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SA MEDIESE TYDSKRIF 5 DESEMBER 1981
5. Proceedings of the 1974 Conference on Standards of Occupational Lead Exposure (1975): J. occup. Med., 17,98. 6. Gross, S. B. (1979): Oral and [nhalarion Lead Exposllres in Hi/man SlIbjecrs. New York: Lead Industries Association, Inc. 7. Hernberg, S. in Zenz, C, ed. (1975): Ocwparional Medicine, Principles and Pracrical Applicarions, chapt. 30. Chicago: Yearbook Medical Publishers. 8. Irving, L. M., Harrison, W. 0., Webster, 1. er 0/."(1978): Lancet, 1,4. 9. Lane, R. E., Hunter, D., Malcolm, D. er at. (1968): Brit. med. J., 4, 501. 10. Baker, E. L., Landrigan, P. J., Harbour, A. G. er at. (1979): Brit. J. industr. Med., 36, 314. . 11. Hammond, P. B., Lerner, S. J., Garrside, P. S. er al. (1980): J. occup. Med., 22, 475. 12. World Health Organization (1977): Lead (Environmental Health Criteria, no. 3). Geneva: WHO. 13. Benson, G. J., George, H. H. S., Lichfield, M. H. er al. (1976): Brit. J. industr. Med., 33, 29. 14. Piomelli, S., Davidow, B., Guinee, V. F. er al. (1973): Pediatrics, SI, 254. 15. Lamola, A. A., Joselow, M. and Yamane, F. (1975): Gin. Chem., 21, 93. 16. Tomokuni, K., Osaka, 1. and Ogata, M. (1975): Arch. environm. Hlth, 30, 588. 17. Fischbein, A., Eisinger, J. and Blumberg, E. W. (1976): Mt Sinai J. Med., 43, 294. 18. Joselow, M. M. and Flores, G. (1977): Amer. industr. Hyg. Ass. J., 38,63. 19. Herber, R. F. M. and Wibowo, A. E. E. (1980): T. soc. Geneesk., 58,425. 20. Grandjean, P. (1979): Brit. J. industr. M.ed., 36, 52. 21. Zielhuis, R. L. and Wibowo, A. E. E (1978): T. soc. Geneesk., 56, 676. 22. lee, W. R. (1981): J. ray. CoIl. Phyens Lond., 15,48. 23. Hesley, K. L. and Wimbish, G. H. (1981): Amer. industr. Hyg. Ass. J.,42,42.
appeared to be adequate in the one case in which it was applied (worker G), being combined with other laboratory tests before a decision was raken.
As of June 1981 a ZPP reading of 20 j.1g1 g Hb, thought to correlate with a Pb-B value of 70 j.1g1dl, was adopted as the criterion for removal from exposure.
I. Zielhuis, R. L. and Wibowo, A. E. E. (1978): Ned. T. Geneesk., I22, 793. 2. Waldron, H. A. (1978): J. soc. Occup. Med., 28, 27. 3. Moore, M. R., Campbell, B. C and Goldberg, A. ill Lenihan, J. and Fletcher, W. W., ed. (1977): The Chemical Em,iromnenr (Environment and Man, vol. 6), p. 89. Glasgow: Blackie & Son. 4. Commission of Inquiry on Occupational Health (1976): Report (RP 55). Pretoria: Government Printer.
Medical standards for workers nuclear installations
L. C. VAN OUDENHOVE DE ST G~RY History Summary
South Africa is moving into the nuclear energy age, and most practitioners are probably not aware of the implications in medical practice. The demands upon workers in this area are very strict, and the doctor who may have to examine them must be aware of this. This article is designed to outline the procedures necessary in examining candidates for employment in the nuclear energy industry.
S. Atr. med. J., 60,896 (1981).
Very strict international srandards have been established for nuclear personnel and made applicable by the Atomic Energy Board to any South African licence holder (corporate or individual). The basic investigation of any candidate for employment in a nuclear plant as a 'radiation worker' consists of a personal history, physical examination and complementary examinations.
809 Medical Centre, Hererengracht" Cape Town L. C. VAN OUDENHOVE DE ST GERY, M.D.
Date received: 21 April 1981.
Only persons over the age of 18 may be employed at nuclear installations and, in principle, women under the age of 50 cannot be employed as radiation workers at nuclear installations, although of course they may be employed in departments outside. A complete family history is necessary as well as a history of previous work with particular attention to toxic, dusty, noisy ~d glary jobs and any previous exposure to ionizing radiation (which would include any exposure to medical radiological apparatus). All dosimetric information must be recorded accurately and transmitted to an accredited health physicist. In taking the patient's history, it is important to,remember that every detail is wonh taking note of and that enquiry must be made systematically, system by system. Every exposure of skin to toxins and dust must be noted, with special reference to chronic skin disease of any nature that could be made worse or reactivated by ionic radiation. Inability to rrear any skin condirion successfully is ground for rejection, and any skin change due to previous radiation constitutes ~n absolute contraindication to employment. Cardiovascular system. As regards the cardiovascular system all the' conventional contraindications to industrial employment are valid, for the principle involved is not so much that these constitute a bar to employment but that the work in a nU,clear installation requires the most complete state of fitness possible. Any chronic disease of the respiratory system that
SA MEDICAL JOURNAL 5 DECEMBER 1981
could enhance the danger of internal contamination or be aggravated by such contamination is a contraindication. Digestive system. Basically, disorders of the disgestive system which are conrraindications ro work in a nuclear plant are the same as those in normal industry; it is clear that chronic inte tinal ulceration or any chronic inflammarory condition would be a contraindication ro acceptance. In so~e cases the candidate may be reviewed 3 months later, after treatment. Nervous system. The condition of the nervous system must be carefully reviewed and in doubtful cases the candidate should be referred for neurological, psychological or psychiatric investigation. The emotional balance of the worker is of primary importance, as is his ability ro observe strict discipline and work in a team. Renal diseas~ is usually a bar to employment. Ears, nose and throat. Any previous chronic or acute inflammatory condition affecting the ear, nose and throat must be enquired after and if necessary treated before a final decision abour employment. Hearing must be tested. Endocrine system. In the endocrine system the critical organ·is the thyroid, on accounr of possible contamination by iodine-131. Uncontrolled diabetes is an absolute contraindication. Scars and wounds. Surgical scars must be investigated from two angles: (1) a surgical scar implies previous disease, about which enquiry should be made; and (ii) any scar enhances the effect of contamination and is a handicap to deconramination. Any wound that may cause problems with skeletal contamination is a reason for temporary exclusion from work in a radiation or contamination zone. Special attention must be paid ro fractures, especially recent fractures, on account of the strontium-90 effect- on callus. The presence of any malignant tumour, past or present, constitutes an absolute contraindication ro employment. The blood. Enquiry must be made into any past disorder of the blood in the applicant or his family; this is an area requiring careful investigation, since any blood disorder constitutes a contraindication ro radiation work. Enquiry must also be made about previous radiotherapy, and the dosimetric results must be communicated to and discussed with an accredited health physicist.
urinary and genital systems must also be investigated. Ears, nose and throat. Chronic infections of the throat or nose constitute reasons for rejection. The condition of the ears must be looked inro, with particular emphasis on perforation of the eardrum. Any perforation or chronic inflammation of the external audirory meatus is ground for rejection unless the individual undergoes a successful tympanoplasty or other curative operation. Basic hearing capacity must be tested; if in doubt the candidate must be referred ro an E T specialist. In any case an audiogram is obtained annually. Loss of20 dB at the entrance examination makes a candidate unacceptable. Eyes. There are no actual standards for visual acuiry, but the general rule is that if the candidate is wearing glasses he should be able to execute essential manoeuvres at his place of work in the shortest possible time even under the most complex circumstances, and he must be able to wear a mask or other protective gear prescribed for work in contaminated areas. Glasses may be replaced by special plastic unbreakable glasses adapted to the protective gear. Certain jobs such as telemani pulations in a hot cell or in the fuel pool demand perfect vision and absolute depth dimension view. The importance of colour vision varies from department to department and from job to job. Colour blindness would not constitute an absolute factor for disqualification and must be weighed up against the demands of the job. The significance of narrowing of the visual field would depend upon the tasks ro be performed and the cause of the impairment. Nervous system. The neurological balance sheet is probably the most important part of a pre-employment examination. Any serious abnormality constitutes an absolute contraindication, and this includes the psychological field, in which claustrophobia, for example, would disqualify a radiation worker. Balance is of particular importance since the worker must be able ro climb steps and ladders and work at heights without danger to himself, and any candidate with attacks of dizziness or fainting would therefore be disqualified. Since most workers must be able to do shift work disorders of sleep will constitute a bar, and any lack of co-ordination and reaction speed also disqualifies him.
For obvious reasons it is the general policy nor to employ female staff in a radiation area. If they have to be employed women should be examined just as systematically as men, and a gynaecological examination should be performed if there is any indication of uterine or ovarian disease or of pregnancy. Most female personnel are of course employed ourside the controlled zone; nevertheless for medical, legal and psychological reasons it is highly advisable not to employ female staff without an initial complete medical balance sheet, as well as repeat examinations when required.
This must be prolonged, complete and systematic; in view of the responsibility involved and the rules that must be strictly applied to new workers, this examination can never be too strict. Skin. Any skin lesions must be looked for, especially on the face, scalp, neck, hands and trunk. Chronic and resistant acne, if widespread, constitutes a reason for rejection because of the risk of repeated contamination of the area. Skin tumours or degenerative changes in the skin should be carefully noted. If the candidate shows signs of biting his nails, he must be warned about the danger of contamination through this and rejected ifhe persists with the habit. Skin lesions due to radiation may constitute a reason for temporary or permanent suspension. Cardiovascular system. Examination of the heart and blood vessels is the same as in general medical examinations, bur it. is useful to have a pre-employment ECG and to repeat this at intervals. Examination of the respiratory system is basically the same as in all industrial medicine, bur in addition lung capacity must be assessed. Chronic bronchitis, asthma or emphysema is a reason for rejection, and tuberculosis is of course a complete bar. Abdomen. Apart from general abdominal examination, care should be taken to look for hernias, liver enlargement and splenic enlargement, all of which are grounds for rejection. Any interruption of the mucosa membrane of the gastro-intestinal tract such as a peptic or intestinal ulcer is a contraindication. The
These examinations are intended to cover the special risks and responsibilities in a nuelear installation and are therefore as important as, if nor more importanr than, the general clinical examination. Two of the systemic examinations are compulsory (the biological balance sheet and the ophthalmological balance sheet) and one is optional (chest radiography).
Biological balance sheet
The most important component of the biological balance sheet is the haematological examination. This will include a complete blood co-unt and the other standard haematological examinations. The red cell count should not be below 3,8 x
SA MEDIESE TYDSKRIF 5 DESEMBER 1981
1Q6/J.Ll or above 5,5 x 1Q6/J.L1. The total white cell count should not exceed 12000/I.Ll or fall below 4000/J.Ll. Blood tests should be carried out twice, once with the candidate fasting and once after breakfast. The polymorphonuclear count should be between 35% and 80% of the total white cell count. Haemostasis (coagulation, bleeding time, etc.) should also be studied. Any abnormality requires investigation as to its cause and consequences. The blood sugar and blood urea levels should be estimated. Renal function should be studied by chemical and cytological examination of freshly passed urine, an Addis count and urea and creatinine clearance tests whenever possible; these are mandatory if any abnormality or suggestion of abnormality is present. The legal justification for this emphasis on the haematological examination is the extreme sensitivity of the haematopoietic system to ionizing radiation. The acceptable standards are those established by the International Atomic Authority made applicable within South Africa by the Atomic Energy Board (AEB) in Pretoria. Medically acceptable standards are set by the laboratory and will provide guidance for the approved doctor's decision; however, they are not hard and fast, since one must take into account changes caused by passing events and diseases. \Vhenever results are outside the accepted standards, the examination should be repeated after 2 - 3 weeks and whenever possible a reason for the abnormality should be established. If results are abnormal on three successive occasions the candidate should be declared unfit for work as a classified radiation worker. operate a nuclear installation may be maintained. The second duty of the doctor is to perform such re-examinations and complementary investigations as he deems necessary, on his own responsibility.
Certificate of fitness for radiation work
If all the above examinations and investigations have been completed, the approved doctor must compile a medical balance sheet from which he can conclude whether the candidate is fit for work in a nuclear installation. This decision must be fmal and no reasons need be given for it. It is briefly communicated on a preprinted form without any explanation or justification, but should mention the qualifications for the pOSt in question. All examination forms and other medical documents are kept under the control of the approved medical officer himself. General fitness for work will depend upon the demands ofthe particular post, since often the job will be equivalent to that in another industrial plant. The appnwed medical officer l1)ust be furnished with a complete job description before the candidate has been examined or re-examined. He must also decide on fitness for nuclear risks. If ,the candidate is found fit for the three basic risks - radiation, external contamination, and internal contamination - then he is fit for radiation work and any potentially hazardous job in a controlled zone. If, however, he is unfit for any ofthe three basic risks, he is not fit to work as a radiation worker but only for specified jobs in a controlled zone. Ifthe candidate is unfit for the three basic risks he is unfit even to work in a controlled zone and can only be employed in the same capacity as an ordinary member of the public outside this zone.
Ophthalmological balance sheet
This should preferably be drawn up by an ophthalmologist chosen by the approved medical practitioner and include a study of visual acuity with or without correction, the fundi, intraocular pressure, and biomicroscopic examination of the crystalline lens. These last two examinations are of imponance since it must be accepted that any irradiation, especially with neutrons, may produce a cataract. Exposure of an eye with increased intra-ocular pressure to ionizing radiation will quickly worsen the condition. Both glaucoma and cataract are complete barriers to radiation work.
If a candidate is found unfit for work owing to some complaint which is likely to disappear with or without appropriate treatment within a relatively short period, the doctor may declare the candidate acceptable after successful treatment. This might happen in the case of a patient with acne, for example, or a temporal blood disorder due to an infection. The decision to accept or defer a worker is the exclusive prerogative of the approved medical officer of the nuclear installation.
Fitness for special operations Chest radiography
A chest radiograph is essential to exclude any form of tuberculosis and should only be omitted if clinical examination has shown beyond any doubt the absence of pulmonary disease and if the worker has been or will be exposed to substantial radiation. In the nuclear industry there are certain routine or emergency operations such as refuelling of a power reactor, repair of leaks, or confinement in situations with unusual risk of higher radiation and/or contamination. In these or similar situations the docto, must re-examine the candidates in question, or in cases of urgency decide by whom and under which circumstances the operations can be carried out. It must always be kept in mind that there is a remote possibility that these workers may receive during a very short time a dose higher than the annual permitted level and therefore need subsequent treatment and exemption from radiation work for a period oftime established by the doctor in consultation with an accredited health physicist. During his period of training or work an approved radiation worker may, whether as a result of radiation or not, develop certain symptoms or disorders. He must then be referred to the doctor, who in turn must refer to the employee's medical file and balance sheet and decide whether funher investigations are needed, whether treatment is required and by whom (the employee's own doctor or not), and whether the employee's certificate of fitness as a radiation worker can be maintained, modified or withdrawn. It must be emphasized that all these ruks and indications are not static but must be continuously adapted to changes in national or international legislation, evolution in radiobiology and the introduction of new techniques in industrial medicine and nuclear physics.
When the personal questionnaire has been completed, the clinical examination concluded and the results of all the other examinations received, the approved doctor must, as elsewhere in industry, decide whether other investigations ·are required. For instance, when there is a hearing defect he may refer the candidate to an otorhinolaryngologist of his choice, or to complete the biological balance sheet he may request a glucose tolerance test or liver or respiratory function tests. \Vhen there is a possible abnormality in the nervous system, the doctor must decide whether it is necessary to refer the candidate to a neurologist, a psychiatrist or a psychologist. The primary duty of an approved medical officer to a nuclear plant is to respect all rules, prescriptions and standards laid down internationally and regularly amended, and to apply these rules as prescribed by the International Atomic Authority and made applicable within South Africa by the AEB, so that..the licence to
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