Under surveillance

Risk assessment was the theme that ran throughout the whole day at an IRS conference held recently on COSHH (The Control of Substances hazardous to health) and health surveillance.

Every speaker began by stressing the importance of carrying out a suitable and sufficient risk assessment before considering appropriate control measures.

Occupational hygienist Alvin Woolley opened the conference by setting health surveillance into the context of control measures. His opening comment was that ‘health surveillance does not control or prevent occupational ill health by itself’. It is one element in an integrated control programme. He used the mnemonic ACME (see Figure 1) to outline the basic requirements of COSHH and to be used as an easy way to remember what is required by legislation and the COSHH code of practice (ACoP), which was introduced earlier this year.1

The new ACoP focuses on good practice and introduces eight principles for employers to consider regardless of any exposure limits. The Health & Safety Executive (HSE) has also introduced a single type of exposure limit – namely a Workplace Exposure Limit (WELs), which replaces both the Maximum Exposure Limit (MELs) and Occupational Exposure Standards (OESs).

COSHH Regulation 11 covers health surveillance and specifies that it should only be undertaken where there are valid techniques for detecting disease and that the technique is low risk to employees (see Figure 2).

However Woolley commented that educating and training was an important part of control, because employees need to understand the problem as well as the nature of the substances they are handling. In his experience as an occupational hygienist, he said he had found that risk assessments were often poorly carried out, suitable health surveillance not considered, and that 89% of ventilation companies’ advise inappropriate ventilation as a control measure. He concluded that there is still a lot to be done to prevent the 10,000 deaths a year in the UK attributable to hazardous substances.

Dr David Fishwick, from Sheffield Occupational and Environmental Lung Injury Centre, then gave an overview of occupational asthma.
He talked about the research done on the New York firefighters following the terrorist attacks on September 11 – after they had been exposed to a number of respiratory irritants, 90% of which were greater than 10 microns:



  • Mineral wool
  • Fibre glass
  • Asbestos
  • Wood
  • Paper
  • Cotton
  • Polycyclic hydrocarbons.

The conclusion is that RADS – Reactive Airway Dysfunction Syndrome – is common and is a wheezy, asthma-like state following an accident or spill. Fishwick recommends the maxim: ‘Think accidents, think asthma, think RADS’

Fishwick continued by exploring occupational asthma, giving examples of causes from:



  • Animals – urine, prawns, etc
  • Plants – flour, latex, henna, etc
  • Wood and barks – oak, mahogany, etc
  • Chemicals and metals – TDI, platinum salts, etc
  • Enzymes – fungal amylase, etc
  • Other – such as colophony and oil mists.

He stated that the key to suspecting occupational asthma lies with taking a history, including hobbies and home activities, as well as finding out about existing ventilation and humidifier systems and generally having a knowledge of the working environment.

He also advised finding out if the symptoms are the same, better or worse on rest days or holidays. He recommended the BOHRF (British Occupational Health Research Foundation) document on occupational asthma,3 as well as the HSE health surveillance MS25.4

Fishwick has volunteered to read any peak flow measurements that readers may wish to send to him and to send a copy of the respiratory questionnaire that he uses (see contact details at the end of the article).

Looking at the practical aspects of respiratory health surveillance, Robert Dunn, operations manager at Oxford University Occupational Health Service, outlined the roles, responsibilities and procedures used by the OH service at the university, where nearly 25,000 staff and research students are employed.

Many of these are working with substances that come under COSHH, including the animal handling. Following risk assessment procedures, a pre-placement health assessment is carried out on those who will be working with identified respiratory sensitisers. Each individual has to complete a questionnaire outlining their past history, and then the department that is to employ the individual must complete an individual risk assessment form according to the specific role of the client. Oxford University OHS has interpreted the HSE Guidance note MS25 and included three levels of surveillance, rather than just two. These are:



  • Low-level surveillance
  • Standard surveillance
  • High-level surveillance.

A leaflet has been devised by the OH staff that provides information on respiratory sensitisers. This is then given to each employee who is likely to work with respiratory sensitisers. Where spirometry is required, the OH department uses computerised spirometry with the results fed directly from the client into the computer, recorded and analysed straight onto the client’s medical record. Dunn said that this is proving to be a valuable method because it enables spirometry testing to be taken out into the workplace using a laptop and mouthpiece; this cuts down on time away from work for the employees and incidences of non attendance at the OH department.

Dr Sian Williams, consultant OH physician from the Royal Free Hampstead NHS Trust, reminded the conference of the place of blood borne viruses (BBVs) under COSHH, as well as the containment conditions laid down under the Advisory Committee on Dangerous Pathogens (ACDP).

She commented that Protection against blood borne infections in the workplace: HIV and hepatitis 1995 is still current.5 The risk remains very low; research data on HIV prevalence studies of heathcare workers show seroprevalence as low, or lower, than the general population.6

She said that the Royal Free has tested hundreds of staff – post needlestick injury – over the years and so far no-one has tested positive. But, despite all the procedures to prevent needlestick and sharps injuries, these still occur because people continue to ignore safe systems of working.

Chris Packham, a dermatological engineer and a partner in EnviroDerm Services, discussed the important significance of skin conditions and health surveillance under COSHH, and presented the information available from Technical Bulletin No 4 on his website.7

Anne Harriss, reader in OH at South Bank University, concluded the day by talking about the ethical implications of health surveillance under COSHH, highlighting in particular the issues of linking health assessment with risk assessment and record keeping. She stressed the need for transparency and clear written procedures detailing:



  • what is actually meant by health surveillance
  • who, what, why, when and how of the processes
  • the actual procedures and recording of results
  • procedures following abnormal results.

Harriss queried the fact whether health surveillance, which is not evidence-based is ethical, and she went on to outline the ethical principles that provide a framework for moral decision-making



  • Beneficence
  • Autonomy
  • Non-Maleficence
  • Justice.8

The day demonstrated that there was much more to COSHH and health surveillance than merely the utilisation of screening procedures,9 and that it is important for OH professionals to ensure that it is only carried out following appropriate risk assessment.

Contact Dr David Fishwick by e-mail at d.fishwick@sheffield.ac.uk

Greta Thornbory is an OH and educational consultant with nearly 30 years experience in practice and teaching. She has worked with government departments, professional bodies, pharmaceutical, educational and other companies on a variety of occupational health and safety projects.

References
1. HSE (2005) Control of substances hazardous to health; approved code of practice, HSE
2. Banauch G et al (2003) Persistent hyper reactivity and reactive airways dysfunction in firefighters at the World Trade Centre, Am J Crit Care Med 2003: 168: 54-62
3. British Occupational Health Research Foundation (undated) Occupational Asthma: a guide for employers, workers and their representatives, BOHRF www.bohrf.org.uk/content/asthma.htm
4. HSE Guidance Note MS 25 (second edition) Medical Aspects of occupational asthma
5. Protection against blood-borne infections in the workplace: HIV and hepatitis, ACDP (1995) The Stationery Office
6. Beltrami EM, Williams IT, Shapiro CN, Chamberland ME (2000) Risk and management of blood borne infections in healthcare workers. Clinical Microbiology Reviews 13; 385-407
7. www.enviroderm.co.uk
8. Westerholm, Nilstun & Ouvreteit (eds) (2004) Practical ethics in occupational health, Oxford: Radcliffe Publishing
9. Beaglehole R, Bonita R, Kjellstrm T (2001) Basic Epidemiology, WHO (www.who.int)

ACME

Assess
Control
Monitor
Educate and train

Health surveillance under COSHH may include

Biological monitoring
Medical surveillance
Lung function tests
Enquiries about symptoms
Skin checks
Review of records


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