Planning a health monitoring program
Information to be provided by the PCBU
The PCBU must provide you with the following information:
- About the business or undertaking and the worker
- name and address of the person conducting the business or undertaking, and
- the name and date of birth of the worker (note: any additional information about the worker must not be supplied without the worker’s consent).
- About the work
- the work the worker is, or will be, carrying out that has triggered the requirement for health monitoring, and
- if the worker has started that work, how long the worker has been carrying out that work.
- Additional information that should be supplied to the registered medical practitioner may include:
- a list of the hazardous chemicals that the worker is or will be exposed to
- the dates that the worker last used the chemicals
- the safety data sheet (SDS) for the chemicals, and
- relevant risk assessment reports, details of workplace exposure standards and results of any air monitoring carried out at the workplace.
- Risk assessment reports should contain information about:
- likely exposures at the workplace
- control measures that are in place to minimise exposure
- investigations of results where workplace exposure standards have been exceeded, or
- where surface wipe testing indicates accumulation of chemicals on surfaces.
Information about other hazardous chemicals to which the worker may be exposed, may help you determine if additive or synergistic effects are possible. For example, if the adverse effects of the hazardous chemical may be exacerbated or if the threshold for adverse effects may be lower.
To gain a better understanding of the workplace, you may wish to organise a workplace visit with the PCBU.
Decide what health monitoring techniques and tests to use
Deciding what health monitoring procedure to use involves making decisions about the entire health monitoring program, as well as individual test methods to use. For example it includes details like the frequency of testing needed during the health monitoring program. It should also include consideration of implementing action levels or identifying key symptoms that will allow proactive review of work processes and controls to ensure that adverse health effects and conditions are not experienced by workers. For example, where a disease is caused by chronic exposure to a hazardous chemical, you could use the workplace exposure standard as a measure to decide if an X-ray is required. Where exposure to a hazardous chemical results in an effect on lung function, you could use the action level for a workplace exposure standard (fifty per cent of the relevant standard) if spirometry or other lung function testing is required.
The clinical and medical assessments undertaken as part of a health monitoring program for asbestos or a hazardous chemical listed in Schedule 14 is specified in the WHS Regulations (Hazardous chemicals requiring health monitoring) and described in the individual chemical documents. There are provisions where alternative tests may be used for example where new technology or equipment becomes available. Given your medical experience, you may be aware of alternative tests that are of equivalent or superior quality to detect the same endpoint. You may consider these alternative tests as more appropriate, depending on the individual worker. Any alternative tests to those specified in the WHS Regulations should be discussed with the PCBU, who has a duty to ensure appropriate health monitoring is provided, and formally recommended.
The potential chemical-associated adverse effects differ from one chemical to another. The individual chemical guides provide some information about the potential acute and chronic toxicity effects associated with exposure to asbestos or a chemical listed in Schedule 14. This information is provided to assist you in identifying potential signs of injury, illness or disease that may be associated with exposure to the relevant hazardous chemical. Depending on discussions with the worker and the results of the specified medical tests or biological monitoring results, you may wish to perform additional medical examinations to assess potential effects on a worker’s health. The target organ, acute and chronic toxicity sections in the individual chemical documents provides information to help guide what these follow up examinations may look like.
Under the model WHS Regulations (regulation 436), there are specific health monitoring requirements for workers exposed to asbestos. These are listed in Hazardous chemicals requiring health monitoring and detailed further in the health monitoring guidance for asbestos and the Code of Practice: How to safely remove asbestos.
Chemicals listed in Schedule 14 to the WHS Regulations
Schedule 14 to the WHS Regulations lists hazardous chemicals, including inorganic lead that must be considered for health monitoring if they are used at a workplace.
Further information, including detailed information on the health monitoring tests and procedures, and the information required for the preparation of a health monitoring program, can be found in the separate Health monitoring guides for hazardous chemicals for each hazardous chemicals listed in Schedule 14 and asbestos.
Chemicals that are not listed in Schedule 14
The determination of appropriate techniques and test methods for hazardous chemicals not listed in Schedule 14 to the WHS Regulations is a matter for you and the PCBU.
Techniques and test methods used in a health monitoring program should be practical, accurate and safe. A health monitoring program should be proactive and assess the risk of adverse health effects or detect adverse health effects at an early stage.
Researching and understanding the health effects of a hazardous chemical and the symptoms of exposure can inform decisions about what an appropriate technique or test method might be. The following examples are provided to illustrate how a test method may be chosen:
Examples of how a test method may be chosen
For a chemical that is known to cause respiratory irritation or reduction in respiratory function
Respiratory questionnaire or spirometry (lung function test) or both may be used to assess effects of inhaling a chemical.
For a chemical that is known to cause specific observable health effects including skin or eye irritation or a rash
Health monitoring may involve simple observation of the worker’s eyes and skin by a competent person (for example an occupational nurse) or through trained self-observation and reporting.
Where exposure to the chemical is known to cause that chemical or a metabolite to be present in urine, blood or exhaled air
Urine, blood or exhaled air analysis for levels of a chemical or metabolite may be used to assess exposure from any route (ingestion, inhalation or absorption through the skin).
For monitoring to be useful, the correlation between urine, blood or exhaled air levels and health effects or the no observed adverse effects (NOAEL) or lowest observed adverse effects level (LOAEL) needs to be known.
For example, if a level of 50 µg/L of the chemical in urine correlates with a specific exposure level (e.g. concentration of the hazardous chemical in air) or known health effects, this may be used in health monitoring to inform action levels and medical recommendations.
Validated analytical test methods must also be available. The analytical method needs to be specific to the chemical, should not deliver false positive results, and be reproducible and accurate.
Where there are no valid methods to detect levels of exposure at which injury, illness or disease may occur or the link between work and illness is uncertain, health monitoring may take the form of a review of absence due to illness records and symptom reporting.
Health monitoring may also include self-checks, for example skin checks for redness, itching or other symptoms. Self-checking is only effective as a health monitoring method if workers are trained on what to look for and how to report symptoms.
Biological exposure monitoring
For some chemicals, biological monitoring is a way of assessing chemical exposures by measuring and evaluating biological levels of the chemical or its metabolites in body tissues, body fluids (for example, urine or blood), or in exhaled breath of an exposed worker.
Biological monitoring assesses total exposure from all routes:
- ingestion, and
- absorption through the skin.
Biological monitoring is particularly useful where skin absorption of the hazardous chemical is significant and where controls rely upon the use of personal protective equipment, such as gloves and respirators. Results can be compared to baseline test results or biological exposure standards.
Biological exposure monitoring allows you as the registered medical practitioner to proactively inform the:
- worker of potential adverse health outcomes, and
- PCBU of possible problems with work practices or control measures.
When interpreting results from these tests, you may need to consider the specificity of the test and any potential confounding factors. Information about specificity and potential confounding factors have been included in the individual chemical guides.
Biological exposure monitoring methods can be quantitative or non-quantitative. Quantitative tests, where there is a correlation of the result with worker exposure and potential adverse health effects, are considered more appropriate for a health monitoring program. However, there may be circumstances where use of a non-quantitative method is appropriate as a follow up test to confirm exposure to a hazardous chemical if the available quantitative method lacks specificity. The individual chemical guides provide further information on monitoring methods including specificity, quantitative nature of the tests to inform your recommendations for alternative or follow up biological exposure monitoring.
Where test results show there is a significant increase over time or where the levels approach the biological exposure standard, remedial action should be recommended to the PCBU to reduce exposure. Remedial action by the PCBU may include an investigation into the level of exposure, changes to workplace controls or the worker’s temporary transfer to an alternative job.
Preferred tests for biological exposure monitoring are those that are less invasive and provide the same degree of accuracy and reliability. For example, collection and analysis of urine samples is generally preferable to taking blood samples.
Biological exposure standards
A biological exposure standard is a specified concentration of a chemical or chemical metabolite in body tissue, fluid or breath or a measurable biochemical change in the worker.
Biological exposure standards and biological guidance limit values are provided in the individual hazardous chemical guides to assist your assessment of the level of exposure to a chemical in the workplace and the risk of adverse health effects.
Where appropriate, a worker’s test results should be compared with the biological exposure standard or biological exposure guidance value provided in Health monitoring guides for hazardous chemicals.
Respiratory questionnaires can be used to assist you to carry out health monitoring programs for those chemicals that affect the respiratory system, and these can be combined with spirometry to give a full view of adverse respiratory effects.
Special considerations - pregnancy and breastfeeding
Workers may express concern about the potential effects of workplace exposure on pregnancy, pregnancy outcomes and breastfeeding, for example:
- an increased rate of spontaneous abortion
- teratogenic effects leading to foetal abnormalities, and
- developmental effects on infants.
Some examples of chemicals that may have adverse effects on reproduction and development include:
- organic solvents
- aromatic hydrocarbons – benzene, toluene, xylene
- halogenated hydrocarbons – tetrachloroethylene, trichloroethylene, dichloromethane
- ketones – methyl ethyl ketone, and
- heavy metals – lead and cadmium.
For some hazardous chemicals, such as lead, the effects on reproduction and development of the foetus, infants and children are well documented. Maternal exposure to organic solvents as a group is consistently associated with a modest increased risk for birth defects and, somewhat less consistently, for spontaneous abortion. In such cases, the need for avoiding further exposure is obvious.
However, for many hazardous chemicals there is limited quality information regarding potential embryofoetal effects. The GHS profile of the hazardous chemicals may provide information regarding the classification of the health hazards. Alternatively, you may need to independently source further information. Any potential exposure should be eliminated or minimised wherever possible.
Commencing the health monitoring program
As the registered medical practitioner, you should prepare a program of health monitoring in consultation with the PCBU.
This program needs to be specific to the worker and the workplace chemical being used. It may include examinations that can be undertaken by another suitably qualified person, for example an occupational health nurse, or by the worker themselves after they have received proper training and education. The program should also consider the personal preferences and situation of the worker, including religious and cultural sensitivities.
The frequency of health monitoring will depend on the hazardous chemical that has triggered health monitoring and the test results. There are specific requirements for lead and asbestos. However for other hazardous chemicals the frequency of health monitoring may vary depending on:
- frequency of chemical use
- for example daily, weekly or seasonal use of certain chemicals
- results from previous health monitoring, air monitoring or surface wipe testing, and
- reports of any symptoms of exposure or signs of injury, illness or disease associated with worker use of hazardous chemicals.
If a spill, leak or loss of containment of the hazardous chemical occurs, a worker may experience high acute exposure to a hazardous chemical posing a risk to health. If a spill, leak or loss of containment incident occurs, the PCBU should organise a health monitoring appointment as soon as practicable after the incident, even if this is outside of the health monitoring timetable scheduled for the individual.
The PCBU may also refer a worker for health monitoring if they feel their health is at risk or if they do not feel well and think that it may be related to the use of or exposure to chemicals within the workplace.
As the registered medical practitioner, you have the overall responsibility for carrying out the health monitoring. However, you may need to seek advice from other professionals such as an occupational physician, a pathology laboratory or workplace health and safety professionals.
When discussing the health monitoring program with the worker for the first time you should explain:
- health monitoring as a legal requirement under the model WHS Regulations
- what is involved in the health monitoring program, for example
- the frequency of testing and
- which tests may be needed (e.g. blood tests and respiratory tests)
- any requirement for them to see a doctor or specialist
- how a registered medical practitioner is chosen and their qualifications
- who pays for the health monitoring
- if and how monitoring results may affect their work tasks, for example explaining circumstances where the worker may need to move to other tasks, and
- the record keeping requirements.
Before work starts – baseline monitoring
Baseline health monitoring of the worker may be required before the worker starts work with a hazardous chemical, so that changes to the worker’s health can be detected.
For chemicals that require health monitoring, the following information should be collected and included on the health monitoring report. A template health monitoring report is available for asbestos and each of the hazardous chemicals listed in Schedule 14. Some of this information will be provided by the PCBU.
Demographic data—provided by the PCBU
- name and date of birth of the worker.
Demographic data—collected by the registered medical practitioner
- sex (the sex of the worker must be recorded not the gender that the worker identifies with because certain chemicals have effects at different levels of exposure for different sexes e.g. female reproductive effects of lead), and
- current residential address of the worker.
Details of the work—provided by the PCBU
- a description of the work that triggered the requirement for health monitoring
- details of control measures used in current work, including whether suitable personal protective equipment is used, and
- if the worker has started that work, how long the worker has been carrying out that work.
Previous work history—collected by the registered medical practitioner
- past work history, including previous known or suspected exposures to the hazardous chemical currently being used and other hazardous chemicals, and
- potential for exposure in current work.
Medical history—collected by the registered medical practitioner
- presence of symptoms that may be due to or exacerbated by exposure
- relevant medical conditions that may increase health risk from exposure, and
- other relevant information, for example smoking history.
Discussions about the health monitoring program—performed by the registered medical practitioner
A discussion about the health monitoring program should be conducted with the patient. Information about the program including what is involved, for example the frequency and type of testing, and information about the effects of exposure to the chemical and how to recognise and report symptoms should be provided to the worker.
Discussions should also include instances when health monitoring may change. For example, this may be required if it is indicated by test results or symptoms or if the worker falls pregnant.
Physical examination—performed by the registered medical practitioner
A physical examination may be required and should place emphasis on the target organs or systems for the chemical being used.
Details of the physical examinations required for each chemical are provided in Health monitoring guides for hazardous chemicals. For some chemicals a physical examination is only required if work and medical history indicates this is necessary, such as where symptoms are present. In other cases, collection and analysis of biological samples, for example urine or blood may also be required.
During health monitoring
As the registered medical practitioner, you should ensure that the health monitoring program, test methods and procedures are followed throughout the program.
Regular feedback should be provided to both the PCBU and the worker if results indicate the worker is being or has been exposed to a chemical or if the worker is showing adverse health effects as a result of exposure.
You should ensure the quality of the health monitoring program through quality assurance practices. Where specific tests are required, the analytical laboratory providing the test service should be accredited for the procedure with the National Association of Testing Authorities.
If the collection of biological samples is part of the health monitoring program, any instructions from the laboratory providing the test service regarding the collection, storage and transport of the samples should be followed to ensure results are accurate.
Health Monitoring Report
A health monitoring report is required by the PCBU as soon as practicable after the health monitoring is carried out in relation to a worker.
A health monitoring report template is provided in Health monitoring guides for hazardous chemicals for each hazardous chemicals listed in Schedule 14 and asbestos. Other templates, forms and formats of health monitoring reports are acceptable and may also be used.
Removal from work
Should test results or symptoms indicate the worker has been exposed to a hazardous chemical that has triggered health monitoring and is suffering from symptoms or a health condition due to exposure, the supervising registered medical practitioner may make a recommendation to the PCBU to have the worker removed from work with the chemical.
In such instances, the PCBU will be required to remove the worker immediately from carrying out such work. This recommendation should be provided with a request for review of control measures.
It is important that if the decision for removal is based on the results of biological tests and that the results are confirmed either through re-testing the sample or collecting a subsequent sample.
Return to work
Should a worker be removed from work, they must not return to work until they have been assessed as medically fit and, where relevant, test results are below the biological exposure standard. This should include your assessment of resolution of symptoms and remediation undertaken by the PCBU. As the registered medical practitioner, you must formally recommend the worker can return to work with the specified chemical to the PCBU.
In some cases such as lead, there are specific regulatory requirements for blood lead levels for the worker to return to work. For more information see Health monitoring guides for hazardous chemicals.
Termination of health monitoring – data to be collected
Final medical examination
A final medical examination should be conducted by you when the worker has finished working with the chemical that triggered health monitoring.
As with baseline monitoring, the focus of the final medical examination varies for individual chemicals and may involve collection of biological samples. The final examination should also place emphasis on any symptoms or conditions observed during the health monitoring program.
Workers with continuing symptoms of exposure or health conditions due to exposure should be advised to seek continuing medical examinations.
Health monitoring report
A final health monitoring report must be provided to the PCBU.