OC 560/26 fitness for work with ionising radiations: Experience from the medical review panel
This OC, which cancels and replaces OC 560/26 (version 1), examines appealed decisions of appointed doctors (under the Ionising Radiations Regulations 1999) regarding an employee's fitness to work with ionising radiation.
Introduction
1 This OC gives details of the Medical Review Panel that was established under the Ionising Radiations Regulations 1985. The panel was established to review appealed decisions of appointed doctors concerning employee's fitness to work with ionising radiation. The Medical Review Panel and appeal procedure remain in place under the Ionising Radiations Regulations 1999, regulation 24(9).
2 The outcomes of six cases are considered, from which some general conclusions are drawn. Some appeals could be avoided if appointed doctors were encouraged to consult HSE's Medical Inspectorate (MI) in cases of doubt prior to certifying a worker unfit. HSE's MI medical staff may wish to discuss the content of this guidance with appointed doctors at the periodic review of their appointed status.
Background
3 The Ionising Radiations Regulations 1999 (IRR 99) regulation 24(9) states that if an employee is aggrieved by a decision made by an appointed doctor or employment medical adviser regarding his or her fitness to work with ionising radiations, as recorded in the health record, then the individual may apply to HSE for the decision to be reviewed. The procedure for such appeals is described in the HSE publication "Guidance for Appointed Doctors: Revised 2003; The Ionising Radiations Regulations 1999" which is available from Medical Inspectors through local HSE offices.
4 For the sake of this guidance, six applications for review that had been decided by the Panel are considered. Two appeals resulted from decisions made at pre-employment medical examination and four from the result of annual review medicals. The medical conditions that resulted in the appeals are skin diseases, mental illness, and malignant disease treated by radiotherapy. Brief details of the individual cases are given in the Appendix.
Conclusions
5 On the basis of the cases described in the Appendix, the following general comments can be made.
6 The advice given in "Guidance for Appointed Doctors: Revised 2003" (issued to appointed doctors) has been confirmed as a result of the decisions of the Medical Review Panel, particularly with regard to individuals suffering from episodes of mental illness and where there is a history of malignant disease treated by radiotherapy. With regard to diseases of the skin, the Medical Review Panel has highlighted the need to consider the condition of exposed areas of the skin and also protective measures available. Fitness for work with ionising radiation may be made subject to conditions as discussed in "Guidance for Appointed Doctors: Revised 2003" paragraphs 44-46 "The Skin".
7 The number of occasions where an individual is genuinely found to be unfit for work with ionising radiation are few, particularly when the number of review examinations are considered. It may be helpful to advise appointed doctors, particularly those working part-time in occupational health, to consult with a Medical Inspector prior to recording an individual as unfit. This may further reduce the already small number of appeals. As these appeals are both expensive and time consuming this would be of benefit to the individuals concerned, their employers and HSE.
Appendix: Appeals reviewed by the medical review panel
Skin disease
1 Three appeals have been made for review of decisions regarding fitness of individuals suffering from skin disease, psoriasis in two cases and eczema in one. Both of the decisions were made at pre-employment examination that resulted in an appeal related to skin conditions. In each of the three cases the individual was considered to be 'unfit' in view of the possibility of skin contamination from exposure to unsealed sources. In each case the appeal resulted in the individual being considered as fit for work with ionising radiations but subject to conditions. Notes on the individual cases follow.
Diagnosis - Eczema of variable extent
2 When seen at pre-employment examination this individual suffered from extensive eczema affecting the anterior trunk, the face and the dorsal surfaces of the feet. It was intended that this man should work as a plater for a company undertaking work on nuclear power plants. At the time of the examination no further information was available on the potential exposure to ionising radiation, and as exposure to unsealed sources could not be excluded the individual was classed 'unfit'. The decision of the Medical Review Panel was that the individual was fit for exposure to ionising radiations but that his work should be such as to not bring him into contact with open sources and that this should be noted on the health record.
Diagnosis - Psoriasis
3 This individual was to be employed as an industrial cleaner, in the course of which he would be exposed to low specific activity scale from the steam cleaning of storage tanks. He was found, on examination, to suffer from guttate psoriasis, extensively affecting the trunk and upper arms, and at the time of the examination the employee was unable to explain the nature of the protective clothing that would be used by him in the course of his work. In reviewing this case the Medical Review Panel noted that the guidance issued to appointed doctors, Medical Surveillance of Radiation Workers (now superseded by "Guidance for Appointed Doctors: Revised 2003") made particular reference to skin conditions involving exposed areas of the body and that these sites were clear in this case. The panel concluded that the individual could be considered fit for exposure to unsealed sources provided that certain conditions were met. These included the appropriate use of protective clothing and monitoring of clothing and skin for contamination. Also the condition of the skin should be subject to regular (3-monthly) assessment to check that the exposed areas had not become affected and any appropriate treatment should be continued.
Diagnosis - Psoriasis
4 This employee worked as a non-destructive testing operative and had been noted to suffer from mild psoriasis affecting the skin of the fingers of both hands at previous statutory medical examinations when he had been passed fit. With a change of appointed doctor the decision on fitness was reversed on the basis of the advice published for appointed doctors. The Medical Review Panel considered that the individual was fit to be exposed to ionising radiation, provided that full protective clothing was worn when in a contaminated area.
Comment
5 Two main issues arise from these three cases. Firstly, it is essential to have full information on the real risk of exposure to ionising radiation from unsealed sources during the proposed work and this will, in turn, require knowledge of the type of protective equipment that it is intended will be used. Without this information it is not possible to reach a valid decision regarding fitness for exposure.
6 Secondly, the option of classifying an individual as fit subject to certain conditions may be appropriate when considering individuals with skin disease who may be exposed to unsealed sources. Again, it may be necessary to have advice from the employer regarding the precautions that will be taken to prevent and to monitor skin contamination. Whether exposed areas of skin are affected will also be an important consideration.
Mental health
7 The Medical Review Panel has considered two cases where a classified person has suffered an episode of mental illness. In each case the employee worked in a large site with its own medical department. One employee had been admitted to a psychiatric hospital where a diagnosis of stress-induced psychosis was reached. Another had a diagnosis of a psychotic illness made following an acute episode at work that resulted in referral to a psychiatric hospital. In both cases the decision regarding unfitness was made taking account of the safety implications of the episode of mental illness. Both of these decisions were upheld by the Medical Review Panel.
Comment
8 The advice given to appointed doctors in "Guidance for Appointed Doctors: Reviewed 2003" paragraph 42 "Psychiatric Illness" is that mental health problems which might result in a danger to the employee or his/her colleagues should be taken into consideration in deciding on fitness to work with ionising radiation. To this extent, the medical assessment must extend beyond the fitness of the individual to be exposed to ionising radiation. The Panel received advice from consultant psychiatrists that despite completing therapy and currently exhibiting rational behaviour, each man was at some risk of recurrence of unstable episodes.
History of malignant disease
9 An industrial radiographer had been diagnosed as suffering from a reticulosis 17 years previously and had been successfully treated with radiotherapy. After regular follow-up for many years he had been discharged from further follow-up 2 years prior to a review medical examination. He had previously been certified as fit for work with ionising radiation. When later examined by a different appointed doctor this opinion on fitness was reversed. The Medical Review Panel upheld the appeal and declared the employee fit for exposure to ionising radiation.
Comment
10 "Guidance to Appointed Doctors: Reviewed 2003" paragraphs 35-36 "Previous Medical Exposure to Ionising Radiation" indicate that a past history of radiotherapy is not a contra-indication to work as a classified person, although such a history should be recorded for epidemiological and other purposes (See also paragraph 62 "Risk Estimates" and paragraphs 66-68 "Cancer in a classified person"). Individual cases should be assessed on their merits, taking account of the quality of the cure, the understanding and wishes of the individual and the nature of the work to be undertaken. It is not entirely clear in this case why the previous decision on fitness was reversed by the appointed doctor. Between the time of the appointed doctor's decision and the sitting of the Panel, the International Commission on Radiological Protection published a helpful recommendation (ICRP - 60 Recommendations of the International Commission on Radiological Protection, Annals of ICRP 21, 1991) which, in essence, states that previous radio-therapy should not, in itself, bar a person from employment as a radiation worker.