Understanding Occupational Health: Myth & Legislations Dr Obadiah Lulu Elekima,MPH, M.Sc(Tox.), M.Sc...

Understanding Occupational Health: Myth & Legislations

Dr Obadiah Lulu Elekima,MPH, M.Sc(Tox.), M.Sc M.Sc(Occ Med), MBA, AFOM, MRCOG (1), MFOM, Ph.D, FRSPH Lead Consultant Occupational Physician,Worcester Acute Hospitals NHS Trust, UK

Senior Lecturer & Consultant Public Health Physician,

University of Port Harcourt, Nigeria

Content (1)

• What is Occupational Medicine (OM)?

• Work-related Ill –health (WRI)/Occupational Diseases-Burden & Mortality-Overview

• Training in OM

• What are Occupational Health Services (OHS)?

• Who is an Occupational Health Physician (OHP)?

• Problems with Occupational Health Practise in Nigeria

• OH Legislations in the UK

Content (2)

• Recommendations

• Federal, State & Local Governments

• Medical & Dental Council of Nigeria (MDCN)

• Organisations (Public & Private) & Individuals

• Conclusions

Occupational Health…. What is it?

“..the promotion and maintenance of the highest degree

of physical, mental and social well being of workers in

all occupations.” (ILO/WHO 1950)

OcPrincipal role of Occupational Medicinecupational

Health…. What is it?

……. is the provision of health advice to organisations

and individuals to ensure that the highest standards of

Health and Safety at Work can be achieved and

maintained (Fac of Occup Med, UK).

Work-Related Disease/occupational disease Burden & Morality-Overview(1)cupational

• When prevention and control measures at work fail,

occupational diseases (OD) can occur.

• OD cause huge suffering and losses to workers, businesses,

social security funds and societies at large.

• Diseases caused by work kill six times more workers than

work-related accidents (ILO, 2014).


• estimated that there are globally about 2.02 million deaths

annually caused by disease due to work13,

• annual global number of cases of non-fatal work-related

disease is estimated to be 160 million.

• OD cause immeasurable human suffering to victims and their

families, & entail major economic losses for enterprises and

societies as a whole


• OD also results in lost productivity and reduced work capacity.

• Globally, ILO estimates that around 4 per cent of the world’s gross

domestic product (GDP), or about US$2.8 trillion, is lost owing to

work-related accidents and diseases in direct and indirect costs .

• Identification and reporting of OD or work-related ill-health (WRI)- posed a huge challenge in most countries.

• OD can be invisible in public policy discussion, since in most countries, especially developing countries, there is very limited reporting of such diseases.

• Identification & reporting made worse by lack of OH legislations.

Training in Occupational Medicine (OM)? (1)

A clinical specialty -just as surgery, general/internal medicine, paediatrics, obstetrics & gynaecology etc

A faculty of the royal college of physicians (UK), American College of Occupational & Environmental Medicine (USA) and other equivalents.

Need broad clinical knowledge of the different specialties of medicine to be able to train and qualify in OM

In the UK, needs a Minimum of 4 years of postgrad training after Senior House Officer (SHO) or at least 3 years post graduation. Similarly in Australia and some EU countries.

Satisfactorily completion of competencies, pass the prescribed Board or Faculty of the Appropriate College Examinations (2 parts-I & II), Complete a Dissertation, awarded MFOM (equivalent to Fellowship awarded in different specialties in Nigeria following the exit exams) & put on the Specialist Register.

Slight Variation in the USA but still requires regulated period of training and board certification

Training in Occupational Medicine (OM)? (2)

What OH Services involve? (1)

A. Clinical Occupational health activities

• Pre-employment assessments-Health screening

• Periodic medical examinations (including health

surveillance)

• Post sickness absence review

• Immunisations including Travel Advice

• Health Promotion, education and counselling

(Health Promotion)-Good Health is Good Business

• Treatment• Rehabilitation of employees back into the

workplace

B. Workplace assessments= Evaluation of workplace to reduce or eliminate exposure• Recognition• Evaluation• Control

What OH Services involve (2)

C. General advice and support

• Advice on compensation

• Disaster planning including advice on managing

chemical incidents

• Food hygiene (Food industry)

• Advice on environmental issues


D. Other activities

• Audit, quality assurance and evaluation

• Worker protection and business protection


What is not Occupational Medicine? (1)

• All other medical Specialties other than OM i.e. Family Medicine (FM)/ General Practitioner (GP), surgery, Obstetrics & Gynaecology (O&G), Paediatrics, General Public Health.

• A medical doctor who does Appendicectomy or herniorraphy- Not surgeon

• Performing Caesarian Section (C/S) or “TOP” –does not make the doctor an Obstetrician or Gynaecologist.

• In a similar way, having retainerships or just working in an industry or company without training in OM does not make the doctor a Specialist Occupational Physician.

Who is an Occupational Physician (OHP) /Occupational Health Practitioners (OHP)?

Doctor-Specialises in Occupational Medicine after a regulated period of training by a recognised professional body, acquired competences, passed the prescribed examinations, and on the Specialist Register e.g. MFOM, FFOM (UK), FACOEM (USA).= Consultant/Specialist Occupational Physician

Doctors in the USA-generally, start training in Public Health but specialised in Occupational Medicine (Board Certified)

Doctors- in active OH practise + AFOM or AFOM-recognised as Specialist in Occupational Medicine

Doctors whose primary employment is in an occupational setting and have acquired at least 10 years of experience should be described as OHP with or without the Diploma in OH/M.Sc in Occupational Medicine*

Who is not an Occupational Health Specialist?

• Any doctors who do not fall under the definitions above & Not trained in OH including *(General Public Health Physicians), Professionals-Surgeons, Paediatricians, Internists, Obstetricians & Gynaecologists, Medical Officers, Family Physicians (FP)/General Practitioners (GPs)

• Other Nurses other than trained Occupational Health Specialist Nurses

• Allied Health Professionals-Environmental Health Officers, Physiotherapists,

• Just doing a dissertation in work-related topic or among workers or in a work-environment DOES NOT MAKE YOU AN OH PHYSICIAN/Specialist. E.g. some of our colleagues in General Public Health.

Who is an Occupational Health Specialist Nurse (SOHN)?

• Nurse -Specialises in Occupational Health Nursing after a regulated period of training by a recognised professional body, acquired competences, passed the prescribed examinations, and on the Specialist Register e.g. on Occupational Health/Public Health section of the Specialist Register of Royal College of Nursing (RCN, UK)) or the American College of Nursing

Who is NOT an Occupational Health Specialist Nurse (SOHN)?

Any nurse or midwife or general public health nurse who does not meet the above criteria.

Problems with OH Practise in Nigeria? (1)

Lack of the folowing:

regulated OH practice-open to AbuseAppropriate regulations to govern/guide OH PracticeAppropriate Professional Body to standardise the registration and regulation of OH practitioners doctors, Nurses and other HCWs EnforcementAppropriate Health & Safety regulatory body independent of the Ministry of Labour/Ministry of Health e.g. HSE (UK) , OSHA (USA)Understanding the of OM Specialtyunderstanding of the requirement for OH practiceunderstanding of the Occupational Medicine Specialty by the MDCN (Medical and Dental Council of Nigeria)



recognition of the Faculty of Occupational Medicine as a Specialty and or as a Subspecialty by the Medical and Dental Council of Nigeria.

clarity in the understanding of the differences between the practises of Occupational Medicine/Health specialists and Health & Safety officers or Environmental Officers

respect and ignorance on the part of our medical colleagues in other specialties about Occupational Health/Medicine and its practises.

understanding of the relationship between health and work i.e. the impact of Health on Work and the Impact of Work on Health. Need to be Healthy to work efficiently & effectively. To work safely such that your work does not make you become unwell.

Non-existence of an Employment Tribunal-look specifically at employment laws & Work-related issues


Of recognition that workers need to be Healthy to work efficiently & effectively. To work safely such that your work does not make you become unwell.

Non-existence of an Employment Tribunal or equivalent courts -dealing specifically with employment laws & Work-related issues


Encouragement

• the Faculty of Public Health of the Nigeria Medical Postgraduate College- recently approved subspecialty training in Occup & Environmental medicine but still early days.

• the Faculty of Community Medicine of the West African College of Physicians (WACP) is also considering training in Occup & Environmental medicine as a Subspecialty. Already has Draft document for Approval by College (Delayed by EBOLA CRISIS!!!)

I understand:

Occupational Health Legislations (1)

• OH or Work-related legislations in Nigeria are still very rudimentary and limited to what had existed since the Factory Act. Even when claims are made that the Acts or Regulations have been updated, they are either NOT enforced, Ambiguous, Not Clear or Not Effective.

• It would be difficult to effectively practise OH without clear, unambiguous and Effective legislations.

• Difficult to practise OH without enforcing the regulations

• However, we can borrow a leaf from the UK or USA or other countries with more advanced OH legislations. Typical Example of some of the Regulations in the UK that we may be able to adapt are as follows:


Major Sources of Law in the UK:

•Statute- Acts of Parliament compromising primary legislation

•Common law- the principles of law accumulated from the decisions of judges in cases presented to them in courts over the years;

•European Directives & Regulations


Types of OH related laws

•Criminal law:

• Primarily deters & punishes offenders through prosecutions by the State and its Public Officials-Crown Courts or criminal courts (Magistrates Courts).

• Successful convictions requires ‘beyond reasonable doubt’ & results in a penalty for the offender e.g. fines or prison sentences.

• Breaches of health & Safety legislation, HSE & local authorities (local governments) bring about criminal prosecutions.


• Civil law:

• Primarily compensates for injury or loss proved to be resulting from a failure to carry out a duty of care owed to the wronged party.

• Successful claim requires a proof on ‘balance of probabilities’ and results in awarding of damages or compensation to the plaintiff (Complainant).

• Health & Safety cases in civil courts arise mainly from either breach of statutory duty or negligence, where the claimant must prove that he was owed a duty of care by the defendant and that his injuries or losses were a foreseeable consequence of failure by the defendant to take reasonable care.


What are Regulations?

•Regulations are laws made by Parliament and usually made under the Health & Safety at Work Act (legally binding as the parent Act).

•Approved Codes of Practice (ACoP)-provide guidance on how to apply the law and have a special legal status. Following them is not compulsory. However, in practice not following an ACoP could be difficult to defend and could lead to successful prosecution.

1974-The Health & Safety (H & S) at work Act (HASWA) enacted: Underpins occupational H & S practice in the UK. Enables all other H & S legislations. Imposes statutory duties on employers in the UK to take reasonable care of their employee’s health and safety


The Health & Safety (H & S) at work Act (HASWA), 1974 states:

employers’ statutory duties

employees’ statutory duties to comply with all health and safety at matters at work

successful prosecution could lead to fine or prison terms

Act covers everyone at work, including independent contractors and their employees, the self-employed, visitors, but excludes domestic servants in private households.

Act is the parent of many other statutory regulations, e.g. Management of Health & safety at Work Regulations 1999,



Manual Handling Regulations, & Control of Substances Hazardous to Health Regulations 2002.

Employers’ Statutory Duties Include:

• to ensure so far as reasonably practicable that:

• There is a safe system of work

• There is a safe place of work

• Staff are given information, instruction and training on matters of health and safety and are adequately supervised



There is a safe system for the handling, storage & transport of substances & materials

There is a safe working environment-may include pre-employment medical exam & Equality Act, 2010 or Disability Discrimination Act (DDA), 2005. Although, these were NOT specified under the act.


Employees’ Statutory Duties:

Do nothing to endanger their health

Duty to inform the employer truthfully when requested for information on matters concerning medical history.

Failing to disclose , when requested, material information about previous or current medical conditions may result in fair dismissal.


1992-Display Screen Equipment (DSE) Regulations

1999-Management of Health at work Regulations

COSHH 2004

Control of Asbestos at work regulations-2012

Control of lead at work regualtions-2004

Equality Act, 2010 (replaced Disability Discrimination Act (DDA), 2005) (UK)


Regulations from the Health & Safety at Work Act, 1974

Institutions that Enforce the Act and Regulations

The Health & Safety Commission (HSC) –responsible for Policy The Health & Safety Executive (HSE) responsible for enforcing the Act for

all public services, agriculture, construction & manufacturing industries. The Employment Medical Advisory Service (EMAS)- a division of the HSE-

issues notices to companies or Individuals for breaches of health & safety law.

Environmental Health Officers employed by the local authorities (local govt) –enforce the act in relation to shops, restaurants, hotels, offices



The ‘Six pack’ -came into force in 1993 under HASWA: include

Management of Health & safety at Work Regulations 1999 Workplace (Health, Safety & Welfare) Regulations 1992; Provision and Use of Work Equipment Regulations (PUWER) 1998; Personal Protective Equipment Regulations (PPEs) 192; Manual Handling Regulations 1992; Display Screen Equipment (DSE) Regulations 1992


Management of Health & safety at Work Regulations 1999-Employer’s duties:

‘Suitable & sufficient’ assessment of the health & Safety risks of employees & others in the workplace

Implement measures identified by the risk assessment Training must be provided to all employees Appropriate Health Surveillance Further risk assessment for women of childbearing age Record findings Emergency procedures set up


Workplace (Health, Safety & Welfare) Regulations 1992-covers

The work environment-ventilation, cleanliness, waste, lighting, temperature, room dimensions & space, workstations and seating, floors, surfaces, lavatories, facilities for washing, rest & eating.


Provision and Use of Work Equipment Regulations (PUWER) 1998:

Ensures equipment for work is suitable, complies with standards, safe, maintained safely, regularly inspected, safety measures in place e.g. warning signs.Risk assessment of equipmentRisks controlled as far as reasonably practicableProvide information, training, instructions to all employees


Personal Protective Equipment Regulations (PPEs) 1992

(amended 2002)

Suitable PPEs e.g. masks, gloves, apron, goggles, overallProvide information, training, instructions to all employeesMaintained, regularly inspected, safety measures in place


Manual Handling Regulations 1992

Applied in Transporting or supporting of a load (include: lifting, putting down, pulling, pushing, carrying or moving)

Eliminate risk, where possibleIf not, carry out Manual handling risk assessmentImplement measures to reduce risksEmployees under duty to use safe systems e.g. use of hoist, attend manual handling training, follow instructions


Display Screen Equipment (DSE) Regulations 1992 :

Covers computers, laptops, CCTVs, or any other equipment used for the display of text or graphics used ‘habitually’ (about 30-50% of time at work) at work

Regular breaksDSE workplace assessmentWorkstations-has appropriate lighting, noise, temperature, avoid glare, enough legroom, adjustable chairs (back and height), appropriate softwareProvide regular eye tests


Control of substances Hazardous to Health (COSHH) Regulations 2002 (Amended 2004)

Risk assessment of exposure to hazardous substances at workPrevent exposure if reasonably practicableIf not, exposure adequately controlled

Not exceeding any applicable Workplace Exposure Limits (WEL) Health Surveillance Provide instructions, training & supervision of employees Control measures to follow hierarchy of control measures: elimination,

substitution, isolation/enclosures, engineering controls, PPEs


The Control of Vibration at Work Regulations 2005-employers’ duties:

Risk assessment of exposure to vibration (individuals using vibrating tools: drills, hammer drills, sanders, breakers, hedge cutters, strimmers) Dentists, Dental Technicians, construction workers, carpenters, farmers, oil workers, workers in most industries, mechanics , miners etc)Health surveillanceControl measuresProvide instructions, training & supervision of employeesProvisions appropriate PPEs-anti-vibration gloves, water-resistant clothing, warm clothingExposure Action Value-2.5m/s2

Daily Exposure Limit value (ELV) 5.0ms/s2


Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995:

Employer must report to HSE or local authority via the incident contact centre, any of the following arising out of, or in connection with work:

Death or major injuries from accidentMinor injuries causing the individual to be off work or unable to perform the full range of their normal duties for over 3 daysReportable industrial diseases when confirmed in writing by a doctorDangerous occurrences, including needlestick injuries


The Control of Noise at Work Regulations 2005

Risk assessment of exposure to noise (Workers affected: Dentists, Dental Technicians, construction workers, carpenters, farmers, oil workers, workers in most industries, mechanics , miners etc)Health surveillanceControl measuresProvide instructions, training & supervision of employeesProvisions appropriate PPEs-hearing protectionAt or above 80dB(A) hearing protection must be worn. Hearing checks regularlyAt or above 85dB(A) a programme control measures must be implemented to reduce the risk of exposure to a minimum


The Control of Asbestos at Work Regulations 2012

•Avoid exposure to asbestos at work

Equality Act, 2010 (Disability Discrimination Act, 1995 (Amended 2005)

•Employers: to make reasonable adjustments to be able to accommodate employees with disability.

Disability: Physical or Mental impairment with substantial adverse effect, long-term (likely to last or lasted 12 months or more), requires regular treatment, tendency to relapse e.g. mental health anxiety & depression, bipolar disorders, cancers, HIV, multiple sclerosis, diabetes, hypertension, NOT Disabled: personality disorders, Alcohol, drug or nicotine addiction unless complications of their addictions i.e. liver failure, mental illness


Medical Assessment of Oil & Gas UK (OGUK) & UK offshore operations association (UKOOA)

Regulates Oil & Gas Workers in the UK

Pre-employment/pre-placement medicalMinimum age for employment: 18 yrs

Periodic medical- 3 yearly up to age 39 yrs, 2 yrly between 40 and 50 yrs, & annually.

more frequent medical after significant absence due to injury or illness. measurements-height, weight, body mass index (BMI), visual acuity, colour

vision, systematic physical exams BMI> 35 (Unacceptable)


Investigations: urinalysis, pulmonary function, audiometric testing Certification of dental fitness; routine dental surveillance Catering staff to have at least one stool sample cultured for pathogens

HIV does NOT debar from employment BUT symptoms and signs of AIDS related Complex debars

Malignancy (unfit) but decided case by case basis Alcohol & substance abuse-positive test=exclusion But companies ready

to assist Medications: cytotoxics, anticoagulants, immunosuppressants, insulin,

anticonvulsants, oral steroids, routine use of psychotropic agents, tranquillizers, narcotics, hypnotics are unfit to work offshore


Chronic ear disease or vertigo, significant symptomatic nasal airway obstruction, recurrent or chronic sinus infection

Hearing loss in better ear greater than 35dBA for lower frequencies or 60dBA for higher frequencies

Neurological disorders e.g. epilepsy, cerebral disorders-unacceptable Peripheral vascular disease.eg. varicose veins with ulceration, varicose

eczema or active deep vein thrombosis-unacceptable

Medical conditions Unfit/unacceptable for Offshore work:

• CVS, chronic lung dis, Mental disorders, chronic kidney dis, liver dis, GI disorders (active peptic ulceration, IBD, symptomatic hiatus hernia, haemorrhoids, fistulae, anal fissures, cholelithiasis, pancreatitis, abdominal herniae)

Recommendations (1)

Federal Government, State & Local Governments Actions

Enact Laws/Legislations- regulations to govern/guide OH PracticeAppoint appropriate body/Committee consisting of Occupational Professionals to assist with drafting the legislations and advising the government.Establishment of Health & Safety regulatory body similar to HSE (UK) & OSHA (USA) independent of the Ministry of Labour/Ministry of Health –Headed by Occupational Physician but with membership from other health professional groupsEstablishment of Employment Tribunals to address specifically employment cases & employment laws

Recommendations (2)

Federal Government, State & Local Governments Actions

Monitoring & Regulatory systemBetter understanding of the relationship between health and work i.e. the impact of Health on Work and the Impact of Work on Health. To raise the profile of Occupational MedicineTo make Occupational services mandatory for all organisations-small, medium and large organisations, both private and public-through legislations.

Equality Act or Disability Discrimination Act Law MUST be Established: Avoid wrongful dismissals, rejection for employment, retired too early, discrimination against disabled people e.g. air crew with HIV

Recommendations (3)

Mandatory for organisations to employ OH physician with the right OH qualifications-ensure appropriate advice & correct OH Practise.

Environmental laws to stop pollution especially work-related by companies, individuals or organisations.

Medical & Dental Council of Nigeria

Better understanding of the OH SpecialtyEstablishment of the Faculty of Occupational MedicineRegistration of Accredited Specialist qualifications acquired from Reputable medical bodies e.g. American Board Certification, MFOM & other equivalents under category A of the Specialist Register- as there are currently OH specific training programmes in Nigeria.

Recommendations (4)

Recognition of medical Doctors with over 10 yrs experience practising OM full time as their primary assignment as Specialist in some capacity. Establishment -appropriate pathways with various bodies such as the WACP, the Nat. Postgrad. Med. College of Nigeria, the American College of Occupational & Environmental Medicine, The Faculty of Occupational Medicine of the Royal College of Physicians, UK and others for the recognition of Medical Doctors without OH qualifications but with at least 10 years of continuous OH practice as Specialist in Category B of the Specialist Register for the first 2 yrs of registering the Specialty.Set up regulations for Occupational Health Practice


Recommendations (5)


to standardise the registration and regulation of OH practise by doctors and other HCWs

Enforcement of professional registrations & Restriction of OH Practices to qualified OH Specialists only

Postgraduate Medical Colleges

Time both the Nigeria Medical Postgraduate College & the West African College of Physicians (WACP) gave recognition to Specialist OH Physicians trained outside from reputable accredited bodies & support their registrations under Category A of the Additional Registration.

Time both Faculties of Public Health & Community Medicine of the Nigeria Postgrad. Med. College & WACP considered the benefits to the colleges & the Nation of having trained OH consultants & award Fellowships of the colleges to OM Specialists/consultants who trained outside Nigeria from reputable accredited bodies to boost training & development of future specialists in OM.

Recommendations (6)

Recommendations (7)


Establish genuine pathways for recognising Medical Doctors without formal training but practising OM full time as their primary assignment for at least 10 yrs as Specialists in some capacity during the first 2yrs of establishment of OM Specialty/Subspecialty.

To stand shoulder to shoulder to clarity the friction between Occupational Medicine/Health specialists and Health & Safety officers or Environmental Officers.

Faculties of Public Health of the 2 colleges to build better relationships with external faculties of Occupational Medicine, FOM (UK) or ACOEM (USA)-effective & Robust dev. OM in Nigeria.

Recommendations (8)


• Work towards closer integration & Reciprocal Recognition with external faculties of Occupational Medicine i.e. FOM (UK) & ACOEM) (USA) & others.

Both Colleges to offer appropriate advice to both the MDCN & Fed Govt to ensure the growth & development of OM in Nigeria.

Both Colleges to stop the dirty Politics & Cold War and work together for the growth of OM, the medical profession and the greater benefit of Nigeria & Nigerians.

Recommendations (9)

Organisations –Public & Private & Individuals

To recognise the distinct role of OH Physicians & Nurses and the value they add to the organisation

To re-configure services such that OH services will be made distinct and separate from Family Medicine/GP practices, Paed., O & G, Surgery and other clinical services.

To stop confusing other clinical services especially family medicine/GP practices as OH services. The diagnosis, investigations & treatment of various medical conditions except work-related are not part of OH role.

Families and dependents of employees should be seeing Family Physicians or other clinicians for their medical problems and not OH.

Recommendations (10)

• OH services are purely for workers, - it is about adjustments that could be made to make individuals work safely.


OH services are about ensuring that the work environment & the systems of work are safe

Ensure recruit individuals with specialist OH qualifications and not confuse it with fellowships/memberships from other clinical specialities-as you will give you better value for money.

By employing a well trained OH physician (Not Imitations) & appropriate OH legislations, you will get the following benefits:Reduction in work-related Disease burden, injuries & mortality Less Litigations & payment for compensationsIncreased Productivity as sicknesses absences will be brought to a minimum Appropriate advice and adjustments to work will cut down the duration of sickness absences.A Healthier workforce will by far be more productiveCut down a lot of unnecessary overheads

Recommendations (11)


Conclusions

Establishment of OH laws that are enforceable with appropriate support structures is paramount to the future development of OH in Nigeria.

Thank you for lending me your ears & your time.

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Understanding Occupational Health: Myth & Legislations Dr Obadiah Lulu Elekima,MPH, M.Sc(Tox.), M.Sc...

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