Several important federal regulations and consensus documents provide guidance on the design and operation of a medical surveillance program. They include but are not limited to OSHA 29 CFR 1910.120 “Hazardous Waste Operations and Emergency Response,” EPA 40 CFR 311 “Worker Protection,” NFPA 1500 “Standard on Fire Department Occupational Safety and Health Program,” and NFPA 1581 “Standard on Fire Department Infection Control Program.” Individual states may also have pertinent medical surveillance directives that emergency response agencies should adhere to in operating their programs. Medical surveillance requirements may vary between firefighters, EMS, and law enforcement. Thus, those responsible for their agencies’ medical surveillance programs should be intimately familiar with the rules and regulations affecting their departments, including the potential variation in requirements for various personnel. The Centers for Disease Control has created a technical assistance website, document, and training materials for emergency responder health monitoring and surveillance at www.cdc.gov/niosh/topics/erhms.

Currently, OSHA 29CFR 1910.120 requires employers to implement medical surveillance programs in the following situations.

• For employees who may be exposed to hazardous substances or health hazards at or above permissible limits (PELs) for 30 days or more per year
  
• In the absence of PELs, for employees working at levels above the published exposure levels for a given substance
  
• Employees who wear a respirator for 30 days or more per year
  
• Hazmat employees, defined as personnel who plug, patch, or temporarily control leaks from containers holding hazardous substances
  
• All employees who are injured as a result of overexposure in an emergency incident involving hazardous substances

The Environmental Protection Agency’s (EPA) standard varies slightly from the Occupational Safety and Health Administration’s (OSHA) standard in that it includes volunteers who work for government agencies engaged in emergency response, such as firefighters. The EPA standard also applies to employees of state and local governments in states that lack OSHA-approved plans.

Medical surveillance is the process by which the health of an emergency responder is maximized and risks are minimized [1–3]. The process includes the systematic collection, analysis, and evaluation of health data in a defined population to identify patterns or trends suggesting adverse health effects or needs for further investigation or remedial action [2–5]. Medical surveillance is applicable not just to hazardous materials (hazmat) entry team members but firefighters, EMS personnel, responders to large-scale mass casualty incidents (MCIs), and law enforcement officers. Members serving in specialty capacities such as dive teams, SWAT teams, and civil disturbance units may be subject to additional comprehensive medical monitoring programs [1,6,7]. A 2009 report from the World Trade Center Medical Monitoring and Treatment Program (now operated by NIOSH as the World Trade Center Health Program) detailing the evaluation results of more than 20,000 emergency responders and ongoing medical treatment for 2,000 personnel with physical problems and 2,900 with mental health issues, reinforces that every response agency regardless of size should have a defined medical surveillance program to maximize responder health and safety [8]. The goal of the medical surveillance program is to promote [1,6,7]:

• early recognition of hazardous materials exposure-related occupational disease
  
• early intervention and treatment
  
• effective management of the occupational disease process
  
• illness prevention.

The health hazards faced by today’s emergency responders include chemicals such as carcinogens, toxins, irritants, and corrosives, as well as infectious agents and radiation-emitting substances. Psychological stress and temperature extremes are also considered health hazards. OSHA 29 CFR 1910.120 stipulates that the medical surveillance program be comprehensive and address all foreseeable risks [9]. The program should be maintained by the employer and operate under the direction of an occupational medical director who is licensed in the state where the program is operated. This physician may be an employee of the agency or a contractor hired to fulfill this role. The physician must be familiar with occupational medicine, toxicology, and the job-related activities of the personnel he or she is overseeing [7]. Hiring an occupational medicine physician to provide this service is often limited by funding, and operational medical directors are increasingly being asked to fill this role, or departments may contract with comprehensive occupational medicine service providers.

The effectiveness of a medical surveillance program requires definition of the mission of the program, its components, and operating procedures for surveillance activity before, during, and after an incident. The overarching purpose of medical surveillance is elimination of a responder’s exposure to harmful, disease-causing situations [1,6,7]. Thus, careful attention is paid to identifying potential health hazards as soon as possible and correcting practices that may jeopardize a responder’s health and safety. The components of a medical surveillance program include:

• having dedicated staff to conduct the program
  
• suitable office space to operate the program
  
• protocols for individual testing, biological monitoring, exposure monitoring, and determination of job-related risks and exposures
  
• tracking systems
  
• compliance with medical information privacy requirements.

Available funding should be sufficient to provide competitive salaries for the staff, necessary office space and technology (including occupational health software programs), and examination equipment. Sufficient time and expertise should be available to allow for regular analysis of ongoing responder clinical data and review of incident reports to identify at-risk practices and recommend prescriptive improvements to reduce harm risks whenever possible.

The medical surveillance program also involves performing medical screening. This screening includes five categories of examination [7]: post offer of employment, baseline, annual or periodic, job termination, and exposure- or injury-specific medical examinations. These government-required exams should be complemented by a medical monitoring program. Each of the surveillance elements is covered in more detail below.

Employers with medical surveillance programs must maintain responders’ health records during the length of their service, and for a minimum of 30 years post resignation or retirement. Responders are entitled to access their records within 15 days of a request [7,9].

Many medical surveillance programs have focused on injury prevention through implementation of rigorous physical conditioning programs, healthy lifestyle reminders, and work performance evaluations. These programs may operate under the oversight of the medical director or other designated physician, athletic trainers, physical therapists, or physician extenders.

Initial employment examination

The preemployment physical is performed once a conditional job offer has been made to a candidate and must be completed in compliance with the 1990 Americans with Disabilities Act. The examination typically includes a lengthy questionnaire inquiring about various aspects of the candidate’s past and current health, pertinent family history, and off-duty employment and hobbies. Immunization and vaccination status may also be determined. The physical exam should be conducted by a licensed physician or physician extender. In addition, the following tests may be ordered and their results reviewed with the candidate [2,4,5,7,10].

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