Part II: Medical surveillance program requirements for individual designated substances

Asbestos

Medical examinations – General

With respect to the medical examinations required under subsection 20(4) of O. Reg. 490/09, the medical examinations for workers exposed to asbestos shall be carried out:

1. Prior to placement.
2. Periodically, as follows, while exposed:
   • At least once every five years, beginning 10 years after first exposure with any employer, or
   • More frequently, if required by the examining physician.
3. Upon exiting placement, as follows:
   • Medical examinations are required for workers with more than 10 years of exposure, unless the most recent medical examination was performed within the last 12 months^{footnote 2[2]}.

Pre-placement medical examinations

Pre-placement medical examinations shall include:

1. Initial medical and occupational history including:
   • Previous exposure (both occupational and non-occupational) to asbestos, including timeframe of first exposure to asbestos with any employer.
   • History of past or present respiratory disorders.
   • Personal habits (e.g. smoking and hygiene).

   Note: The administration of a respiratory questionnaire is recommended.

2. A physical examination focusing on the respiratory system.
3. Provision of health information consistent with paragraph 1 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for asbestos in accordance with this Code.

Periodic medical examinations

Periodic medical examinations shall include:

Note: The administration of a respiratory questionnaire is recommended.

1. Updating of a worker’s medical and occupational history including:
   • Frequency and duration of exposure to asbestos since previous examination;
   • Enquiry for signs and symptoms that may be an early indication of:
     • Asbestosis (e.g. exertional dyspnea, new or worsening cough),
     • Malignancy (e.g. new or worsening cough, hemoptysis, pleuritic pain, weight loss).
   • Personal habits (e.g. smoking and hygiene).
2. A physical examination focusing on the respiratory system, if clinically warranted.
3. Provision of health information consistent with paragraph 1 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for asbestos in accordance with this Code.

Exit medical examinations

Exit medical examinations shall include:

Note: The administration of a respiratory questionnaire is recommended.

1. Updating of a worker’s medical and occupational history including:
   • Frequency and duration of exposure to asbestos since previous examination;
   • Enquiry for signs and symptoms that may be an early indication of
     • Asbestosis (e.g. exertional dyspnea, new or worsening cough).
     • Malignancy (e.g. new or worsening cough, hemoptysis, pleuritic pain, weight loss).
   • Personal habits (e.g. smoking and hygiene).
2. A physical examination focusing on the respiratory system, if clinically warranted.
3. Provision of health information consistent with paragraph 2 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for asbestos in accordance with this Code.

Clinical tests for asbestos

Types

The following clinical tests are required for pre-placement, periodic and exit medical examinations with respect to exposure to asbestos:

It is recommended that the chest radiographs be read by a physician certified by the Royal College of Physicians and Surgeons of Canada (RCPSC), and educated and experienced in the practice of reading chest radiographs.

Note: To avoid unnecessary X-rays, the examining physician shall, where practical, obtain the relevant medical records from another facility if the worker has been previously examined within the past year. It is recommended that chest radiographs obtained be re-read based on the potential exposure to asbestos, if required.

Note: All relevant data shall be corrected to body temperature and pressure (BTPS).

1. Imaging: Chest Radiograph (postero-anterior) (PA)
2. Pulmonary Function Tests (PFT)^{footnote 3[3]}, (to be taken in conjunction with chest radiograph):
   • FEV1, FVC, FEV1/FVC ratio

Frequency

Chest radiograph and PFT, to be done every 5 years after 10 years of exposure or as required by the examining physician.

Action levels/Removal from exposure criteria

There are no specific action levels/removal from exposure criteria.

An assessment of a worker’s fitness to continue working in exposure to asbestos is based on the results of the medical examination in conjunction with the results of the clinical tests. If the examining physician determines that the worker is fit with limitations or unfit, the physician shall take action in accordance with section 29 of O. Reg. 490/09.

Where the examining physician determines that the signs of asbestos-induced disease are present, the examining physician should consider whether the worker should be referred to a respirologist or other knowledgeable specialist educated and experienced in the practice of evaluating work-related lung diseases for further medical assessment.

Return to work in exposure to asbestos criteria

A worker’s return to work in exposure to asbestos is to be decided on a case by case basis by the examining physician, in consultation with a respirologist or other knowledgeable specialist educated and experienced in the practice of evaluating work-related lung diseases, if any, and after careful review of sources of exposure and protective measures in the workplace to ensure worker exposure to asbestos is minimized and within acceptable levels.

Benzene

Medical examinations – General

With respect to the medical examinations required under subsection 20(4) of O. Reg. 490/09, the medical examinations for workers exposed to benzene shall be carried out:

1. Prior to placement.
2. Periodically, as follows:
   • Annually, or
   • More frequently, if required by the examining physician.
3. In the event of an acute exposure requiring immediate medical attention.
4. Upon exiting placement, unless the most recent medical examination was performed within the last 6 months^{footnote 4[4]}.

Pre-placement medical examinations

Pre-placement medical examinations shall include:

1. Initial medical and occupational history including:
   • Previous exposure (both occupational and non-occupational) to:
     • Benzene and other hematological toxins
     • Toluene
     • Ionizing radiation
     • Chemotherapy
   • Personal history of blood or bone marrow disorders including:
     • Genetic hemoglobin abnormalities
     • Bleeding abnormalities
     • Abnormal function of formed blood elements
   • History of renal or liver dysfunction, neurological or dermatologic disorders.
   • Medication use, personal habits (e.g. smoking, alcohol consumption).
   • Family history of blood or bone marrow disorders including hematologic neoplasms.
2. A physical examination focusing on the systems affected by benzene, including the hematologic system.
3. Provision of health information consistent with paragraph 1 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for benzene in accordance with this Code.

Periodic medical examinations

Periodic medical examinations shall include:

1. Updating of a worker’s medical and occupational history including:
   • New exposures to potential marrow toxins.
   • Frequency and duration of exposure to benzene since previous examination.
   • Changes in medication, personal habits.
   • The appearance of signs or symptoms related to blood disorders.
   • Enquiry for symptoms consistent with benzene exposure which may precede or follow clinical signs, including:
     • Headache
     • Dizziness
     • Loss of appetite/nausea
     • Shortness of breath
     • Excessive tiredness
2. A physical examination focusing on the systems affected by benzene, including the hematologic system, if clinically warranted.
3. Provision of health information consistent with paragraph 1 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for benzene in accordance with this Code.

Acute exposure medical examinations

Medical examinations carried out in the event of an acute exposure to benzene shall include:

1. Enquiry for symptoms consistent with benzene exposure, including:
   • Headache
   • Dizziness
   • Loss of appetite/nausea
   • Shortness of breath
   • Excessive tiredness
2. A physical examination focusing on the systems affected by benzene, including the hematologic system, if clinically warranted.
3. Clinical tests for benzene in accordance with this Code.

Exit medical examinations

Exit medical examinations shall include:

1. Updating of a worker’s medical and occupational history including:
   • New exposures to potential marrow toxins.
   • Frequency and duration of exposure to benzene since previous examination.
   • Changes in medication, personal habits.
   • The appearance of signs or symptoms related to blood disorders.
   • Enquiry for symptoms consistent with benzene exposure which may precede or follow clinical signs including:
     • Headache
     • Dizziness
     • Loss of appetite/nausea
     • Shortness of breath
     • Excessive tiredness
2. A physical examination focusing on the systems affected by benzene, including the hematologic system, if clinically warranted.
3. Provision of health information consistent with paragraph 2 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for benzene in accordance with this Code.

Clinical tests for benzene

Types

The following clinical tests are required for pre-placement, periodic, acute exposure and exit medical examinations with respect to exposure to benzene:

Pre-placement medical examinations

1. A complete blood count (CBC) including: hemoglobin, hematocrit, erythrocyte count and erythrocyte indices [mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC)], leucocyte count with differential, band neutrophils (if present) and thrombocyte (platelet) count.

Periodic medical examinations

1. S-Phenylmercapturic acid (S-PMA) in urine collected at the end of a work shift.
   • In scheduling S-PMA tests, it should be understood that workers are to provide urine samples at the end of a work shift representative of typical exposures.

Acute exposure medical examinations

1. S-Phenylmercapturic acid (S-PMA) in urine.

Exit medical examinations

1. A complete blood count (CBC) including: hemoglobin, hematocrit, erythrocyte count and erythrocyte indices [mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC)], leucocyte count with differential, band neutrophils (if present) and thrombocyte (platelet) count.

Frequency

Periodic medical examinations

S-PMA, in urine collected at end of a work shift to be done annually or more frequently as required by the examining physician.

1. Levels below 25 µg/g creatinine S-PMA in urine require no additional testing.
2. Levels at or above 25 µg/g creatinine S-PMA in urine require a complete blood count (CBC) test as soon as practicable and monthly for 3 months following the exposure, except as specified in^{footnote 5[5]}Note below or more frequently as required by the examining physician.

Acute exposure medical examinations

Tests for S-Phenylmercapturic acid (S-PMA) in urine, as follows:

1. Levels below 25 µg/g creatinine S-PMA in urine require no additional testing.
2. Levels at or above 25 µg/g creatinine S-PMA in urine require a complete blood count (CBC) test as soon as practicable and monthly for 3 months following the exposure, except as specified in the note below ^{footnote 6[6]} or more frequently as required by the examining physician.

Action levels/Removal from exposure criteria

An assessment of a worker’s fitness to continue working in exposure to benzene is based on the results of the medical examination in conjunction with the results of the clinical tests. If the examining physician determines that the worker is fit with limitations or unfit, the physician shall take action in accordance with section 29 of O. Reg. 490/09.

Levels of S-Phenylmercapturic acid (S-PMA) in urine at or above 25 μg/g creatinine trigger the review of engineering controls, work practices, worker health status and personal hygiene practice.

1. Review level:
2. Removal from exposure criteria:
   1. Signs or symptoms consistent with benzene exposure.
   2. Abnormalities on biological monitoring with persistent abnormalities on repeat CBC testing at two weeks.

Upon removal, the worker should be referred to a hematologist or other knowledgeable specialist educated and experienced in the practice of evaluating work-related blood disorders, for further medical investigation where there are persistent abnormalities in CBC.

Return to work in exposure to benzene criteria

A worker’s return to work in exposure to benzene is to be decided on a case by case basis by the examining physician in consultation with a hematologist, or other knowledgeable specialist educated and experienced in the practice of evaluating work-related blood disorders, if any, and after careful review of sources of exposure and implementation of protective measures in the workplace to ensure worker exposure to benzene is minimized and within acceptable levels.

Coke oven emissions

Medical examinations – General

With respect to the medical examinations required under subsection 20(4) of O. Reg. 490/09, the medical examinations for workers exposed to coke oven emissions shall be carried out:

1. Prior to placement.
2. Periodically, as follows, while exposed:
   • At least once every five years, beginning 10 years after first exposure with any employer, or
   • More frequently, if required by the examining physician.
3. Upon exiting placement, as follows:
   • Medical examinations are required for workers with more than 10 years of exposure, unless the most recent medical examination was performed within the last 12 months^{footnote 7[7]}.

Pre-placement medical examinations

Pre-placement medical examinations shall include:

1. Initial medical and occupational history including:
   • Previous exposure to coke oven emissions, including timeframe of first exposure to coke oven emissions with any employer.
   • History of past or present respiratory or dermatologic disorders.
   • Personal habits (e.g. smoking and hygiene).

   Note: The administration of a respiratory questionnaire is recommended.

2. A physical examination focusing on the respiratory and dermatologic systems.
3. Provision of health information consistent with paragraph 1 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for coke oven emissions in accordance with this Code.

Periodic medical examinations

Periodic medical examinations shall include:

Note: The administration of a respiratory questionnaire is recommended.

1. Updating of a worker’s medical and occupational history including:
   • Frequency and duration of exposure to coke oven emissions since previous examination;
   • Enquiry for signs and symptoms that may be an early indication of:
     • Respiratory disorders, including malignancy and chronic bronchitis (e.g. new or worsening cough, shortness of breath, hemoptysis, pleuritic pain, weight loss).
     • Dermatologic disorders, including malignancy.
   • Personal habits (e.g. smoking and hygiene).
2. A physical examination focusing on the respiratory and dermatologic systems, if clinically warranted.
3. Provision of health information consistent with paragraph 1 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for coke oven emissions in accordance with this Code.

Exit medical examinations

Exit medical examinations shall include:

Note: The administration of a respiratory questionnaire is recommended.

1. Updating of a worker’s medical and occupational history including:
   • Frequency and duration of exposure to coke oven emissions since previous examination;
   • Enquiry for signs and symptoms that may be an early indication of:
     • Respiratory disorders, including malignancy and chronic bronchitis (e.g. new or worsening cough, shortness of breath, hemoptysis, pleuritic pain, weight loss).
   • Personal habits (e.g. smoking and hygiene).
2. A physical examination focusing on the respiratory and dermatologic systems, if clinically warranted.
3. Provision of health information consistent with paragraph 2 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for coke oven emissions in accordance with this Code.

Clinical tests for coke oven emissions

Types

The following clinical tests are required for pre-placement, periodic and exit medical examinations with respect to exposure to coke oven emissions:

It is recommended that the chest radiographs be read by a physician certified by the Royal College of Physicians and Surgeons of Canada (RCPSC), and educated and experienced in the practice of reading chest radiographs.

Note: To avoid unnecessary X-rays, the examining physician shall, where practical, obtain the relevant medical records from another facility if the worker has been previously examined within the past year. It is recommended that chest radiographs obtained be re-read based on the potential exposure to coke oven emissions, if required.

Note: All relevant data shall be corrected to body temperature and pressure (BTPS).

1. Imaging: Chest Radiograph (postero-anterior) (PA)
2. Pulmonary Function Tests (PFT)^{footnote 8[8]}, (to be taken in conjunction with chest radiograph):

Frequency

Chest radiograph and PFT, to be done every 5 years after 10 years of exposure or as required by the examining physician.

Action levels/Removal from exposure criteria

There are no specific action levels/removal from exposure criteria.

An assessment of a worker’s fitness to continue working in exposure to coke oven emissions is based on the results of the medical examination in conjunction with the results of the clinical tests. If the examining physician determines that the worker is fit with limitations or unfit, the physician shall take action in accordance with section 29 of O. Reg. 490/09.

Where the examining physician determines that the signs of coke oven emissions-induced disease are present, the examining physician should consider whether the worker should be referred to a respirologist, dermatologist or other knowledgeable specialist educated and experienced in the practice of evaluating work-related lung or skin diseases for further medical assessment.

Return to work in exposure to coke oven emissions criteria

A worker’s return to work in exposure to coke oven emissions is to be decided on a case by case basis by the examining physician, in consultation with a respirologist, dermatologist or other knowledgeable specialist educated and experienced in the practice of evaluating work-related lung or skin diseases, if any, and after careful review of sources of exposure and protective measures in the workplace to ensure worker exposure to coke oven emissions is minimized and within acceptable levels.

Isocyanates

Medical examinations – General

With respect to the medical examinations required under subsection 20(4) of O. Reg. 490/09, the medical examinations for workers exposed to isocyanates shall be carried out:

1. Prior to placement.
2. Periodically, as follows:
   • At 6 month intervals for the first two years.
   • Annually thereafter or more frequently, if required by the examining physician.
3. In the event of an acute exposure requiring immediate medical attention.
4. Upon exiting placement unless the most recent medical examination was performed within the last 6 months^{footnote 9[9]}.

Pre-placement medical examinations

Pre-placement medical examinations shall include:

Note: The administration of a respiratory questionnaire is recommended.

1. Initial medical and occupational history including:
   • Previous exposure (both occupational and non-occupational) to isocyanates.
   • History of past or present respiratory or dermatologic disorders (e.g. allergies, asthma, skin rashes).
2. A physical examination focusing on the systems affected by isocyanates, including the respiratory and dermatologic systems.
3. Provision of health information consistent with paragraph 1 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for isocyanates in accordance with this Code.

Periodic medical examinations

Periodic medical examinations shall include:

Note: The administration of a respiratory questionnaire is recommended.

1. Updating of a worker’s medical and occupational history including:
   • A history of frequency and duration of exposure to isocyanates since previous examination.
   • Enquiry for signs and symptoms of respiratory problems and skin rashes, particularly on hands and face.
2. A physical examination, focusing on the systems affected by isocyanates, including the respiratory and dermatologic systems, if clinically warranted.
3. Provision of health information consistent with paragraph 1 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for isocyanates in accordance with this Code.

Acute exposure medical examinations

Medical examinations carried out in the event of an acute exposure to isocyanates shall include:

1. Enquiry for signs and symptoms of respiratory problems and skin rashes, particularly on hands and face.
2. A physical examination focusing on the systems affected by isocyanates, including the respiratory and dermatologic systems, if clinically warranted.
3. Clinical tests for isocyanates in accordance with this Code.

If respiratory or dermatologic symptoms persist, the worker should be referred to a respirologist, dermatologist or other knowledgeable specialist educated and experienced in the practice of evaluating work-related lung or skin diseases for further medical assessment.

Exit medical examinations

Exit medical examinations shall include:

Note: The administration of a respiratory questionnaire is recommended.

1. Updating of a worker’s medical and occupational history including:
   • A history of frequency and duration of exposure to isocyanates since previous examination.
   • Enquiry for signs and symptoms of respiratory problems and skin rashes, particularly on hands and face.
2. A physical examination focusing on the systems affected by isocyanates, including the respiratory and dermatologic systems, if clinically warranted.
3. Provision of health information consistent with paragraph 2 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for isocyanates in accordance with this Code.

Clinical tests for isocyanates

Types

The following clinical tests are required for pre-placement, periodic, acute exposure and exit medical examinations with respect to exposure to isocyanates:

1. Pulmonary function tests (PFT)^{footnote 10[10]}:

   Note: All relevant data shall be corrected to body temperature and pressure (BTPS).

   • FEV1, FVC and FEV1/FVC ratio

Frequency

1. Every 6 months for the first two years,
2. Annually thereafter, or as required by the examining physician.

Action levels/Removal from exposure criteria

As long as their condition is stable, a worker should not be removed from exposure pending further medical assessment to confirm a medical condition resulting from exposure to isocyanates. Removal from isocyanates exposure may present a barrier to diagnosis and determination of work restrictions.

An assessment of a worker’s fitness to continue working in exposure to isocyanates is based on the results of the medical examination in conjunction with the results of the clinical tests. If the examining physician determines that the worker is fit with limitations or unfit, the physician shall take action in accordance with section 29 of O. Reg. 490/09.

Individuals with respiratory symptoms and/or changes in pulmonary function testing (15% or greater fall in FEV1 from baseline) should be referred to a respirologist or other knowledgeable specialist educated and experienced in the practice of evaluating work-related lung diseases, for further medical assessment.

Return to work in exposure to isocyanates

Individuals who are determined to have respiratory or dermatologic sensitization to isocyanates should not have any subsequent exposure to isocyanates.

Lead

A. Inorganic lead

Medical examinations – General

With respect to the medical examinations required under subsection 20(4) of O. Reg. 490/09, the medical examinations for workers exposed to inorganic lead shall be carried out:

1. Prior to placement.
2. Periodically, as follows:
   • Annually or more frequently if required by the examining physician.
3. In the event of an acute exposure requiring immediate medical attention.
4. Upon exiting placement unless the most recent medical examination was performed within the last 6 months^{footnote 11[11]}.

Pre-placement medical examinations

Pre-placement medical examinations shall include:

1. Initial medical and occupational history including:

   Note: Potential non-occupational sources of inorganic lead may include but are not limited to: leaded paint and leaded pipes in the home, handling of munitions and firearm usage and some unlicensed imported medications/herbal products.

   • Previous exposure (both occupational and non-occupational) to inorganic lead.
   • Enquiry for signs and symptoms consistent with exposure to inorganic lead focusing on:
     • Gastrointestinal
     • Nervous
     • Musculoskeletal
     • Hematologic, and
     • Renal systems.
   • Personal habits (e.g. smoking and hygiene).
2. A physical examination focusing on the systems affected by inorganic lead including:
   • Gastrointestinal
   • Nervous
   • Musculoskeletal
   • Hematologic, and
   • Renal systems.
3. Provision of health information consistent with paragraph 1 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for inorganic lead in accordance with this Code.

Periodic medical examinations

Periodic medical examinations shall include:

1. Updating of a worker’s medical and occupational history including:
   • Frequency and duration of exposure to inorganic lead since previous examination.
   • Enquiry for signs and symptoms consistent with exposure to inorganic lead focusing on:
     • Gastrointestinal
     • Nervous
     • Musculoskeletal
     • Hematologic, and
     • Renal systems.
   • Personal habits (e.g. smoking and hygiene).
2. A physical examination, if clinically warranted, focusing on the systems affected by inorganic lead including:
   • Gastrointestinal
   • Nervous
   • Musculoskeletal
   • Hematologic, and
   • Renal systems.
3. Provision of health information consistent with paragraph 1 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for inorganic lead in accordance with this Code.

Acute exposure medical examinations

A medical examination carried out in the event of an acute exposure to inorganic lead shall include:

1. Enquiry for signs and symptoms consistent with exposure to inorganic lead focusing on:
   • Gastrointestinal
   • Nervous
   • Musculoskeletal
   • Hematologic, and
   • Renal systems.
2. A physical examination, if clinically warranted, focusing on the systems affected by inorganic lead including:
   • Gastrointestinal
   • Nervous
   • Musculoskeletal
   • Hematologic, and
   • Renal systems.
3. Clinical tests for inorganic lead in accordance with this Code.

Exit medical examinations

Exit medical examinations shall include:

1. Updating of a worker’s medical and occupational history including:
   • Frequency and duration of exposure to inorganic lead since previous examination.
   • Enquiry for signs and symptoms consistent with exposure to inorganic lead focusing on:
     • Gastrointestinal
     • Nervous
     • Musculoskeletal
     • Hematologic, and
     • Renal systems.
   • Personal habits (e.g. smoking and hygiene).
2. A physical examination, if clinically warranted, focusing on the systems affected by inorganic lead including:
   • Gastrointestinal
   • Nervous
   • Musculoskeletal
   • Hematologic, and
   • Renal systems.
3. Provision of health information consistent with paragraph 2 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for inorganic lead in accordance with this Code.

Clinical tests for inorganic lead

Important: For workers working in exposure to inorganic lead prior to January 1, 2020 and with a blood lead level exceeding the “Action Levels/Removal from Exposure Criteria” set out in this Code, please see section “Conditional Phase-In Period* for Workers Participating in a Medical Surveillance Program for Inorganic Lead Prior to January 1, 2020.

Types

The following clinical tests are required for pre-placement, periodic, acute exposure and exit medical examinations with respect to exposure to inorganic lead:

1. Blood lead level

Frequency

1. At a minimum, every 4 months for the first 12 months, following testing in relation to pre-placement medical examinations to address potential exposures through hygiene and work practices.
2. Monthly for blood lead level > 1 μmol /L.
3. Every 3 months for blood lead level 0.5 μmol/L - 1 μmol/L.
4. Every 6 months for blood lead level < 0.5 μmol/L.

Note: The above schedule for blood lead level testing may be inadequate for certain situations where the exposures are very high and/or highly variable. In these situations the examining physician should tailor the blood lead level testing schedule to address the special risks of different types of work and exposures.

Action levels/Removal from exposure criteria

An assessment of a worker’s fitness to continue working in exposure to inorganic lead is based on the results of the medical examination in conjunction with the results of the clinical tests. If the examining physician determines that the worker is fit with limitations or unfit, the physician shall take action in accordance with section 29 of O. Reg. 490/09.

1. Review levels:

   The blood lead action levels for initiating a review of engineering controls, work practices, health status, personal hygiene practices and non-occupational sources of lead are:

   • For general population of workers:
     • Blood lead level > 0.25 μmol/L increase from baseline, or
     • Blood lead level > 0.5 μmol/L (single measure - confirmed by immediate repeat testing).
   • For women who are pregnant or of childbearing potential:
     • Blood lead level > 0.25 μmol/L (single measure - confirmed by immediate repeat testing).
2. Removal from Exposure Criteria (confirmed occupational exposure):

   The levels for removal of the worker from exposure to inorganic lead are as follows:

   • For general population of workers:
     • Blood lead level > 1.0 μmol/L (two measures, one month apart), or
     • Blood lead level > 1.4 μmol/L (single measure – confirmed by immediate repeat testing).
   • For women who are pregnant or of childbearing potential:
     • Blood lead level > 0.5 μmol/L.

Return to work in exposure to inorganic lead criteria

• For general population of workers:
  • Blood lead level < 0.7μmol/L
• For women who are pregnant or of childbearing potential:
  • Blood lead level < 0.25 μmol/L

and after careful review of sources of exposure and implementation of protective measures in the workplace to ensure worker exposure to inorganic lead is minimized and within acceptable levels.

Conditional phase-in period^{footnote 12[12]} for workers participating in a medical surveillance program for inorganic lead prior to January 1, 2020

Workers participating in a medical surveillance program for inorganic lead prior to January 1, 2020 with a blood lead level (BLL) exceeding the “Action Levels/Removal from Exposure Criteria” for inorganic lead set out in this Code may, in consultation with their examining physician and subject to the following conditions and restrictions, consent to be monitored for exposure to inorganic lead above an established individual baseline BLL while their overall body burden of inorganic lead declines over time.

The following conditions and restrictions apply to conditional phase-in periods:

1. All conditional phase-in periods expire on January 1, 2025. Following this date, all workers participating in medical surveillance under this Code are subject to the “Action Levels/Removal from Exposure Criteria” set out on pages 26-27 of this Code.
2. Eligible workers must have been participating in a medical surveillance program for inorganic lead prior to January 1, 2020.
3. Sources of exposure to inorganic lead and protective measures in the workplace must be examined and assessed to ensure that a worker’s exposure to inorganic lead is minimized.
4. A worker’s baseline BLL must be established and based on testing carried out no earlier than 1 year prior to, and no later than 4 months following, the introduction of this Code. A worker with BLL testing falling outside this timeframe is not eligible for participation in a conditional phase-in period.
5. Frequency of clinical tests: BLL testing shall be carried out at least once every 4 months.
6. Removal from exposure to inorganic lead: The levels for removal of the worker from exposure to inorganic lead are as follows:
   1. Blood lead level > 1.9 µmol/L or > 0.25µmol/L increase from baseline BLL (single measure - confirmed by immediate repeat testing).
7. Return to work in exposure criteria:
   1. BLL ≤ baseline BLL, and
   2. Careful review of sources of exposure to inorganic lead and implementation of protective measures in the workplace to ensure worker exposure to inorganic lead is minimized.

B. Organic lead

Medical examinations – General

With respect to the medical examinations required under subsection 20(4) of O. Reg. 490/09, the medical examinations for workers exposed to organic lead shall be carried out:

1. Prior to placement.
2. Periodically as follows:
   • Annually or more frequently if required by the examining physician.
3. In the event of an acute exposure requiring immediate medical attention.
4. Upon exiting placement unless the most recent medical examination was performed within the last 6 months^{footnote 13[13]}.

Pre-placement medical examinations

Pre-placement medical examinations shall include:

Note: signs and symptoms of organic lead toxicity are different from inorganic lead toxicity.

1. Initial medical and occupational history including:
   • Previous exposure (both occupational and non-occupational) to organic lead.
   • Enquiry for potential mild manifestations of organic lead toxicity including:
     • Insomnia and nervous excitation
     • Nausea
     • Vomiting
     • Tremor
2. A physical examination focusing on the nervous system (e.g. looking for tremor, hyperreflexia, ataxia), the cardiovascular system (e.g. hypertension, bradycardia) and mental status.
3. Provision of health information consistent with paragraph 1 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for organic lead in accordance with this Code.

Periodic medical examinations

Periodic medical examinations shall include:

Note: signs and symptoms of organic lead toxicity are different from inorganic lead toxicity.

1. Updating of a worker’s medical and occupational history including:
   • Frequency and duration of exposure to organic lead since previous examination
   • Enquiry for potential mild manifestations of organic lead toxicity including:
     • Insomnia and nervous excitation
     • Nausea
     • Vomiting
     • Tremor
2. A physical examination, if clinically warranted, focusing on the nervous system (e.g. looking for tremor, hyperreflexia, ataxia), the cardiovascular system (e.g. hypertension, bradycardia) and mental status.
3. Provision of health information consistent with paragraph 1 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for organic lead in accordance with this Code.

Acute exposure medical examinations

A medical examination carried out in the event of an acute exposure to organic lead shall include:

Note: signs and symptoms of organic lead toxicity are different from inorganic lead toxicity.

1. Enquiry for potential mild manifestations of organic lead toxicity including:
   • Insomnia and nervous excitation
   • Nausea
   • Vomiting
   • Tremor
2. A physical examination, if clinically warranted, focusing on the nervous system (e.g. looking for tremor, hyperreflexia, ataxia), the cardiovascular system (e.g. hypertension, bradycardia) and mental status.
3. Clinical tests for organic lead in accordance with this Code.

Exit medical examinations

Exit medical examinations shall include:

Note: signs and symptoms of organic lead toxicity are different from inorganic lead toxicity.

1. Updating of a worker’s medical and occupational history including:
   • Frequency and duration of exposure to organic lead since previous examination.
   • Enquiry for potential mild manifestations of organic lead toxicity including:
     • Insomnia and nervous excitation
     • Nausea
     • Vomiting
     • Tremor
2. A physical examination, if clinically warranted, focusing on the nervous system (e.g. looking for tremor, hyperreflexia, ataxia), the cardiovascular system (e.g. hypertension, bradycardia) and mental status.
3. Provision of health information consistent with paragraph 2 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for organic lead as required by this Code.

Clinical tests for organic lead

Types

The following clinical tests are required for pre-placement, periodic, acute exposure and exit medical examinations with respect to exposure to organic lead:

1. Lead in urine sample^{footnote 14[14]}: Taken at the end of the work shift at the end of the work week (except in the case of acute exposure medical examinations).

Frequency

Lead in urine:

1. At a minimum, every 4 months during the first 12 months of placement following testing in relation to pre-placement medical examinations, to address potential exposures through hygiene and work practices.
2. Thereafter, annually or sooner if change in work practices or primary prevention measures.

Action levels/Removal from exposure criteria

An assessment of a worker’s fitness to continue working in exposure to organic lead is based on the results of the medical examination in conjunction with the results of the clinical tests. If the examining physician determines that the worker is fit with limitations or unfit, the physician shall take action in accordance with section 29 of O. Reg. 490/09.

The detection of lead in urine triggers the review of engineering controls, work practices, worker health status and personal hygiene practices.

1. Review Level:
2. Removal from Exposure Criteria:

   The level for removal of the worker from exposure to organic lead is as follows:

   • Lead in urine > 0.075 μmol/L (20μg/L).

Return to work in exposure to organic lead criteria

Return to work in exposure to organic lead is at the discretion of the examining physician after careful review of sources of exposure and implementation of protective measures in the workplace to ensure worker exposure to organic lead is minimized and within acceptable levels.

Mercury

A. Mercury and non-alkyl mercury compounds

Medical examinations – General

With respect to the medical examinations required under subsection 20(4) of O. Reg. 490/09, the medical examinations for workers exposed to mercury and non-alkyl mercury compounds shall be carried out:

1. Prior to placement.
2. Periodically, as follows:
   • Annually or more frequently, if required by the examining physician
3. In the event of an acute exposure requiring immediate medical attention.
4. Upon exiting placement unless the most recent medical examination was performed within the last 6 months^{footnote 15[15]}.

Pre-placement examinations

Pre-placement medical examinations shall include:

1. Initial medical and occupational history including:

   Note: Potential non-occupational sources of mercury and non-alkyl mercury compounds include recent dental amalgam procedures that may transiently elevate urinary mercury levels.

   • Previous exposure (both occupational and non-occupational) to mercury and non-alkyl mercury compounds.
   • Enquiry for signs and symptoms associated with exposure to mercury and non-alkyl mercury compounds focusing on:
     • Nervous
     • Renal
     • Respiratory, and
     • Dermatologic systems.
2. A physical examination focusing on the systems affected by mercury and non-alkyl mercury compounds including:
   • Nervous
   • Renal
   • Respiratory, and
   • Dermatologic systems.
3. Provision of health information consistent with paragraph 1 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for mercury and non-alkyl mercury compounds in accordance with this Code.

Periodic medical examinations

Periodic medical examinations shall include:

1. Updating of a worker’s medical and occupational history including:
   • Frequency and duration of exposure to mercury and non-alkyl mercury compounds since previous examination.
   • Enquiry for signs and symptoms associated with exposure to mercury and non-alkyl mercury compounds focusing on:
     • Nervous
     • Renal
     • Respiratory, and
     • Dermatologic systems.
2. A physical examination, if clinically warranted, focusing on the systems affected by mercury and non-alkyl mercury compounds including:
   • Nervous
   • Renal
   • Respiratory, and
   • Dermatologic systems.
3. Provision of health information consistent with paragraph 1 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for mercury and non-alkyl mercury in accordance with this Code.

Acute exposure medical examinations

A medical examination carried out in the event of an acute exposure to mercury or non-alkyl mercury compounds shall include:

1. Enquiry for signs and symptoms associated with exposure to mercury and non-alkyl mercury compounds focusing on:
   • Nervous
   • Renal
   • Respiratory, and
   • Dermatologic systems.
2. A physical examination, if clinically warranted, focusing on the systems affected by mercury and non-alkyl mercury compounds including:
   • Nervous
   • Renal
   • Respiratory, and
   • Dermatologic systems.
3. Clinical tests for mercury and non-alkyl mercury compounds in accordance with this Code.

Exit medical examinations

Exit medical examinations shall include:

1. Updating of a worker’s medical and occupational history including:
   • Frequency and duration of exposure to mercury and non-alkyl mercury compounds since previous examination.
   • Enquiry for signs and symptoms associated with exposure to mercury and non-alkyl mercury compounds focusing on:
     • Nervous
     • Renal
     • Respiratory, and
     • Dermatologic systems.
   • A physical examination, if clinically warranted, focusing on the systems affected by mercury and non-alkyl mercury compounds including:
     • Nervous
     • Renal
     • Respiratory, and
     • Dermatologic systems.
2. Provision of health information consistent with paragraph 2 of the Worker Health Information section in Part I of this Code.
3. Clinical tests for mercury and non-alkyl mercury compounds in accordance with this Code.

Clinical tests for mercury and non-alkyl mercury compounds

Types

The following clinical tests are required for pre-placement, periodic, acute exposure and exit medical examinations with respect to exposure to mercury and non-alkyl mercury compounds:

1. Spot urinary mercury test.

Frequency

1. At a minimum, every 4 months for the first 12 months following testing in relation to pre-placement medical examinations to address potential exposures through hygiene and work practices.
2. Annually thereafter or sooner if change in work practices or primary prevention measures.
3. Monthly or sooner if clinically indicated, for spot urinary mercury tests > 0.15 μmol/L or 0.03 mg/L. A positive test that is > 0.15 μmol/L should be validated with a 24 hour urinary mercury test.

Action levels/removal from exposure criteria

An assessment of a worker’s fitness to continue working in exposure to mercury and non-alkyl mercury compounds is based on the results of the medical examination in conjunction with the results of the clinical tests. If the examining physician determines that the worker is fit with limitations or unfit, the physician shall take action in accordance with section 29 of O. Reg. 490/09.

A spot urinary mercury test > 0.15 μmol/L or 0.03mg/L, confirmed with a 24 hour urinary mercury test, triggers the review of engineering controls, work practices, worker health status and personal hygiene practices.

The level for removal of the worker from exposure to mercury and non-alkyl mercury compounds is as follows: Spot urinary mercury test > 0.30 μmol/L or 0.06 mg/L, confirmed with a 24 hour urinary mercury test.

1. Review levels:
2. Removal from exposure criteria:

Return to work in exposure to mercury and non-alkyl mercury compounds criteria

Spot urinary mercury test ≤ 0.15 μmol/L or 0.03 mg/L and after careful review of sources of exposure and implementation of protective measures in the workplace to ensure worker exposure to mercury and non-alkyl mercury compounds is minimized and within acceptable levels.

B. Mercury (Alkyl compounds)

Medical examinations – General

With respect to the medical examinations required under subsection 20(4) of O. Reg. 490/09, the medical examinations for alkyl mercury compounds shall be carried out:

1. Prior to placement.
2. Periodically as follows:
   • Annually or more frequently, if required by the examining physician.
3. In the event of an acute exposure requiring immediate medical attention.
4. Upon exiting placement unless the most recent periodic medical examination was performed within the last 6 months^{footnote 16[16]}.

Pre-placement medical examinations

Pre-placement medical examinations shall include:

1. Initial medical and occupational history including:
   • Enquiry for dietary sources of alkyl mercury compounds with particular emphasis on the frequency, amount and types of seafood consumed.

     Note: Studies have shown that background exposure and variability in blood mercury level result primarily from methyl mercury in seafood. For example, a person who eats seafood:

     • Infrequently to occasionally, would be expected to have a blood mercury level of < 0.025 μmol/L;
     • Regularly up to 3 times per week, would be expected to result in blood mercury level in the range of 0.075 μmol/L;
     • With high mercury levels (e.g. certain fish species) greater than 3 times per week, would be expected to have a blood mercury level of 0.15 μmol/L – 0.25 μmol/L.
   • Enquiry for signs and symptoms associated with exposure to alkyl mercury compounds focusing on:
     • Nervous
     • Renal, and
     • Dermatologic systems.
2. A physical examination focusing on the systems affected by alkyl mercury compounds including:
   • Nervous
   • Renal, and
   • Dermatologic systems.
3. Provision of health information consistent with paragraph 1 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for alkyl mercury compounds in accordance with this Code.

Periodic medical examinations

The periodic medical examination shall include:

1. Updating of a worker’s medical and occupational history including:
   • Frequency and duration of exposure to alkyl mercury compounds since previous examination.
   • Enquiry for signs and symptoms associated with exposure to alkyl mercury compounds focusing on:
     • Nervous
     • Renal, and
     • Dermatologic systems.
2. A physical examination, if clinically warranted, focusing on the systems affected by alkyl mercury compounds including:
   • Nervous
   • Renal, and
   • Dermatologic systems
3. Provision of health information consistent with paragraph 1 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for alkyl mercury compounds in accordance with this Code.

Acute exposure medical examinations

A medical examination carried out in the event of an acute exposure to alkyl mercury compounds shall include:

1. Enquiry for signs and symptoms associated with exposure to alkyl mercury focusing on:
   • Nervous
   • Renal, and
   • Dermatologic systems.
2. A physical examination, if clinically warranted, focusing on the systems affected by alkyl mercury compounds including:
   • Nervous
   • Renal, and
   • Dermatologic systems.
3. Clinical tests in accordance with this Code.

Exit medical examinations

Exit medical examinations shall include:

1. Updating of a worker’s medical and occupational history including:
   • Frequency and duration of exposure to alkyl mercury since previous examination.
   • Enquiry for signs and symptoms associated with exposure to alkyl mercury focusing on:
     • Nervous
     • Renal, and
     • Dermatologic systems.
2. A physical examination, if clinically warranted, focusing on the systems affected by alkyl mercury compounds including:
   • Nervous
   • Renal, and
   • Dermatologic systems.
3. Provision of health information consistent with paragraph 2 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for alkyl mercury compounds in accordance with this Code.

Clinical tests for mercury (Alkyl compounds)

Types

The following clinical tests are required for pre-placement, periodic, acute exposure and exit medical examinations with respect to exposure to alkyl mercury compounds:

1. Blood mercury level

Frequency

1. At a minimum, every 4 months for the first 12 months following testing in relation to pre-placement medical examinations to address potential exposures through hygiene and work practices.
2. Annually thereafter, or sooner if change in work practices or primary prevention measures.
3. Monthly for blood mercury level > 0.25 μmol/L.

Action levels/Removal from exposure criteria

An assessment of a worker’s fitness to continue working in exposure to alkyl mercury compounds is based on the results of the medical examination in conjunction with the results of the clinical tests. If the examining physician determines that the worker is fit with limitations or unfit, the physician shall take action in accordance with section 29 of O. Reg. 490/09.

Blood mercury level > 0.25 μmol/L triggers the review of engineering controls, work practices, worker health status and personal hygiene practices.

Note: Base blood mercury level for individual may vary according to diet.

1. Review levels:
2. Removal from Exposure Criteria (confirmed occupational exposure):

   The level for removal of the worker from exposure to alkyl mercury compounds is as follows:

   • Blood mercury level > 0.25 μmol/L.

Return to work in exposure to alkyl mercury compounds criteria

Blood mercury level ≤ 0.25 μmol/L or at the discretion of physician and after careful review of sources of exposure and implementation of protective measures in the workplace to ensure worker exposure to alkyl mercury compounds is minimized and within acceptable levels.

Silica

Medical examinations – General

With respect to the medical examinations required under subsection 20(4) of O. Reg. 490/09, the medical examinations for workers exposed to silica shall be carried out:

1. Prior to placement.
2. Periodically, as follows, while exposed:
   • At least once every five years, beginning 10 years after first exposure with any employer, or
   • More frequently, as required by the examining physician.

   Note: Greater frequency of medical examinations may be recommended for heavier exposures or where there are changes in job tasks that may require additional medical surveillance.

3. Upon exiting placement, as follows:
   • Medical examination is required for workers with more than 10 years of exposure, unless the most recent medical examination was performed within the last 12 months^{footnote 17[17]}.

Pre-placement medical examinations

Pre-placement medical examinations shall include:

1. Initial medical and occupational history including:

   Note: The administration of a respiratory questionnaire is recommended.

   • Previous exposure (both occupational and non-occupational) to silica including timeframe of first exposure to silica with any employer.
   • History of past or present respiratory and musculoskeletal disorders, including:
     • Silicosis
     • Chronic obstructive pulmonary disease
     • Tuberculosis and other mycobacterial diseases
     • Lung cancer
     • Connective tissue disease
   • Personal habits (e.g. smoking and hygiene).
2. A physical examination focusing on the respiratory and musculoskeletal systems.
3. Provision of health information consistent with paragraph 1 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for silica in accordance with this Code.

Periodic medical examinations

Periodic medical examinations shall include:

1. Updating of a worker’s medical and occupational history to include:
   • Frequency and duration of exposure to silica since previous examination.
   • Enquiry for signs and symptoms that may be an early indication of:
     • Silicosis (e.g. exertional dyspnea, new or worsening cough).
     • Malignancy (e.g. new or worsening cough, hemoptysis, pleuritic pain, weight loss).

     Note: The administration of a respiratory questionnaire is recommended.

2. A physical examination focusing on the respiratory and musculoskeletal systems, if clinically warranted.
3. Provision of health information consistent with paragraph 1 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for silica in accordance with this Code.

Exit medical examinations

Exit medical examinations shall include:

1. Updating of a worker’s medical and occupational history to include:

   Note: The administration of a respiratory questionnaire is recommended.

   • Frequency and duration of exposure to silica since previous examination.
   • Inquiry for signs and symptoms that may be an early indication of:
     • Silicosis (e.g. exertional dyspnea, new or worsening cough).
     • Malignancy (e.g. new or worsening cough, hemoptysis, pleuritic pain, weight loss).
2. A physical examination focusing on the respiratory and musculoskeletal systems, if clinically warranted.
3. Provision of health information consistent with paragraph 2 of the Worker Health Information section in Part I of this Code.
4. Clinical tests for silica in accordance with this Code.

Clinical tests for silica

Types

The following clinical tests are required for pre-placement, periodic and exit medical examinations with respect to exposure to silica:

It is recommended that chest radiographs be read by a physician certified by the Royal College of Physicians and Surgeons of Canada (RCPSC), and educated and experienced in the practice of reading chest radiographs.

Note: To avoid unnecessary X-rays, the examining physician shall, where practical, obtain the relevant medical records from another facility if the worker has been previously examined within the past year. It is recommended that chest radiographs obtained be re-read based on the potential exposure to silica, if required.

Note: All relevant data shall be corrected to body temperature and pressure (BTPS).

1. Imaging: Chest Radiograph (postero-anterior) (PA)
2. Pulmonary Function Tests (PFT)^{footnote 18[18]}, (to be taken in conjunction with chest radiograph):
   • FEV1, FVC, FEV1/FVC ratio

Frequency

Chest radiograph and PFT to be done every 5 years after 10 years of exposure or as required by examining physician.

Action levels/removal from exposure criteria

There are no specific action levels/removal from exposure criteria.

An assessment of a worker’s fitness to continue working in exposure to silica is based on the results of the medical examination in conjunction with the results of the clinical tests. If the examining physician determines that the worker is fit with limitations or unfit, the physician shall take action in accordance with section 29 of O. Reg. 490/09.

Where the examining physician determines that the signs of silica-induced disease are present, the examining physician should consider whether the worker should be referred to a respirologist, rheumatologist or other knowledgeable specialist educated and experienced in the practice of evaluating work-related lung or connective tissue diseases for further medical assessment.

Return to work in exposure to silica criteria

A worker’s return to work in exposure to silica is to be decided on a case by case basis by the examining physician, in consultation with a respirologist, rheumatologist or other knowledgeable specialist educated and experienced in the practice of evaluating work-related lung or connective tissue diseases, if any, and after careful review of sources of exposure and implementation of protective measures in the workplace to ensure worker exposure to silica is minimized and within acceptable levels.