Emerging Health Related Problems at Work

Darryl Lucian S. Bautista, MD Health Control Division OSHC

WHY THE WORKPLACE?

Workers spend a significant portion of their day at work. Presence of existing facilities, services, personnel for health care delivery. Easy to implement health promotion activities. Facilitates monitoring, recording and reporting.

The Problems
Each of these health-related issues has certain similarities with the others:
They cost the enterprise a great deal of money; They impact on productivity; Their outcomes can have a far-reaching effect beyond the workplace; They are quite different from the traditional workplace hazards and their management requires unique strategies.

Emerging health-related problems at work

Increased absenteeism Increased turnover Loss of skills Loss of tacit knowledge Declining morale

Insurance costs Retirement funds Safety and health Medical assistance Counselling Increasing demands for training and recruitment

Increased health problems in the community with declining markets labour pool and suppliers

Increased costs

Declining profits

Declining productivity
Source: UN AIDS

Hepatitis B

HEPATITIS B
HBsAg Positive, %
Taiwan Vietnam China Africa Philippines Thailand 10.0-13.8 5.7-10.0 5.3-12.0 5.0-19.0 5.0-16.0 4.6-8.0 4.4-13.0 4.0 2.6-5.1 2.4-4.7 1.4-8.0 0.2-0.5

HBsAg Prevalence
High ( 8%) Intermediate (2% to 8%) Low (< 2%)

Japan Indonesia

The Philippines is hyperendemic for Hepatitis B

South Korea India Russia US

Mast EE, et al. MMWR Recomm Rep. 2006;55:1-33. Custer B, et al. J Clin Gastroenterol. 2004;38(10 suppl):S158-S168.

1 out of 8 Filipinos have Hepatitis B infection

Many are declared UNFIT TO WORK without the benefit of a complete medical evaluation. Many are considered CONTAGIOUS to others resulting in stigmatization, discrimination and non-employment. Many are considered a LIABILITY due to fear that they will become sick on the job. Many are not counseled and educated about their disease.

Current Workplace Issues

Conduct of routine screening for hepatitis B in the preemployment medical examination for OFWs ---> Basis is unclear Mandatory Hepatitis B screening in the preemployment setting regardless of the type of occupation Prospective employers for both overseas and local employment dictates screening

Current Workplace Issues

Many Filipinos with hepatitis B who are HBsAg positive have been discriminated from employment, both local and overseas As they have been declared UNFIT TO WORK even if there is no medical, legal or logical basis that such a state is inappropriate for employment

High-risk Occupations
Exposure to sharp instruments/needles that have the potential to cause a break in the skin and expose another person to infectious blood or body fluids - Largely limited to the health care setting morticians, embalmers, forensic pathologists prison service staff in regular contact with inmates emergency frontline responders Those individuals whose work involve the exchange of body fluids (commercial sex workers)

High-risk Occupations
Tattooists Ear and body piercers Beauticians and hairdressers Local authority services e.g. refuse disposal and street cleaners Sewage process workers Professional and semi-professional contact sports

Perception : An HBV+ applicant may develop illness while on the job Majority (70-80%) can live an otherwise healthy life particularly when properly monitored and treated

Hepatitis B should not be treated differently from any other chronic illness
Such as hypertension, diabetes and tuberculosis which all need medical evaluation, counseling, monitoring and assessment for treatment eligibility Criteria exist for granting fitness for overseas employment (as per DOH AO No. 2007-0025) Revised Guidelines for Conducting Medical Fitness for Seafarers

Perception : A HBV+ job applicant may transmit the infection to others in the workplace
Occupations that do not involve exposure to blood and body fluids are considered LOW RISK for the transmission of Hepatitis B.

Types of Viral Hepatitis

A
Source Mode of Transmis sion Chronic Infection
Feces FecalOral

B
Blood, body fluids Childbirth, Needle, Sex, Blood Transfusion Yes

C
Blood, body fluids Childbirth, Needle, Sex, Blood Transfusion Yes

D
Blood, body fluids Needle, Sex, Blood Transfusion

E
Feces FecalOral

G
Blood Blood Transfusion

No

Yes

No

Uncertain if pathogenic

Hepatitis B can be transmitted through the following:

Mother to child (during pregnancy or childbirth) Sexual contact Exposure to contaminated blood or body fluids (semen, vaginal secretions, etc) Unscreened blood for transfusion Unscreened organ donors for transplant Cuts on the skin and mucosa Sharing personal items (toothbrushes, razors, etc) Needlestick and sharps injuries Acupuncture, tattooing, piercing, manicure, pedicure Inadequately sterilized dental and surgical instruments
Guidelines on the Evaluation of the HBsAg-Positive Workers for Employment

Hepatitis B : Modes of Transmission

Hepatitis B has not been documented to be transmitted by:

Ordinary workplace activities Coughing, sneezing Sharing utensils, plates and glasses Sharing office supplies, computers Sharing lavatory seats Handshaking, hugging and kissing Swimming pools Public dining places and crowed areas Drinking fountains
Guidelines on the Evaluation of the HBsAg-Positive Workers for Employment

How can we prevent HBV in the workplace?

Adhere to universal or standard precautions Provide personal protective equipment Vaccination of susceptible (HBsAg negative, anti-HBs negative) especially in high-risk occupations (e.g. healthcare workers)

How can we prevent HBV in the workplace?

Systems of work are usually implemented by standard operating procedures; used to supplement other control measures : Laboratory rules e.g. Prohibiting eating, drinking and smoking and the application of cosmetics in working areas where there is a risk of contamination Sharps policy - Avoiding the use of, or exposure to, sharps, such as needles, glass, etc. Waste disposal policy - Where sharps are unavoidable, safe disposal procedures such as the use of sharps bins made available at point of use, and forbidding the re-sheathing of needles. Decontamination and disinfection procedures

Existing Policies in the Philippines

Legislation on hepatitis B vaccination for children - eg. REPUBLIC ACT NO. 7846 - AN ACT REQUIRING COMPULSORY IMMUNIZATION AGAINST HEPATITIS-B FOR INFANTS AND CHILDREN BELOW EIGHT (8) YEARS OLD Non-discrimination practice in the workplace DOLE Department Order No. 5 series of 2010 Guidelines for the Implementation of Workplace Policy and Program on Hepatitis B

Department Advisory No. 5 s. 2010

Guidelines for the Implementation of Workplace Policy and Program on Hepatitis B Mandatory for all private workplaces to have a policy on Hepatitis B and to implement a workplace program Hepatitis B Immunization is encouraged to all establishments. Immunization is required for high risk occupations (health care workers) There shall be no discrimination of any form on the basis of Hepatitis B status Job applicants and workers shall not be compelled to disclose their Hepatitis B status and other related medical information.

Substance Use and Abuse

Estimated number of drug users in the Philippines:

1999 - DDB Survey estimated 3.4 M - 1.8 M regular users - 1.6 M occasional users 2001 - SWS Survey estimated 2.2 9.3 M 2004 - DDB Survey estimated 6.7 M 2008 - DDB DILG Survey estimated 1.7 M

DRUGS of ABUSE

Profile of Current Drug Users

(DDB-DILG 2008 Survey)
Age Group Sex Civil Status Status of Employment Educational Attainment Nature of Drug Taking Drugs of Abuse 20 -29 years old (31.68%) Male to Female 11:1 Single (53.42%) Unemployed (32.82%) Employed (20.19%) High School Level (40.68%) Poly Drug Use Methampetamine Hydrochloride (Shabu) 66.94% Cannabis (Marijuana) 25.90% Inhalants (Contact Cement) 6.61%

Pertinent Workplace Provisions of RA 9165

Article III Dangerous Drugs Test and Record Requirements. Article V Promotion of a National DrugFree Workplace Program with the participation of Private and Labor Sectors and the DOLE. Article VI Participation of Private and Labor Sectors in the Enforcement of this Act.

Pertinent Workplace Provisions of RA 9165

Article III
Dangerous Drugs Test and Record Requirements. The following shall be subjected to undergo drug testing: Officers and employees of public and private offices, whether domestic or overseas, shall undergo a random drug test as contained in the companys work rules and regulations, which shall be borne by the employer, for purposes of reducing the risk in the workplace.

RA 9165 : Article III

MANDATORY TESTING RANDOM TESTING
- applicants for drivers - Students license, firearms - Employees of public license/permit to carry and private offices firearms - persons charged with criminal offense - candidates for public office - military, police and law enforcers

Pertinent Workplace Provisions of RA 9165

Article V
Section 47: Drug-Free Workplace: It is deemed a policy of the State to promote drug-free workplaces using a tripartite approach.
c. Pursuant to the functions of the Board under Section 81(a) of the Act, the existing Civil Service rules and policies needed to respond to drug abuse in the public sector shall be adopted.

DOLE
Department Order 53-03
Guidelines for the Implementation of a Drug-Free Workplace Policies and Programs for the Private Sector. In accordance with the provisions of Republic Act 9165. Drafted by the multi-sectoral Task Force on the Prevention and Control of Substance Abuse in the Workplace and reviewed by the Tripartite Industrial Peace Council (TIPC).

Drug-Free Workplace
Mandatory for all private workplaces with more than 10
employees to have policy and program Training of assessment team that will address prevention, treatment and rehabilitation. Drug testing and rehabilitation should be done in DOH-accredited institutions.

No termination for first-time offenders.

Repeat offenders, possess, distributes, sell, transport are unlawful acts dealt under RA 9165.

HIV/AIDS

HIV and AIDS

H- Human I- Immunodeficiency V- Virus
virus which causes AIDS A- Acquired I- Immune D- Deficiency S- Syndrome serious and usually fatal condition in which the bodys immune system is severely weakened and cannot fight off infection.

HIV/AIDS
HIV remains dormant in the body for several years before some unknown factors trigger the infections associated with AIDS Median incubation period for adult can be as long as 10 years. During this period, the people with HIV may look healthy and being unaware of their infection status.

People with HIV DO NOT mean they have AIDS.

HIV Infection
A lifetime infection No vaccine to prevent it No cure No signs and symptoms Destroys the immune system Can be detected with HIV-antibody test Virus does not live long outside the body

HIV/AIDS CASES, August 2012

Proportion of Modes of Sexual Transmission

HIV Modes of Transmission

HIV is NOT transmitted

through casual contact in any setting schools, workplace, or social settings. through shaking hands, hugging, or a casual kiss. through insect, food, water, clothes, toilets, swimming pools, and drinking and eating utensils.

HIV Testing
The HIV antibody test Detects HIV antibodies in the blood, not HIV Antibodies develop 3-12 weeks to 6 months after infection WINDOW PERIOD antibodies cannot be detected in blood, but patient infective during this period

HIV- antibody Test Results

POSITIVE HIV-antibody
Detection of antibodies in the blood indicates that infection has occurred The person can infect others A positive HIV-antibody test result does not mean that a person has AIDS

NEGATIVE HIV-antibody
HIV antibodies were not detected in the persons blood May indicate that the person is not infected OR The person may be infected but has not produced detectable quantities of HIV antibodies

HIV Testing
Testing is voluntary If a person wants to know his/ her HIV status
to protect ones partner from infection to know if it is safe to conceive

Pre and post- test counseling is required

HIV Prevention
REMEMBER ABCDE!
Abstinence Be Faithful Correct and consistent condom use Do not use Drugs Education

Benefits of HIV/AIDS Programs

1. Minimize workplace disruption and lost
productivity 2. 3. 4. Reduced health care costs by preventing new infections Company demonstration of concern for the welfare of workers and families Assurance that HIV (+) workers receive appropriate counseling, medical and social support

Workplace Interventions on HIV and AIDS Prevention

Problems in policy and program implementation: Lack of management and worker support Lack of technical capability to implement their policies and programs Focal persons have other functions STI, HIV and AIDS discussions not well accepted by both management and workers

Department Order 102-10

in pursuant to the Republic Act 8504 or the Philippine AIDS Prevention and Control Act of 1998

Mandatory for all private workplace to have

policy and program on HIV and AIDS No compulsory HIV testing as a condition for employment No discrimination and termination based on suspicious or actual HIV status of worker Worker is not oblige to reveal his HIV status in a low-risk occupation HIV positive workers have responsibility to prevent transmission of the virus

HIV/AIDS Prevention and Control Workplace Policy and Program

It is MANDATORY for all private workplaces to have policy on HIV/AIDS

Components of the program: A. Advocacy, Information, Education and Training B. Social Policy C. Diagnosis, Treatment and Referral

Advocacy, Information, Education and Training

Topics for information and education activities:

Magnitude of epidemic Cause, nature, transmission Preventive measures Diagnosis,care,support,treatment Impact on individual, family and community Workplace policy and program National laws

Social Policy
1. Non-discriminatory
Workers shall not be discriminated against from pre- to post-employment regardless of the HIV status, be it actual, perceived or suspected with HIV infection

Workers shall not be terminated from work, if the basis is the actual, perceived or suspected HIV status

Social Policy
2. Confidentiality
HIV/AIDS related information should be kept only in medical files. Workers must not be asked to disclosed HIV-related personal information. Access to personal data relating to HIV status should be bound by the rules of confidentiality.

Social Policy
3. Work Accommodation and Arrangement Employers should take measures to reasonably accommodate the workers with AIDS-related illnesses. ....through flexible leave arrangements, rescheduling of working time and arrangement for return to work.

Diagnosis, Treatment and Referral

Services for Sexually Transmitted Infections

Referral Mechanism to access the services

Voluntary Confidential Counseling and Testing (VCCT)

Roles and Responsibilities

EMPLOYERS Develop, implement, evaluate and fund policy and program Address all aspects of implementation Ensure that policy and program in adherence to legislations and guidelines Ensure that all workers know how to maintain confidentiality Ensure non-discriminatory practices Provide personal protective equipment to prevent HIV exposure Network with organizations

Roles and Responsibilities

WORKERS

Take active role in educating and training their members. Promoting healthy lifestyle. Non-discriminating against co-workers Must not have access to personnel data relating to HIV status Comply with universal precaution and preventive measures Enjoined to share information to their families and communities

Roles and Responsibilities

Company Safety and Health Personnel

Oversee implementation of HIV and AIDS prevention and control program Provide access to medical experts for diagnosis and treatment of the disease through a referral system If competent, may provide counseling Provide up-to-date medical information on HIV and AIDS

Implementation and Monitoring

Safety and Health Committee Monitoring and evaluating the implementation within the establishment. DOLE Regional Office In collaboration with DOH, DILG and LGU Oversee, monitor, and disseminate information on HIV/AIDS Prevention and Control Workplace Program.

Implementation and Monitoring

OSHC Provide preventive services and technical assistance in the implementation of HIV/AIDS program BWC Enforce the guideline, related OSH Standards and other related policies and legislations

Consequences of Policy and Program Violations

Shall be subject to the pertinent provisions of RA 8504. - Penalties for misleading information - Penalties for violating confidentiality - Penalties for discriminatory acts

Tuberculosis

 9th among the 22 high burdened countries (HBCs) worldwide

Global TB Control Report 2009

4th in Case Notification Rate (TB all forms) amongst the WPRO countries
TB Control in the Western Pacific Region, 2009 Report

TB is 6th in mortality and morbidity FHSIS Report 2007

Approximately 100 Filipinos die of TB each day

SOURCE: WHO Global TB Report 2009

Top 10 Causes of Deaths in the Philippines 2009

Cause 1 Diseases of the heart 2 Cerebrovascular diseases 3 Malignant neoplasm 4 Pneumonia 5 Tuberculosis 6 Chronic lower respiratory diseases 7 Diabetes mellitus 8 Nephritis, nephrotic syndrome and neprosis 9 Assault 10 Perinatal-period illnesses All Other Causes of Deaths Total Deaths
Source: 2009 National Statistics Office Data

Number of cases 100,908 56,670 47,732 42,642 25,470 22,755 22,345 13,799 12,227 11,514 124,758 480,820

Percentage 21.0 % 11.8 % 9.9 % 8.9 % 5.3 % 4.7 % 4.6 % 2.9 % 2.5 % 2.4 % 25.9 % 100 %

Estimated TB incidence (all cases) DOTS population coverage Rate of new SS+ cases DOTS case detection rate DOTS treatment success rate

290/ 100,000 pop. 100 % 130/ 100,000 pop. 75% 88%

TB Cases 75% case detection rate 88% treatment success rate

TUBERCULOSIS

caused by the bacteria, Mycobacterium tuberculosis caused by droplet nuclei released when sneezing and coughing Symptoms: weight loss, low grade afternoon fever, persistent cough and sometimes, blood-streaked expectoration or hemoptysis

TB TRANSMISSION
An infected person forced TB bacteria from the lungs into the air. Another person may breath in the bacteria. If the bacteria makes it to the lungs and are not killed by the bodys immune system, the person becomes infected. M. tuberculosis can exist in the air up to six hours.

TB TRANSMISSION
Predisposing Factors
Age Immuno-suppressed individuals
Prolonged steroid therapy

Precipitating Factors
Occupation (e.g. Health Workers) Repeated close contact with infected individual Recurrence of infection

Systemic Infection
Diabetes Mellitus End-stage Renal Disease HIV / AIDS

TB TRANSMISSION
TB IS NOT SPREAD BY: Casual contact Sharing utensils or food Sharing cigarettes or drinking containers Exchanging saliva or body fluids Shaking hands Body contact

General:
Low Grade Fever Night Sweats Anorexia Weight Loss Easy Fatigability

Pulmonary:
Productive or nonproductive cough >2 weeks Hemoptysis Chest or back pains Dyspnea Chest tightness

TB DIAGNOSIS
Purified Protein Derivative (PPD)

Chest X-ray

Sputum Exam (3 days) (gold standard)

TB TREATMENT
Tuberculosis is a curable disease. Early detection and diagnosis is necessary to render infected individuals treatment. TB treatment is a combination of 3-4 anti-TB drugs. NEVER a single drug for TB treatment! This will worsen the patients condition. TB DOTS (Directly Observed Therapy Short) course.

DOTS Strategythe Solution!

(Directly Observed Therapy Short Course)

With DOTS
88% CURE RATE

OSHC 2010

TB INFECTIOUSNESS
Patients are NOT considered infectious if:
Have received appropriate therapy for 2-3 weeks; Show favorable clinical response to therapy; Have negative smear results from sputum specimen collected serially.

Department Order 73-05

Guidelines for the Implementation of Policy and Program on TB Prevention and Control in the Workplace It shall be mandatory for all private establishments to formulate and implement a policy and program. Preventive strategies - Sputum smear microscopy for symptomatic - Management using Directly Observed Treatment Short Course (DOTS) - Improve workplace condition : ventilation, worker density, facilities Reporting of TB cases to DOLE Non-discrimination : Continuing employment Work accommodation

Components of Policies & Programs

1. PREVENTIVE STRATEGIES
TB advocacy, education and training Measures to improve workplaces

1.TB awareness program on the CUP particularly the DOTS 2.Workers given proper information to strengthen immune responses against TB infection 3.Improving workplace conditions 4.Capability building and training

Components of Policies & Programs

2. MEDICAL MANAGEMENT
1. 2. 3. 4. Adopt DOTS in management of TB in workers and dependents Refer workers and family members with TB to private or public DOTS centers TB Benefits Policy of ECC, SSS, and PhilHealth shall be followed Diagnosis and treatment of TB cases shall be in accordance with CUP and NTP

Components of Policies & Programs

2. MEDICAL MANAGEMENT
What benefits can PhilHealth members and their qualified dependents avail of from the package?
All qualified PhilHealth members and their dependents suffering from TB may avail of free diagnostic work-up, consultation services and anti-TB drugs on or after enrolment to DOTS.
The outpatient anti-TB DOTS benefit package is designed for NEW CASES OF PULMONARY AND EXTRAPULMONARY TUBERCULOSIS FOR CHILDREN AND ADULTS. New case A patient who has never had treatment for TB or who has taken anti-TB drugs for less than one month. PhilHealth shall not cover the following TB cases: Failure, Relapse and Return After Default (RAD) cases. Examination of three (3) sputum specimens is mandatory to all adult TB patients prior to enrollment to the DOTS facility.

Components of Policies & Programs

3. RECORDING AND REPORTING
1. Companies shall report all diagnosed cases of TB to the Department of Labor and Employment

Use appropriate form, i.e., the Annual Medical Report. (OSHS RULE 1965.01 (4) and Rule 1053.01 (1)).
2. SSS will report to Philippine Coalition Against Tuberculosis (PhilCAT)

Components of Policies & Programs

4. SOCIAL POLICY
4.1 Non-discrimination Workers who have or had TB shall not be discriminated against:

Support for adequate diagnosis and treatment. Ensure continuing employment for as long as they are certified by the companys accredited health provider as medically fit. Restoration to work as soon as their illness is controlled.

Components of Policies & Programs

4. SOCIAL POLICY
4.2 Work Accommodation Based on agreements between the management and workers, measures should be taken to accommodate and support workers through; flexible leave arrangements rescheduling of working times arrangements for return to work

Components of Policies & Programs

4. SOCIAL POLICY
4.3 Restoration to Work The worker may be allowed to return to work with reasonable working arrangements as determined by the company Health Care Provider and/or the DOTS provider.

Components of Policies & Programs

5. ROLES AND RESPONSIBILITIES
Employees
Workers who have symptoms of TB shall seek immediate assistance from their health service provider Also those at risk, i.e., those with family members with TB, shall do the same. Once diagnosed, they shall avail of the DOTS and adhere to the prescribed course of treatment

Employers
Any contact in the workplace shall be traced and the contacts shall be clinically assessed. In the context of their Corporate Social Responsibility and OSH and related programs, employers are encouraged to extend the TB program to their workers families and their respective communities.

Thank you for Listening