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896 SA MEDIESE TYDSKRIF 5 DESEMBER 1981

appeared to be adequate in the one case in which it was applied 5. Proceedings of the 1974 Conference on Standards of Occupational Lead
Exposure (1975): J. occup. Med., 17,98.
(worker G), being combined with other laboratory tests before a 6. Gross, S. B. (1979): Oral and [nhalarion Lead Exposllres in Hi/man SlIbjecrs.
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As of June 1981 a ZPP reading of 20 j.1g1 g Hb, thought to 475.
correlate with a Pb-B value of 70 j.1g1dl, was adopted as the 12. World Health Organization (1977): Lead (Environmental Health Criteria, no.
3). Geneva: WHO.
criterion for removal from exposure. 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.
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17. Fischbein, A., Eisinger, J. and Blumberg, E. W. (1976): Mt Sinai J. Med., 43,
I. Zielhuis, R. L. and Wibowo, A. E. E. (1978): Ned. T. Geneesk., I22, 793. 294.
2. Waldron, H. A. (1978): J. soc. Occup. Med., 28, 27. 18. Joselow, M. M. and Flores, G. (1977): Amer. industr. Hyg. Ass. J., 38,63.
3. Moore, M. R., Campbell, B. C and Goldberg, A. ill Lenihan, J. and Fletcher, 19. Herber, R. F. M. and Wibowo, A. E. E. (1980): T. soc. Geneesk., 58,425.
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p. 89. Glasgow: Blackie & Son. 21. Zielhuis, R. L. and Wibowo, A. E. E (1978): T. soc. Geneesk., 56, 676.
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Medical standards for workers In
nuclear installations
L. C. VAN OUDENHOVE DE ST G~RY

History
Summary
Only persons over the age of 18 may be employed at nuclear
South Africa is moving into the nuclear energy age, installations and, in principle, women under the age of 50 cannot
and most practitioners are probably not aware of the be employed as radiation workers at nuclear installations,
implications in medical practice. The demands although of course they may be employed in departments
upon workers in this area are very strict, and the outside.
doctor who may have to examine them must be A complete family history is necessary as well as a history of
aware of this. This article is designed to outline the previous work with particular attention to toxic, dusty, noisy ~d
procedures necessary in examining candidates for glary jobs and any previous exposure to ionizing radiation (which
employment in the nuclear energy industry. would include any exposure to medical radiological apparatus).
All dosimetric information must be recorded accurately and
S. Atr. med. J., 60,896 (1981). 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.
Very strict international srandards have been established for
Every exposure of skin to toxins and dust must be noted, with
nuclear personnel and made applicable by the Atomic Energy
special reference to chronic skin disease of any nature that could
Board to any South African licence holder (corporate or
be made worse or reactivated by ionic radiation. Inability to rrear
individual).
any skin condirion successfully is ground for rejection, and any
The basic investigation of any candidate for employment in a
skin change due to previous radiation constitutes ~n absolute
nuclear plant as a 'radiation worker' consists of a personal
contraindication to employment.
history, physical examination and complementary examinations.
Cardiovascular system. As regards the cardiovascular
system all the' conventional contraindications to industrial
809 Medical Centre, Hererengracht" Cape Town employment are valid, for the principle involved is not so much
L. C. VAN OUDENHOVE DE ST GERY, M.D. that these constitute a bar to employment but that the work in a
nU,clear installation requires the most complete state of fitness
Date received: 21 April 1981. possible. Any chronic disease of the respiratory system that
SA MEDICAL JOURNAL 5 DECEMBER 1981 897

could enhance the danger of internal contamination or be urinary and genital systems must also be investigated.
aggravated by such contamination is a contraindication. Ears, nose and throat. Chronic infections of the throat or
Digestive system. Basically, disorders of the disgestive nose constitute reasons for rejection. The condition of the ears
system which are conrraindications ro work in a nuclear plant are must be looked inro, with particular emphasis on perforation of
the same as those in normal industry; it is clear that chronic the eardrum. Any perforation or chronic inflammation of the
inte tinal ulceration or any chronic inflammarory condition external audirory meatus is ground for rejection unless the
would be a contraindication ro acceptance. In so~e cases the individual undergoes a successful tympanoplasty or other
candidate may be reviewed 3 months later, after treatment. curative operation. Basic hearing capacity must be tested; if in
Nervous system. The condition of the nervous system must doubt the candidate must be referred ro an E T specialist. In
be carefully reviewed and in doubtful cases the candidate should any case an audiogram is obtained annually. Loss of20 dB at the
be referred for neurological, psychological or psychiatric entrance examination makes a candidate unacceptable.
investigation. The emotional balance of the worker is of primary Eyes. There are no actual standards for visual acuiry, but the
importance, as is his ability ro observe strict discipline and work general rule is that if the candidate is wearing glasses he should
in a team. be able to execute essential manoeuvres at his place of work in the
Renal diseas~ is usually a bar to employment. shortest possible time even under the most complex
Ears, nose and throat. Any previous chronic or acute circumstances, and he must be able to wear a mask or other
inflammatory condition affecting the ear, nose and throat must protective gear prescribed for work in contaminated areas.
be enquired after and if necessary treated before a final decision Glasses may be replaced by special plastic unbreakable glasses
abour employment. Hearing must be tested. adapted to the protective gear. Certain jobs such as
Endocrine system. In the endocrine system the critical telemani pulations in a hot cell or in the fuel pool demand perfect
organ·is the thyroid, on accounr of possible contamination by vision and absolute depth dimension view. The importance of
iodine-131. Uncontrolled diabetes is an absolute colour vision varies from department to department and from
contraindication. job to job. Colour blindness would not constitute an absolute
Scars and wounds. Surgical scars must be investigated from factor for disqualification and must be weighed up against the
two angles: (1) a surgical scar implies previous disease, about demands of the job. The significance of narrowing of the visual
which enquiry should be made; and (ii) any scar enhances the field would depend upon the tasks ro be performed and the cause
effect of contamination and is a handicap to deconramination. of the impairment.
Any wound that may cause problems with skeletal Nervous system. The neurological balance sheet is probably
contamination is a reason for temporary exclusion from work in a the most important part of a pre-employment examination. Any
radiation or contamination zone. Special attention must be paid serious abnormality constitutes an absolute contraindication,
ro fractures, especially recent fractures, on account of the and this includes the psychological field, in which
strontium-90 effect- on callus. The presence of any malignant claustrophobia, for example, would disqualify a radiation
tumour, past or present, constitutes an absolute contraindication worker. Balance is of particular importance since the worker
ro employment. must be able ro climb steps and ladders and work at heights
The blood. Enquiry must be made into any past disorder of without danger to himself, and any candidate with attacks of
the blood in the applicant or his family; this is an area requiring dizziness or fainting would therefore be disqualified. Since most
careful investigation, since any blood disorder constitutes a workers must be able to do shift work disorders of sleep will
contraindication ro radiation work. Enquiry must also be made constitute a bar, and any lack of co-ordination and reaction speed
about previous radiotherapy, and the dosimetric results must be also disqualifies him.
communicated to and discussed with an accredited health
physicist.
Female personnel
Clinical examination For obvious reasons it is the general policy nor to employ female
staff in a radiation area. If they have to be employed women
This must be prolonged, complete and systematic; in view of the should be examined just as systematically as men, and a
responsibility involved and the rules that must be strictly applied gynaecological examination should be performed if there is any
to new workers, this examination can never be too strict. indication of uterine or ovarian disease or of pregnancy. Most
Skin. Any skin lesions must be looked for, especially on the female personnel are of course employed ourside the controlled
face, scalp, neck, hands and trunk. Chronic and resistant acne, if zone; nevertheless for medical, legal and psychological reasons it
widespread, constitutes a reason for rejection because of the risk is highly advisable not to employ female staff without an initial
of repeated contamination of the area. Skin tumours or complete medical balance sheet, as well as repeat examinations
degenerative changes in the skin should be carefully noted. If the when required.
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 Complementary examinations
constitute a reason for temporary or permanent suspension.
Cardiovascular system. Examination of the heart and These examinations are intended to cover the special risks and
blood vessels is the same as in general medical examinations, bur responsibilities in a nuelear installation and are therefore as
it. is useful to have a pre-employment ECG and to repeat this at important as, if nor more importanr than, the general clinical
intervals. examination. Two of the systemic examinations are compulsory
Examination of the respiratory system is basically the (the biological balance sheet and the ophthalmological balance
same as in all industrial medicine, bur in addition lung capacity sheet) and one is optional (chest radiography).
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 Biological balance sheet
should be taken to look for hernias, liver enlargement and splenic The most important component of the biological balance sheet
enlargement, all of which are grounds for rejection. Any is the haematological examination. This will include a complete
interruption of the mucosa membrane of the gastro-intestinal blood co-unt and the other standard haematological
tract such as a peptic or intestinal ulcer is a contraindication. The examinations. The red cell count should not be below 3,8 x
898 SA MEDIESE TYDSKRIF 5 DESEMBER 1981

1Q6/J.Ll or above 5,5 x 1Q6/J.L1. The total white cell count should operate a nuclear installation may be maintained. The second
not exceed 12000/I.Ll or fall below 4000/J.Ll. Blood tests should duty of the doctor is to perform such re-examinations and
be carried out twice, once with the candidate fasting and once complementary investigations as he deems necessary, on his own
after breakfast. The polymorphonuclear count should be responsibility.
between 35% and 80% of the total white cell count. Haemostasis
(coagulation, bleeding time, etc.) should also be studied. Any Certificate of fitness for radiation work
abnormality requires investigation as to its cause and
If all the above examinations and investigations have been
consequences.
completed, the approved doctor must compile a medical balance
The blood sugar and blood urea levels should be estimated.
sheet from which he can conclude whether the candidate is fit for
Renal function should be studied by chemical and cytological
work in a nuclear installation. This decision must be fmal and no
examination of freshly passed urine, an Addis count and urea and
reasons need be given for it. It is briefly communicated on a
creatinine clearance tests whenever possible; these are
preprinted form without any explanation or justification, but
mandatory if any abnormality or suggestion of abnormality is
should mention the qualifications for the pOSt in question. All
present.
examination forms and other medical documents are kept under
The legal justification for this emphasis on the haematological
the control of the approved medical officer himself.
examination is the extreme sensitivity of the haematopoietic
General fitness for work will depend upon the demands ofthe
system to ionizing radiation. The acceptable standards are those
particular post, since often the job will be equivalent to that in
established by the International Atomic Authority made
another industrial plant. The appnwed medical officer l1)ust be
applicable within South Africa by the Atomic Energy Board
furnished with a complete job description before the candidate
(AEB) in Pretoria. Medically acceptable standards are set by the
has been examined or re-examined.
laboratory and will provide guidance for the approved doctor's
He must also decide on fitness for nuclear risks. If ,the
decision; however, they are not hard and fast, since one must take
candidate is found fit for the three basic risks - radiation,
into account changes caused by passing events and diseases.
external contamination, and internal contamination - then he is
\Vhenever results are outside the accepted standards, the
fit for radiation work and any potentially hazardous job in a
examination should be repeated after 2 - 3 weeks and whenever
controlled zone. If, however, he is unfit for any ofthe three basic
possible a reason for the abnormality should be established. If
risks, he is not fit to work as a radiation worker but only for
results are abnormal on three successive occasions the candidate
specified jobs in a controlled zone. Ifthe candidate is unfit for the
should be declared unfit for work as a classified radiation worker.
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 Temporary disqualifications
chosen by the approved medical practitioner and include a study
of visual acuity with or without correction, the fundi, intra- If a candidate is found unfit for work owing to some complaint
ocular pressure, and biomicroscopic examination of the which is likely to disappear with or without appropriate
crystalline lens. These last two examinations are of imponance treatment within a relatively short period, the doctor may declare
since it must be accepted that any irradiation, especially with the candidate acceptable after successful treatment. This might
neutrons, may produce a cataract. Exposure of an eye with happen in the case of a patient with acne, for example, or a
increased intra-ocular pressure to ionizing radiation will quickly temporal blood disorder due to an infection. The decision to
worsen the condition. Both glaucoma and cataract are complete accept or defer a worker is the exclusive prerogative of the
barriers to radiation work. approved medical officer of the nuclear installation.

Fitness for special operations


Chest radiography In the nuclear industry there are certain routine or emergency
A chest radiograph is essential to exclude any form of operations such as refuelling of a power reactor, repair of leaks,
tuberculosis and should only be omitted if clinical examination or confinement in situations with unusual risk of higher radiation
has shown beyond any doubt the absence of pulmonary disease and/or contamination. In these or similar situations the docto,
and if the worker has been or will be exposed to substantial must re-examine the candidates in question, or in cases of
radiation. 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
Results during a very short time a dose higher than the annual permitted
level and therefore need subsequent treatment and exemption
When the personal questionnaire has been completed, the from radiation work for a period oftime established by the doctor
clinical examination concluded and the results of all the other in consultation with an accredited health physicist.
examinations received, the approved doctor must, as elsewhere During his period of training or work an approved radiation
in industry, decide whether other investigations ·are required. worker may, whether as a result of radiation or not, develop
For instance, when there is a hearing defect he may refer the certain symptoms or disorders. He must then be referred to the
candidate to an otorhinolaryngologist of his choice, or to doctor, who in turn must refer to the employee's medical file and
complete the biological balance sheet he may request a glucose balance sheet and decide whether funher investigations are
tolerance test or liver or respiratory function tests. \Vhen there is needed, whether treatment is required and by whom (the
a possible abnormality in the nervous system, the doctor must employee's own doctor or not), and whether the employee's
decide whether it is necessary to refer the candidate to a certificate of fitness as a radiation worker can be maintained,
neurologist, a psychiatrist or a psychologist. modified or withdrawn.
The primary duty of an approved medical officer to a nuclear It must be emphasized that all these ruks and indications are
plant is to respect all rules, prescriptions and standards laid down not static but must be continuously adapted to changes in
internationally and regularly amended, and to apply these rules national or international legislation, evolution in radiobiology
as prescribed by the International Atomic Authority and made and the introduction of new techniques in industrial medicine
applicable within South Africa by the AEB, so that..the licence to and nuclear physics.

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