Any person suffering from a medical condition likely to cause sudden incapacity should not drive Any person unable to control his/her vehicle safely should not drive \200 A medical pract itioner must prepare a medical report using Form D4. Medical assessment \200 Height \200 Weight \200 Smoking history \200 Alcohol consumption \200 Current medication \200 Corrected visual acuity >6/9 in the better eye and >6/12 in the other eye with uncorrected visual acuity being >3/60 in each eye Visual \201 elds intact \200 Medical history \200 epilepsy \200 other neurological conditions \200 diabetes \200 psychiatric illness \200 cardiovascular disease \200 blood pressure \200 musculoskeletal disease suf \201 cient to interfere with vehicle con trol. The \201 nal decision regarding \201 tness for Group 2 driving lies with the DVLA \200\231s medical adviser and not the examining doctor. Forklift truck operators Task demands Operation of a forklift truck, whether in a factory, on a farm, or on a build- ing site, can be associated with the following hazards: \200 Pr oximity to other vehicles and people 24_Smedley_Chap24.indd 474 1/2/2013 12:38:06 PM FITNESS TO DRIVE 2 475 Noisy environments \200 Relatively con \201 ned spaces \200 Frequent reversing and man euvering. General principles \200 There are no regulations governing \201 tness to oper ate forklifts on private ground. HSE has published useful guidance (see b p. 475, Legislati on and guidance) If the forklift is to be operated on the public highway, the operator must meet current DVLA standards on \201 tness to drive Operators should be 17 or over. Construction workers must be age 18. Agricultural workers should be over school-leaving age The \201 tness required is only that suf \201 cient for the task to be carried out safely and ef \201 ciently. Individuals with a disability should be assessed bearing i n mind good employment practices and disability legislation. Fitness requirements Include good eyesight, adequate hearing, and reasonable head/neck mobi l- ity. The ability to look over the shoulder is important; no condition that predisposes t o sudden loss of consciousness. Assessment frequency \200 Assess at pre-employment \200 Assess at 5-yearly intervals fr om age 40 \200 Over age 65 review annually \200 An operator with a medical condition sh ould be reviewed more frequently if this is indicated. Speci \201 c issues \200 Visual acuity should be 6/12 (corrected) with adequate visual \201 elds \200 Hearing should be suf \201 cient to understand instructions and warnings \200 Alcohol/drug addiction renders a worker un \201 t to operate a lift truck \200 C areful assessment is necessary where there is a history of psychosis \200 Poorly controll ed angina or conditions predisposing to loss of consciousness (arrhythmias, transient ischaemic attack (TIAs)) are a bar to work with lift trucks Epilepsy is acceptable where the criteria for a car license are met \200 Diabetes is perm itted subject to good glycaemic control. Loss of awareness of hypoglycaemia will probably render the diabetic un \201 t \200 Musculoskele tal problems should not signi \201 cantly impair the driver \200\231s ability to look up, sideways, or over the shoulder. Legislation and guidance \200 A guide to vehicle licensing requirements including de \201 nitions of license categories and vehicles is given at: M http://direct.gov.uk/ \200 HSE (2000). Safety in Working with Lift Trucks , HS(G)6. HSE, London. Available at: M http://www.hse.gov.uk/pubns/priced/hsg6.pdf 24_Smedley_Chap24.indd 475 1/2/2013 12:38:06 PM CHAPTER 24 Fitness for speci \201 c work 476 Fitness for professional diving Purpose To establish whether a worker is \201 t to undert ake diving at work and to identify, at an early stage, diving-related illnesses such as dys baric osteonecrosis. Dif \201 culties may arise when individuals undertake diving activity for hire or reward and do so out with (and in breach of) regula- tions (see b p. 544, Divi ng at Work Regulations 1997). General principles \200 Statutory medical assessments can only be carried out by an HSE approved medical examiner of divers. The examiner has to satisfy the HSE that they have the required knowledge of diving medicine to carry out this work. Usually, this knowledge is a cquired by attending a 5-day diving medicine course The initial medical assessment involves the prospective diver completing a medical questionnaire, which is then validated by his/ her GP. The approved me dical examiner then reviews this and advises whether the individual has a medical condition that would disqualify him/her from diving without a full assessment Prior to commencing diver training the prospective diver should undergo a full diving medic al examination. The results of this are recorded on form MA2 which includes the certi \201 cate of \201 tness to dive. The white copy of MA2 is given to the diver and the pink low er copy should be retained by the medical examiner for 7yrs Where a diver is found un \201 t to dive, he/she has the right to appeal this decision to HSE within 28 days. Assessment frequency \200 The medical certi \201 cate is valid for any period stipulated by the examining doctor up to a maximum of 12mths \200 Where a diver is medically un \201 t for work for >14 days or suffers a neurological, cardiorespiratory, or ear disorder, his/her \201 tness to dive must be reassessed by an approved examiner. Speci \201 c issues \200 Female divers should not dive when pregnant \200 CXR and long -bone views are only required where clinically indicated \200 The British Thoracic Societ y has issued guidelines on respiratory aspects of \201 tness for diving Extensive guidance on diving \201 tness standards is provided in the HSE publication MA1 which is available on the HSE website. The underlying principle is that the diver should not be at increased risk of a diving accident because of an existing medical condition. 24_Smedley_Chap24.indd 476 1/2/2013 12:38:06 PM FITNESS FOR PROFESSIONAL DIVING 477 Investigations required at diving medical Initial examination Annual review Exercise testing (step test) Exercise testing (step test) Resting ECG Resting ECG (5-yearly from age 40) Urinalysis Urinalysis Spirometry Spirometry Audiometry Full blood count Relevant legislation and guidance \200 Diving at Work Regulations 1997 \200 HSE The Med ical Examination and Assessment of Divers , MA1. HSE Books, London. Available at: M http://www.hse.gov.uk/diving/ma1.pdf \200 British Thoracic Society (2003). Guidelines on respiratory aspects of \201 tness for diving. Thorax , 58, 3 \200\22313. 24_Smedley_Chap24.indd 477 1/2/2013 12:38:06 PM CHAPTER 24 Fitness for speci \201 c work 478 Fitness for work in food handlers De \201 nition of a food handler A food handler manufact ures, prepares, or transports food, and may come into direct contact with the food or with machines handling unwrapped food. This de \201 nition includes engineers, cleaners, and th ose visiting the premises. The de \201 nition also includes those preparing or serving foo d in canteens and shops. Health screening Fitness for work is assessed by health screening. The screening process ai ms to exclude individuals with medical conditions that may pose a risk of microbiological o r general contamination of food products. The assess- ment should also identify conditions that may be caused or exacerbated by work, or jeopardize employee safety. Therefore, it sho uld identify the following: \200 Those suffering from, or carriers of, infectious disease which can be transmitted to the product, e.g. Norovirus infection of the GI tract \200 T hose suffering from conditions, such as an infected wound or skin condition, which can transmit pathogens Those suffering from conditions (e.g. respiratory/musculoskeletal) which may be exacerbated by work or make work unsafe (allergies/ blackouts). Screening process A questionnaire is completed before starting work, by visitors, or exist- ing employees returning from absence from work. Examples of questions are shown in the box opposite. Those with no positive answers can start work; those with a positive response mu st be assessed by a competent OH professional. Questionnaires are con \201 dential and mus t be handled as sensitive information under the Data Protection Act. 2 By law all food handlers must receive training in food hygiene. Legislation and guidance \200 NHS Plus, Royal College of Physicians, Faculty of Occupatio nal Medicine (2008). Infected food handlers: occupational aspects of management. A national guideline . RCP, London. Available at: M http:// www.nhsplus.nhs.uk/providers/clinicaleffe ctiveness-guidelines-evidence based.asp Food Handlers: Fitness to Work. Food Standards Agency. M http:// www.food.gov.uk/multimedia/pdfs/publication/ \201 tnesstoworkguide09v2. pdf 24_Smedley_Chap24.indd 478 1/2/2013 12:38:06 PM This page intentionally left blank CHAPTER 24 Fitness for speci \201 c work 480 Fitness for air passenger travel 1: the physics and physiology of air travel Many employees are required to \202 y as part of their job. This can cover a large spectrum from freque nt to infrequent \202 ying, and short to long-haul \202 ight. The main issues to consid er when advising about air travel are sum- marized here. Relative hypoxia \200 Most passenger aircraft are pressurized to between 4000 and 8000 fe et at their cruising altitude. This 20 \200\22330% reduction in air pressure results in a r eduction of the partial pressure of oxygen inspired Due to the sigmoid nature of the oxyhaemoglobin dissociation curve, this only results in ab out a 10% fall in oxyhaemoglobin saturation in healthy people (Fig. 24.1) However, those with signi \201 cant lung disease and a degree of hypoxia will operate on t he steeper section of the curve (Fig. 24.1). They are at risk of signi \201 cant desaturat ion. The risk varies between patients, particularly depending on hypoxic drive As a rough guide, in- \202 ight oxygen is likely to be needed if the individual \200\231s oxygen saturation (SaO 2 ) at sea level is less than 90%. Pressure change The reduction in ambient pressure also results in an increase in volume of any gas trapped in a body cavity: PV = constant (Boyle \200\231s law). Gas expansion in an aircraft cabin can be of the order of 20 \200\22340%. This is demonstrated by the need to \200\230clear the (middle) ears \200\231 when ascend- ing or descending. Other closed and s emi-closed cavities will be similarly affected. (cid:2) In ascending to altitude, passenger s are effectively decompressing in a similar way to an ascending diver. Therefore, traveler s who have been on diving holidays should carefully plan their last days of diving to reduc e the risk of decompression illness during their \202 ight home. Low humidity The air conditioning of cabin air results in low humidity and can lead to a mo dest drying of mucous membranes. There is no evidence that even the longest \202 ight wou ld contribute to passengers becoming dehydrated. Seated immobility \200 Air travel leads to long periods of sitting with limited posture c hanges. Flights longer than 4h are considered a risk factor for developing DVT Travelers with pre-existing risk factors (e.g. recent surgery, known clotting disorders, ma lignancy, etc.) should seek medical advice. Preventative strategies range from leg exercise s/stockings to medication (e.g. aspirin, heparin). 24_Smedley_Chap24.indd 480 1/2/2013 12:38:06 PM FITNESS FOR AIR PASSENGER TRAVEL 1 481 Noise and motion Noise (engine noise, cabin ventilation systems, and air \202 ow over the exter- nal surfaces) is not a hazard to hearing, but may be a factor in travel fatigue. Stu dies have shown that 0.5% of passengers have vomited and 8.4% experience nausea in \202 i ght, especially in turbulence. Stress New environments, time pressures, and delays can increase stress in vul- nerable peo ple. Fear of \202 ying is common and can normally be dismissed, but desensitization is av ailable for the few who are severely affected. 100 80 ) % ( 2 O a S / n o i t a r u t a s 60 t e e F t e e F l e v e l 0 0 0 8 0 0 0 5 a e S 40 n e g y x O 20 0 2 4 6 8 10 12 14 16 KPa 0 20 40 60 pO2 80 100 120 mmHg Fig. 24.1. Effect of cabin pressure on oxygen saturation in a healthy passenger. Those with cardiovascular and respiratory disease where SaO 2 is below 90% may operate on the steeper part of the curve with signi \201 cant desaturation at altitude. 24_Smedley_Chap24.indd 481 1/2/2013 12:38:06 PM CHAPTER 24 Fitness for speci \201 c work 482 Fitness for air passenger travel 2: speci \201 c medical conditions Medical conditions tha t need assessment prior to \202 ight can be divided: \200 Stable chronic (e.g. chronic obstructive pulmonary disease) \200 Chronic with recent change (myocardial infarction and angina) \200 Acute (e.g. illness, injury, surgery). The physiological challenges of air travel outlined on the previous page need to be taken into account in the assessment of \201 tness to \202 y. Most large airlines have medical advisers who advise on \201 tness to \202 y. Usually, a few weeks in advance, the passenger and his/her doctor are asked to complete a Medical In formation Form (MEDIF). This allows the airline to assess the risks of travel and/or any sp ecial facilities needed (e.g. stretcher, oxygen, escort). Extensive guidance is available from government, regulators, and airlines (see b p. 483, Fu rther information and guidance). Most guidance is prag- matic and often not evidence based, and speci \201 c rules can vary between carriers. The most important examples are given h ere. Cardiovascular and respiratory disease \200 Broadly, if a passenger can walk 50m without dyspnoea, the relative hypoxia at altitude will not generally present signi \201 cant dif \201 culty \200 Recent cardiovascular event should result in caution because of the relative hypoxia and risk of further acute event. As a general guide, do not allow air trav el if myocardial infarct within 10 days if uncomplicated (3 \200\2234wks with complications ), coronary angioplasty within 3 \200\2235 days, cerebrovascular accident within 3 days Pneumothorax: passengers with pneumothorax should not \202 y for 6wks. Diabetes \200 Crossing time zones and disruption of sleep/meal patterns can risk destabilizing control Diabetic passengers should be advised to stay on home time for medication until arrival Modern (basal bolus) regimes make problems less likely with good education, and medication should be carried in hand baggage because of low temperatures in the aircraft hold. Sharps (e.g. needles) must be declared for security reasons. Pregnancy Most carriers will allow travel up to the 36th week for single pregnancies and th e 32nd week for multiple pregnancies. Infectious disease \200 It is an international health regulation that individuals should not \202 y during the infectious phase of a contagious disease The main risk is the proximity of others (rather than spread via the cabin air, which is \201 ltered) and acute worsening of the condition. 24_Smedley_Chap24.indd 482 1/2/2013 12:38:07 PM FITNESS FOR AIR PASSENGER TRAVEL 2 483 Other \200 Recent surgery: advise against \202 ying within 10 days, because of risk of trapped gas (eye, abdomen) and DVT ENT conditions: those affecting Eustachian tube patency can cause tympanic membrane rupture Anemia: risk of severe hypoxia if hemoglobin is <7.5g/dL \200 Psychiatric: patients with acute psychotic illness require an escort and available sedation Fractures: restrict \202 ying for 24 \200\22348h. On-board facilities for dealing with medical emergencies All cabin staff are trained in \201 rst aid, including de \201 brillation when auto- matic external de \201 brillators ( AEDs) are carried. Aircraft are required to carry extensive \201 rst aid and medical pack s, which include drugs to treat the commonly occurring ailments. Many airlines also subscri be to air-to- ground medical services which can advise crew and medical attendants. Further information and guidance Federal Aviation Administration. Passenger health and safe ty guidance . Available at: M http://www. faa.gov/passengers/ \202 y_safe/health/ British Thoracic Society Guidelines (2011). Air travel guidelines . Available at: M http:// www. brit-thoracic.org.uk/guidelines/air-travel-guideline.aspx British Lung Foundation lea \202 et on \202 ying with a lung condition. M http://www.lun guk.org/you-and- your-lungs/living-with-a-lung-condition/air-travel 24_Smedley_Chap24.indd 483 1/2/2013 12:38:07 PM CHAPTER 24 Fitness for speci \201 c work 484 Fitness for work in professional pilots: commercial pilots/aircrew Regulation/standards \200 The international standards for the medical \201 tness of aircrew are maintained an d updated by the International Civil Aviation Organization (ICAO) In the UK, the European Aviation Safety Agency (EASA) currently de \201 ne standards for airworthiness, operations, and licensing compliant with the ICAO standards. A number of private or sport \202 ying regulations remain under UK Civil Aviat ion Authority (CAA) oversight \200 These regulatory provisions cannot cover every aeromed ical situation. Therefore, to facilitate \202 exibility, \200\230accredited medical conc lusion \200\231 (a decision by one or more medical experts), operational limitations, and r elevant pilot skill and experience can be taken into account if the licensing authority bel ieves that this would not jeopardize \202 ight safety. However, this \202 exibility sta ndard has resulted in different national regulators around the world applying different sta ndards. Medical assessment of pilots Process \200 Aircrew are medically examined annually under t he age of 40yrs, and 6-monthly thereafter if undertaking single pilot operations \200 A health declaration is completed and a physical examination performed. Clinical tests focus on visual performance and ECG and audiogram when required Any pilot not meeting the standard is referred to the regulatory authority, who de \201 nes what further investigation/evidence is required A medical certi \201 cate to \202 y may be temporarily or permanently suspended at any time if there is a risk to \202 ight safety. Principles Fitness for aircrew is based on two broad principles: the physical and men- tal capability to \202 y/operate the aircraft, and the risk of an acute incapacitat- ing even t whilst \202 ying (which could lead to a fatal accident). Functional capability \200 Visual acuity: good vision is required for long distance (to t axi, take off, and land the aircraft under visual conditions), intermediate (reading and op erating cockpit instruments), and near distance (reading maps/ \202 ight plans, etc.) Color vision: acceptable color discrimination is required to identify signal lights from ai r traf \201 c control, and other aircraft, vehicles, buildings, etc. Visual \201 eld: a normal visual \201 eld is required to maintain an adequate look-out to identify and avoid other aircraft Good hearing is required for communicating with and understanding instructions from air tra f \201 c control and other members of the \202 ight crew, sometimes on a noisy \202 ig ht deck 24_Smedley_Chap24.indd 484 1/2/2013 12:38:07 PM FITNESS FOR WORK IN PROFESSIONAL PILOTS 485 Physical operation of aircraft controls and switches, and ability to assist passengers in the event of emergency Psychological stability: cognitive functions are important in dealing with complex aircraft and air traf \201 c environments. Also, a proportion of accidents worldwide have been att ributed to untreated depressive illness, alcohol and substance misuse, and the suicidal int ent of one or more of the crew. Incapacitation risk \200 Over the last two decades in the UK and elsewhere, and latterly within the European member states, an annual medical incapacitation risk limit of 1% has be en applied in two-pilot public transportation operations. This is known as the \200\2301% rule \200\231, and assumes a target all-cause fatal accident rate for large public transpor tation aircraft of 1 per 10 7 \202 ying hours, not more than 10% of which should be due t o one system failure (e.g. pilot failure), and not more than 10% of system failures should be due to a subsystem failure (e.g. medical incapacitation) This gives a target fatal accident rate due to aircrew medical incapacitation of 1 accident per 10 9 h. This is almost unachievable in single-pilot operat ions The times during which the aircraft is closest to the ground (i.e. take- off and initial climb, and approach and landing) are the accident-critical phases. At the t ime the 1% rule was formulated, it was considered that in- \202 ight incapacitation of one of the pilots would result in a fatal accident in about one in 1000 such events. Therefore in order to achieve the target medical cause fatal accident rate of one accident per 10 9 h, neither pilot should have a risk of medical incapacitation greater than one in 10 6 h, i .e. approximately 1% in 1yr. Note that the maximum DVLA Group 2 (LGV) driving risk is 2%. (cid:2) However, since its development there have been important changes to airline operati ons. Flights have become longer and aircraft more auto- mated, so a higher risk might be to lerable whilst maintaining \202 ight safety. Some States accept risks of 2% per annum, al though this has not been accepted universally. Cabin crew Cabin crew \201 tness is currently not formally regulated in the UK, and there is no published work supporting health standards in relation to safety. New EASA standards for cabin crew are to be introduced based on an initial medical examination followed by pe riodic reassessment. Clinical examination/investigation is only required if an abnormality or condition is disclosed/discovered. Most airlines rely on a focused health enquiry by que stionnaire, which relates to international travel health and providing regular and ef \201 cient service. This minimizes operational dif \201 culties due to recurrent sickness abse nce. Further information ICAO. Available at: M http://www.icao.int/Pages/default.aspxpilots/airc rew 24_Smedley_Chap24.indd 485 1/2/2013 12:38:07 PM CHAPTER 24 Fitness for speci \201 c work 486 Fitness for military service Recruits Principles of screening \200 Recruits to the armed forces must undergo intensive training, which is physically arduous and mentally taxing. Th ey need to be of robust constitution, free from disease and injury. Given the investment pl aced in individuals in military training, those who are likely to be lost from training on medical grounds need to be screened out On completion of training, personnel may operate in locations remote from medical care, and in situations where illness or injury of one individual may have profound and immediate ef fects on units \200 Opportunities for \202 exibility of employment are very limited, an d to remain in the military most individuals will need to be \201 t for unrestricted acti ve service (i.e. at sea or on operations) This isolation means that medical follow-up of existing conditions can be impossible, and medication may not be available An initial engagement in the military can be for many years, and so any chronic effects fro m past conditions or injuries must be considered \200 These all mitigate towards setting a high initial standard of \201 tness for the military. This standard needs to be generic since many different centers are providing recruitment medicals. The minimum standards app ly across all three services, but certain branches of the military, notably aircrew and div ers, have higher requirements (see b p. 487). Screening process \200 In the UK, initial medicals will normally be carried out by unifor med or civilian medical of \201 cers on contract to MOD, and where appropriate a full hist ory will also be obtained from the recruit \200\231s GP. Specialist referral may be necessa ry Candidate is assessed using a grading system PULHHEEMS and compared with a pre-determined p ro \201 le for his/her chosen specialization If successful, following the medical examination, the candidate will be required to complete a \201 tness assessment. In service \200 Many countries maintain a separate military health system. In the UK this is limited to responsibilities for primary care (including occupational health, community mental health, and rehabilitation) and operational medical care. Secondary care is the resp onsibility of the NHS, although some cases may be fast tracked to obtain an early return to service Decisions on \201 tness for work are the prerogative of service medical of \201 cers and MOD civilian medical practitioners. NHS GPs may only treat military personnel as temporary residents, and can only certify them as un \201 t to travel rather than un \201 t to wor k A detailed system of Medical Employability Standards (MESs) describing capability in each environment has now been introduced 24_Smedley_Chap24.indd 486 1/2/2013 12:38:07 PM FITNESS FOR MILITARY SERVICE 487 Where individuals fall below standards in the long term (normally >12mths), they will be required to appear before a medical board to assess functional capac ity. The relevant service personnel departments will subsequently decide if they can contin ue to serve under speci \201 ed restrictions. If long-term employment is not available, th ey will be medically retired. Speci \201 c medical conditions affecting \201 tness for entry to UK Armed Services \200 Personnel with a history of anxiety do not do well in the armed forces, and so equal weight must be given to mental \201 tness. Repeated self-harm, mood disorders, and ongoin g medication will normally be a bar to entry Chronic medical conditions such as asthma, epilepsy, eczema, and migraine are usually incompatible with service Orthopedic conditions or injuries, particularly affecting the lower limbs, are likely to prejudice new entry training There are speci \201 c eyesight requirements for individual branches and services, as well as an overall minimum generic standard. If in doubt, a proper opthalmological evaluation i s essential Conditions requiring regular medication, speci \201 c diets, and allergies will normally b e unacceptable for service because of operational constraints affecting supply, catering, e tc. Many conditions, such as cardiological murmurs, will require formal specialist evaluation Further information is available from Armed Forces Careers Of \201 ces. Military pilots In the UK and many countries, civilian aviation authorities have no jurisdi c- tion over aircraft on the military register. Furthermore, the high medical standards set for commercial aircrew in order to ensure \202 ight and pas- senger safety are not alway s enough to satisfy the demands of military \202 ying. Therefore, a separate system of st andards and regulatory systems is required. These are additional to the considerations that apply to any military recruit outlined here. Standards \200 In view of joint operations with other air forces, some joint standardization is also necessary These standards will be re \202 ected in a system of medical grading which should only be applied by those speci \201 cally trained and familiar with the requirement There may be an additional requirement imposed for aptitude testing, and cognitive testing may form part of a separate non-medical assessment. May incl ude ability to tolerate high G forces where appropriate. 24_Smedley_Chap24.indd 487 1/2/2013 12:38:07 PM CHAPTER 24 Fitness for speci \201 c work 488 Medical standards for military pilots The following are relevant in the assessment of medical standards for military pilots: \200 Flight safety \200 Aviation environment Risk of incapacitation \200 Hypoxia, hypobaria, acceleration, extremes of temperature, noise, vibration Mission accomplishment \200 Operational ef \201 ciency \200 Cost effectiveness \200 Escape and evasion \200 Nuclear biological chemical \200 War role Ability to complete task \200 Ability to perform task repeatedly \200 Is outcome worth investment \200 Ability to survive if shot down \200 Ability to operate warfare environ ment Relevant legislation The Armed Services are currently exempt from the disability provisions of The Equality Act 2010. 24_Smedley_Chap24.indd 488 1/2/2013 12:38:07 PM This page intentionally left blank CHAPTER 24 Fitness for speci \201 c work 490 Fitness for work in health care De \201 nition HCWs are those whose work involves medical management of patients, and wider aspects of their health and social care. Health care work is one of the most common occupations in the UK, including almost 2 million employees in t he public (NHS) and private sectors. Three groups of HCW have been de \201 ned for practical purposes: \200 Clinical and othe r staff: including those in primary care and students, who have regular clinical contact with patients. This includes doctors, dentists, nurses; p aramedical professionals such as occupational therapists, physiotherapists, radiographers; ambulance workers \200 Laboratory and other staff (including mortuary staff): who have direct contact with potentially infectious clinical specimens and may additionally be expos ed to pathogens in the laboratory. This includes those in academic (or commercial research) laboratories who handle clinical specimens. They do not normally have direct contact with patients Non-clinical ancillary staff: who may have social contact with patients, but not usually of a prolonged or close nature. This group includes receptionists, ward clerks, administrativ e staff working in hospitals and primary care, and maintenance staff such as engineers, gar deners, cleaners, etc. Speci \201 c hazards and occupational disorders in health care \200 Infection (see b p. 103, Biological hazards and b p. 149, Occupational infections, for individual hazards and diseases) Violence (see b p. 136, Violence and aggression) \200 Musculoskeletal disorders: low back (see b p. 254, Low back pain) and neck/shoulder pain) Stress (see b p. 308, Stress 1: recognition and assessment; b p. 311, Stress 2: interventions/risk controls) Latex allergy (see b p. 202, Latex allergy) \200 Dermatitis (see b p. 242, Dermatitis 1; b p. 244, Dermatitis 2) \200 Radiation (see b p. 18, Ionizing radiation 2: principles of radiation protection) \200 Cytotoxic drugs. Fitness assessment Health care work covers a very wide range of duties. HCWs often change r ole, and robust arrangements should be made to identify internal job changes, with reassess ment of \201 tness where appropriate. Standard health clearance 1 for new HCW includes ch ecks for tuberculosis disease/immu- nity, HBV immunization with post-immunization testing o f immunity, and the offer of HIV and HCV tests. Immunity from vaccine-preventable infections is advisable (Table 24.1) 1 Department of Health. (2007). Health clearance for tuberculosis, hepatitis B, hepatitis C and HIV: new healthcare workers \200\231. DH, London. 24_Smedley_Chap24.indd 490 1/2/2013 12:38:07 PM FITNESS FOR WORK IN HEALTH CARE 491 Table 24.1 Immunization requirements for HCWs Recommended routine assessment of immunity and immunization Clinical (1) Laboratory (2) Non-clinical (3) DPT and MMR BCG not routinely recommended + + For polio, only boost those handling fecal specimens; diphtheria special arrangements to boost those handling organisms History of routine childhood immunization: diphtheria, polio, tetanus (DPT); mumps, measles , rubella (MMR); tuberculosis (BCG) or positive measles, rubella antibodies, and Mantoux te st if no satisfactory history of immunity and immunization of non-immune History of infection with varicella (chicken pox) or positive varicella antibodies if histo ry unsatisfactory and immunization of non-immune + + + History of immunization against hepatitis B and immunization, followed by check of serology in non-immune + + + If exposed to blood or body \202 uids History of immunization against hepatitis A and typhoid and immunization of non-immune Only if handling speci \201 c organisms Only if exposed to sewage, e.g. drainage engineers In \202 uenza: offer of annual immunization + Only if handling organisms Cholera, meningococcus ACW 135Y, smallpox, tick-borne encephalitis, yellow fever, rabies, J apanese encephalitis, anthrax Only if handling speci \201 c organisms Detailed guidance: Department of health. Chapter 12. In: Immunization against infectious di sease . Available at: M http://www.dh.gov.uk/health/category/publications/reports-publicati ons/ Special \201 tness requirements \200 Fitness for exposure prone procedures (see b p. 49 4, Fitness for exposure prone procedures 1; b p. 496, Fitness for exposure prone procedures 2) \200 Fitness to work with children and vulnerable patients (see b p. 498, Fitness to work with children). 24_Smedley_Chap24.indd 491 1/2/2013 12:38:07 PM CHAPTER 24 Fitness for speci \201 c work 492 Transfer of information about \201 tness for work Transfer of OH records or conclusions a bout \201 tness for work (including immunization status) should only be done with the emp loyee \200\231s consent. Smart cards (transferable electronic record) are increasingly used for some staff groups, e.g. junior doctors and medical students. Specialist skills for professionals who care for HCWs It is recognized that OH and other he alth professionals who provide care and support to healthcare practitioners need particular skills, including the management of alcohol and substance abuse. The Faculty of Occupation al Medicine and Royal College of Psychiatrists have published guidance on competencies for OH Physicians and psychiatrists, respectively. 24_Smedley_Chap24.indd 492 1/2/2013 12:38:08 PM This page intentionally left blank CHAPTER 24 Fitness for speci \201 c work 494 Fitness for exposure prone procedures 1 De \201 nition of EPPs EPPs are health care proced ures where there is a risk that injury to the HCW may result in the exposure of the patient \200\231s open tissues to the blood of the worker (bleed-back). Procedures include those w here the worker \200\231s gloved hands may be in contact with sharp instruments, needle tip s and sharp tissues (spicules of bone or teeth) inside a patient \200\231s open body cavity , wound, or con \201 ned anatomical space where the hands or \201 ngertips may not be co mpletely visible at all times. Categorization of EPPs EPPs are classi \201 ed according to the likelihood that infection would be transmitted from an infected HCW to the patient. Category 1 Procedures where the hands and \201 ngertips of the worker are usually vis- ib le and outside of the body most of the time and the possibility of injury to the worker \200\231s gloved hands from sharp instruments and/or tissues is slight. This means that the risk of the HCW bleeding into the patient \200\231s open tissues should be remote. Category 2 Procedures where the \201 ngertips may not be visible at all times but injury to the worker \200\231s gloved hands from sharp instruments and/or tissues is unlikely. If injury occurs it is likely to be noticed and acted upon quickly to avoid the HCW \200\231s blood contaminating the patient \200\231s open tissues. Category 3 Procedures where the \201 ngertips are out of sight for a signi \201 cant par t of the procedure, or during certain stages, and in which there is a distinct risk of inju ry to the worker \200\231s gloved hands from sharp instruments and/or tissues. In such circ umstances it is possible that exposure of the patient \200\231s open tissues to the HCW \200\231s blood may go unnoticed or would not be noticed immediately. Transmission from infected HCW to patients following EPPs \200 HBV transmission from HbeA g positive HCW is well documented. Several transmissions from HbeAg negative HCW prompted the use of HBV viral load testing in determining \201 tness for EPPs HCV \200\2245 reported incidents of transmission to 15 patients in the UK, and at least 4 other incidents worldwide HIV \200\2243 reported incidents with 8 possible transmissions worldwide. None in the UK de spite 28 noti \201 cation exercises in 7,000 patients up to the year 2003.The risk of tran smission to patients is very low. Duties of health care workers HCWs who carry out EPPs and believe they have been exposed to BBV have a duty to seek professional advice on whether they should be tested. HCWs who kno w they are infected must seek and follow con \201 dential occupational health and expert m edical advice. 24_Smedley_Chap24.indd 494 1/2/2013 12:38:08 PM FITNESS FOR EXPOSURE-PRONE PROCEDURES 1 495 Duties of employers Employers in the health care sector must \200 Ensure that staff are a ware of the guidance on BBV and EPPs \200 Make every effort to arrange occupational adjus tments, re-training, or (as a last resort) ill health retirement for infected employees \200 Promote a climate wh ich encourages con \201 dential disclosure \200 Arrange for HCW to have access to a Cons ultant Occupational Physician. Table 24.2 Summary of testing protocol to assess \201 tness for EPPs Initial screening (minimum documentation of \201 tness for EPPs) Periodic annual screening All HCW undertaking EPPs HBsAg \200\223ve or HBsAg +ve, but HBeAg \200\223ve and HBV DNA< 10 3 copies /mL Annual HBsAg if non-responder to vaccine (persistent anti-HBs <10 IU/L) and not naturally i mmune (anti-HBc \200\223ve) Annual HBV DNA (must remain below 10 3 geq/mL) New HCW Anti-HCV \200\223ve or Anti-HCV +ve AND HCV RNA \200\223ve and Anti-HIV \200\223 ve Routine assessment of \201 tness for EPPs Laboratory tests (summary in Table 24.2) \200 In new HCW: 1 HBsAg (and, if negative, HBeAg with viral load testing (HBV DNA) in those who are HBeAg +ve) and HCV antibody (and, if +ve, HCV RNA) \200 and HIV antibody. Must be carried out on an identi \201 ed validated sample (IVS), i.e.: \200 blood sample taken in an occupational health department \200 photographic proof of identity provided \200 sample not delivered to laboratory by HCW Must be carried out in an accredited laboratory. Only two speci \201 c laboratories are de signated by DH for HBV DNA testing (see HSC 2000/020 under Further reading and guidance ( b p. 496, Exposure prone procedures 2). 1 New HCW are de \201 ned as those who are new to the NHS, those who are starting a post o r training involving EPPs for the \201 rst time, and those who are returning to the NHS a nd many have been exposed to BBV while they were away. All locum and agency recruited HCW p erforming EPPs should be treated as new HCW. 24_Smedley_Chap24.indd 495 1/2/2013 12:38:08 PM CHAPTER 24 Fitness for speci \201 c work 496 Fitness for exposure prone procedures 2 Restrictions from work involving EPPs Box 24.1 summ arizes the current UK guidance on initial restriction of the practice of HCWs who are infec ted with blood-borne viruses, and the speci \201 c circumstances under which HCWs can be a llowed to return to EPPs following appropriate treatment.