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Wednesday, 02 March 2011 15:13

Occupational Health and Safety Practice: The Russian Experience

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The work of people in the medical profession has great social value, and in recent years the urgent problem of the labour conditions and the state of health of HCWs has been studied actively. However, the nature of this work is such that any preventive and ameliorating measures cannot eliminate or reduce the main source of the hazards in the work of physicians and other HCWs: contact with a sick patient. In this respect the problem of prevention of occupational illness in medical workers is rather complicated.

In many cases the diagnostic and medical equipment and the methods of treatment used in medical institutions can affect the health of HCWs. Therefore, it is necessary to follow hygienic standards and precautionary measures to control the levels of exposure to unfavourable factors. Studies carried out in a number of Russian medical institutions have revealed that the labour conditions at many workplaces were not optimum and could induce the deterioration of the health of medical and support personnel, and sometimes cause the development of occupational diseases.

Among the physical factors that can substantially affect the health of medical personnel in the Russian Federation, ionizing radiation should be ranked as one of the first. Tens of thousands of Russian medical workers encounter sources of ionizing radiation at work. In the past, special laws were adopted to limit the doses and levels of irradiation at which specialists could work for a long period without health risk. In recent years x-ray control procedures were extended to cover not only radiologists, but surgeons, anaesthetists, traumatologists, rehabilitation specialists and mid-level personnel. The levels of radiation at worksites and the x-ray doses received by these individuals sometimes are even higher than the doses received by the radiologists and radiology laboratory assistants.

Instruments and equipment generating non-ionizing radiation and ultrasound are also widespread in modern medicine. Since many physiotherapy procedures are used precisely because of the therapeutic benefits of such treatment, the same biological effects may be hazardous to those involved in administering them. Persons encountering instruments and machines generating non-ionizing radiation are often reported to have functional disturbances in the nervous and cardiovascular systems.

Studies of working conditions where ultrasound is used for diagnostic or therapeutic procedures revealed that the personnel were exposed during as much as 85 to 95% of their working day to levels of high frequency, low intensity ultrasound comparable to the exposures experienced by operators of industrial ultrasonic defectoscopy. They experienced such impairments of the peripheral neuro-vascular system as angiodistonic syndrome, vegetative polyneuritis, vegetative vascular malfunction and so on.

Noise is rarely reported as a substantial factor of occupational risk in the work of Russian medical personnel, except at dental institutions. When using high-speed drills (200,000 to 400,000 rev/min) the maximum energy of the sound falls at a frequency of 800 Hz. The noise levels at a distance of 30 cm from the drill placed in the mouth of the patient vary from 80 to 90 dBA. One-third of the whole sound spectrum falls within the range most harmful to the ear (i.e., between 1000 and 2000 Hz).

Many noise sources gathered in one place can generate levels exceeding permissible limits. To create optimum conditions it is recommended that anaesthetizing machines, respiratory equipment and artificial blood circulation pumps be taken out of operating rooms.

In surgery departments, especially in operating rooms and in rehabilitation and intensive care departments, as well as in some other special rooms, it is necessary to maintain the required parameters of temperature, humidity and air circulation. The optimal layout of modern medical institutions and the installation of ventilation and air-conditioning plants provide the favourable microclimate.

However, in operating suites built without optimal planning, occlusive clothing (i.e., gowns, masks, caps and gloves) and exposure to heat from lighting and other equipment lead many surgeons and other members of the operating teams to complain of “overheating”. Perspiration is mopped from surgeons’ brows lest it interfere with their vision or contaminate the tissues in the surgical field.

As a result of the introduction into medical practice of treatment in hyperbaric chambers, physicians and nurses now are often exposed to heightened atmospheric pressure. In most cases this affects surgical teams performing operations in such chambers. Exposure to conditions of increased atmospheric pressure is believed to lead to unfavourable changes in a number of body functions, depending on the level of the pressure and the duration of the exposure.

Working posture is also of great importance for physicians. Although most tasks are performed in sitting or standing positions, some activities require long periods in awkward and uncomfortable positions. This is particularly the case with dentists, otologists, surgeons (especially microsurgeons), obstetricians, gynaecologists and physiotherapists. Work requiring long periods of standing in one position has been associated with the development of varicose veins in the legs and haemorrhoids.

Continual, intermittent or casual exposure to potentially hazardous chemicals used in medical institutions also can affect medical personnel. Among these chemicals, inhalation anaesthetics are considered to have the most unfavourable influence on humans. These gases can accumulate in large amounts not only in operating and delivery rooms but also in pre-op areas where anaesthesia is induced and in recovery rooms where they are exhaled by patients coming out of anaesthesia. Their concentration depends on the content of the gas mixtures being administered, the type of equipment being used and the duration of the procedure. Concentrations of anaesthetic gases in the breathing zones of surgeons and anaesthetists in the operating room have been found ranging from 2 to 14 times the maximum allowable concentration (MAC). Exposure to anaesthetic gases has been associated with impaired reproductive capacity of both male and female anaesthetists and abnormalities in the foetuses of pregnant female anaesthetists and the spouses of male anaesthetists (see chapter Reproductive system and the article “Waste anaesthetic gases" in this chapter).

In the treatment rooms where many injections are performed, the concentration of a medicine in the respiration zone of nurses can exceed permissible levels. Airborne drug exposure can happen when washing and sterilizing syringes, removing air bubbles from a syringe, and while dispensing aerosol therapy.

Among chemicals which could affect the health of medical personnel are hexachlorophene (possibly causing teratogenic effects), formalin (an irritant, sensitizer and carcinogen), ethylene oxide (which has toxic, mutagenic and carcinogenic characteristics), antibiotics that cause allergies and suppressed immune response, vitamins and hormones. There is also the possibility of exposure to industrial chemicals used in cleaning and maintenance work and as insecticides.

Many of the drugs used in the treatment of cancer are themselves mutagenic and carcinogenic. Special training programmes have been developed to prevent workers involved in preparing and administering them from exposure to such cytotoxic agents.

One of the features of job assignments of medical workers of many specialties is contact with infected patients. Any infectious disease incurred as a result of such contact is considered to be an occupational one. Viral serum hepatitis has proved to be the most dangerous for the staff of medical institutions. Viral hepatitis infections of laboratory assistants (from examining blood samples), staff members of haemodialysis departments, pathologists, surgeons, anaesthetists and other specialists who had occupational contact with the blood of infected patients have been reported (see the article “Prevention of occupational transmission of bloodborne pathogens” in this chapter).

There has apparently been no recent improvement in the health status of HCWs in the Russian Federation. The proportion of cases of work-related, temporary disability remained at the level of 80 to 96 per 100 working doctors and 65 to 75 per 100 mid-level medical workers. Although this measure of work loss is quite high, it should also be noted that self-treatment and informal, unreported treatment are widespread among HCWs, which means that many cases are not captured by the official statistics. This was confirmed by a survey among physicians which found that 40% of the respondents were ill four times a year or more but did not apply to a practising physician for medical care and did not submit a disability form. These data were corroborated by medical examinations which found evidence of disability in 127.35 cases per 100 workers examined.

Morbidity also increases with age. In these examinations, it was six times more frequent among HCWs with 25 years of service than among those with less than 5 years of service. The most common diseases included circulatory impairments (27.9%), diseases of the digestive organs (20.0%) and musculoskeletal disorders (20.72%). Except for the last, most of the cases were non-occupational in origin.

Sixty per cent of doctors and 46% of mid-level personnel were found to have chronic diseases. Many of these were directly associated with job assignments.

Many of the observed diseases were directly associated with job assignments of those examined. Thus, microsurgeons working in an awkward posture were found to have frequent osteochondroses; chemotherapists were found to suffer frequently from chromosome abnormalities and anaemia; nurses who were in contact with a large variety of medicines suffered various allergic diseases, ranging from dermatoses to bronchial asthma and immunodeficiency.

In Russia, health problems of medical workers were first addressed in the 1920s. In 1923 a special scientific-consultative bureau was founded in Moscow; the results of its studies were published in five collections entitled Labour and Life of Medical Workers of Moscow and Moscow Province. Since that time other studies have appeared devoted to this problem. But this work has been carried on in the most fruitful way only since 1975, when the Laboratory of Labour Hygiene of Medical Workers was established in the RAMS Institute of Occupational Health, which coordinated all the studies of this problem. After analysis of the then-current situation, research was directed at:

  • studies of the features of labour processes in the main medical specialties
  • assessment of the factors of the occupational environment
  • analysis of the morbidity of medical workers
  • elaboration of measures for optimization of labour conditions, reduction of fatigue and prevention of morbidity.

 

Based on the studies carried out by the Laboratory and other institutions, a number of recommendations and suggestions were prepared, aimed at reduction and prevention of the occupational diseases of medical workers.

Instructions were established for pre-employment and periodic medical examinations of health care workers. The aim of these examinations was to determine the fitness of the worker for the job and to prevent common and occupational diseases as well as occupational accidents. A list of hazardous and dangerous factors in the work of medical personnel was prepared which included recommendations for frequency of examinations, the range of specialists to take part in the examinations, the number of laboratory and functional studies as well as a list of medical contra-indications for work with a specific hazardous occupational factor. For every studied group there was a list of occupational diseases, enumerating the nosological forms, approximate list of job assignments and hazardous factors which can cause the respective occupational conditions.

In order to control the working conditions in treatment and prevention institutions, a Certificate of Sanitary and Technical Conditions of Labour in the health care institutions was developed. The certificate can be used as a guide for conducting sanitary measures and improvement of labour safety. For an institution to complete the certificate, it is necessary to carry out a study, with the help of specialists in sanitary service and other respective organizations, of the general situation in the departments, rooms and wards, to measure the levels of health and safety hazards.

Departments of hygiene of the preventive medicine institutions have been established in the modern centres of sanitary-epidemic inspections. The mission of these departments includes perfecting measures for the prevention of nosocomial infections and their complications in hospitals, creating optimal conditions for treatment and protecting the safety and health of HCWs. Public health doctors and their assistants conduct the preventive monitoring of design and construction of buildings for health care institutions. They see to the compliance of the new premises with the climate conditions, required arrangement of worksites, comfortable labour conditions and systems of rest and nutrition during the work shifts (see the article “Buildings for health care facilities” in this chapter). They also control technical documentation for the new equipment, technological procedures and chemicals. The routine sanitary inspection includes the monitoring of the occupational factors at the worksites and accumulation of the received data in the above-mentioned Certificate of Sanitary and Technical Conditions of Labour. Quantitative measurement of working conditions and prioritization of health improvement measures are established according to hygienic criteria for assessments of labour conditions which are based on indicators of the hazard and danger of labour environment factors and the heaviness and intensity of the working process. The frequency of laboratory studies is determined by the specific needs of each case. Each study usually includes measurement and analysis of microclimate parameters; measurement of indicators of air environment (e.g., content of bacteria and hazardous substances); assessment of the effectiveness of ventilation systems; assessment of the levels of natural and artificial illumination; and measurement of noise levels, ultrasound, ionizing radiation and so on. It is also recommended that time-keeping monitoring of the exposures of the unfavourable factors be conducted, based on the guideline documents.

According to instructions of the Russian government, and in keeping with current existing practice, the hygienic and medical standards should be revised following the accumulation of new data.

 

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