return to work?
Should restricted duties, redeployment or retirement on the grounds of ill health be considered at this stage?
Are there any legal implications for the management of this case?
The answers to these questions allow the employer to actively manage and plan ahead for the employee’s return to work. Confidential medical information is not necessary for the manager to manage. Occupational health professionals may also add value to these reports by identifying workplace factors that may have contributed to the condition, suggesting ways of protecting this employee and others who may be similarly exposed, offering advice on rehabilitation and reintegration strategies; and where appropriate, helping the employee to address the occupational factors that may lead to protracted sickness absence. Absence from work is itself a risk factor for developing other conditions, through social exclusion, isolation and deteriorating physical condition. Many experts view work as therapeutic, and early, safe, sustainable, return to work as beneficial.
Immunisation
This is provided by occupational health departments for health-care workers and laboratory and research staff, or where the workforce includes many employees travelling abroad as part of their job duties. Travel to exotic locations requires that the necessary immunisations against communicable diseases are provided. Where this is performed by occupational health departments, it also involves general health advice for other infectious diseases, for example sexually transmitted diseases, and food-borne infections.
Health education and counselling
The encouragement of workers to look after their health in terms of healthy lifestyles, proper diets, avoidance of smoking, consumption of alcohol in moderation, adequate exercise; and reduction of cardiovascular risk factors has been incorporated into the activities of many occupational health services. These efforts are aimed at using access to the workforce to reduce risk factors for diseases in general, and to introduce measures to prevent occupational disorders.
Treatment
The functions of occupational health services may include provision of services from first aid and treatment of minor injuries to the provision of full curative medicine facilities. The extent of clinical services within departments of occupational health varies from non-existent to the availability of dentists, chiropodists and opticians.
Rehabilitation
Occupational health staff can liaise with clinicians and worksite managers for the facilitation of rehabilitation and return to work. Familiarity with the workplace and job alternatives and an understanding of the illness or disability stand the occupational health staff in good stead for this activity.
Workplace assessments
It follows that, without exposure, there is no effect. Therefore, the evaluation of the workplace to eliminate or reduce exposure is critical in achieving the aims of the occupational health department. These tasks are usually carried out by occupational hygienists, who structure their work in terms of recognition, evaluation and control as follows.
Recognition
This is not really a function, but includes the understanding of the toxicology of contaminants or disease aetiology, the industrial process itself (and all of its hazards) and the law.
Evaluation
This often starts at the point of a walk-through survey, where knowledge of the process/contaminant means that decisions can be made without recourse to measurements, and extends to situations in which sophisticated measurements and/or analytical techniques are necessary to quantify the contaminant with the required accuracy/ precision.
Control
The most important attribute of any occupational health professional, but specifically an occupational hygienist, is to be able to improve the work environment. Occupational hygienists use their knowledge of disciplines, such as industrial chemistry, chemical engineering, ventilation design, etc., to try to ensure that the putative agent is either eliminated or controlled.
General advice and support
Advice on compensation
Where an occupational disease has been diagnosed, occupational health services are able to advise the patient on obtaining benefits through workers’ compensation schemes.
Disaster planning and advice on dealing with chemical incidents
Planning committees for the development of procedures to deal with chemical spills, road and rail accidents with the discharge of chemicals into the environment, and emissions from industrial sites, often include staff from occupational health services. Occupational health professionals can facilitate communication with managers of industrial sites, and advise on the nature and extent of exposure, possible health effects, and appropriate personal protective equipment for rescue and emergency crew.
Food hygiene
The provision of advice to food handlers and on precautions for the safe handling of food is an important role for occupational health services in the food industry. In addition to the need to ensure the health of the workforce, there is the additional requirement to ensure the safety of the food product.
Advice on environmental issues
Occupational health services are increasingly covering safety and environmental issues, such that some departments are now organised as safety, health and environment (SHE) services.
Other activities
Audit, quality assurance and evaluation
Part of the work of occupational health services involves compliance with internal and external quality standards. An audit or systematic, critical review of the structure, process and outcome can lead to steps to improve the quality of the service (see Chapter 13).
Worker protection and business protection
The challenge for occupational health services is to provide a balance of functions: to detect and control workplace hazards early; to recognise occupational disease without missing non-occupational illness; to provide effective health surveillance; to facilitate treatment, rehabilitation and return to work; and to ensure that the business of the employer can be conducted safely without detriment to the health of the workforce.
3
Occupational Diseases
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Lesen Sie weiter in der vollständigen Ausgabe!
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