Health surveillance

What is health surveillance?

Health surveillance is any activity which involves obtaining information about employees' health and which helps protect employees from health risks at work.

The objectives of health surveillance are

• Protecting the health of employees by early detection of adverse changes or disease;
• Collecting data for detecting or evaluating health hazards;
• Evaluating control measures.

It should not be confused with general health screening or health promotion.

When is health surveillance required?

Health surveillance is appropriate when employees are exposed to residual risk of harm from hazardous substances, following all appropriate means of control, and;

• The agent is known to be associated with an identifiable disease or an adverse health effect; and
• There is a reasonable likelihood that the disease or the effect may occur under the particular conditions of work; and
• There are valid techniques for detecting indications of the disease or effect.

The technique used should not place employees at an increased risk or cause unacceptable harm.

Situations where health surveillance may be appropriate

• Where employees are liable to be exposed to substances known to cause skin sensitisation (allergic contact dermatitis).
• Where employees are liable to be exposed to substances known to cause urticaria.
• Where there have been previous cases of work related skin disease, such as dermatitis or urticaria in the workforce/place.
• Where there is reliance on PPE, eg gloves as an exposure control measure; eg printers wearing gloves to protect against solvents used during press cleaning, or paint sprayers using two-pack paints wearing gloves and overalls. Even with the closest supervision there is no guarantee that PPE will be effective at all times.
• Where there is evidence of skin disease in jobs within the industry; eg frequent or prolonged contact with water (termed 'wet-working') causing dermatitis in hairdressers and healthcare workers.
• Where employees are liable to be exposed to hexavalent chromium compounds eg mists from chrome plating baths causing chrome ulcers in platers.

This is not a definitive or exhaustive list and there will be many other instances where health surveillance is required.

The most frequently and consistently reported examples of occupations and associated agents are listed in table 1 for allergic and contact dermatitis, table 2 for urticaria and table 3 for cancer. These tables are not all inclusive. Your risk assessment should identify if health surveillance is required.

Medical surveillance using an HSE appointed doctor may be necessary if workers are involved in the manufacture of pitch or potassium or sodium chromate or dichromate. For further details see Schedule 6 of the Control of Substances Hazardous to Health Regulations (as amended) 2002 and Guidance for appointed doctors (MS32).

What is suitable health surveillance for occupational contact dermatitis?

Higher level health surveillance

Higher level health surveillance is appropriate when the evidence for a hazard is clear and/or there is potential for significant exposure. For example

• When workers are exposed to substances and processes where occupational contact dermatitis is a known problem, and the employer knows that despite risk reduction measures being in place, exposure can happen, and that occupational contact dermatitis is not uncommon in their industry or work sector.
• If you have a confirmed case of occupational dermatitis.

Action for higher level health surveillance

Higher level health surveillance should include the following measures:

• Assessing workers' skin condition before or as soon as possible after they start a relevant job to provide a baseline.
• Regular visual skin inspections by a 'responsible person'. The frequency of the inspections will depend on the nature of the risk, but a brief monthly routine is often appropriate.
• Telling employees about likely exposures and symptoms to watch out for
• Telling employees about how (and whom) to report such symptoms if they occur between inspections.

Higher level health surveillance may include employee questionnaires (eg annually).

Lower level health surveillance

Lower level health surveillance is appropriate where:

• There is only occasional or potential exposure;
• Control is adequate; or
• You decide to move to lower level surveillance in consultation with a health professional.

Action for lower level health surveillance

Lower level health surveillance could include one or all of the following:

• An annual questionnaire, done by the trained 'responsible person'
• Telling employees about likely exposures and symptoms to watch out for
• Telling employees about how (and whom) to report such symptoms if they occur.

A sample questionnaire for skin health surveillance is available.

Who carries out health surveillance?

A 'responsible person' is someone in your organisation who is given the responsibility to help deliver a health surveillance system from within the workplace. They will have received training or coaching on what they need to do to perform this role effectively – which may involve training from a health professional, a health & safety professional, management or any other, as appropriate.

This person's role in the health surveillance system should be clearly defined and they should be someone who is trusted by the workforce, with good communication/interpersonal skills.

The role of the 'responsible person' is to:

• Assess the condition of a new employee's skin before, or as soon as possible after, they start work;
• Periodically check employees' skin for the early signs of skin disease;

• Keep records securely;
• Tell the employer the outcome of these checks, so they can review their control measures and risk assessment and seek expert help on cases of skin disease.

A 'responsible person' can be an employee provided with suitable training. They should know:

• The substances in their workplace that can cause skin disease;
• The types of skin diseases they can cause;
• What the early signs of those diseases look like;
• How exposure happens through handling, use, maintenance etc;
• What controls are in place and the consequences of any shortcomings;

Detection of an adverse health effect

The 'responsible person' should know what action to take on finding a problem. This includes:

• Reporting to the employer on the disease and exposure controls;
• Advising the affected employee(s) to see an appropriate health professional;
• Keeping records of observations;
• Keeping records secure.

A responsible person, on finding any skin problems,  should advise the employer when to seek expert help.  For example, an appropriately qualified doctor or nurse will need to be called on to deal with employees with skin problems, as they may no longer be fit to be exposed, or may need restrictions placed on exposure.

Occupational health referral

Employers need to consider what you will do if skin disease means a worker is no longer fit to perform their job, or there are restrictions on what they can do. You may need to adapt the workplace or even move affected staff to alternative duties. An occupational health provider would be able to assist with some of these decisions.

Action on health risks

Control measures need to be improved where indicators of skin disease are found. Employers should consider the following:

• What work has the employee been doing/for how long?
• Have all risks in the work activity been assessed?
• Have other workers who are similarly exposed had their health reviewed?
• Have you chosen the most effective and reliable controls?
• Have you considered all routes of exposure?
• Is the employee trained, both for the job and in the use of any equipment used to control risk?
• Have you maintained/checked the control measures to make sure they stay effective?
• Is any necessary personal protective equipment (PPE), including protective clothing, provided and used correctly?
• Could activities outside work have caused skin disease?

You should consider all the above, in tandem with the results from the subsequent health surveillance, when implementing additional or improved control measures.

Health records

A health record must be kept for all employees under health surveillance for at least 40 years from the date of last entry because often there is a long period between exposure and onset of ill health.

What information should be included in health records?

Individual health records should include details about the employee and the health surveillance procedures relating to them.

Employee details should include:

• surname
• forename(s)
• gender
• date of birth
• permanent address, including post code
• National Insurance number
• date present employment started
• an historical record of jobs in this employment involving exposure to identified substances requiring health surveillance

Recorded details of each health surveillance check should include:

• the date they were carried out and by whom
• the results of the checks carried out
• where any skin problems are identified, the results of decisions made by an appropriately qualified doctor or nurse on the employee's fitness for continued exposure or any restrictions they have advised.
• if increased health surveillance is required
• the date of or the interval before the next health surveillance check.