- Email: [email protected]
Occupational health in health care workers
Public Health Forum 19 Heft 72 (2011) http://www.elsevier.de/phf
Occupational health in health care workers Friedrich Hofmann und Ulrich Sto¨ßel Due to the growing number of people working in the German Health care system (+15% since the year 2000) occupational health in health care workers attires much more attention than in former times. This interesting field of occupational medicine has first been described by Bernardino Ramazzini (1634 – 1714) in the year 1700 (Ramazzini, 1953): One chapter of his book ‘‘De morbis artificum’’ dealt with infections in midwifes caused by treatment of infectious pregnant women. 200 years later the German author (and dermatologist) Gottfried Benn (1886 – 1956) reported a syphilis prevalence of 0.4% in the same occupational group (Benn, 1987). At the same time tuberculosis was also recognised as a specific health problem of health care workers. During the second half of the 20th century hepatitis B was regarded as the most important hazard. At the same time when first hepatitis B-vaccines were produced (1981) other biological (HIV) and non-biological hazards were identified, e.g. teratogenic viral infections in hospital employees, the handling of antineoplastic agents, allergies and other skin diseases, psychosocial stress and last but not least back pain (Emmett, 1987). The breakthrough for occupational health in health care workers came in 1986 with the first ‘‘Freiburger Symposium Arbeitsmedizin im Gesundheitsdienst’’ (since then 25 national symposia took place) (Hofmann et al., 1994-2011; Hofmann und Sto¨ßel, 1987-1992). In 1990 the International Commission on Occupational Health (ICOH) founded a scientific committee which organised
several international congresses in this area (Hagberg et al., 1993, 1995; Hofmann et al., 1999). They were accompanied by the edition of proceedings and a practical guide which was edited by collaboration of the committee-members (Hasselhorn et al., 1999). Other congresses in North America and North Africa were organised thereafter. Today occupational health in health care workers (Gestal Otero, 1993) is a well established science within occupational medicine identifying -
environmental, biological (table 1), chemical, physical, and psychosocial hazards. th
During the second half of the 20 century biological hazards in health care were first regarded as an exclusive occupational hazard (health care workers are infected by their patients). Today infection of patients by their doctors and nurses play an important role, too: To date, more than 1,000 nosocomial HBV-, HCV- and HIVinfections of patients caused by surgeons, dentists, and nurses have been reported in the international literature (Perry et al., 2006; Ross et al., 2000). Injuries with syringes and other sharps (so-called needles stick injuries, NSI) cause both infections of personnel and patients. Technical (e.g. use of safe instruments, double gloving, safe disposal of waste), organisational and immunological (e.g. HBV-vaccination, Post exposure prophylaxis) aspects of health care have to be trained during everyday life of medical personnel. Efficient
prevention includes a reporting-system designed by occupational health physicians (virologists and other specialists in the field of infectiology) providing a 24-hours-service for the management of NSI. Other infections can be prevented by use of a couple of vaccines and measures of personal protection (e.g. masks). Chemical hazards include exposure to - aldehydes during disinfection of surgical instruments and hospital beds, - organic solvents e.g. in histology laboratories, - cytotoxic drugs in oncology-units (and pharmacies), - volatile anaesthetic gases in operating theatres. These hazards can be prevented by measures of personal protection and by technical means (e.g. hoods, charcoal filters for absorption of volatile anesthetics, gloves, masks). Physical hazards are caused - mechanically (e.g. lifting of patients) by overexertion or - by exposure to ionising radiation (e. g. in radiological units, in radiation therapy departments or in nuclear medicine). Examples for preventive measures concerning musculoskeletal diseases are back school programs and the use of lifting aids. Radiation exposure is a function of time, distance and shielding. Management of radiation is, therefore, by - reducing the time of exposure, - increasing the distance to the source of radiation and by
26.e1
Public Health Forum 19 Heft 72 (2011) http://www.elsevier.de/phf
Table 1: Biological hazards in health care workers (selection). Bacterial infections
Viral infections
Other infections
B. pertussis C. diphtheriae M. tuberculosis N. meningitides S. aureus Streptococci
Cytomegalovirus Hepatitis A-virus Hepatitis B-virus Hepatitis C-virus Herpes simplex virus Human immunodeficiency virus Influenzavirus Rubellavirus Varicella-Zoster-Virus
Blastomyces Cryptococci Plasmodia Prions
- placing absorbing material around the radiation-source. Psychosocial hazards which include both behavioural and organisational aspects of health care work are of growing importance as can be seen in a lot of surveys esp. on physicians and nurses in different settings (ambulatory, stationary) (Hofmann, Sto¨ßel Vol. 1-6, 1986-1992; Hofmann, Reschauer, Sto¨ßel; Volumes 7-24; 1993-2011) Stress, burn out, depression, early retirement from work, suicidal tendencies, broken work-life balances as to mention some of the unhealthy consequences of the work in this field are some of the important outcomes we have to recognize. The modelling of causal pathways to determine psychosocial factors affecting the health of health care workers does in general not differ from other professions. We always have to take into account the
26.e2
- macro level (aspects of the social structure), - meso level (aspects of social formations and psychosocial factors), and the - individual level (psychological factors) (Martikainen et al., 2002; Kompier, 2005). Preventive approaches based on the knowledge we have today are much more sophisticated as in the decades before. Not only the occupational health physician but also other professionals like psychologists, sociologists and educational professionals are engaged in the development and evaluation of work site health promotion programs, often in teams, with special focus on psychosocial factors of work. This efforts mostly are and often embedded in health management structures. The leading philosophy
in these approaches is not a pathogenetic but a salutogenetic one: What keeps health care workers healthy in their work, so they can better help their patients? Der korrespondierende Autor erkla¨rt, dass kein Interessenkonflikt vorliegt. Literatur siehe Literatur zum Schwerpunktthema. www.elsevier.de/phf-literatur doi:10.1016/j.phf.2011.06.014
Univ. Prof. Dr. med. Dr. rer. nat. Friedrich Hofmann Bergische Universita¨t Wuppertal Fachbereich D – Abteilung Sicherheitstechnik Lehrstuhl fu¨r Arbeitsphysiologie, Arbeitsmedizin und Infektionsschutz Gaußstraße 20 42119 Wuppertal [email protected]
Public Health Forum 19 Heft 72 (2011) http://www.elsevier.de/phf
Summary Since the second half of the 20th century occupational health in health care workers is a well-established part of occupational medicine. Identification of environmental, biological, chemical, physical, and psychosocial hazards has lead to a number of preventive measures: Technical (e.g. use of safe instruments and double gloving as protection) and immunological (vaccinations) measures against biological hazards), and technical (lifting aides) and personal (backschools) intervention to prevent musculoskeletal disorders are well-designed examples.
Keywords: occupational health = Arbeitsmedizin, health care workers = Bescha¨ftigte im Gesundheitsdienst, infections = Infektionen, radiation = ionisierende Strahlung, ICOH = ICOH
References Benn G. Die Ansteckung mit Syphilis in der Krankenpflege. In: Sa¨mtliche Werke, Studienausgabe. Klett-Cotta, Stuttgart 1987, Band 7: 417–9. Emmett EA, editor. State-of-the-Art-reviews: Occupational Medicine, Health Problems of Health Care Workers. Philadelphia: Hanley and Belfus Inc.; 1987. Gestal Otero JJ. Riesgos del trabajo del personal sanitaria. Interamericana, secunda edicio´n, McGraw-Hill; 1993 Hagberg M, Hofmann F, Sto¨ßel U, Westlander G. Occupational Health for Health Care Workers, 2 ecomed. Landsberg/Lech; 1995
Hagberg M, Hofmann F, Sto¨ßel U, Westlander G. Occupational Health for Health Care Workers, 1 ecomed. Landsberg/Lech; 1993 Hasselhorn HM, Toomingas A, Lagerstro¨m M, editors. Occupational Health for Health Care Workers – a practical guide. Elsevier; 1999 Hofmann F, Michaelis M, Sto¨ßel U, Symington I. Occupational Health for Health Care Workers, 3 ecomed. Landsberg/Lech; 1999 Hofmann F, Reschauer G, Sto¨ßel U, editors. Arbeitsmedizin im Gesundheitsdienst, 7–24. Edition FFAS Freiburg; 1994-2011 Hofmann F, Sto¨ßel U, editors. Arbeitsmedizin im Gesundheitsdienst, 1–6. Stuttgart: GentnerVerlag; 1987-1992. Kompier M. Assessing the psychosocial work environment - ‘‘subjective’’ versus ‘‘objective’’
measurement. Scand J Work Environ Health 2005;31:405–8. Martikainen P, Bartley M, Lahelma E. Psychosocial determinants of health in social epidemiology. International Journal of Epidemiology 2002;31:1091–3. Perry JL, Pearson RD, Jagger J. Infected health care workers and patient safety: A double standard. Am J Infect Contr 2006;34:313–9. Ramazzini B. De morbis artificum, diatriba, editio novissima, romae 1953. Ross S, Viazov S, Gross T, Hofmann F, Seipp HM, Roggendorf M. Transmission of the Hepatitis C Virus from a Patient to an Anesthesiology Assistant to Five Patients in a Hospital. N Engl J Med 2000;343:1851–4.
26.e3
Occupational health in health care workers Friedrich Hofmann und Ulrich Sto¨ßel Due to the growing number of people working in the German Health care system (+15% since the year 2000) occupational health in health care workers attires much more attention than in former times. This interesting field of occupational medicine has first been described by Bernardino Ramazzini (1634 – 1714) in the year 1700 (Ramazzini, 1953): One chapter of his book ‘‘De morbis artificum’’ dealt with infections in midwifes caused by treatment of infectious pregnant women. 200 years later the German author (and dermatologist) Gottfried Benn (1886 – 1956) reported a syphilis prevalence of 0.4% in the same occupational group (Benn, 1987). At the same time tuberculosis was also recognised as a specific health problem of health care workers. During the second half of the 20th century hepatitis B was regarded as the most important hazard. At the same time when first hepatitis B-vaccines were produced (1981) other biological (HIV) and non-biological hazards were identified, e.g. teratogenic viral infections in hospital employees, the handling of antineoplastic agents, allergies and other skin diseases, psychosocial stress and last but not least back pain (Emmett, 1987). The breakthrough for occupational health in health care workers came in 1986 with the first ‘‘Freiburger Symposium Arbeitsmedizin im Gesundheitsdienst’’ (since then 25 national symposia took place) (Hofmann et al., 1994-2011; Hofmann und Sto¨ßel, 1987-1992). In 1990 the International Commission on Occupational Health (ICOH) founded a scientific committee which organised
several international congresses in this area (Hagberg et al., 1993, 1995; Hofmann et al., 1999). They were accompanied by the edition of proceedings and a practical guide which was edited by collaboration of the committee-members (Hasselhorn et al., 1999). Other congresses in North America and North Africa were organised thereafter. Today occupational health in health care workers (Gestal Otero, 1993) is a well established science within occupational medicine identifying -
environmental, biological (table 1), chemical, physical, and psychosocial hazards. th
During the second half of the 20 century biological hazards in health care were first regarded as an exclusive occupational hazard (health care workers are infected by their patients). Today infection of patients by their doctors and nurses play an important role, too: To date, more than 1,000 nosocomial HBV-, HCV- and HIVinfections of patients caused by surgeons, dentists, and nurses have been reported in the international literature (Perry et al., 2006; Ross et al., 2000). Injuries with syringes and other sharps (so-called needles stick injuries, NSI) cause both infections of personnel and patients. Technical (e.g. use of safe instruments, double gloving, safe disposal of waste), organisational and immunological (e.g. HBV-vaccination, Post exposure prophylaxis) aspects of health care have to be trained during everyday life of medical personnel. Efficient
prevention includes a reporting-system designed by occupational health physicians (virologists and other specialists in the field of infectiology) providing a 24-hours-service for the management of NSI. Other infections can be prevented by use of a couple of vaccines and measures of personal protection (e.g. masks). Chemical hazards include exposure to - aldehydes during disinfection of surgical instruments and hospital beds, - organic solvents e.g. in histology laboratories, - cytotoxic drugs in oncology-units (and pharmacies), - volatile anaesthetic gases in operating theatres. These hazards can be prevented by measures of personal protection and by technical means (e.g. hoods, charcoal filters for absorption of volatile anesthetics, gloves, masks). Physical hazards are caused - mechanically (e.g. lifting of patients) by overexertion or - by exposure to ionising radiation (e. g. in radiological units, in radiation therapy departments or in nuclear medicine). Examples for preventive measures concerning musculoskeletal diseases are back school programs and the use of lifting aids. Radiation exposure is a function of time, distance and shielding. Management of radiation is, therefore, by - reducing the time of exposure, - increasing the distance to the source of radiation and by
26.e1
Public Health Forum 19 Heft 72 (2011) http://www.elsevier.de/phf
Table 1: Biological hazards in health care workers (selection). Bacterial infections
Viral infections
Other infections
B. pertussis C. diphtheriae M. tuberculosis N. meningitides S. aureus Streptococci
Cytomegalovirus Hepatitis A-virus Hepatitis B-virus Hepatitis C-virus Herpes simplex virus Human immunodeficiency virus Influenzavirus Rubellavirus Varicella-Zoster-Virus
Blastomyces Cryptococci Plasmodia Prions
- placing absorbing material around the radiation-source. Psychosocial hazards which include both behavioural and organisational aspects of health care work are of growing importance as can be seen in a lot of surveys esp. on physicians and nurses in different settings (ambulatory, stationary) (Hofmann, Sto¨ßel Vol. 1-6, 1986-1992; Hofmann, Reschauer, Sto¨ßel; Volumes 7-24; 1993-2011) Stress, burn out, depression, early retirement from work, suicidal tendencies, broken work-life balances as to mention some of the unhealthy consequences of the work in this field are some of the important outcomes we have to recognize. The modelling of causal pathways to determine psychosocial factors affecting the health of health care workers does in general not differ from other professions. We always have to take into account the
26.e2
- macro level (aspects of the social structure), - meso level (aspects of social formations and psychosocial factors), and the - individual level (psychological factors) (Martikainen et al., 2002; Kompier, 2005). Preventive approaches based on the knowledge we have today are much more sophisticated as in the decades before. Not only the occupational health physician but also other professionals like psychologists, sociologists and educational professionals are engaged in the development and evaluation of work site health promotion programs, often in teams, with special focus on psychosocial factors of work. This efforts mostly are and often embedded in health management structures. The leading philosophy
in these approaches is not a pathogenetic but a salutogenetic one: What keeps health care workers healthy in their work, so they can better help their patients? Der korrespondierende Autor erkla¨rt, dass kein Interessenkonflikt vorliegt. Literatur siehe Literatur zum Schwerpunktthema. www.elsevier.de/phf-literatur doi:10.1016/j.phf.2011.06.014
Univ. Prof. Dr. med. Dr. rer. nat. Friedrich Hofmann Bergische Universita¨t Wuppertal Fachbereich D – Abteilung Sicherheitstechnik Lehrstuhl fu¨r Arbeitsphysiologie, Arbeitsmedizin und Infektionsschutz Gaußstraße 20 42119 Wuppertal [email protected]
Public Health Forum 19 Heft 72 (2011) http://www.elsevier.de/phf
Summary Since the second half of the 20th century occupational health in health care workers is a well-established part of occupational medicine. Identification of environmental, biological, chemical, physical, and psychosocial hazards has lead to a number of preventive measures: Technical (e.g. use of safe instruments and double gloving as protection) and immunological (vaccinations) measures against biological hazards), and technical (lifting aides) and personal (backschools) intervention to prevent musculoskeletal disorders are well-designed examples.
Keywords: occupational health = Arbeitsmedizin, health care workers = Bescha¨ftigte im Gesundheitsdienst, infections = Infektionen, radiation = ionisierende Strahlung, ICOH = ICOH
References Benn G. Die Ansteckung mit Syphilis in der Krankenpflege. In: Sa¨mtliche Werke, Studienausgabe. Klett-Cotta, Stuttgart 1987, Band 7: 417–9. Emmett EA, editor. State-of-the-Art-reviews: Occupational Medicine, Health Problems of Health Care Workers. Philadelphia: Hanley and Belfus Inc.; 1987. Gestal Otero JJ. Riesgos del trabajo del personal sanitaria. Interamericana, secunda edicio´n, McGraw-Hill; 1993 Hagberg M, Hofmann F, Sto¨ßel U, Westlander G. Occupational Health for Health Care Workers, 2 ecomed. Landsberg/Lech; 1995
Hagberg M, Hofmann F, Sto¨ßel U, Westlander G. Occupational Health for Health Care Workers, 1 ecomed. Landsberg/Lech; 1993 Hasselhorn HM, Toomingas A, Lagerstro¨m M, editors. Occupational Health for Health Care Workers – a practical guide. Elsevier; 1999 Hofmann F, Michaelis M, Sto¨ßel U, Symington I. Occupational Health for Health Care Workers, 3 ecomed. Landsberg/Lech; 1999 Hofmann F, Reschauer G, Sto¨ßel U, editors. Arbeitsmedizin im Gesundheitsdienst, 7–24. Edition FFAS Freiburg; 1994-2011 Hofmann F, Sto¨ßel U, editors. Arbeitsmedizin im Gesundheitsdienst, 1–6. Stuttgart: GentnerVerlag; 1987-1992. Kompier M. Assessing the psychosocial work environment - ‘‘subjective’’ versus ‘‘objective’’
measurement. Scand J Work Environ Health 2005;31:405–8. Martikainen P, Bartley M, Lahelma E. Psychosocial determinants of health in social epidemiology. International Journal of Epidemiology 2002;31:1091–3. Perry JL, Pearson RD, Jagger J. Infected health care workers and patient safety: A double standard. Am J Infect Contr 2006;34:313–9. Ramazzini B. De morbis artificum, diatriba, editio novissima, romae 1953. Ross S, Viazov S, Gross T, Hofmann F, Seipp HM, Roggendorf M. Transmission of the Hepatitis C Virus from a Patient to an Anesthesiology Assistant to Five Patients in a Hospital. N Engl J Med 2000;343:1851–4.
26.e3