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Penyakit pekerjaan dan pengawalannya

Dr Azlan bin Darus MBChB MPH MPH(Occ Health) MFOM Centre of Occupational and Environmental Health Faculty of Medicine University of Malaya

Kursus Keselamatan dan Kesihatan Pekerjaan: PPUM

Isu-isu keselamatan dan kesihatan di hospital


Adakah hospital suatu tempat kerja? Rawatan kepada pesakit. Bagaimana dengan perawat? Perawat:
Tidak mementingkan diri sendiri Mementingkan pesakit bagaikan lilin membakar diri

Hospital sebagai suatu tempat kerja yang kompleks.

Penyakit pekerjaan
Penyakit yang timbul akibat daripada aktiviti di tempat kerja Akibat daripada pendedahan kepada hazad di tempat kerja: biologikal, kimia, ergonomik, fizikal dan psikososial

Diabetes, hypertension, etc

Penyakit am

Penyakit di tempat kerja


Penyakit pekerjaan Penyakit berkaitan pekerjaan

Pneumokoniosis, keracunan asbestos dsb

Sakit belakang, lelah,

PHYSICAL HAZARD

ERGONOMIC HAZARD

BIOLOGICAL HAZARD

PSYCHOSOCIAL HAZARD

CHEMICAL HAZARD

Cabaran menangani penyakit pekerjaan


Kebanyakannya mempunyai pelbagai punca Tempoh patensi yang lama Punca-punca lain tak dapat nak di nyahkan Punca yang tak dapat dikaitkan degan jitu Kekurangan maklumat penyelidikan

Mengenal pasti penyakit pekerjaan


Mencegah penyakit di masa hadapan: memperbaiki persekitaran kerja, kawalan hazad dan promosi kesihatan Justifikasi untuk modifikasi kerja, pertukaran kerja Pampasan

Hazad penyakit pekerjaan di hospital


Biologi : HIV, HepB, HepC, TB, SARS, flu Kimia: glutaraldehyde, etylene oxide, formal dehyde, sarung tangan getah, gas Fizikal: Radiasi, bunyi bising Ergonomik: Mengangkat barangan berat, berdiri lama Psikososial: tekanan, kerja syif

Contoh penyakit pekerjaan dan pengawalannya

Tuberculosis
Bawaan udara Wad TB, wad respiratori, kecemasan MOH TBIS data (2003 2006): kadar insiden TB = 73.4-77.7 per 100,000 dikalangan HCWs vs 60.3-62.6 per 100,000 dikalangan orang awam

Rafiza et al. Prevalence and risk factors of latent tuberculosis infection among health care workers in Malaysia. BMC Infectious Diseases 2011, 11:19
Factors significantly associated with latent tuberculosis infection were aged 35 years and older [9.49 (CI: 2.22; 40.50)], history of living in the same house with close family members or friends who had active tuberculosis [8.69 (CI: 3.00; 25.18)], worked as a nurse [4.65 (CI: 1.10; 19.65)] and being male [3.70 (CI: 1.36; 10.02)]

Secara mutlak, agak sukar mengenal pasti sama ada benar-benar TB daripada pesakit
Pencegahan
Sistem pengudaraan PPD

HIV, HepB, HepC


Jangkitan melalui cecair badan Tertusuk jarum, kecederaan alt tajam, terdedah kepada bendalir tubuh. Kebanyakannya berkaitan dengan
Recapping of needles Membuang jarum bukan di tempatnya Kecuaian

Biological Hazards

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Risiko penyakit akibat terdedah kepada HIV di tempat kerja


~ 0.3% in HIV-contaminated needle stick injuries ~ 0.09% in case of contact with the mucous membrane

Infection HBV(eAg+ve) HCV HIV

Risk of seroconversion 33% 3% 0.3%

Walaupun risiko kecil, kos atau kesan adalah BESAR!:


Perspektif pekerja
Penyakit seumur hidup, tidak boleh sembuh, cuma boleh dikawal Kos rawatan yang tinggi Stigma, tekanan, masalah keluarga dan masyarakat

Majikan
Gangguan kerja Kos bagi melatih pekerja baru Insurans dan kos perubatan Produktiviti

Transmisi daripada pesakit kepada anggota kesihatan Transmisi daripada anggota kesihatan kepada pesakit
Yang mana lebih kerap? Yang mana lebih penting?

Worldwide incidence of HCW infected with HIV 106 (up to December 2002)1 Worldwide possible transmissions of HIV from infected healthcare workers to patients:
a Florida dentist2 a French orthopaedic surgeon3 a Spanish gynaecologist4
1 Health Protection Agency. Occupational transmission of HIV summary of published reports. March 2005 Edition (data to end of December 2002). London: Health Protection Agency, March 2005.http://www.hpa.org.uk/infections/topics_az/bbv/ pdf/intl_HIV_tables_2005.pdf 2 Ciesielski C, Marianos D, Ou C-Y, Dumbaugh R, Witte J, Berkelman R et al. Transmission of human immunodeficiency virus in a dental practice. Ann Int Med 1992; 116: 798-805. 3 Lot F, S guier J-C, F gueux S, Astagneau P, Simon P, Aggoune M et al. Probable transmission of HIV from an orthopaedic surgeon to a patient in France. Ann Int Med 1999; 130: 1-6. 4 Bosch X. Second case of doctor-to-patient HIV transmission. The Lancet Infectious Diseases 2003; 3: 261.

Oleh itu perlukah anggota kesihatan disaring untuk HIV sebelum prosedur seperti pembedahan?
Tiada bukti keberkesanan Window period orang yang telah dijangkiti masih lagi mempunyai keputusan negatif Medikolegal

Apakah langkah yang lebih praktikal?


Assume all blood, tissues, and some body fluids from individuals are a potential source of infection; hence: practice strict universal precautions Anggap semua darah, bendalir tubuh daripda SEMUA pesakit berpotensi untuk memberi jangkitan, oleh itu mesti mengamalkan prosedur yang betul (universal precaution) Kawalan kejuruteraan: alat yang lebih selamat Post-exposure prophylaxis (PEP) Budaya kerja selamat

Table 1. Incidence of sharps / needle stick injury in UMMC 2008-2010

Year Number of reported cases

2008

2009

2010 (Jan-20 December) 102

127

106

Figure 1. Incidence of sharps/needle stick injury in UMMC according to job in 2009


20 18 16 14 12 10 8 6 4

2
0

Penyakit-penyakit lain
SARS, Influenza A (H1N1) Avian flu (? Transmisi manusia) Transmisi: batuk (udara) Kesan berpanjangan Kejadian tidak boleh diramal, oleh itu HCW perlu sentiasa bersedia dan lebih peka tentang wabak-wabak yang berlaku

SARS Epidemic
Spread from Hotel M, Hong Kong

Canada
Guangdong Province, China

F,G A A F,G
Hotel M Hong Kong

18 HCW
11 close contacts

Hong Kong SAR

A
H,J H,J B

K I, L,M

Ireland 0 HCW

95 HCW

C,D,E
C,D,E
Singapore

>100 close contacts

I,L,M
United States 1 HCW

B
Vietnam
37 HCW
21 close contacts

34 HCW
37 close contacts

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Slide berikutnya adalah didalam Bahasa Inggeris

Glutaraldehyde
An organic compound with pungent colorless oily liquid Used to disinfect medical and dental equipment Also used for industrial water treatment and as a chemical preservative

Chemical Hazards

RM 2009/10

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Exposure:
Hospital staff who work in areas with a cold sterilizing procedure that uses glutaraldehyde (for example, gastroenterology and cardiology departments) Hospital staff who work in operating rooms, dialysis departments, endoscopy units, and intensive care units where glutaraldehyde formulations are used in infection control procedures Central service (supply) workers who use glutaraldehyde as a sterilant Research technicians, researchers, and pharmacy personnel who either prepare the alkaline solutions or fix tissues in histology and pathology labs Laboratory technicians who sterilize benchtops with glutaraldehyde solutions Workers who develop x-rays.

Health effects:
Occupational asthma Skin sensitization leading to dermatitis Mucous membrane irritation

Diagnosis of occupational disease is possible through skin patch testing Implications:


Job modification Compensation if causing permanent disablement

Ethylene oxide
Flammable, colourless, slightly sweet odour gas at room temperature Used as cold sterilizing agent for medical supplies
Exposure mainly in CSSD Among sterilizer operators Exposure can occur due to:
changing pressurized ethylene oxide gas cylinders leaking valves, fittings and piping, sterilizer door gaskets opening the sterilizer door at the end of a cycle removal of items from the inadequate general room ventilation

Health effects:
Mucous membrane irritation Documented effects: pulmonary oedema, occupational asthma, peripheral neuropathy Epidemiological studies: increased risk of leukemia Animal studies: confirmed leukemia, brain tumour, peritoneal mesotheliomas IARC classification: Class 1 carcinogen (latest data 2011)

Diagnosis of occupational cancer can be challenging

Chemical hazard in Hospital


Chemotherapy Cleaning agents Solvents- spirit Fixatives in Pathology lab Anaesthetic agents

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Formaldehyde
AKA: methanal, pungent odour, gas in room temperature, usually used in liquid form (37% solution of formaldehyde in water) Odour threshold level (OT) is 0.5 1 ppm. Ceiling limit (TLV) is 0.3 ppm. OT/TLV ~ 3.3 Used in pathology, histology (tissue fixation), and renal dialysis unit, CSSD (where formaldehyde is used as sterilizing agent), mortuaries (embalming process)

Health effects:
Irritant and allergic contact dermatitis Occupational asthma Mucous membrane irritation Epidemiological studies suggested respiratory cancers (esp. nasal cancer) Animal studies: confirmed squamous cell cancers of nasal cavity in high level exposure (~14 ppm) IARC classification: Class 1 carcinogen (latest data 2011)

Latex gloves (sarung tangan getah) dan alahan pada kulit


Kerap digunakan di hospital Sering dikaitkan dengan alahan pada kulit Implikasi:
Pengubahsuaian kerja, relokasi Bukan penyakit yang berkekalan

Contact dermatitis due to Agriculture insecticides (methyl bromide)

Contact dermatitis due to Agriculture insecticides DERMATITIS DUE TO DETERGENT EXPOSURE (methyl bromide)

Chloracne

RM 2009/10

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Nettis E. et al. Occupational irritant and allergic contact dermatitis among healthcare workers. Contact Dermatitis. 2002 Feb; 46(2): 101-7. We found that allergic contact dermatitis and irritant contact dermatitis were considered to be work-related in 16.5% (72/436) and 44.4% (194/436) of diagnoses, respectively. Occupational irritant contact dermatitis is due to exposure to a wide range of irritants in the workplace, such as soaps, solvents, cleansers and protective gloves, which conspire to remove the surface lipid layer and/or produce cellular damage. In this study the major relevant aetiological agents that induced occupational allergic contact dermatitis were: nickel sulphate (41 patch positivities), components of disinfectants [glutaraldehyde (5) and benzalkonium chloride (7)] and rubber chemicals [thiuram mix (15), carba mix (9) and tetramethylthiuram monosulphide (6)]

Masalah ergonomik
Kerap Hazad: barangan yang berat, pesakit
Carrying and transferring bed ridden patient, transferring patient to and from OT, pushing food trolley, long hours of operation

Kakitangan berisiko : jururawat, pembantu perawatan, kakitangan am Berbeza mengikut kategori pekerjaan
Ergonomik pejabat Pengendalian pesakit

Ergonomic Hazard

RM 2009/10

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Isu keselamatan dan kesihatan pekerjaan di hospital: Psikososial


Tekanan kerja shif, terlalu banyak kerja, kebosanan, tiada motivasi, pengurusan tidak cekap, kekurangan latihan.. Tekanan peribadi gangguan seksual, diskriminasi

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Tekanan psikososial
Selalu tidak diendahkan Mempengaruhi perkhidmatan dan kesihatan para pekerja Beberapa kawasan dikenal pasti sebagai mempunyai tekanan yang tinggi
Kecemasan Unit Rawatan Rapi
ICU CCU

Laura KB, et al. Extended Work Shifts and the Risk of Motor Vehicle Crashes among Interns. NEJM, 2005, 352 (2): 125 -134 We found that the odds that interns will have a motor vehicle crash on the commute following an extended work shift were more than double the odds after a non-extended shift [or= . ( . , . )]. Near-miss incidents were more than five times as likely to occur after an extended work shift as they were after a non-extended shift [or= . ( . , . )]. In a prospective analysis, every extended work shift that was scheduled in a month increased the monthly risk of any motor vehicle crash by . ( . , . ). In the intervention study, interns worked . hours/week less (p< . ), slept . hours/week more (p< . ), and had less than half the rate of attentional failures while working during on-call nights (p= . ) on the intervention schedule as compared with the traditional schedule. Additionally, we found interns made . times as many serious diagnostic errors during the traditional schedule as during the intervention schedule (p< . ).

Physical Hazards

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Kesimpulan
Hospital mempunyai bahaya-bahayanya yang tersendiri Kakitangan hospital perlukan kesedaran yang tinggi berkenaan risiko yang ada di tempat kerja masing-masing , dan kebarangkalian mendapat penyakit-penyakit yang boleh disebabkan oleh aktiviti di tempat kerja masing-masing

Kesimpulan
Mengawal penyakit pekerjaan hanya dibuat melalui proses pencegahan melalui penambahbaikan persekitaran dan proses kerja Kaktangan hospital mempunyai peranan yang penting, terutama sekali didala mengamalkan cara kerja selamat dan kawalan hygiene yang baik melalui universal precaution.

Ex-gratia skim pampasan untu kecacatan kekal bagi kecederaan dan penyakit pekerjaan untuk kakitangan kerajaan

Bekerjalah dengan selamat


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