The objectives are to explore the impact of asthma and the ability to perform work. It will discuss the assessment of the fitness to work process, and look at the role of the occupational health nurse in carrying out the assessment.
1.3 Client presentation
Peter is currently 59 years old. He attended the occupational health department as part of his six monthly health surveillance. The health surveillance consists of skin prick tests for sensitivity to the complex platinum salts, spirometry and a questionnaire covering incidents of rhinitis, chest tightness or wheezing since last health surveillance. He discussed that in retrospect he had been suffering with watery eyes at work. He had some blepharitis of his left upper lid, and had had a cough that he couldn’t shift. These symptoms are all indicative of an allergy to the complex platinum salts. However his skin prick test was negative, thus demonstrating that there was not an allergy to hexachloroplatinates.
- Sequence of care study
The care study will look at the client profile, initially looking at Peter’s past medical and employment history to identify any previous exposures or health problems. It will look at the client presentation when a health problem was first identified, and look at the signs and symptoms that suggested that there was a health issue. Referral and liasing with others such as the occupational health physician and general practitioner will be identified. In order to understand Peter’s diagnosis of occupational asthma the pathophysiology of allergy to the complex salts of platinum will be explained. Once one is able to understand how an individual becomes sensitised to complex platinum salts the assessment of fitness to work criteria will be looked at. This chapter will look at initial fitness to work assessment pre-employment and the continued process of health surveillance under the COSHH Regulations (1999). It will look at the criteria specific to working with the complex platinum salts and the environment in which the salts are refined. Finally the facilitation for continued employment will be discussed and related to current, relevant legislation.
By reviewing the case study a conclusion will be made regarding how the case was handled and making recommendations as necessary.
- Client profile and pathophysiology
- Background
In order to gain a greater understanding of the impact that a diagnosis can have on an individual’s working life this section will look at Peter’s past history. It will look at his previous employment history with reasons for career changes. It will look at Peter’s home life and outside interests. The health status of Peter at his pre-employment medical will be looked at to give baseline values which will demonstrate the extent of deterioration of lung function due to respiratory sensitisers. The section will then discuss the pathology of allergy to complex salts of platinum
- Profile
Peter is 59 years old and has worked for the company for twenty-four years. Peter joined the company in 1977 as a process operator within the platinum refinery. He still works within the platinum refinery but is now a shift team leader. The platinum is refined 24 hours a day. Each shift lasts twelve hours, working four days on, four days off and on to four nights on then four nights off. This pattern suits Peter due to the time it gives him to see his grandchildren and play golf, as well as the extra earnings through shift allowances. Peter lives at home with his wife. He has two daughters and three grandchildren. Peter enjoys playing a round of golf when he can and took up cycling with the encouragement of his daughter four years ago following a hospital admission for chest pain.
Prior to joining the company to work refining platinum, Peter had previously worked as a builder, mostly building swimming pools. Job security was the main reason that he sought a career change. Peter was generally fit through his manual work. At that time he had no other hobbies or interests. Peter had smoked 20 cigarettes a day until 1970, when he successfully gave up smoking. He had no other past medical problems and at his pre-employment medical was found fit to work as a process operator within the platinum refinery.
At the pre-employment medical baseline spirometry and skin prick tests were performed. Peter’s spirometry was slightly better than predicted for a man of his age.
Peter’s results were recorded as:
FEV1 4.65 (predicted FEV1 score 4.55) and FVC 6.00 (predicted score FVC 5.48).
Peter was not found to be atopic, in other words he was not allergic to common allergens such as cat fur, house dust mite, or grass pollen.
Peter’s past medical history since working with the company has mostly been without incident until recent years. Peter had a chest infection with some bronchitis in 1996. This was treated by the GP with antibiotics and a Becotide inhaler. Peter attended the occupational health department at this time and spirometry and skin prick testing were carried out as part of the six monthly surveillance to ensure that Peter was not becoming sensitised to the complex platinum salts. The occupational health department also provided Peter with a Peak Flow device to monitor his lung function and identify any changes or patterns that may be due to work place exposures. Peter monitored his peak flow for a month all told with no significant changes between work, or home. His cough gradually improved and the Becotide inhaler was discontinued by his GP.
In 1999 Peter had two incidents when he was exposed to platinum and palladium fume. In March 1999 Peter removed a lid from a tray of platinum and palladium salts that were baking in the ovens. The process was not complete as the salts had not hardened. Peter raked over the salts, which released fumes. Peter was wearing PPE in the form of an airstream visor, but still inhaled some fumes. At the time Peter felt immediate burning in the back of his throat and had an unpleasant taste in his mouth. The next day Peter had a cough with yellow sputum. Peter was referred to and seen by the occupational health physician the next day. Peter had no significant change to his spirometry and was diagnosed as having irritant bronchitis and prescribed Simple Linctus. Later that year in the November Peter spilt hot platinum liquor on his left wrist. On examination there was a red patch 2.5cms that looked like a burn rather than urticaria. Accident forms were completed as part of the normal process.
2.3 Client Presentation
Peter’s continued symptoms were picked up on a routine six monthly health surveillance check. Peter stated that his eyes always seemed watery and had been like this for several months. On examination he had Blepharitis of the left upper lid. On a physical chest examination by the occupational health physician Peter was found to have rhonchi of the left lower lobe. The occupational health physician decided that Peter was not currently fit to remain at work as he worked with respiratory sensitisors, and referred him to his general practitioner. Peter was reviewed by the occupational health physician ten days later. His general practitioner had referred Peter for an x-ray which was normal. Peter’s eyes had improved, but he felt that they always improved when he was in fresh air away from work. Peter’s cough however, remained. He was still coughing up thick yellow sputum. Peter remained unfit for work and was reviewed again one week later. At this review Peter was coughing up thick white sputum. He had been prescribed a Salbutamol inhaler by his general practitioner. A chest examination was performed by the occupational health physician. On examination Peter had occasional rhonchi but air entry to his lungs was much improved. A spirometry was performed and whilst the values were normal they were lower than Peter’s normal range. The FEV at 3.85 was 12.4% lower than the value of 4.4, three years previous. Peter experienced coughing on forced expiration. The continued symptoms meant that Peter was not fit to work within the platinum refinery, but would be fit to work within the offices.
It appeared that Peter had developed an allergy, possibly initiated by palladium fume. With Peter’s and the general practitioner’s agreement Peter was referred to Professor Newman Taylor at the Brompton Hospital for assessment and challenge tests to identify the cause of the symptoms.
2.4 Pathology of allergy to complex salts of platinum.
An allergy or hypersensitivity is an abnormal, vigorous immune response in which the immune system causes damage as it fights off a perceived “threat” that would otherwise be harmless to the body (Marieb 2000). There are several different types of allergies, but the most common type is immediate hypersensitivity, or acute hypersensitivity. This allergic response is triggered by the release of histamine when IgE antibodies bind to mast cells. Histamine causes the small blood vessels in the area to become dilated and leaky. It is this action that is attributed to the allergic symptoms of runny nose, watery eyes, and itching, reddened skin. If an allergen is inhaled as with the complex platinum salts, then the symptoms of asthma appear because the smooth muscle in the walls of the bronchioles contract, constricting the passages and therefore restricting the air flow.
According to Cross (1998), many people who present for the first time with occupational asthma, state that they have worked with the substance for months or years. A latent period between first exposure and the development of symptoms is typical of the disease. The interval from initial exposure can be quite short i.e., a few months, or even years for exposure to the complex platinum salts. It appears, in some instances that there is a dose response relationship with more frequent sensitisation to individuals who are more heavily exposed. For some categories of respiratory sensitisers such as complex platinum salts, there is evidence that factors such as smoking and atopy may increase the risk of the likelihood of sensitisation (Agius 1995). Atopy is a characteristic of a large percentage of the population. An atopic individual is someone who is sensitive to common allergens such as house dust mites, grass pollen, and cat fur. Occupational sensitisation to some asthmagens does not bear any relationship to atopy, however the likelihood to some other agents is increased in atopics. Individuals who are atopic run an increased risk of developing immunoglobulin (IgE) antibody and asthma in response to some of the occupational sensitisers (Cross 1998). Once sensitised to an occupational allergen, individuals with bronchial hyper-responsiveness have an increased risk of developing occupational asthma. Tobacco smoking has also been shown to increase the risk of developing specific IgE and asthma caused by some agents such as complex platinum salts (Cross 1998). The mechanism that the effect of smoking is not known, but is felt by Newman Taylor (1994), to be the consequence of injury, whatever its cause, to the respiratory mucosa. In platinum refining, a history of atopy has long been contra-indicated to employment exposure (Merrick 1990), but as Shelmerdine (1995) states, opinion has changed and atopic individuals are now employed in all areas, however, smokers are not employed in the platinum refinery. This change has come about following studies that have shown that smoking is a bigger and more significant risk of sensitisation, whereas the risk associated with atopy is insignificant (Venables et al 1989, Newman Taylor 1994).
3.0 Assessment of fitness to work
- Background
This section will look at the process of assessment of fitness to work. It will link fitness to work criteria with job specification, looking at pre-employment assessment and continuing health surveillance on employment.
3.2 Fitness to work criteria
The role of the occupational health nurse is to promote health at work and to protect the health of the worker (Hodges 1997).One of the activities undertaken by occupational health nurses is pre-employment and post placement health assessment. The primary purpose of a health assessment of fitness to work is to make sure that an individual is fit to perform the task effectively and without risk to his own or others’ health and safety (Cox & Edwards 1995). Fitness to work takes two paths. Employers need to know that job applicants are medically suitable for recruitment, and that existing employees are fit to return to work following a period of sickness absence. Pre-employment health screening has a number of purposes (Stokes 1998). It can identify employees that would be more vulnerable if they developed any form of occupational ill health. It can identify individuals who already suffer from occupational ill-health or pre-existing disease, and establish whether they are not only able to do a job, but do it without increased risk of accident. A Pre-employment health assessment also serves as a means of obtaining baseline screening for future health surveillance. There is no statutory obligation to perform pre-employment medicals’ with most jobs. However, employers and employees have legal duties under the Health and Safety at Work etc Act (1974). Employers must protect the health and safety of employees, and protect others who may be affected by their undertaking. Employers also have an obligation to regard the health of their employees under the Management of Health and Safety at Work Regulations (1992).
Health surveillance is one component of an occupational health programme which should seek to promote and maintain the health of all employees at the given workplace, who are at risk of developing adverse health effects resulting from exposure to specific hazards. In the refining of platinum and handling of other compounds, there is a risk of exposure to hazards other than chloroplatinates e.g. chlorine, ammonia, and hydrazine. Many of these may cause adverse health effects or aggravate pre-existing conditions. A high standard of personal hygiene is required and the wearing of personal protective equipment is a necessity, often including respiratory protective equipment. The objectives of the health surveillance programme for platinum salts exposures are:
By pre-placement examination:
- To identify pre-existing disease which may be aggravated by the risks at work, or which may mask early signs of allergy to the complex halogeno salts of platinum.
- To identify pre-existing conditions which may prevent the necessary high standard of personal hygiene.
- To identify the factors which increase the risk of developing allergy to the complex halogeno salts of platinum.
During employment:
- To identify and assess cases of allergy to the complex halogeno salts of platinum at an early stage, so that appropriate action can be taken to prevent the development of adverse health effects.
The components of the pre-placement examination include:
- Occupational history, in particular enquiry about previous exposure to platinum salts and respiratory sensitisers or irritants
- Medical history, with particular enquiry for previous respiratory disease and indications of atopy, medication e.g. beta blockers which may aggravate an asthmatic reaction.
- Physical examination
- Spirometry
- Skin prick test with common allergens appropriate to the local environment and sodium hexachlorplatinate.
There are certain criteria that individuals who apply to work within the platinum refinery have to meet. The selection of employees for work with allergenic platinum salts requires that they be free from pre-existing disease, which may be aggravated if they develop allergy to the complex halogeno salts of platinum. They should not be susceptible to the effects of associated occupational hazards and should be fit to comply with the safety and hygiene requirements. As Newman Taylor (1994) explains there are three major factors that contribute to the development of occupational asthma: atopy, tobacco smoking and intensity of exposure. The incidence within a platinum refinery of respiratory symptoms and positive skin prick test response to ammonium hexachlorplatinate was found to be greater among atopics, and four to five times greater in smokers (Venables et al 1989). The most important fitness to work criteria for individuals who work in the platinum refinery is the absence of a history of asthma. All applicants within the platinum refinery undergo a medical performed by the occupational health physician. Part of the medical includes pre-employment spirometry to ensure that there is no obstructive or restrictive airways disease present. Skin prick tests are also performed to identify if an individual is atopic, although atopic individuals are not excluded, and to ensure that they are not sensitive to the complex platinum salts. An individual would only have a positive reaction to platinum salts if they had had previous exposure. Pre-employment skin testing can only detect previously acquired sensitisation and cannot predict future sensitisation (Davies & Ryecroft 1995). Smokers are not passed fit to work in the platinum refinery due to the increased risk factor in developing occupational asthma and Scarisbrick & Hendrick (1995) agree that the arguments for excluding smokers from platinum refineries is more compelling than the argument for excluding atopic individuals.
Criteria for and contra-indications to employment need to be considered with respect to anti-discrimination legislation such as the Disability Discrimination Act (1995). This requires a full evaluation of risk, the increase in risk due to particular factors or the effect on the health of the individual who may develop allergy to the complex halogeno salts of platinum. Factors that are considered include:
- Allergy to complex salts of platinum from previous work. This is an absolute exclusion.
- Asthma, as bronchial hyperresponsiveness would be expected to be aggravated by allergy to the complex halogeno salts of platinum, and existing asthma would mask the development of allergy to the complex halogeno salts of platinum.
- Chronic respiratory disease with FVC or FEV1 two standard deviations or more below predicted values (normally 1 litre below normal). The FEV1/FVC should normally exceed 70%.
- Allergic rhinitis may make it difficult to maintain the necessary standards of hygiene.
- Skin disease e.g. dermatitis, neuro-dermatitis, or severe psoriasis, which would prevent adequate washing and showering.
- Skin disease e.g. chronic ulceration which provides a portal of entry to surface contamination.
Once employed health surveillance under COSHH Regulations (2000), for workers within the platinum refinery is carried out six monthly by the occupational health nurse. The subjects under surveillance are made aware of the symptoms of allergy to the complex halogeno salts of platinum and the significance of persistence of symptoms. They are made aware, on induction, of the need to report any persistent symptoms to the occupational health department if they occur in between routine tests to allow investigation. The routine health surveillance includes:
- A questionnaire for symptoms of allergy to the complex halogeno salts of platinum.
- Review of recent medical history
- Spirometry
- Skin prick testing with sodium hexachlorplatinate.
- Work environment
In order to understand fully the work process and environment as part of induction all new occupational health staff are encouraged to visit the refinery. It is only with insight that one can fully appreciate the problems encountered by the workers, and be competent at assessing fitness to work. The platinum refinery is a large warehouse type building. There are offices and small laboratories where product sampling and quality testing is undertaken, along one side of the building. At the far end near the baking area are the store rooms which are strongrooms in which the refined platinum salts are stored prior to being dispatched. The refinery itself is cold in the winter and warm in the summer. The only area that is always warm is the muffles area where ovens bake the platinum salt sponges. Pipes carry chemicals through out the site and within the refinery these run overhead. There is an upper gantry which houses the large glass column dissolvers and Pfauder vessels for the dissolving of platinum in hydrochloric acid and chlorine gas. The area looks like a large scale chemistry set with bunsen burners reminiscent of school days. The whole area is generally dirty in appearance due to the type of work undertaken. It cannot be described as a comfortable or pleasing working environment. All employees within the refinery are provided with protective clothing in the form of workshirts and trousers and a laboratory coat or boilersuit. They are also provided with protective boots or wellingtons. Hats are also provided and these tend to be of a baseball style as they are more popular. All protective clothing is laundered on site. Showers are provided in the changing rooms, and showering time is incorporated within the shift to encourage employees to do so. Whilst the work environment is poor due to the nature of the work the facilities are good. The shower rooms are clean and modern. The rest rooms are comfortable with free drinks and free lunches provided in the canteen.
3.2.2 Peter enjoys his work in the refinery and has made many good friends over the years. He accepted that he needed to transfer to the office area whilst his allergy was investigated, and was pleased that he was able to continue at work. The occupational health physician was able to liase with the manager to facilitate continued work for Peter at this point. Peter attended challenge tests and whilst the diagnosis of allergy to palladium diamine was confirmed his condition deteriorated through the exposure to the compounds during provocation tests. His condition became such that he was unable to work due to constant shortness of breath and wheeze. Peter found that even attending the occupational health department for review made him more short of breath, despite the department not being near the refinery. Peter is currently under the care of his GP and Brompton Hospital. It has been recommended that Peter takes early retirement on the grounds of ill health, and this has been put into action. Peter’s diagnosis of occupational asthma has been reported to the HSE as it is a prescribed disease.
4.0 Conclusion and Recommendations
4.1 This chapter will make conclusions as to how Peter’s case was handled and where necessary make recommendations for the way in which similar cases could be handled in the future.
4.2 Peter over a period of twenty-four years has become sensitised to one of the complex platinum salts. As discussed previously allergy to complex platinum salts occurs through continued exposure. It is not possible to predict who will become allergic. The risk of workers developing an allergy is reduced as much as possible through research backed practices. For example: smokers are not employed within the refinery as they have been demonstrated to be more likely to develop allergy to complex platinum salts than non-smokers. Health surveillance is carried out routinely at six monthly intervals to identify early symptoms of allergy developing. It would appear that in 1999 Peter had two episodes of increased exposure to the complex platinum salts through accidents, his allergy could be a dose response relationship as discussed earlier. An allergy to palladuim diamine itself is extremely rare. The diagnosis was not identified sooner as Peter did not show a response when skin prick tested with hexachloroplatinates, as it was not this compound to which he was allergic.
- Recommendations:
- The pre-employment health assessment and six monthly health surveillance should continue as at present.
- The managers should ensure that greater emphasis is put on the reporting of any symptoms that could be allergy linked. This should be emphasised at induction and at team briefs and appraisals, with the reasons why explained.
- The importance of early reporting to the occupational health department should be emphasised when attending six monthly surveillance, with reasons clarified
- Copies of environmental monitoring reports should be sent to occupational health so that current exposure levels are known by the occupational health team.
References
R. Agius (1995) Occupational Asthma and Rhinitis. Part 111- health surveillance and secondary prevention, Occupational Health Review, 55, pp28-31.
Cannon J, P. Cullinan and A. Newman Taylor (1995) Consequences of Occupational Asthma, British Medical Journal, 311(7005): pp602-603.
Cleare, MJ, EG. Hughes, B. Jacoby, J. Pepys (1976) Immediate (type 1) allergic responses to platinum compounds. Clinical Allergy, 6, pp183-195.
Cox RAF, and FC. Edwards editors (1995) Fitness for Work. The medical Aspects, 2nd edition, Oxford, Oxford University Press.
Crawford, M (1999) Breathing Space, Occupational health, 51(3), pp33-4.
Cromwell, O, J. Pepys, WE. Parish and EG Hughs, (1979) Specific IgE antibodies to platinum salts in sensitized workers. Clinical Allergy, 9, pp109-117.
Cross, S (1998) Asthma at work – cause and effect. Practice Nurse, 15 (9), pp538-42.
Davies, NF. And RJG. Ryecroft (1995) Dermatology, in Cox, RAF, FC. Edwards, RI, McCallum (editors) Fitness for Work. The medical Aspects, 2nd edition, Oxford, Oxford University Press, pp102-112.
Health and safety Commission. (1999) Control of Substances hazardous to health Regulations 1999 Approved Codes of practice (3rd edition), Norwich: HMSO.
Health and safety Executive. (1992) Management of Health and Safety at Work. Management of Health and Safety at Work Regulations 1992. Approved Code of Practice, Norwich: HMSO.
Health and Safety Executive (1998) Medical Aspects of Occupational Asthma. Guidance notes MS25, (2nd edition), HSE Books
Hodges, D. (1997) ‘The role of the occupational health nurse’, in Oakley K. (editor) Occupational Health Nursing, London: Whurr Publishers Ltd, pp1-29.
Madan,I. (1996) ABC of Work Related Disorders: OCCUPATIONAL ASTHMA AND OTHER RESPIRATORY DISEASES, British Medical Journal, 313, pp291-294.
Madden V (1998) Short of Breath, Occupational health, 50(8),pp 25-26.
Marieb EN. (2000) Essentials of Human Anatomy and Physiology (6th Edition), California: Addison Wesley Longman Inc.
Newman Taylor, AJ. (1994) ‘Occupational Asthma’, in Raffle, PAB, PH. Adams, PJ. Baxter and WR. Lee (editors) Hunter’s Diseases of Occupations, Kent: Edward Arnold Publishers, pp470-485.
Newman Taylor, AJ, (1998) ABC of allergies. Asthma and Allergy. British medical Journal, 316(7137):997
Parliament (1974) Health and Safety at Work etc Act 1974, London: HMSO
Parliament. (1995) Disability Discrimination Act 1995, London: HMSO.
Ross, DJ, BA. Sallie, JC. McDonald (1995) SWORD ’94: surveillance of work related and occupational respiratory disease in the UK. Occupational medicine, 45:175-8.
Scarisbrick, DA and DJ. Hendrick (1995) Respiratory disorders, in Cox, RAF, FC. Edwards, RI, McCallum (editors) Fitness for Work. The medical Aspects, 2nd edition, Oxford, Oxford University Press, pp286-306.
Stokes B. (1998) Management of Health Risks. Guidance on Workplace Health Risks Issues. Health and safety in Practice. Management of health Risks. Croner 29 November.
Venables, K. & M. Chan-Yeung (1997) Occupational Asthma, The lancet, 349,pp1465-69.
Venables K, M. Dally, A. Nunn, J. Stevens. R. Stephens, N. Farrer, J. Hunter, M. Stewart, E. Hughes, and A.N. Taylor (1989) Smoking and occupational allergy in workers in a platinum refinery. British Medical Journal, 299, pp 939-942.