COVID-19 Medical surveillance and fitness for duty

In the workplace, we need to comply with the Occupational Health and Safety Act (OHS Act) and the relevant regulation within the OHS Act. Regarding COVID-19 the OHS Act and the Hazardous Biological Regulation are applicable.

Occupational Health and Safety Act, 1993 Hazardous Biological Agents Regulations:

Hazardous biological agents are micro-organisms, including those that have been genetically modified, pathogens, cells, cell cultures and human endoparasites that have the potential to provoke an infection toxic effect. They are subdivided into the following groups –

a) Group I HBA are HBA that is unlikely to cause human disease.

b) Group 2 HBA are HBA that may cause human disease and be a hazard to exposed persons, which is unlikely to spread to the community and for which effective prophylaxis and treatment is usually available; c) Group 3 HBA are HBA that may cause severe human disease, which presents a serious hazard to exposed persons and which may present a risk of spreading to the community, but for which effective prophylaxis and treatment is available;

d) Group 4 HBA are HBA that causes severe human disease and is a serious hazard to exposed persons and which may present a high risk of spreading to the community, but for which no effective prophylaxis and treatment is available.

COVID-19 is a group 4 HBA according to the OHS Act and the HBA regulation.

Occupational Health and Safety Act, 1993 Hazardous Biological Agents Regulations:

2. Scope of application 

1) Subject to subregulation (2), these Regulations shall apply to every employer and self-employed person at a workplace where –

a)     HBA is deliberately produced, processed, used, handled, stored, or transported; or

b)     an incident, for which an indicative list is given in Annexure A to these Regulation occurs that does not involve a deliberate intention to work with an HBA but may result in persons being exposed to HBA in the performance of his or her work

What is medical surveillance?

·        Medical surveillance describes activities that target the health changes of an exposed person.

·        Medical screening is designed to detect early signs of work-related illness by administering tests to supposed healthy persons.

·        Testing modalities may include tools such as questionnaires, physical examinations, and medical investigations.

·        Behind the implementation of engineering, administrative, and work practice controls (including personal protective equipment).

·        Used as a mechanism to determine whether the usual prevention activities in the hierarchy of controls are effective.

Elements of a medical surveillance program

·        Identification of the group(s) of workers for which medical surveillance will be appropriate as determined by the risk groups.

·        An initial medical examination and collection of medical and occupational histories.

·        Periodic medical examinations/testing at regularly scheduled intervals.

·        Post-incident examinations and medical screening after uncontrolled or nonroutine increases in exposures.

·        Ongoing data analyses to evaluate collected information for surveillance and/or screening purposes

·        Worker training to recognize symptoms of exposure.

·        A written protocol and appropriate record keeping.

·        Employer actions in response to the identification of potential hazards and risks to health.

Medical surveillance in line COVID-19 risk

?       Risk-based.

?       Determined at the guidance of the Occupational Medical Practitioner.

?       Early detection of infected employees:

o  Removal of infected individuals and isolated.

o  Early referral for appropriate treatment, care and timeous return to work of affected workers.

?       Prevent spread to other unaffected staff, consumers, visitors and clients:

o  Prompt identification and isolation of potentially infectious individuals.

o  Quarantining.

o  Contact tracing.

o  Effective return to work practices.

o  Workplace restrictions

Workers who are at an increased risk for workplace/occupationally acquired COVID-19 are:

?       Healthcare workers.

?       Emergency response and public safety workers.

?       Post-mortem care.

?       Laboratory workers.

?       Airline operators.

?       Retail workers.

?       Border protection and transport security workers.

?       Correctional facility workers.

?       Solid waste and wastewater management workers

?       Environmental health workers.

?       In-home repair workers.

?       Travel to high-risk places.

Risk categorization

High Risk

?       Have frequent and/or close contact with (i.e. within 2 meters of) people have COVID-19

?       Having unprotected direct contact with infectious secretions or excretions of a COVID-19 infected person.

?       Health care workers, Laboratory staff and mortuary staff.

Medium Risk

?       Have frequent and/or close contact with (i.e. within 2 meters of) people who may be infected with SARS-CoV-2, but who are not known or suspected COVID-19

?       Close contact with the general public.

?       Airline staff, Retail staff, Border protection, Public transport industry, Correctional facility operations

Low Risk

?       Do not require contact with people known to be or suspected of being infected with SARS-CoV-2

?       Nor frequent close contact with (i.e. within 2 meters of) the general public

Medical surveillance tools for COVID-19

Self-monitoring:

?       Employees monitor themselves for fever by taking their temperature twice a day and symptoms of COVID-19 (e.g., fever, cough, shortness of breath, sore throat, myalgia, malaise).

?       They should be provided with a plan for whom to contact if they develop fever or respiratory symptoms.

Active monitoring:

?       Regular communication with potentially exposed employee(s) to assess for the presence of fever or symptoms of COVID-19.

?       For employees with high exposure in the workplace.

?       Communication should occur at least once each day.

?       It can be delegated by occupational health or infection control program.

Self-Monitoring with delegated supervision:

?       Employees perform self-monitoring with oversight by occupational health or infection control programmes.

?       On days employees are scheduled to work, facilities could consider measuring temperature and assessing symptoms before starting work.

Example of a screening tool

Types of screening

Symptom questionnaire.

Temperature screening:

?       Fever is either measured temperature >38oC or subjective fever.

?       Fever may be intermittent or may not be present in some patients, such as those who are elderly, immunosuppressed, or taking certain medications (e.g., NSAIDs).

?       Clinical judgement should be used to guide the testing of patients in such situations.

?       Medical evaluation may be recommended for lower temperatures (< 38oC) or other symptoms (e.g., muscle aches, nausea, vomiting, diarrhoea, abdominal pain headache, runny nose, loss of taste and smell fatigue) based on the assessment by Occupational Health Practitioner.

Medical surveillance is determined by risk

High risk,

?          Active monitoring.

?          If they develop any fever OR symptoms consistent with COVID-19.

?          They should immediately self-isolate.

Medium risk

?          Self-monitoring until 14 days after the last potential exposure.

?          Check their temperature twice daily and remain alert for symptoms.

?          Ensure they are afebrile and asymptomatic before leaving home and reporting for work

?          Asymptomatic workers are not restricted from work.

Low risk

?       No identifiable risk category does not require monitoring or restriction from work.

Recommended procedure

1.     Determine the risk of COVID -19 to your employees.

2.     Screening of employees for COVID-19 related symptoms and report such symptoms to a designated person and / or occupational health practitioner.

3.     At the start and end of each shift, designated persons and / or occupational health practitioner must check with employees whether they have experienced a sudden onset of any of the following symptoms.

4.     Should an employee report any of the symptoms?

a.     They should immediately be provided with a surgical mask, and

b.     Referred to the designated staff at the workplace so that arrangements can be made for COVID-19 testing.

5.     Should an employee report any additional symptoms as outlined in the symptom monitoring sheet

a.     They should be provided with a surgical mask, and

b.     Referred to the occupational health clinic, family practitioner or primary care clinic for further clinical evaluation and requirement for COVID-19 testing if indicated.

6.     On receiving their results, the employee and/or health professional should notify their workplace so that the employee is managed accordingly (this should be actively followed up to prevent delays)

a.     Notify to the NICD.

b.     Contact tracing

Workplace protocols that need to be in place and organisation-specific:

These should include protocols

?       In the event of a symptomatic person to be referred to testing and treatment.

?       In the event of a positive employee in the organization- requiring isolation and contact tracing.

?       Return to work protocol of infected employee(s).

?       Restriction of infected employees in the workplace following return to work.

Return to work- exclude from work until:

?       Test-based strategy.

o  Resolution of fever without the use of fever-reducing medications, and

o  Improvement in respiratory symptoms (e.g., cough, shortness of breath), and

o  Negative results of COVID-19 testing from at least two consecutive swab specimens collected ≥24 hours apart.

?       Non-test-based strategy.

o  All symptoms have resolved.

o  14 days have passed since the onset of symptoms

Return to work

All employees on returning to work after isolation or quarantine period should follow general work restrictions that include:

?       Undergo medical evaluation to confirm that they are fit to work.

?       Wearing of surgical masks always while at work for 21 days from the initial test.

?       Implement social distancing measures as appropriate.

?       Adherence to hand hygiene, respiratory hygiene, and cough etiquette.

?       Continued self-monitoring for symptoms.

?       Seek medical re-evaluation if respiratory symptoms reoccur or worsen.

?       In the case of health workers avoiding contact with severely immunocompromised patients

Fitness to work

?       A Medical assessment is done to determine if medically the employee can perform the job or task under the working conditions that are experienced at the time.

?       Takes into account the job specifications of the employee and the risks posed to the employee

?       This should be done when:

o  There has been a significant change in the working conditions.

o  The medical condition may have severe outcomes due to the level of exposure by the job.

o  Returning worker post-infection.

Clinically extremely vulnerable.

?       Solid organ transplant recipients.

?       Cancers

o  Those undergoing active chemotherapy.

o  Lung cancer who are undergoing radical radiotherapy.

o  Cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment.

o  Having immunotherapy or other continuing antibody treatments for cancer.

o  Having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors.

o  Who has had a bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs?

?       Severe respiratory conditions including all cystic fibrosis, severe asthma and severe chronic obstructive pulmonary (COPD).

?       Rare diseases and inborn errors of metabolism that significantly increase the risk of infections (such as Severe combined immunodeficiency (SCID), homozygous sickle cell).

?       On immunosuppression therapies a significant increase the risk of infection.

?       Women who are pregnant with significant heart disease, congenital or acquired.

Other vulnerable workers:

?       Age greater than 60.

?       Cardiovascular disease.

?       Diabetes mellitus.

?       Chronic respiratory disease.

?       Chronic renal disease.

?       Pregnant workers.

?       Employees on immunosuppressive therapy i.e. systemic corticosteroids.

?       HIV diagnosed workers who are virally unsuppressed

Considerations for the Return to Work Strategy (Health Workers – HW’s)

?       Facilities have considered local testing availability and the facility’s ability to maintain staffing levels when deciding on which testing strategy to apply, and those factors may change over time.

?       If testing is limited or must be rationed:

o  facilities have used the non-test-based strategy to determine return to work, to conserve testing for the diagnosis of persons suspected of having COVID-19.

?       In situations of critical staffing shortages:

o  Some facilities have conferred with the local public health authorities and allowed COVID-19 infected HWs to return to work earlier than indicated.

o  This has been determined on a case-by-case basis, and facilities have considered duty restrictions, such as only permitting infected HWs to care for COVID-19 patients or limiting them to non-patient care activities

Considerations for the Return to Work Strategy (HWs)

?       In the setting of community transmission, all HWs are at some risk for exposure to COVID-19, whether in the workplace or in the community.

?       Devoting resources to contact tracing and retrospective risk assessment could divert resources from other important infection prevention and control activities.

o  Reinforce the need for standard precautions for all patient encounters.

o  Stress the importance of hand hygiene, cough etiquette, and respiratory hygiene.

o  Enforce social distancing between HWs and patients when not involved in direct patient care.

o  Instruct all HWs at the facility to report recognized exposures.

o  Have staff regularly self-monitor for fever and symptoms

o  Remind staff to avoid reporting to work when ill.

o  When resources are available, always instruct staff to wear a medical mask when in the facility as an additional protective measure to limit potential spread among staff and to patients.

If you suspect you have been exposed to COVID-19

?     Alert your supervisor and occupational health clinic immediately

?     If you are experiencing symptoms, inform your health care provider about any contacts and recent travel to areas affected by COVID-19

Acknowledgements

?       NHLS Management 

?       NIOH Outbreak Response Team 

?       NICD

Reference:

1.      Volmink O. Medical surveillance and fitness for duty in the time of COVID-19 2020 [cited 2020 06 May ]. Available from: https://www.nioh.ac.za/wp-content/uploads/2020/04/Return-to-work.Medical-surveillance-and-fitness-for-duty-COVID-19.final_.pdf.

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