Hands-on Approach [Sep 2009]
The awareness and control of hand and arm vibration risks
Hands-on Approach
The awareness and control of hand and arm vibration risks
Hand-arm Vibration Syndrome (HAVS) can probably be grouped in the mythological category of one of those diseases that someone else always gets. In many respects it ranks alongside lung cancer, heart disease and liver failure. Not in terms of fear factor or short term impact but because the causes are widely known and there is reluctance on the part of some to act. Unlike cancer, heart disease and liver failure though HAVS won't kill you but its victims often suffer a similar loss of dignity and quality of life - at best periodic but intense pain in the hands and fingers, the inability to do up buttons or handle money and at worst, the indignity of having to be fed or of having to have someone help you when you go to the toilet
Vibration exposure levels
HSE research during the 1990s estimated that around five million British workers were exposed to HAV in the workplace. Approximately 1.7 million were believed to be exposed at levels above the exposure action value (EAV) with around 900,000 of these exposed above the current exposure limit value (ELV). The EAV is a daily amount of vibration exposure above which employers are required to take action to control exposure. The greater the exposure level, the greater the risk and the more action employers will need to take to reduce the risk. For HAV the EAV is a daily exposure of 2.5 m/s2 A(8). On the other hand the ELV is the maximum amount of vibration an employee may be exposed to on any single day. For HAV the ELV is a daily exposure of 5 m/s2 A(8). It represents a high risk above which employees should not be exposed. At the end of the 90s around 288,000 people were estimated to have Vibration White Finger (VWF).
For HSE's part it may help if I outline a little of what's been put in place to help tackle HAVS. Obviously we have a legal role to play but at the highest level we have a programme of activities, in partnership with leading stakeholders, aimed at:
- Seeking 90% compliance by 2010 with the exposure limit values for HAV set out in the Control of Vibration at Work 2005 Regulations
- Controlling new cases of HAVS (as an occupational disease) sufficiently to enable workers to remain at work without disability by 2015
Additionally we are continuing to work with supplier stakeholders, e.g. machinery and equipment manufacturers, to help and influence them in developing HAV control technology in their products and in providing sufficient information to enable employers to carry out their risk assessments.
We will also continue to:
- Write to key manufacturers and suppliers of powered hand-tools in target sectors to raise awareness of their duties under the Supply of Machinery (Safety) Regulations 1992 as amended and employers' duties under the 2005 Regulations
- Inspect a range of suppliers of powered hand-tools to ascertain, for example, the extent to which they supply information to enable the machine to be used safely or take steps to minimise HAV at source in the design of their products
- Report on the level of compliance with supply legislation in the manufacturers and suppliers visited
Working with frontline stakeholders, e.g. construction, heavy fabrication and foundries, we will continue to focus on the development and take up of reasonably practicable controls for HAV. We have already identified high vibration processes for which there are alternatives, but wish to work with industry to help develop the next generation of controls. Here we will be aiming to:
- Develop, promote and enforce reasonably practicable control options in the targeted sectors
- Deliver improvements in the level and quality of occupational health surveillance for HAVS
- Work with industry to foster good practice and identify further reasonably practicable controls
Regulations to prevent and reduce the risks
Basically the Control of Vibration at Work Regulations require employers to prevent or reduce risks to health and safety from exposure to vibration at work, including:
- Assessing the vibration risk to employees
- Taking action to reduce vibration exposure that produces those risks
Deciding if employees are likely to be exposed above the:
- Daily EAV and if they are: introduce a programme of controls to eliminate risk, or reduce exposure to as low a level as is reasonably practicable
- Daily ELV and if they are: take immediate action to reduce their exposure below the limit value
- Making sure the legal limits on vibration exposure are not exceeded
- Providing information and training to employees on health risks and the actions being taken to control those risks
- Carrying out health surveillance (regular health checks) where there is a risk to health
- Consulting trade union safety representatives or employee representatives on proposals to control risk and to provide health surveillance
- Keeping a record of the risk assessment and control actions
- Keeping health records for employees under health surveillance
- Reviewing and updating the risk assessment regularly
Safeguarding employees through health surveillance
Health surveillance is about having procedures to detect work-related ill health at an early stage and acting on the results. The main aims are to safeguard the health of employees (including identifying and protecting people at increased risk), and also to check the long-term effectiveness of control measures. In the case of hand-arm vibration, one of the specific aims is to prevent employees developing an advanced stage of hand-arm vibration syndrome (HAVS) associated with disabling loss of hand function. It is possible that employees who are exposed to vibration may have mild symptoms of HAVS. If they are not aware that they have the disease, health surveillance can help them to recognise that the first symptoms of HAVS have started to develop.
The symptoms of HAVS include:
- Numbness and tingling in the fingers, and a reduced sense of touch and temperature, due to damage to nerves in the hand. This damage can make it difficult to feel, and to work with, small objects
- Periodic attacks during which the blood circulation in the fingers is impaired and parts of the fingers become white (blanched). This is sometimes known as 'vibration white finger', 'dead finger' or 'dead hand'. During these attacks the fingers feel numb. As blood circulation returns to normal, either by itself or after rewarming the fingers, they are typically throbbing, red and painful. Although vibration causes the condition, it does not bring on the attacks. The main trigger for these symptoms is exposure to the cold, e.g. being outdoors early on a winter's morning, or by localised or general body cooling in otherwise warm environments. Rarely, in very advanced cases, blood circulation may be permanently affected.
- Joint pain and stiffness in the hand and arm
- Grip strength can be reduced due to nerve and muscle damage
An individual employee with HAVS may not experience the complete range of symptoms, e.g. there may be nerve damage symptoms without there being blood circulation problems and vice versa. The symptoms of HAVS are usually progressive as exposure to vibration continues, e.g. the effects on blood circulation are seen initially in the tips of the affected fingers, with changes spreading up the finger. The thumb may also be affected. Carpal tunnel syndrome, a disorder of the hand and arm, which may involve tingling, numbness, pain and weakness in parts of the hand, can also be caused by exposure to vibration.
Employees suffering from HAVS can experience difficulty in carrying out tasks in the workplace involving fine work or manipulative work and are less able to work in cold conditions. The disease may have an impact on earnings and on social and family life. Everyday tasks may become difficult, e.g. fastening small buttons on clothes. Attacks of 'white finger' will take place not only at work, but during other activities, especially if people get cold, such as when washing the car or watching outdoor sports. The damage to the hands may be irreversible.
After symptoms first appear, generally the longer an employee is exposed to vibration, the worse the symptoms become, although the rate of deterioration will vary from person to person. How much symptoms may improve when people are no longer exposed to vibration is not well understood, but it is thought that nerve damage does not recover after exposure stops. The effects on blood circulation may improve after reducing or stopping vibration exposure in people below about 45 years old and when the disease has not yet reached the advanced stage associated with disability. Any improvement will be slow, taking several years and smoking may also slow down recovery.
Health surveillance should be provided for vibration-exposed employees who:
- Are likely to be regularly exposed above the action value of 2.5 m/s2 A(8)
- Are likely to be exposed occasionally above the action value and where the risk assessment identifies that the frequency and severity of exposure may pose a risk to health
- Have a diagnosis of HAVS (even when exposed below the action value)
For the self-employed there is no legal requirement to have health surveillance for HAVS. However, it is important for their well-being, and for their ability to remain in work, that they identify any early signs of HAVS and take appropriate action. It is therefore recommended that they follow this guidance if they think they are at risk from vibration.
Employers need to ensure that they achieve an effective health surveillance programme in the workplace, including co-operation from employees. When they plan to introduce health surveillance, employers should explain to their employees and their safety or employee representatives what they are proposing to do and give them the opportunity to comment on their proposals. Employees need to be given information about the reasons for carrying out health surveillance and they need to understand their roles and responsibilities.
A simple approach to health surveillance involves working through a number of stages. Briefly, this 'tiered' system works as follows:
- Tier 1 is a short questionnaire (initial screening questionnaire) used as a first check for people moving into jobs involving exposure to vibration. The replies to the questionnaire will indicate whether they need to be referred to Tier 3 for a HAVS health assessment
- Tier 2 is a short questionnaire (annual screening questionnaire) that can be issued once a year to employees exposed to vibration risks to check whether they need to be referred to Tier 3 for a HAVS health assessment
- Tier 3 involves a HAVS health assessment by a qualified person (e.g. an occupational health nurse). If the assessment shows that the employee has HAVS, the employee Tier 4 will apply
- Tier 4 involves a formal diagnosis and is carried out by a doctor qualified in occupational health. The doctor will advise employers on the employee's fitness for work
- Tier 5 is optional and involves referral of the employee for certain tests for HAVS. The results may help the doctor assess fitness for work
It may help employers keep costs down if they adopt this approach. If they have any positive responses at Tier 1 or 2 which means moving on to Tier 3, they will need to use qualified occupational health professionals but it is not necessary for each employee to be referred to them. In this tiered approach, most appointments with specialists are limited to cases where symptoms that may be suggestive of HAVS have been reported.
It is useful to appoint a 'responsible person' as part of the health surveillance programme (Tier 2) to help explain to the employees how the simple screening questionnaire operates. This person:
- Should be carefully selected to have experience of the working environment and be able to gain the confidence and co-operation of employees
- Need not be qualified but should have received training from an occupational health professional
- Should understand the health surveillance procedures and the importance of confidentiality
- Should be able to describe to the employee the symptoms of HAVS but should not attempt to diagnose disease
- Should not make judgements about the cause of the symptoms if an employee discloses that they have symptoms
Completed questionnaires could be sorted, and referrals handled in house, by the responsible person, as long as this is acceptable to employees. However, it may be appropriate for the questionnaires to be treated as confidential and returned to suitably competent health professionals. In the first instance, any employee reporting symptoms should be referred to a 'qualified person' (usually an occupational health nurse) for clinical assessment (Tier 3). The qualified person can make an informed assessment of the nature of reported symptoms on the basis of a confidential interview and limited medical examination. A formal diagnosis of HAVS should only be made by a competent doctor (Tier 4). An employee with HAVS should be reassessed at regular intervals and may need additional investigations in order to detect any progression of the disease.
Employers should make sure that nurses and doctors offering to carry out health surveillance have appropriate qualifications and training and will provide them with appropriate information. If there is a lack of competence, mistakes have the potential for serious consequences for them and the employees.
Appropriate occupational health qualifications for health surveillance of HAVS are:
- For doctors: Diploma, Associateship or Membership of the Faculty of Occupational Medicine (DipOm, AFOM, MFOM)
- For nurses - Diploma or Degree in Occupational Health or MSc
- Certification for both doctors and nurses from a Faculty of Occupational Medicine approved training course in HAV
An employee found to have HAVS should be informed of this by an appropriate health professional. Employers can be told about an individual employee being diagnosed with HAVS, as long as the employee gives their consent. They may receive advice about any recommended restrictions that relate to the employee's job. Even if the individual does not give consent for medical information to be passed on, employers should receive advice on fitness for work with exposure to vibration for each employee, undergoing health surveillance. They should also expect to obtain anonymised information, e.g. for groups of employees.
Additionally they will need to make a decision about an individual employee if the doctor advises that they are not fit for work with exposure to vibration. The employee is at risk of developing disabling loss of hand function if exposure is allowed to continue. Employers should consider assigning the employee to alternative work where there is no risk from further exposure to vibration.
If an employer is informed that an employee has been diagnosed with HAVS but is still fit for work with exposure to vibration, it is good practice for them to consider taking further action to reduce that employee's exposure. Health surveillance results should be used to check the long-term effectiveness of the control measures. If the number of employees with HAVS has increased, or if the disease is progressing in affected individuals, they will need to review their risk assessment and action plan.
If no symptoms are reported on the screening questionnaire, there is no need to refer the employee for further assessment, but they should complete the simple questionnaire again on an annual basis (Tier 2). HSE recommends that after three years of a vibration-exposed employee reporting no symptoms they should be referred for a consultation with an occupational health nurse to provide an opportunity to explore more fully any possible symptoms that the individual may have overlooked.
Employers should keep a health record for each individual for as long as they are under health surveillance, although they may wish to retain it for longer. It is good practice to offer individual employees a copy of their health records when they leave employment, if a business should cease trading or the employee ceases to be exposed to vibration. The record should be kept up to date and should include:
- Identification details of the employee
- The employee's history of exposure to vibration
- The outcome of previous health surveillance in terms of fitness for work, and any restrictions required
- The Tier 1 and Tier 2 questionnaire results (as long as they are not confidential) even if an employee has said they have no symptoms
Health records should not contain personal medical information, which must be kept in confidence in the medical record held by the occupational health professional. The enforcing authority is entitled to ask to see the health records as part of their checks that employers are complying with the Vibration Regulations.
Employers could ask an occupational health service provider to provide a complete service on their behalf. They should be able to:
- Advise on a suitable health surveillance programme for employees
- Set up the programme
- Provide the necessary training and supervision for staff if they are going to help with the basic health surveillance
- Provide suitably qualified and experienced staff to carry out Tiers 3, 4 and 5 of the health surveillance
- Provide reports on employees' fitness to continue work with vibration exposure
The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR) place a duty on employers to report any cases of HAVS arising from certain work activities or of carpal tunnel syndrome associated with exposure to vibration. The duty comes into effect when employers receive a formal written diagnosis from a doctor confirming that the employee has either of these conditions and that there is reason to believe that the disease is likely to have an occupational origin. Before reporting HAVS to the Incident Contact Centre (Tel: 0845 300 9923 or http://www.riddor.gov.uk/), they should check that the employee is currently doing a job involving one of the specific activities listed in Schedule 3 of RIDDOR. They are also required to keep details of any report they make for at least three years.
HSE and its partners have come a long way since 1974. Understandably there have been highs and lows but we've always known that there would be challenges. We are getting there but we still need help, help to reach those who appear to have slipped beneath the health and safety radar. And perhaps thats where you play a part by spreading the word - spreading the word that HSE's websites, and its vibration websites in particular, have a considerable amount of information and guidance that's absolutely free of charge.
Author Details:
Colin ChattenHealth & Safety Executive
Noise & Vibration Policy Unit5S.1, Redgrave Court, Merton Road, Bootle, L20 7HSwww.hse.gov.uk
