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Ampath Medical Surveillance Guidelines Metal Chemicals AMPATH MEDICAL SURVEILLANCE GUIDELINES METAL CHEMICALS TABLE OF CONTENTS Introduction 3 Definitions 4 Biological monitoring 7 Biological effect monitoring 15 Health program 15 Food handler’s health program 16 Driver’s health program 16 Substance abuse in the workplace 17 Alcohol in the workplace 17 Target organs for alcohol abuse 21 Drugs in the workplace 22 Ampath drugs of abuse screening and confirmatory tests on urine 23 Conditions under which a pathologist will testify in court 23 Chain of custody 24 Hazardous chemical regulations 25 Designing and implementing a program of medical surveillance 25 Assessment of potential exposure 25 Table 3 substances 26 Available tests 27 Test interpretation 31 Ampath Quality Assurance 33 Designing exposure profiles 34 Work related hazardous chemical exposure 36 Chemical exposure: DNA adducts 37 Target organs for chemical exposure 39 Chemical exposure profiles 40 Aniline 40 Acetone 41 Benzene 42 Carbon disulphide 43 Carbon monoxide 44 Cyanide 45 Ethyl benzene 46 NN-dimethylformamide 47 Furfural 48 N-hexane 49 © Ampath Medical Surveillance Guideline 1 Isocyanate 50 Methanol 51 Methyl chloroform 52 Methyl ethyl ketone 53 Methyl isobutyl ketone 54 Nitrobenzene 55 Organophosphorous cholinesterase inhibitors 56 Paraquat 57 Parathion 58 Pentachlorophenol 59 Perchloroethylene 60 Phenol 61 Polycyclic aromatic hydrocarbon(PAH) 62 Styrene 64 Toluene 65 Trichloroethylene 67 Xylene 68 Metals 69 Diagnosis and investigation of occupational exposure to metals; a general review 69 Target organs for metal exposure 72 Metal allergies in the workplace 73 MELISA testing in Ampath 73 Aluminium 74 Antimony 75 Arsenic 76 Cadmium 77 Chrome VI 78 Cobalt 79 Fluoride 80 Lead 82 Manganese 85 Mercury 86 Nickel 87 Vanadium 88 Client registration 89 Ampath electronic results 90 Report formats 91 Contact details 93 Useful websites 95 References and acknowledgements 96 2 © Ampath Medical Surveillance Guideline INTRODUCTION Occupational health is a multi-dimensional field, encompassing science, social progress, economics, law, employment studies, and issues common to every family. The health and safety of people at work is a critical concern for all societies and all countries. The field of occupational health touches on fundamental aspects of working life: • making a living • providing for a family • staying healthy • avoiding unnecessary risk of injury • protecting oneself and others from harm • creating useful products and services for societal benefit • anticipating and preventing future problems • sharing information • the right to knowledge of potential health hazards • fairness and justice in the treatment of workers • achieving responsibility and accountability in the workplace • minimizing the risk of necessary but hazardous work Occupational health (medical surveillance and biological monitoring) excellence requires a multi-disciplinary approach to prevent health impairment that might result from excessive, acute or chronic exposure to occupational hazards and risks in particular for chemical agents. Early detection of such excessive and hazardous exposures may significantly decrease the occurrence of adverse health effects, by reducing the level of exposure, in areas and people found to be at risk. Monitoring of exposure is a procedure which consists of the routine assessment and the interpretation of biological (human) and/or ambient (environmental) parameters in order to detect the earliest physiological, abnormal and pathological changes This approach requires a systematic Program of anticipation, recognition and identification of: • the definition of permissible levels of exposure, that is, levels that according to the present status of knowledge are estimated to cause no adverse effects during the lifetime of the workers, • the regular assessment of the health risks associated with exposure by comparing the employee populations health outcomes with their exposures limits and • implementing and reviewing preventive actions and health assessments. The World Health Organization defines Occupational Health as follows: • Promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations • Prevention among workers of departures from health caused by their working conditions • Protection of workers in their employment form risks resulting from factors which are inimical to health • The placing and maintenance of a worker in an occupational environment adapted to his physiological and psychological conditions. © Ampath Medical Surveillance Guideline 3 DEFINITIONS medical surveillance (occupational health and safety (ohs) act) Medical Surveillance means a planned program of periodic examination of employees (which may include clinical examinations, biological monitoring or medical tests) by an occupational health practitioner or, in prescribed cases, by an occupational medicine practitioner. health surveillance Health surveillance is the periodic medico-physiological examination of exposed workers (prior, during and on leaving the workplace) with the objective of protecting health and preventing occupationally-related disease. The detection and diagnosis of established disease is outside the scope of this definition even though both exposure monitoring and diagnosis of occupational disease programs are interrelated with health surveillance – health surveillance data should trigger a critical review of exposure information and ensure appropriate referral for the diagnosis of occupational disease. Similarly, as for health surveillance, exposure and occupational disease data should trigger a review of health surveillance program with necessary improvements. biological monitoring (occupational health and safety (ohs) act) Biological monitoring means a planned program of periodic collection and analysis of body fluid, tissues, excreta or exhaled air in order to detect and quantify the exposure to, or absorption of, any substance or organism by human beings. For clarification, the measurement of specific substances, for example lead, mercury and chrome are undertaken. biological effect monitoring Biological effect monitoring is the measurement of a reversible biochemical change caused by the absorption of the substance,the degree of change being below that associated with toxic injury (poisoning) and not associated with a known irreversible pathological effect. Exposure can be assessed either by measuring the concentration of the agent in the workplace air by stationary or personal sampler (ambient monitoring), or by measuring some biological parameters (biological monitoring). Strictly speaking, biological monitoring of exposure to chemical agents means measurement of a substance or its metabolite in various biological media (text from the ACGIH in the USA, BAT in Germany and HCS regulation in SA defines the most accepted standards (BEIs – Biological Exposure Indices) and regularly updates the set of acceptable levels, however the relationship between increased levels and early reversible effects or even early adverse effects remain problematic for some substances (as we lack comprehensive studies or scientific agreement) e.g. zinc/copper/manganese in urine for “metal” exposure, acetone in urine or blood for acetone exposure, toluene-diamine in urine for TDI exposure etc.). Sometimes, the concept of biological monitoring is extended to include also the detection of early reversible non-adverse effect (biological effect monitoring) (e.g. δ-aminolaevulinic acid in urine or zinc protoporphyrin in blood for assessment of exposure to lead, red-cell and serum cholinesterase for organophosphate pesticide exposure etc.). The detection of an adverse effect (e.g. increased protein in urine) indicates that exposure is or has been excessive and therefore such a measurement is more logically included in a program of early detection of health impairment due to chemicals rather than in a biological monitoring program for evaluating exposure. Monitoring: systematic continuous or repetitive health-related activity designed to lead, if necessary, to corrective actions. Ambient monitoring is the measurement and assessment of agents at the workplace and it evaluates ambient exposure and health risk compared to an appropriate reference. occupational exposure limit (hazardous chemical substances (hcs) regulations issued under ohs act) This is the time-weighted average of an airborne hazardous chemical substance (OEL–TWA): the average concentration of a substance in the air over an eight hour work day and a 40-hour work week. Workers exposed to these levels repeatedly are not expected to develop adverse reactions. These levels are considered to be a guide line in the practice of occupational hygiene and not hard and fast rule on hazardous and non-hazardous levels. OEL-CL is the ceiling limit, which should not be exceeded and OEL-RL is the recommended limit. biological exposure indices (bei) (hcs regulations issued under ohs act) Biological Exposure Index of a hazardous substance: this level is a guideline in the monitoring of potentially toxic substances in biological samples. This index serves to alert the occupational health practitioner to the potential exposure of an individual employee to the hazard, thus ensuring correct investigation of the employees’ environment and personal habits, and ensuring 4 © Ampath Medical Surveillance Guideline appropriate action in reducing further exposure of the employee. The BEI values have been determined over an eight hour workday and a 5-day
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