Embed Size (px)
Citation preview
12/13/2019
1
1
Occupational Surveillance Programs:
Lifestyle Exposure Frontiers
AIOH Conference
December 2 2019
Dr. Christine Kennedy MSc MS MD DPhil CCFP FRCPC FCFP CCBOM
Objectives
• Real life examples of occupational surveillance programs in Industry –
mining and oil (eg: Benzene and Silica (respirable crystalline silica))
• Trends in identified cases of disease (lung, cardiopulmonary,
hematological, and neuro sensory hearing loss)
• Clinical cases illustrating non-occupational conditions that are uncovered
in occupational surveillance programs (exposures: recreational drug use,
anabolic steroids, Stimulants, Depressants, Misuse and abuse of pain
medications, tobacco use, nicotine, obesity, recreational UV exposures).
• Exploration of implications for epidemiological trends and workers
compensation claims adjudication in future2
12/13/2019
2
Occupational Surveillance
• Keep workers healthy and ensure that employers are meeting
standards in Occupational Health and Safety Code
regulations and legislation.
• Medical surveillance is about informing prevention: it is
designed to identify, characterize, and mitigate risks before
health effects can occur.
• But what about when the exposures are not directly
occupational and are indeed voluntary lifestyle choices?
3
Where and what Experience?
Occupational Medicine Physician, Public Health Medical Officer, and
currently Medical Director for Opioid Response, Community Mental Health
Addictions, North Zone Alberta Health Services
4
12/13/2019
3
Rates of Voluntary Lifestyle Exposures
• Since at least 2000, when the RCMP started reporting on their monitoring statistics, the
weekly volumes of illicit drugs entering NE Alberta- Wood Buffalo Region and being
consumed there, have exceeded those transiting through both Calgary and Edmonton and
at times, Vancouver.
• The work camps (more than 30,000 mining workers) and city of 66,000 inhabitants
consume the equivalent of what transits through cities with combined populations of 5.5
Million people. (110 times the consumption rate).
• Although no official direct statistics are reported for rates of use for this worker population,
the estimates are very high, with 90% of the worker population having experience of use of
any of the following substances: cocaine, crack cocaine, opioids, stimulants, cannabinoids,
and steroids. In some worker subpopulations, like those working in first responder groups,
firefighting etc, the use of anabolic steroids is almost ubiquitous.
• Tobacco and alcohol usage, is reported as amongst the highest in Canada (with> 30% of
adults reporting current habitual use of tobacco and >80% of adults reporting high or
binge-like alcohol consumption patterns).
• Highest reported use of tanning beds and extreme sun exposures (resulting in serial
sunburns) and very high rates of adult obesity.5
Exposure to Risks
What characteristics of the work and communities result in the pervasive patterns
described above?
• Social Anthropologist and former oil worker, Rylan Higgins, recently wrote that
“Jobs in this sector include shift work in remote places far from home. Interview
after interview revealed families struggling with these arrangements and results
in all kinds of problems. Boom and bust cycles are unpredictable…major labour
and housing shortages can turn, basically overnight, into high unemployment and
housing market crashes”. – Nov 15, 2019 CBC Opinion
• Neuroscience and social science has established the etiology of most addiction
and substance use and dependence issues of individuals to lack of human and
community connection – Thunderbird Partnership Foundation, 2015
6
12/13/2019
4
Occupational Medical Surveillance Programs
7
Medical Surveillance Programs Inclusion Criteria
Noise All persons exposed to noise at 100%
Occupational Exposure Limit (OEL) or greater for
a minimum of one full day/month or 12 days per
year.
Silica, Benzene, Beryllium All persons exposed at 100% of OEL for 30
days/year or greater.
>5% chance of any exposure in one year.
Laser Baseline for all persons working with lasers
Fire fighter Annual Health Assessment as per NFPA 2017
Crane Operator Health Assessment every two years
First responder, mine rescue volunteers Annual Health Assessment. CXR, screening,
PFTs
Example of Silica and Benzene Surveillance Programs
As more monitoring data became available, the criteria has shifted to a IH best practice statistical
method.
Silica Exposed Workers
Silica exposed workers are workers who may reasonably be expected to work in an
area where there is reasonable chance that the airborne concentration of respirable
crystalline silica exceeds or may exceed the OEL at least 30 work days in a 12-
month period.
Statistically, this definition corresponds to a sample set where the percentage of
samples with potential to exceed the OEL (i.e. exceedance fraction) is greater than
or equal to 5%. Employers must conduct health assessments as per Section 40 of
the Alberta Code for silica exposed workers.
8
12/13/2019
5
Silica Surveillance
9
Function Worker Group Positions
Mine Production Utilities Power Engineers
Maintenance Cranes Operators
Mine Production Tailings Labourers
Technical Field Operations Millwrights, Linesmen,
Surveyors
Technical Heat Exchange Power Engineers
10
Example: A Benzene Surveillance Program
Active post-exposure program;
• Employee to be tested for benzene post potential exposure
• If the employee has potential benzene exposure during shift from activities such
as leaks or loss of containment in closed systems.
• To prevent possible additional exposure to Benzene, while waiting for lab results
(3-6 weeks) the employee MUST be placed on the following limitations: “Not to
enter potential benzene exposure areas as listed.”
• Once the lab results are received by the Surveillance Nurse, further follow up
will be completed or the limitations will be removed.
• Results to be kept in employee’s personal medical file.
12/13/2019
6
11
OH&S & ACGIH Requirements
• Post exposure surveillance program meets or exceeds the following requirements:
• The 2009 Alberta Occupational Health and Safety (OH&S) Code
• Health assessments for workers exposed to benzene are not required under
the 2009 Alberta OH&S code.
• Post-exposure surveillance is a best practice to:
– Document an Occupational Injury and collect and process urine specimens for S-
Phenylmercapturic Acid (S-PMA), a marker for benzene exposure, following any
acute exposure to Benzene containing material-see attached Appendix C for
locations (the only time this is NOT necessary is if the employee was wearing
SCBA at the time of exposure)
Use of Statistical Tools for Exposure Assessment – when > 50% of results are censored
(<LOD), professional judgement or non-parametric statistics must be used.
• Censored data often occur for well controlled environments and when the exposure limit
is closed to the limit-of-detection. Simple substitution works well when the percentage of
LOD is small
• Censored results – substitution with LOD/2
Long term average (LTA) exposure:
• Focus on arithmetic mean
• Chronic agents that should not exceed long term OEL
• Exceedance fraction – according to the AIHA, the exposure profile for a homogeneous
exposure group is usually deemed acceptable if it’s highly likely that only a small
percentage of the measurements exceed the OEL (i.e. < 5%)
12
12/13/2019
7
Historic Benzene Exposure Assessments – Production Operators
Worker group # of results Range of results
(ppm)
Arithmetic
Mean (ppm)
95th Percentile
(ppm)
Probability
exceeds OEL
Plant A Process
Op.
50 with 15 results < LOD 0.001 to 0.2 0.025 0.08 0.35%
Plant B process
op.
33 with 13 results < LOD <0.006 to 0.32 0.045 0.176 2.9%
Plant C Process
Op.
24 with 8 results < LOD <0.007 to 0.2 0.027 0.081 0.08%
Plant D & multi-
areas combined
41 with 18 results < LOD <0.006 to 0.32 0.038 0.136 1.8%
Benzene 12-hr Occupational Exposure Limit 0.25 ppm Target: < 5%
13
Historic Benzene Exposure Assessments – Maintenance/Waste Technicians
Worker group # of results Range of results
(ppm)
Arithmetic
Mean (ppm)
95th Percentile
(ppm)
Probability
exceeds OEL
Millwrights 47 with 27 results <
LOD
<0.007 to 0.21 N/A N/A 0*
Electricians 14 with 11 results <
LOD
<0.007 to 0.093 N/A N/A 0*
Instrument Tech 6 with 2 results < LOD <0.008 to 0.19 0.048 0.22 4.3%
Pipefitters 19 with 14 results <
LOD
<0.008 to 0.085 N/A N/A 0*
Welders 4, all < LOD <0.008 to <0.01 N/A N/A 0*
Benzene 12-hr Occupational Exposure
Limit
0.25 ppm Target: < 5%
14
* Based on non-parametric statistical analysis
12/13/2019
8
15
Personal Exposure Assessments and Area Monitoring Requirements
• Industrial Hygiene performs exposure assessments including air monitoring for worker
groups potentially exposed to benzene.
• Ongoing personal full shift monitoring
• Ongoing personal task monitoring
• Work Areas are responsible to identify potential benzene exposure locations and work
activities per the Benzene Code of Practice.
• Airborne benzene gas testing must be performed by competent personnel prior to
entering or working on equipment which previously contained a benzene-containing
material(s), i.e. process streams with benzene concentrations ≥ 0.1% by weight,
and during loss of containment (spills or releases) of benzene-containing
material(s).
• Recordable testing will be established by the work area as identified in the hazard
assessment for the work or work location.
Fire Specialists/First Responders Surveillance
• All employees included in First Response Teams (including fire and mine rescue) are
enrolled in annual medical assessments that include CXR, PFTs, blood work and
ECGs.
• Generally the NFPA 2017 Guidelines are applied.
• From the blood work (Hematocrit, Red Blood Cells) we can see strong indications of
patterns of anabolic steroid use in first responder worker groups
– Up to 60% of first responders showed evidence of anabolic steroid misuse/abuse in
the first 10 years of employment
16
12/13/2019
9
Patterns of Drug Use in Worker Population
• Stimulants (Cocaine, methamphetamines, amphetamines)
• Depressants (Alcohol)
• Opioids
• Tobacco
• Cannabis and cannabinoids
Shift schedule patterns of use:
• 3 days and 3 nights – use of stimulants and then depressants on the switchover day.
• 6 days off
• Large disposable income at young age
• Physical pain, high rate of MSK conditions and injuries
• Living in remote and isolated mine camps, away from community and family
connections
17
Emergency/First Responder Clinical Case
• Male aged 55
• Fasting glucose 6.7, ALT 65, LDL 4.2
• Waist circumference 123cm
• BMI 41
• PFTs: moderate obstruction since 2016 (former smoker 30 pk years, quit in 2016)
• CXR –incidental findings levoscoliosis and diffuse thoracic spine degenerative changes
• Dx: COPD and metabolic syndrome
18
12/13/2019
10
Silica surveillance
• Medical Questionnaire annually
• One view CXR and PFTs (every two years)
• Mask fit testing / respirator fitness annually
• By worker group, where only groups whose observed potential exposures exceed 5%...
19
Silica Case?
• 31yo female heavy equipment operator, 11 years
• Presents with increasing SOB over 5 months
• 6 episodes of “pneumonia”, 4 episodes where antibiotics were prescribed in last two
years.
• Most recent silica surveillance CXR.
• Urgent HR CT Chest recommended by radiologist reading CXR.
Past Medical Hx:
• Extensive cocaine use over 15 years, eight balls, speed balls, average of 60g usage on
“days off”.
20
12/13/2019
11
CXR
21
22
12/13/2019
12
23
24
12/13/2019
13
25
26
12/13/2019
14
27
28
12/13/2019
15
Table 2: Mégarbane and Chevillard 2013
29
Severe Pulmonary Disease Associated with E-cigarette Use
Etiology: The US CDC has identified vitamin E acetate in bronchiolar lavage samples
from 29 patients with e-cigarette associated lung injury. While it therefore appears that
vitamin E acetate is associated with this condition, evidence is not yet sufficient to rule out
contribution of other chemicals of concern. The etiology of Canadian cases has not yet
been determined.
Case counts:
– In Canada, as of November 6, 2019, there have been seven confirmed or probable
cases of severe lung illness related to vaping. There have been no cases to date in
Alberta that have met the definition for a confirmed or probable case.
– In the US, as of November 5, 2019, 2,051 cases have been reported to CDC with
39 deaths.
Case numbers are updated every Thursday, so you can check this link for updated
numbers: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-
disease.html
30
12/13/2019
16
Confirmed Case:
A. Using an e-cigarette ("vaping") or dabbing* in 90 days prior to symptom onset; AND
B. Pulmonary infiltrate, such as opacities on plain film chest radiograph or ground-glass
opacities on chest CT; AND
C. Absence of pulmonary infection on initial work-up: Minimum criteria include negative respiratory
pathogen panel, influenza PCR or rapid test if local epidemiology supports testing. All other
clinically indicated respiratory ID testing (e.g., urine Antigen for Streptococcus pneumoniae and
Legionella, sputum culture if productive cough, Bronchoalveolar lavage (BAL) culture if done,
blood culture, HIV-related opportunistic respiratory infections if appropriate) must be negative;
AND
D. No evidence in medical record of alternative plausible diagnoses (e.g., cardiac, rheumatologic or
neoplastic process).
Probable Case:
A, B, and D above; AND31
Ototoxic Lifestyle Exposures
Research Article
Smoking as a Risk Factor in Sensory Neural Hearing Loss among Workers Exposed to
Occupational Noise Jukka Starck, Esko Toppila, Ilmari Pyykkö Pages 302-305 | Published
online: 08 Jul 2009
Review
Hearing loss, lead (Pb) exposure, and noise: a sound approach to ototoxicity exploration
Krystin Carlson & Richard L. Neitzel Journal of Toxicology and Environmental Health, Part
B, Volume 21, 2018 - Issue 5 Published online: 21 Jan 2019
32
12/13/2019
17
Volume 63, Issue 6, July 2019
Special Issue for X2018, the 9th International
Conference on the Science of Exposure
Assessment
Solar Ultraviolet Radiation Exposure among
Outdoor Workers in Three Canadian
Provinces
Cheryl E Peters, Elena Pasko, Peter Strahlendorf, Dorothy Linn
Holness, Thomas Tenkate
Ann Work Expo Health, Volume 63, Issue 6, July 2019, Pages
679–688, https://doi.org/10.1093/annweh/wxz044
33
Starting the conversation…
What are the potential implications for Worker Compensation Claims worldwide for
- Respiratory and cardiopulmonary conditions
- Neurosensory hearing loss
- Oncologic disease (skin cancers, substance use related and infectious disease)
- MSK conditions
- Neurologic degenerative conditions (alcohol and stimulant use related)
Related to voluntary hazard and risk exposures?
How can we use Occupational Medical Surveillance to support solutions including
prevention and therapeutic interventions, at individual and population levels?
Thank you.
Email: [email protected]
