Legea Suedeza - 2000 - 6 - Occupational-Medical-Supervision

AFS 2005:6
Occupational medical
supervision
The Swedish Work Environment Authority`s provisions on
occupational medical supervision and general receommenda-
tions for applying the provisions.
The Work Environment Authority´s Statute Book

AFS 2005:6
Table of contents
The Swedish Work Environment Authority´s provisions on occupa-

tional medical supervision
Scope ....................................................................................................................... 7
Definitions .............................................................................................................. 7
General rules for medical supervision ............................................................... 8
Medical examiniation ..................................................................................... 10
Register ............................................................................................................ 11
Information to send to the Swedish Work Environment Authority ....... 11
Doctor´s reporting of illness ......................................................................... 12
Obligatory medical supervision ......................................................................... 12
Work involving lead and cadmium ............................................................. 12
Medical examination ................................................................................. 12
Periodic biological exposure control for work involving lead ............ 13
Periodic biological exposure control for work involving cadmium ... 15
Dispension .................................................................................................. 16
Work involving dust which may induce fibrosis: asbestos, quartz and
certain synthetic inorganic fibres ................................................................. 16
Work involving thermosetting plastics ....................................................... 18
Periodic medical examination with employability assessment .......... 18
Medical examination for work involving ester plastic ......................... 19
Work involving extreme physical strain ..................................................... 20
Overhead work on masts and poles ............................................................ 20
Rescue work in smoke-filled or chemically contaminated conditions .... 21
Physical employability requirements ..................................................... 23
Diving work .................................................................................................... 23
Work involving exposure to vibrations ...................................................... 25
Night work ...................................................................................................... 26
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Medical examination ................................................................................ 26
Provisions on fines ......................................................................................... 27

Entry into force and interim provisions ...................................................... 27
The Swedish Work Environment Authority´s general recommenda-

tions for applying the provisions on occupational medical super-
vision.
Background .......................................................................................................... 29
Scope ..................................................................................................................... 30
Definitions ........................................................................................................... 31
General rules for medical supervision ............................................................. 32
General principles ..................................................................................... 32
Chemical substances ................................................................................. 34
Measuring exposure using biological samples ..................................... 35
Dust ............................................................................................................. 37
Biological agents ....................................................................................... 37
Optical and electromagnetic radiation ................................................... 37
Ionizing radiation ..................................................................................... 39
Noise and vibrations ................................................................................ 40
Extreme climatic conditions .................................................................... 40
Work involving the risk of strain injuries .............................................. 41
Work involving extreme physical strain ................................................ 42
Work involving severe mental stress ..................................................... 42
Work involving the risk of accidents ..................................................... 43
Risks of damage to reproductive functions and foetal injury ............. 44
Cancer risks ............................................................................................... 46
Differences in sensitivity .......................................................................... 47
Allergy risks ............................................................................................... 49
Medical examination .......................................................................................... 52
Register ................................................................................................................. 54
Information to send to the Swedish Work Environment Authority ............ 55
Doctor’s reporting of illness .............................................................................. 55
Obligatory medical supervision ........................................................................ 56
Work involving lead and cadmium ............................................................ 56
Health risks ................................................................................................ 56
Medical examination ................................................................................ 59
Periodic biological exposure control for work involving lead ............ 62
Periodic biological exposure control for work involving cadmium .. 64
Dispensation .............................................................................................. 65
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Work involving dust which may induce fibrosis: asbestos, quartz and
certain synthetic inorganic fibres ................................................................. 66
Health hazards ........................................................................................... 66
Asbestos ...................................................................................................... 67
Quartz ......................................................................................................... 69
Certain synthetic inorganic fibres ........................................................... 69
Work involving thermosetting plastics ....................................................... 72
Health hazards ........................................................................................... 72
Periodic medical examination with employability assessment .......... 76
Medical examination for work involving ester plastic ......................... 77
Work involving extreme physical strain ..................................................... 79
Overhead work on masts and poles ............................................................ 79
Health hazards ........................................................................................... 79
Comments on entry into force and interim provisions .................................. 97
Glossary ................................................................................................................ 98
Appendix 1 Overview of obligatory medical supervision .......................... 106

Appendix 2 Summary of medical supervision for lead and cadmium ...... 108
Appendix 3 Classification of disorders and symptoms caused
by vibrations ...................................................................................................... 111
Appendix 4 Questionnaire about allergy problems in working with ther
setting plastics ................................................................................................... 112
Information from the Work Environment Authority ................................... 115
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The Swedish Work Environment Authority’s provisions on occupa-
tional medical supervision
Published 29 March 2005
Decreed on 17 February 2005
The Swedish Work Environment Authority issues the following provi-

sions pursuant to Section 18 of the Work Environment Ordinance (SFS
1977:1166) and following consultations with the National Board of
Health and Welfare 1.
______________
1Cf the following directives
- Council Directive 89/391/EEC of 12 June 1989 on the introduction of measures to en-
courage improvements in the safety and health of workers at work (OJ L 183, 29/06/1989,
p. 1, Celex 319891.0391).
- Council Directive 90/394/EEC of 28 June 1990 on the protection of workers from the
risks related to exposure to carcinogens at work (Sixth individual Directive within the
meaning of Article 16 (1) of Directive 89/391/EEC [OJ L 196, 26/07/1990, p. 1, Celex
319990L0394], last amended by Council Directive 1999/38/EEC [OJ L 138, 01/06/1999, p.
66, Celex 31999L0038]).
- Council Directive 93/104/EC of 23 November 1993 concerning certain aspects of the
organization of working time (OJ L 307, 13/12/1993, p. 18, Celex 31993L0104).
- Council Directive 98/24/EC of 7 April 1998 on the protection of the health and safety
of workers from the risks related to chemical agents at work (fourteenth individual Direc-
tive within the meaning of Article 16(1) of Directive 89/391/EEC [OJ L 131. 05/05/1998,
p. 11, Celex 31998L0024]).
- Council Directive 83/477/EEC of 19 September 1983 on the protection of workers
from the risks related to exposure to asbestos at work (OJ L 263, 24/09/1983, p. 25, Celex
31983L0477), last amended by Directive 2003/18/EC of the European Parliament and of
the Council (OJ L 97, 15/04/2003, p. 48, Celex 32003L0018).
- Directive 2002/44/EC of the European Parliament and of the Council of 25 June 2002
on the minimum health and safety requirements regarding the exposure of workers to the
risks arising from physical agents (vibration) (sixteenth individual Directive within the
meaning of Article 16(1) of Directive 89/391/EEC) (OJ L 177, 06/07/2002, p. 13, Celex
32002L0044).
- Directive 2004/37/EC of the European Parliament and of the Council of 29 April 2004
on the protection of workers from the risks related to exposure to carcinogens or muta-
gens at work (Sixth individual Directive within the meaning of Article 16(1) of Council
Directive 89/391/EEC) (OJ L 158, 30/04/2004, p. 50, Celex 32004L0037).
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Scope
Section 1
These provisions apply to all employers. For the purposes of these pro-
visions, an employer is any person who utilizes hired employees to
carry out work in his or her activity, and an employee is any person
hired to carry out work in such an activity.
Definitions
Section 2
These provisions use the following terms in the sense given for each one
below.
Medical supervision a medical measure in support of improv-

ing the work environment. Such measures
may include biological exposure control,
medical examinations, health check-ups
and employability assessments. Vaccina-
tions are not regarded as medical supervi-
sion.
Biological exposure control a direct or indirect measurement of the
absorption into the organism of a given
substance.
Biological limit value in a biological exposure control, a value
which must not be exceeded.
Medical examination individual examination of each employee,

in which a doctor is in charge and partici-
pates.
Health check-up an examination in which a doctor does not

need to participate, but for which he or
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she makes the final assessment. The ex-
amination may be carried out using a
questionnaire, a personal interview
and/or physicalexaminations and testing.
Employability assessment a doctor’s assessment of whether an ex-

amined individual’s state of health allows
for him or her to carry out tasks which are
subject to medical supervision.
Arrange (medical supervision) the employer’s obligation to arrange med-

ical supervision, offer employees such su-
pervision and ensure that only those who
have undergone medical supervision car-
ry out the tasks for which it was intended.
Offer differs from “Arrange” in that there is no

(medical supervision) obstacle or prohibition to stop the employ-
er employing an individual who has de-
clined to undergo the medical supervision
offered to him or her.
Directive within the meaning of Article 16(1) of Directive 89/391/EEC) (OJ L 177,
06/07/2002, p. 13, Celex 32002L0044).
- Directive 2004/37/EC of the European Parliament and of the Council of 29 April 2004
on the protection of workers from the risks related to exposure to carcinogens or muta-
gens at work (Sixth individual Directive within the meaning of Article 16(1) of Council
Directive 89/391/EEC) (OJ L 158, 30/04/2004, p. 50, Celex 32004L0037).
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General rules for medical supervision
Section 3
When a risk assessment under the Swedish Work Environment Author-
ity’s provisions on systematic work environment management indicates
that medical supervision of employees is justified, such supervision
must be offered them by the employer.
Section 4
Irrespective of the risk assessment referred to in Section 3 above, the
employer must arrange medical supervision of employees for
a) work involving exposure to lead and cadmium as described under
Sections 12-26,
b) work involving exposure to fibrosis-inducing dust: asbestos, quartz
and certain synthetic inorganic fibres as described in Sections 27-31,
c) work involving exposure to thermosetting plastics as described in
Sections 32-40,
d) work involving extreme physical strain: overhead work on masts and
poles, rescue work in smoke-filled or chemically contaminated condi-
tions and diving work as described in Sections 41-56
For work as in items a, b and d above, and for some work as in item c,
medical supervision must lead to an employability assessment.
Irrespective of the risk assessment referred to in Section 3 above, the
employer must offer employees medical supervision for
e) work involving exposure to vibrations as described in Sections 57-62,
and
f) night work as described in Sections 63-67.
Medical supervision arranged or offered in accordance with Sections
3 and 4 above must not involve any costs for the employees.
Section 5
An employee who has undergone medical supervision must be given,
besides the result of the examination, all the information and advice
indicated by the examination result, as well as the result of the em-
ployability assessment as per Section 4, Paragraph 2.
The employer must peruse the employability assessment as per Sec-
tion 4, Paragraph 2.
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Section 6
Employees who have not undergone medical supervision in which an
employability assessment as per Section 4, Paragraph 2 is a requirement
may not be employed to carry out the tasks which prompted the super-
vision requirement.
Employees who have been deemed unemployable following medical
examination or biological exposure control in accordance with these
provisions may not be employed to carry out the tasks which prompted
the supervision.
Section 7
Except when they are prevented from doing so by confidentiality con-
siderations or professional secrecy obligations, employers must peruse
the results of the medical supervision carried out in accordance with
this provision.
If the results of medical supervision indicate that the work in ques-
tion can contribute to ill health, the employer must carry out examina-
tions and apply measures necessary for preventing ill health and acci-
dents at work.
Medical examination
Section 8
Employers who arrange or offer medical supervision must ensure that
the doctor carrying out the supervision has the necessary specialist
competence.
The following categories of doctors are competent to carry out medi-
cal examinations requiring an employability assessment as per Section
4, Paragraph 2:
- registered physicians with specialist competence in occupational
medicine, occupational and environmental health medicine, or equiva-
lent,
- registered physicians with specialist competence in occupational
health care, and
- registered physicians who have undergone staff medical officer train-
ing at the National Institute for Working Life or equivalent training,
receiving a pass grade, and who additionally have at least the equiva-
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lent of two years’ full-time service within civilian occupational health

care or the equivalent within the armed forces.
In addition to the above categories, registered physicians who have
undergone, and received a pass grade for, diving medicine training
certified by EDTC and ECHM or who have at least the equivalent of
two years’ full-time service in hyperbaric medicine, are competent to
conduct medical examinations which require an employability assess-
ment as per Section 4, Paragraph 2, Item d) (work involving extreme
physical strain).
Additionally, registered physicians with documented training in
school health care and at least the equivalent of two years’ full-time
service within school health care are competent to conduct such medical
examinations as are applicable for pupils in secondary and upper sec-
ondary education. For the purposes of these provisions, training in
school health care means a doctor’s postgraduate course in school
health care.
The remaining medical examinations may be carried out by regis-
tered physicians without specialist competence.
Register
Section 9
Employers must keep a register of all employees who have undergone
medical supervision in accordance with these provisions.
The register must contain the following data
a) the employee’s name,
b) what type of exposure or exposures the employee has been subjected
to,
c) the period of time during which the exposure/s occurred,
d) the results of biological exposure controls for exposure to lead and
cadmium, and
e) the results of examinations and, for employability assessments, when
they were carried out and by whom. Data on employability for diving
work must also be registered in a diver’s logbook or equivalent record.
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Information to send to the Swedish Work Environment Authority
Section 10
The employer must send a compilation of the results of medical exami-
nations as per Sections 14-16 or Sections 29-31, or of periodic biological
exposure controls as per Sections 17-21 and/or Sections 22-25, to the
Swedish Work Environment Authority without delay following the end
of the quarter in which the measures were carried out. Such a compila-
tion must include information about the number of employees ex-
amined, divided by type of task, and the name of the doctor in charge of
the supervision. In the case of biological exposure controls for lead and
cadmium, the data must also be divided by gender and different levels
of lead and cadmium in the blood. The name of the laboratory where
the analysis was done must also be included.
Doctor’s reporting of illness
Section 11
Pursuant to Section 2a of the Work Environment Ordinance illnesses
must be reported which may be connected with work and which are of
interest from a work environment perspective. This includes illnesses,
as well as symptoms and complaints,
- that indicate poor working conditions and/or inadequate routines
for work adaptation and rehabilitation,
- that have afflicted many individuals carrying out a specific type of
work, i.e. a number higher than what would be expected, or higher than
what is normally the case for this type of work or a for a specific work-
site,
- that increase in frequency over time,
- for which the connection may be suspected to be related to expo-
sure to carcinogenic or mutagenic substances, and
- for which the connection with work is new, unexpected or rare.
Obligatory medical supervision
Work involving lead and cadmium
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Medical examination
Section 12
Rules regarding medical examination and biological exposure control
apply when the Swedish Work Environment Authority’s provisions on
lead require medical supervision, and when cadmium or materials con-
taining cadmium as a metal or a chemical compound are handled in
such a way that cadmium exposure may occur.
Section 13
A medical examination as specified in Section 14 must be carried out
before the employee begins work with lead or cadmium. However, if an
equivalent medical examination was carried out within three years be-
fore work began, it does not need to be repeated.
Section 14
The medical examination shall at a minimum include occupational
anamnesis, data on relevant exposures, and tobacco and
illness anamnesis. The medical examination must also include a routine
physical check-up with blood pressure measurement and,
- in the case of work involving lead, tests for the blood lead level and
the urine protein quality and,
- in the case of work involving cadmium, tests for the blood and urine
cadmium level as well as chemical diagnosis of signs of possible kidney
effects.
The medical examination must furthermore include the necessary ele-
ments for making an employability assessment.
Section 15
Periodic medical examinations must be carried out with no more than
36-month intervals counting from the date on which work involving
exposure started. The examination must have the same scope as that
specified in Section 14. If exposure is interrupted for a period of more
than twelve months, the examination may be postponed for an equiva-
lent period of time.
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Section 16
Any employee who undergoes a medical examination as specified in
Sections 14 or 15 and is shown to have an illness or debility that implies
an increased risk of ill health due to lead or cadmium exposure is not
employable in the type of work for which the examination was carried
out.
Periodic biological exposure control for work involving lead
Section 17
Periodic biological exposure controls of employees who are exposed to
or will be exposed to lead in their work must be carried out with three-
month intervals counting from the date on which lead exposure began.
Such controls must include testing of blood lead levels. The control may
be brought forward or postponed by a maximum of two weeks. If expo-
sure is interrupted for more than two weeks, the control may be post-
poned for an equivalent period of time, but the period of postponement
may never exceed one month from the date on which work resumed.
Employers must use laboratories that apply appropriate analysis me-
thods and can demonstrate the reliability of their analysis results for
blood lead levels.
Section 18
For women who have turned 50 and for all men who in three consecu-
tive three-month controls have a blood lead level of 1.5 µmol/l or less,
the employer may subsequently arrange periodic biological exposure
controls with six-month intervals as long as the measured blood lead
level does not exceed 1.5 µmol/l. For women under the age of 50 who in
three consecutive three-month controls have a blood lead level of no
more than 0.8 µmol/l, controls may subsequently be held with six-
month intervals as long as the measured blood lead level does not ex-
ceed 0.8 µmol/l. Controls may be brought forward or postponed by a
maximum of one month.
The stipulations in the first paragraph only apply as long as work is
carried out under unchanged or improved conditions in terms of lead
exposure.
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Section 19
For women who have turned 50 and for all men who in three consecu-
tive three- or six-month controls have a blood lead level lower than 0.8
µmol/l and who work under unchanged conditions in terms of lead
exposure, the employer does not need to arrange further periodic con-
trols.
Section 20
If a medical examination or periodic control indicates that blood lead
levels are higher than 1.8 µmol/l (for women who have turned 50 and
for all men) or higher than 1.0 µmol/l (for women under 50) the em-
ployer must investigate the reason for this. The employer must also
ensure that measures in accordance with the provisions on lead are
applied without delay in order to lower the absorption of lead.
Section 21
Any individual who in any control has a blood lead level higher than
2.0 µmol/l (for women who have turned 50 and for all men) or higher
than 1.2 µmol/l (for women under 50) is not employable in work in-
volving lead until a new medical examination in accordance with Sec-
tion 14 has been carried out and a renewed control has shown that the
individual’s blood lead level has dropped to less than 1.8 and 1.0
µmol/l, respectively.
The same applies to individuals who have a blood lead level higher
than 1.8 µmol/l (for women who have turned 50 and for all men) or
higher than 1.0 µmol/l (for women under 50) in three consecutive con-
trols.
Periodic biological exposure control for work involving cadmium
Section 22
Periodic biological exposure controls of employees who are exposed to
or will be exposed to cadmium in their work must be carried out with
six-month intervals counting from the date on which cadmium expo-
sure began. Such controls must include testing of blood cadmium levels.
The control may be brought forward or postponed by a maximum of
one month. If exposure is interrupted for more than one month, the
control may be postponed for an equivalent period of time.
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Employers must use laboratories that apply appropriate analysis me-
thods and can demonstrate the reliability of their analysis results for
blood cadmium levels.
Section 23
If a medical examination or biological exposure control shows that the
blood cadmium level of any individual exceeds 50 nmol/l the employer
must investigate the reasons for this, as well as apply measures in ac-
cordance with Section 7 without delay in order to reduce cadmium ab-
sorption.
Section 24
Any individual who in any medical examination or biological exposure
control has a blood cadmium level higher than 75 nmol/l is not em-
ployable in work involving cadmium until a new medical examination
in accordance with Section 14 has been carried out and a renewed con-
trol has shown that the individual’s blood cadmium level has dropped
to less than 50 nmol/l.
Section 25
Any individual who in three consecutive six-month controls has a blood
cadmium level lower than 50 nmol/l may thereafter undergo controls
every twelve months. The control may be brought forward or post-
poned by a maximum of two months.
The stipulations in the first paragraph only apply as long as work is
carried out under unchanged or improved conditions in terms of cad-
mium exposure, and as long as blood cadmium levels are lower than 50
nmol/ l in controls.
Dispensation
Section 26
The Swedish Work Environment Authority may, following an applica-
tion from an employer, grant a dispensation from the stipulations in
Sections 21 and 24 for a specific employee. If a dispensation is granted
this may be in combination with conditions concerning extra periodic
biological exposure controls or medical examinations.
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Work involving dust which may induce fibrosis: asbestos, quartz

and certain synthetic inorganic fibres
Medical examination
Section 27
Rules regarding medical examinations apply when there is a require-
ment for medical supervision in the Swedish Work Environment Au-
thority’s provisions on asbestos, quartz or synthetic inorganic fibres.
Section 28
Medical examinations as specified under Section 29 must be carried out
before the employee begins work.
However, if an equivalent medical examination was carried out with-
in three years before work began, it does not need to be repeated.
Section 29
At a minimum, the medical examination must include occupational
anamnesis, data on any exposure to fibrosis-inducing dust or other ha-
zardous dust, tobacco and illness anamnesis, a clinical examination of
the respiratory and circulatory organs, a pneumography examination,
and spirometry. The medical examination must be of such scope that it
can be used as a basis for an employability assessment.
Section 30
36-month intervals counting from the date on which work began. The
medical examination must include that which is specified under Section
29 and any further elements necessary in order to assess the continued
employability of the employee in such work as is specified under Sec-
tion 27. However, the pneumography examination must only be carried
out on the third periodic examination and thereafter on every second
examination, provided other examination results do not occasion more
frequent controls.
Spirometry results and pneumographic images taken in another con-
nection may be used for periodic medical examinations, provided the
time intervals are the same and the quality acceptable.
If a spirometry or pneumography as specified in the first or second
paragraph indicates conditions that deviate from the norm, the exami-
17
nation must be supplemented with a medical examination as specified
under Section 29.
Section 31
Any employee who, in a medical examination as specified in Sections 29
or 30, is shown to have an illness or debility which makes him or her
particularly susceptible to illnesses caused by such exposure as moti-
vated the examination, is not employable for the type of work in ques-
tion.
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Work involving thermosetting plastics
Medical examination
Section 32
Rules regarding medical examinations apply when such examinations
are required under the Swedish Work Environment Authority’s provi-
sions on thermosetting plastics.
Section 33
Medical examinations as specified under Section 34 must be carried out
before the employee begins work with thermosetting plastics. However,
if an equivalent medical examination was carried out within two years
before work began, it does not need to be repeated.
Section 34
At a minimum, the medical examination must include occupational and
tobacco anamnesis, as well as illness anamnesis with respect to respira-
tory disease, cutaneous disease, allergy or other hypersensitivity, a clin-
ical examination of the derma and the respiratory tracts, and spirome-
try.
Section 35
Medical examinations as specified under Section 34 must also be ar-
ranged for employees who have shown new signs of respiratory dis-
ease, cutaneous disease or allergy and who have notified the employer
of this. However, common colds and other temporary respiratory com-
plaints for which there is no reason to suspect a connection with work
do not necessarily require a renewed medical examination.
Periodic medical examination with employability assessment
Section 36
For certain types of work with thermosetting plastics, as specified in the
Swedish Work Environment Authority’s provisions on thermosetting
plastics, examinations in accordance with Sections 34 and 35 must be
19
used as a basis for assessing the employee’s employability for the work
in question.
Section 37
A medical examination in accordance with Section 34 must be carried
out before an employee begins work requiring an employability as-
sessment. However, if an equivalent medical examination was carried
out within two years before work began, it does not need to be re-
peated.
A renewed medical examination must be carried out after at least
three but no more than six months after work began.
The employer must additionally arrange medical examinations of all
employees in such work with at most 24-month intervals counting from
the date on which work began.
The medical examinations must result in an employability assessment
for the work in question, in accordance with Section 36.
Section 38
and 37, is shown to have an illness or debility which makes him or her
particularly susceptible to illnesses caused by thermosetting plastics
components or air pollutants which motivated the examination, is not
employable for the type of work in question.
Medical examination for work involving ester plastic
Section 39
The employer must offer employees medical examinations in accor-
dance with Sections 33-35 for work involving reinforced ester plastic.
The medical examination must, in addition to the specifications under
Section 34, focus on symptoms from the central and peripheral nervous
system. Rules for medical examinations in accordance with the first
paragraph do not apply if exposure measurements have shown that the
styrene content is less than 1/5 of the applicable limit value as specified
in the Swedish Work Environment Authority’s provisions on occupa-
tional exposure limit values and measures against air contaminants.
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Section 40
Medical examinations must also be offered to employees with a maxi-
mum interval of six years following the start of work requiring exami-
nation. The medical examination must primarily focus on
symptoms from the central and peripheral nervous system, and on con-
ditions and symptoms which have appeared since the previous exami-
nation.
Work involving extreme physical strain
Overhead work on masts and poles
Medical examination
Section 41
thority’s provisions on work on masts and poles.
Section 42
Medical examinations in accordance with Section 43 must be carried out
on employers who do overhead work on masts and poles
- within the twelve months preceding the beginning of overhead
work,
- before overhead work is resumed, if more than twelve months have
elapsed since the last medical examination,
- before overhead work is resumed by any employee who has had an
illness, an accident or has been subjected to anything else that could
lead to an increased risk of ill health or accidents in overhead work.
Section 43
The medical examination must include anamnesis with particular focus
on illnesses or other ill health which can cause acute consciousness dis-
turbances or other sudden faintness.
The examination must also include a routine physical check-up to
measure blood pressure and any tendency to orthostatic reaction, and to
assess heart and pulmonary status, as well as a practical work test with
ECG recording.
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Practical work tests with ECG recording (exercise ECGs) are carried out
using clinical physiological methods, by electrocardiogram registration
during maximum work strain. A doctor must be present during the
examination, and preparedness for cardiopulmonary resuscitation must
be in place.
In other respects the scope and focus of the examination must be such
that it can form the basis for an employability assessment.
Section 44
twelve-month intervals counting from the date on which work began,
and must focus on events which have occurred since the previous med-
ical examination and which may affect the examined employee’s em-
ployability for overhead work. In other respects the examination must
have the same scope and content as the medical examination specified
in Section 43, with the following exceptions:
- employees under the age of 40 need only do practical work tests
with ECG recording every five years,
- employees who have turned 40 but not yet 50 need only do such
practical work tests every two years.
Section 45
or 44, is shown to have an illness or debility which implies an increased
risk of ill health or accidents in overhead work on masts and poles, is
not employable for the type of work in question.
Rescue work in smoke-filled or chemically contaminated condi-

tions
Medical examination
Section 46
Rules regarding medical examinations and requirements for physical
capacity to work apply when there is a requirement for medical super-
vision in the Swedish Work Environment Authority’s provisions on
rescue work in smoke-filled or chemically contaminated conditions.
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Section 47
Medical examinations in accordance with Section 43 must be carried out
on employers who do rescue work in smoke-filled or chemically conta-
minated conditions
- within the six months preceding the beginning of work,
- before rescue work in smoke-filled or chemically contaminated con-
ditions is resumed, if more than twelve months have elapsed since the
last medical examination,
- before work is resumed by any employee who has had an illness, an
accident or has been subjected to anything else that could lead to an
increased risk of ill health or accidents in rescue work in smoke-filled or
chemically contaminated conditions.
Section 48
The medical examination must comprise:
- determination of physical capacity to work as specified in Section
51,
- practical testing with ECG recording,
- anything else necessary in order to assess whether the employee, in
view of his or her state of health, should work in smoke-filled or chemi-
cally contaminated conditions.
Practical work tests with ECG recording (exercise ECGs) are carried
out using clinical physiological methods, by electrocardiogram registra-
tion during maximum work strain. A doctor must be present during the
examination, and preparedness for cardiopulmonary resuscitation must
be in place.
Section 49
twelve-month intervals counting from the date on which work began,
with the following exceptions:
- employees under the age of 40 need only do practical work tests
with ECG recording every five years,
- employees who have turned 40 but not yet 50 need only do such
practical work tests every two years.
The medical examination must be of the same scope as that specified
in Section 48.
23
Section 50
risk of ill health or accidents when working in smoke-filled or chemical-
ly contaminated conditions is not employable for the type of work in
question.
Physical employability requirements
Section 51
Employees doing work in smoke-filled or chemically contaminated
conditions must have a good physical capacity for work.
Physical capacity for work is determined by means of a six-minute
walk on a treadmill set to a speed of 4.5 km/h and at an 8º upward in-
clination, or to some other combination of speed and inclination which
gives at least the same load (oxygen absorption capacity, VO2).
During the test the employee must be wearing the full emergency
rescue suit excluding the breathing mask. Boots may be replaced by
training shoes. The total weight of the equipment carried during the test
must be 24 ± 0.5 kg.
Any employee who is tested for his or her physical capacity for work
and is unable to achieve, under the specified test conditions, at least the
times and loads specified above, may not work in smoke-filled or chem-
ically contaminated conditions.
Diving work
Medical examination
Section 52
thority’s provisions on diving work.
Section 53
Medical examinations as specified in Section 54 must be carried out on
employees who do diving work:
- within the twelve months preceding the beginning of diving work,
24
AFS 2005:6
- before diving work is resumed, if more than five years – or in the

case of employees aged 40 or more, two years – have elapsed since the
last medical examination,
- before work is resumed by any employee who has had an illness, an
accident or has been subjected to anything else that could lead to an
increased risk of ill health or accidents in diving work.
For employees who only occasionally care for seriously ill patients in
a decompression chamber, it is sufficient if the employer arranges a
medical examination promptly after the first occasion in the decompres-
sion chamber.
Section 54
The medical examination must include anamnesis with a particular
focus on illnesses or other ill health which can imply an increased risk
of ill health or accidents in diving work.
Section 55
Periodic medical examinations must be carried out on employees under
the age of 40 at least every five years. For employees over the age of 40
periodic medical examinations must be carried out at least every two
years. The examination must be of the same scope as specified in Sec-
tion 54.
Section 56
risk of ill health or accidents in diving work is not employable for the
type of work in question.
25
Work involving exposure to vibrations
Medical examination
Section 57
thority’s provisions on vibrations.
Section 58
Medical examinations as specified in Section 59 must be carried out
before work involving exposure to vibrations, and requiring a medical
examination, is begun. However, if an equivalent medical examination
was carried out within twelve months before work began, it does not
need to be repeated.
Section 59
At a minimum, the medical examination must include:
- occupational anamnesis,
- data on earlier illnesses,
- data on use of medication and tobacco,
- anamnesis regarding vibration-related symptoms – when they be-
gan, how frequent and serious they are, their extent and how they cor-
relate with exposure.
Section 60
For work involving exposure to vibrations for hands and arms the med-
ical examination must include, in addition to that which is specified in
Section 59, a special examination of vessels, derma and nerves in the
hands and arms, and a musculoskeletal examination of hands, arms,
shoulders and neck.
For work involving exposure to full-body vibrations the medical ex-
amination must include, in addition to that which is specified in Section
59, a special examination of the back.
Section 61
Periodic medical examinations with the same content as in Sections 59-
60 must be carried out with no more than three-year intervals after
work involving exposure to vibrations has begun. Every second period-
26
AFS 2005:6
ic examination – but not the first one – may be replaced by a simplified

health examination or a questionnaire for screening vibration injuries.
Section 62
Employees who have shown signs of vibration injury in a health exami-
nation or questionnaire as specified in Section 61 must also undergo
medical examinations as specified in Sections 59 and 60.
The same applies to employees who have seen new symptoms appear
or shown signs of vibration injury in some other context, and who have
notified the employer of this.
Night work
Medical examination
Section 63
The medical examination covers employees in night work. Employees
in night work are those who normally do at least three hours of their
daily work during the night, or who will likely complete at least 38 per
cent of their man-year during night hours. The rules in Sections 63-67
do not apply for temporary night work which is not estimated to go on
for more than three months.
Section 64
For the purpose of these provisions, night hours are defined as any pe-
riod of seven consecutive hours which includes the hours between
midnight and 5 am.
Section 65
Employers must offer a medical examination before night work begins
for the first time. However, if an equivalent medical examination was
carried out within twelve months before work began, it does not need
to be repeated.
Periodic medical examinations must be offered with six-year intervals
counting from the date on which night work began, with the following
exception:
- with three-year intervals when the employee has turned 50.
27
Section 66
At a minimum, the medical examination must include occupational
anamnesis, illness anamnesis, relevant data on medication and social
circumstances, and a routine physical check-up. Additionally, the ex-
amination must include anything which may be regarded as relevant to
discovering if the employee would be at particular risk of ill health or
accidents in doing night work.
Section 67
Periodic medical examinations must include that which is specified in
Section 66 but must mainly focus on events since the last medical ex-
amination which may have implications for the employee’s continued
ability to do night work without risk of ill health or accidents.
Provisions on fines
Section 68
The stipulations in Sections 6, 13, 15, 17, 22 first paragraph, 28, 30, 33,
37, 39 first paragraph, 42, 44, 47, 49, 53, 55, 58, 61 and 65 are provisions
pursuant to Chapter 4, Section 5 of the Work Environment Act.
The stipulations in Section 9 are provisions pursuant to Chapter 4,
Section 7 of the same Act.
The stipulations in Section 10 are provisions pursuant to Chapter 4,
Section 8 of the same Act.
Breaches of the provisions listed immediately above may, pursuant to
Chapter 8, Section 2, paragraph 1, item 2 of the Work Environment Act,
lead to fines.
Entry into force and interim provisions
These provisions enter into force on 1 July 2005. However, Section 8 does
not enter into force until 1 January 2008.
Transitionally, but not beyond 1 January 2008, physical capacity to

work as specified in Section 51 may be determined by means of cycling
on a cycle ergometer for six minutes with a load of 200 W.
28
AFS 2005:6
On 1 July 2005 the following provisions issued by the National Board of

Occupational Safety and Health will be repealed:
AFS 1997:8 Medical supervision of night workers and
AFS 2000:7 Medical supervision of work involving
cadmium.
Anyone who was employed before 1 July 2005 in any of the categories
of work covered by these provisions, but for which there was previous-
ly no medical supervision, must undergo periodic medical examina-
tions in accordance with these rules. The first control must be carried
out at the most proximately occurring medical examination, counting
from the day on which work began.
Anyone who was employed before 1 July 2005 in any of the categories
of work covered by these provisions, and for which there was previous-
ly a requirement for medical supervision which has in some way
changed in the new provisions, the new rules apply without any special
steps. When calculating a date for a future periodic medical examina-
tion, the date of the previous medical examination is used as a basis. If a
periodic medical examination has not yet been carried out, the basis of
calculation is the date on which work began.
KENTH PETTERSSON
Yvonne Strempl Maria Hagberg Forss
29
The Swedish Work Environment Authority’s general
recommendations on applying the provisions on occu-
pational medical supervision
The Swedish Work Environment Authority issues the following general

recommendations on the application of its provisions on occupational
medical supervision (AFS 2005:6). Consultations have been held with
the National Board of Health and Welfare.
General recommendations are of a different juridical status than provi-

sions. They are not compulsory, instead their function is to clarify the
import of the provisions. They are intended to inform about suitable
ways of fulfilling the requirements and provide examples of practical
solutions and procedures, as well as give recommendations, back-
ground information and references.
The fundamental document for employers’ responsibilities for the work

environment is the Swedish Work Environment Authority’s Provisions
on Systematic Work Environment Management. The aim of systematic
work environment management is for the employer, by means of inves-
tigation and risk assessment, to establish whether measures are neces-
sary in order to prevent ill health and accidents in the workplace. What
such measures are to consist of is specified in provisions issued by the
Swedish Work Environment Authority.
Background
Stipulations on medical supervision have previously been included in

various trade- or subject-specific provisions along with technical and
occupational hygiene rules. These provisions on occupational medical
supervision bring together the majority of the established medical
measures, while the original provisions retain the requirement that
medical supervision be carried out according to the stipulations in these
provisions. To the greatest extent possible, time intervals between dif-
ferent types of examinations have been coordinated. Medical supervi-
sion of exposure to vibrations has been added in compliance with a new
EU directive. Rules and recommendations on when it may be justified
30
AFS 2005:6
to carry out medical examinations for other reasons have also been add-
ed.
The requirements in this statute are directed at the employer, with the
exception of Section 11. Medical examinations including any employa-
bility assessments are, however, to be carried out by qualified medical
personnel whose skill and competence the employer must rely on. Some
specialist medical terms are used in this statute as instructions to the
medical personnel carrying out the medical examinations. If such terms
are not explained in the running text they will as a rule have been in-
cluded in the glossary at the end.
Scope
Comments on Section 1
Chapter 3, Section 12 of the Work Environment Act stipulates a respon-
sibility for anyone hiring labour. This responsibility applies when an
employer, against compensation, provides labour, employed by him, to
a hirer for the purpose of carrying out work which is part of the hirer’s
activity. The hirer exercises the direct labour management. For the work
carried out on the hirer’s account, therefore, the hirer has a responsibili-
ty which largely corresponds to the employer’s responsibility. He must
apply the same work environment measures as he would have applied
for his own employed staff, as far as measures needed during the pe-
riod of hiring are concerned. Under Section 1, a hirer is the equivalent of
an employer.
Under Sections 3 and 4 the employer is responsible for arranging medi-

cal supervision of employees. In the case of medical examinations and
periodic biological exposure controls to be carried out at regular inter-
vals, the stipulations mean that employer and hirer share a responsibili-
ty for ensuring that these take place during the time of the hiring. It is
important that the agreement between the employer and the hirer clear-
ly states who is to ensure that the medical supervision required is car-
ried out during the hiring period.
Chapter 1, Section 3 of the Work Environment Act stipulates that for the
purposes of applying Chapter 4, Section 5 (which is about medical su-
31
pervision), among others, anyone in training is regarded as equivalent
to an employee.
The Work Environment Act applies for any activity in which an em-
ployee carries out work for an employer (with the exception of work
carried out in the employer’s household). This means that the Work
Environment Act is applicable to any work carried out in Sweden, re-

gardless of whether the person running the activity is a Swedish or a
foreign citizen and of whether the employee is Swedish or foreign.
Definitions
Medical supervision
Rules on vaccinations and other preventive medical measures in the
event of the risk of infection are to be found in the Swedish Work Envi-
ronment Authority’s provisions on microbiological work environment
risks.
Biological exposure control

The measurement of blood levels of lead and cadmium are examples of
biological exposure controls.
Medical examination
During medical examinations it is important that the patient is given
time to talk to the doctor. The medical examination may, under special
requirements, lead to an employability assessment. See Comments on
Section 8 also.
Health check-up
A health check-up can also be carried out e.g. for the purpose of identi-
fying individuals who should have a medical examination. The health
check-up then serves as a health monitoring instrument for groups of
employees without any connection to follow-up medical examinations.
Such check-ups may sometimes consist of written surveys alone, in
32
AFS 2005:6
which case it is important that the questions used are well validated, i.e.
that they have a proven capacity for charting the ill-health under study.
Employability assessment
Even if an employee is deemed employable, certain conditions may
additionally be imposed in order for him or her to be allowed to take up
the work that the assessment concerned. Such conditions may e.g. be
requirements for more frequent medical examinations, or employability
only for certain specified tasks.
Arrange (medical supervision)

Corresponds to the Work Environment Act’s stipulation “to arrange for
the medical examination” and means that the employer must not only
arrange and offer medical supervision but also, under Section 4, that
such medical supervision carries no costs for the employee.
General rules on medical supervision
General principles
Under Chapter 3, Section 2 of the Work Environment Act the employer

must take all precautions necessary to prevent the employee from being
exposed to ill health or accidents. Risks in the work environment should
always in the first instance be addressed by means of preventive work
environment measures directed at physical, psychological and social
factors.
If risks of ill health and accidents still remain, the employer should con-
sider the need for medical supervision with the aim of preventing these
risks. Indicators of insufficient work environment measures might be
accidents in the employer’s own activity or in other companies with
similar activities, or a general experience that an activity like that in
question includes tasks or work stages that imply risks to health or safe-
ty which are difficult to remove or reduce. Further reasons for medical
supervision can sometimes arise from new conditions within the activi-
ty due to changes in production, work routines, manning, etc.
33
Accidents. leakages, production interruptions or other events suspected
of having caused hazardous emissions, radiation, physical or mental
strain, or other risks may also be grounds for carrying out medical su-
pervision of the individuals who are judged to have been exposed.
In order for medical supervision to be useful as an element of work

environment improvement, it needs to be strictly directed at the risks in
the work environment that justify the supervision. The aim of the su-
pervision might be one of the following:
- to detect early indications of ill health in the work environment,
- in addition to assessments on occupational hygiene, to carry out bio-
logical exposure controls by means of analysing body fluids such as
blood, urine, saliva or exhaled air,
- to protect particularly sensitive individuals from the risk of injury,
- to ensure that the employee has sufficient physical and/or mental
work capacity in those special cases where the nature of the work im-
plies extreme physical or mental strain as well as risks which cannot be
completely eliminated by means of work environment measures, and
- to prevent the risk of accidents when it is a consequence of certain
medical conditions e.g. impaired judgement or lowered reaction times
in individuals operating vehicles.
Medical supervision can also be preventive by making the risks in-

volved in work clear to the employees. Information can then be pro-
vided about e.g. working methods that reduce risks, or about symptoms
which may be an early indication of ill health due to the risk in ques-
tion.
At the same time it is important to bear in mind that he human body

has a limited number of ways of reacting to various types of strain of
either a physical or a mental nature. A certain symptom can usually
have many quite different possible causes and need not always have
been caused by risk factors in the work environment. Tiredness, head-
aches, dizziness, nausea, pricking sensations and numbness may some-
times be an indication of the acute effects of hazardous chemical sub-
stances, but it is more common that they are related to mental strain of
different kinds.
34
AFS 2005:6
In order to facilitate the assessment of symptoms it may be appropriate

to carry out medical supervision before a new job is begun and then at
given intervals. It is also advisable to urge the employee to report if any
complaints should appear which may be suspected of being related to
work.
If the results of medical supervision in accordance with Section 3 show

that damage or injury has occurred due to work environment factors, it
is important that the employer renew the investigation of working con-
ditions and the risk assessment, and that he or she applies such meas-
ures as prevent ill health from occurring for the same reason again.
Chemical substances
All chemical substances entering the body can be dangerous, if the dose
is only high enough. “Hazardous substances” refers to substances for
which even exposure to low doses can have an effect. Foreign sub-
stances can be absorbed by the body through inhalation, skin contact or
swallowing. They are then transported via the circulatory system to
different organs in the body. In most organs, but particularly in the
liver, there often follows a metabolism – a process of chemical change –
in which the substance is converted into more water-soluble products
which can more easily leave the body. Sometimes more hazardous in-
termediate products may also be formed. Excretion from the body oc-
curs mainly in urine, the bile ducts and exhaled air. Some foreign sub-
stances can be stored in different organs. Environmental toxins and
some organic solvents can be stored in fatty tissue, for example, some
metals in the skeleton or the kidneys. This can imply greater health risks
from the absorption of fat-soluble substances because these are elimi-
nated slowly. Other substances such as cadmium also leave the body
very slowly.
When hazardous substances come into contact with body tissues, dam-
age can occur. The lungs, skin, liver, kidneys/urinary tracts and blood-
forming organs can be particularly vulnerable. Besides damage to the
organs, sensitisation, genetic damage, cancer and foetal damage can
occur. Classic examples of hazardous substances include certain metals,
organic solvents, irritant or choking gases, pesticides and fibrosis-
35
inducing dust. Hazardous substances can also be present in products
made of plastic or rubber. For some of these substances, these provi-
sions contain rules about compulsory medical supervision.
An idea of the health and accident risks in a given work environment

can be obtained by means of comparing levels of substances in the air
with current occupational exposure limit levels. In today’s Swedish
work environments exposure to excessive levels of hazardous sub-
stances in the air, which imply the risk of long-term damage, is not very
common. One exception is the occurrence of skin and respiratory aller-
gies, which are not uncommon in certain work environments. Skin ex-
posure and absorption through the skin are more difficult to assess, but
in these cases too the Swedish Work Environment Authority’s provi-
sions on occupational exposure limit values and measures against air
contaminants can be of help when assessing the risks.
It is unusual in Sweden today for exposure to chemical substances to be

so high that ordinary blood tests indicate it. Deviating laboratory results
for individuals typically have to do with other circumstances. If such
testing is to be done for work environment purposes, it should be done
as group testing. One method is to make comparisons between groups
of exposed and unexposed employees. Comparisons can also be made
between samples taken before and after a period of work for a group of
employees exposed to a chemical substance suspected of being hazard-
ous. In planning and interpreting such statistical comparisons, special-
ists in occupational medicine or epidemiology should be consulted.
Measuring exposure using biological samples
Biological exposure control involves measuring the body’s absorption

of a chemical substance. Analyses of the substance or of a product con-
verted from it (metabolite) in body fluids such as blood, urine or saliva,
and exhaled air, can provide information about how much of one of
several substances has been absorbed by the body. In contrast with
measurements of air – known as exposure measurements (for compari-
son with the exposure limit value), analysis of biological samples pro-
vides the possibility of assessing absorption through the skin, leaking
breathing masks and increased absorption due to physically demanding
36
AFS 2005:6
work, and exposure during leisure time. They can also provide an idea
of the exposure following e.g. accidents, when exposure measurements
of the air are impossible to carry out.
One uncertain factor, however, is the variation in metabolism between

individuals, which might mean that a high content of conversion prod-
ucts indicates that a fast breakdown/detoxification has occurred. In
another individual the breakdown might be slow, which would give
lower levels of the conversion product at the same exposure level. De-
spite the fact that analyses of body fluids can provide a measurement of
the individuals’ true actual absorption, less is often known about the
connection between the analysis results and health effects than about
measured air content in the work environment and health effects.
Because measured values from biological exposure controls also reflect

side exposure (i.e. other exposure than in the work environment), e.g.
cadmium from smoking tobacco, mercury from freshwater fish, etc.,
such values will not just highlight possible shortcomings of occupation-
al hygiene in the work environment, but will also be significant for risk
assessments and work environment measures at the individual level.
Binding biological limit values exist only for the metals lead and cad-
mium in Sweden. This does not mean, however, that biological sam-
pling of other substances is meaningless – instead it can be a valuable
complement to occupational exposure measurements of the air.
For some substances, principally the heavy metals lead, cadmium and
mercury, and for arsenic, there are good possibilities for risk analysis
using biological exposure controls (urine or blood analyses). The same
applies for carbon monoxide, by means of analysing blood levels of
COHb (carboxyhemoglobin).
Other situations for which biological exposure controls can be useful

include exposure to benzene (benzene in exhaled air or U phenol), cya-
nide (U SCN), the diisocyanates HDI, NDI, TDI and MDI, fluorides (U
fluoride), phtalic acid anhydrides of different types, chrome ( U Cr),
nicotine in tobacco smoke (U cotinine), N-methylpyrrolidone ( U 2-
hydroxymethyl succinimide), organic esters of phosphoric acid (Ery-
acetylcholinesterase), PAH (U 1-hydroxypurene), PCB (S-CB153), sty-
37
rene (U mandelic acid, U phenylglyoxylic acid) and xylene (U methyl-
hippuric acid). The products for analysis are given in parentheses. Oth-
er examples of biological exposure markers are listed in e.g. ACGIH’s
Biological Exposure Indices.
Before a biological exposure control is carried out it is crucial that the

employer ordering it knows how the analysis results are to be assessed
and handled. It is also important to contact the analysing laboratory
about the sampling conditions, not least the time of the sampling in
relation to the exposure, the shelf life and storage of samples, etc.
Some of the analyses mentioned above are more suited to research con-
texts than to routine exposure monitoring. Information about analyses
for biological sampling can be provided by laboratories at clinics of
occupational and environmental health medicine, the National Institute
for Working Life in Umeå, the Institute of Environmental Medicine in
Solna (IMM) and at larger clinical chemistry laboratories.
Dust
Certain types of work may involve the risk of damage to lungs and
respiratory tracts due to inhalation of dust/particles. These might be
particles formed e.g. in welding work, chimney sweeping, work in the
rubber industry or work which involves exposure to environmental
tobacco smoke (passive smoking). For such situations, following a risk
assessment, a programme of regularly recurring spirometric examina-
tions may be considered. Examinations can also be carried out if an
individual employee develops complaints.
Biological agents
Work which involves the risk of infection, toxin effects and hypersensi-
tivity caused by exposure to biological agents, e.g. bacteria, viruses,
moulds and endotoxins is regulated in the Swedish Work Environment
Authority’s provisions on microbiological work environment risks.
These provisions contain rules and recommendations on preventive
measures, e.g. vaccinations. As specified in these provisions, health
38
AFS 2005:6
check-ups and medical examinations may also be required under legis-

lation on e.g. infectious disease control and food handling.
Optical and electromagnetic radiation
Outdoor work involves exposure to ultraviolet (UV) radiation from

sunlight. This primarily affects the eyes and skin. Serious overexposure
causes burns to the skin, with reddening, temporary thickening of the
skin and pigmentation. In the eyes the cells covering the cornea can
become damaged. Acute keratitis (inflammation of the cornea) causes
intense pain and reddening. UV radiation can also lower the body’s
immunity. Long-term effects include prematurely aged, parchment-like
skin and skin cancer. For the eyes, clouding of the lens (a cataract) may
result.
There are also artificial sources of UV radiation which may need to be

considered. Broken covers for halogen lamps and the servicing of gaug-
es that use UV light are sources of exposure which are sometimes over-
looked.
Advice on sunbathing – careful exposure – , wearing clothes that cover

the body and on paying attention to changes to the skin is justified for
most people, but particularly for those whose work involves increased
UV exposure from sunlight or artificial sources.
Insufficient lighting, as well as blinding light sources, can cause eye

problems and muscle pains around the eye and in the neck. Flickering
lights, e.g. from older types of fluorescent tubes, have been reported to
cause less specific complaints such as tiredness and headaches. This can
happen even when the eye is unable to perceive the flickering con-
sciously.
Laser radiation can cause damage to all biological tissue by means of

various mechanisms. These include shockwave effects, thermal effects
and photochemical effects which occur depending on the wavelength,
effect frequency, pulse duration etc. Serious injury occurs when a large
amount of energy is absorbed by tissue in a short time, so that the cell
fluid evaporates and the cells explode. In this way the eye’s lens and
39
retina can also suffer serious damage. The most common type of acute
injury for both eyes and skin, however, is burns. There is a risk of eye
injury at lower exposure levels as well. If someone is subjected to such
laser radiation that the eye is exposed to levels above the maximum
allowable exposure (MAE), an eye examination will be necessary. Work
involving technical equipment intended to generate laser radiation is
regulated in the provisions on lasers.
Electromagnetic fields may, if the field strength is high enough, cause

body tissues to heat up (higher frequencies, over 100 kHz), and symp-
toms to the nervous system in the form of temporary muscle spasms
(frequencies below 100 kHz). Internationally agreed limit values protect
workers against these effects. Some types of work can involve expo-
sures exceeding the limit values. Examples include working with elec-
tric welding equipment, diathermy and working near antennas and
radar equipment. Persons with metal implants or pacemakers may need
to be protected against exposure to strong electromagnetic fields.
Health risks from long-term exposure to low-frequency electromagnetic

fields are a subject of debate. There are studies that suggest a connection
with cancer, primarily leukemia and brain tumours, or with the devel-
opment of dementia. But the majority of published studies are regarded
as disputing such connections. On the other hand, the population’s ex-
posure to certain types of fields remains too short for the issue to be
resolved with complete certainty. It is possible to reduce exposure to
radiation (microwaves) from mobile phones held near the head by a
factor of 50 to 100 (down to 1/50-1/100) by using what is known as
hands-free equipment instead of holding the phone to the ear.
There are currently no recommendations on meaningful special health

check-ups of employees exposed to electromagnetic fields. Persons who
experience problems in the vicinity of electrical equipment, “electro-
sensitivity”, should be given a medical examination in order, among
other things, to rule out other treatable conditions.
40
AFS 2005:6
Ionising radiation
The Swedish Radiation Protection Institute/Radiation Safety Authority

has rules on dose limits and has also issued provisions on medical ex-
aminations for work involving ionising radiation. Damage to the nerv-
ous system, blood-forming organs, skin and mucous membranes, and
cancer and foetal injuries are all well-known risks from high exposure
levels. However, current exposure levels within the annual dose limits
cannot, for example, be traced in the blood – instead the purpose of the
medical examination is preventive, as well as to determine whether the
individual employee’s state of health could be an impediment to work.
The scope of the examinations is exhaustively described in the Radia-
tion Protection Institute’s/Radiation Safety Authority’s provisions and
in the comments that accompany them. Pregnant women have the right
to be transferred to work without ionising radiation during their preg-
nancy.
Very occasionally a substance that emits ionising radiation can have a

chemically toxic effect which is stronger than the effect of the radiation.
This applies to depleted uranium, for example. For this substance the
critical effect is kidney damage, i.e. the effect that appears at the lowest
dose.
Noise and vibrations
The effects of noise – hearing loss, tinnitus and stress-related problems –

are described in the provisions on noise. In addition to the statutory
hearing tests, medical examinations focusing on the effects of long-term
stress such as hypertension (high blood pressure) and cardiovascular
disease may be considered.
Certain chemical substances known as ototoxic substances can have an

effect on hearing. Solvents, certain metals (lead, mercury, manganese)
and substances that inhibit breathing (carbon monoxide and cyanide)
have negative effects. Simultaneous exposure to noise, styrene and tolu-
ene increases the risk of hearing loss by a factor of 10 to 20 compared to
exposure to noise only. Other factors such as high blood pressure, high
41
cholesterol values, tobacco smoking and certain drugs including neo-
mycin and salicylates can also increase the risk of hearing loss when
combined with exposure to noise.
Health problems due to vibrations are described and regulated in a

special section of these provisions.
Extreme climatic conditions
Exposure to intense heat or cold causes particular strains on the body.

To protect it from increasing heat, the sweat glands are activated and
the blood is brought closer to the surface of the skin in order to cool
more effectively. Intense sweating leads to loss of fluid which needs to
be substituted by drinking. Maintaining the salt balance puts an in-
creased strain on the kidney function. Changes in circulation increase
the strain on the heart. These problems are exacerbated if a person is
doing heavy work. Then the muscles produce extra heat while the de-
mands on the heart function increase further because the blood flow to
the muscles is higher. Medical conditions such as reduced cardiovascu-
lar or kidney function may need to be taken into account if the work
involves extreme thermal stress. Even a temporary added strain such as
a short-term infection may be grounds for release from work under
extreme heat conditions, as long as fitness is reduced. The best protec-
tion against thermal stress – which it has not been possible to eliminate
by technical means – is ample fluid intake, reduced physical activity
and breaks in a cooler environment. The provisions on working in in-
tense heat regulate such work situations.
Very long-term exposure to heat radiation, e.g. in glass-blowing or met-

al smelting work, can contribute to the clouding of the eyes’ lenses and
an increased risk of cataracts. These risks are higher when the infrared
component dominates over visible light. The problem can be eliminated
by effectively shielding sources of heat radiation. Most likely the risk of
cataracts is low in today’s Swedish work environments.
Long-term and intense exposure to cold brings general risks of chilling,

with unconsciousness and death as well as local frostbite. Appropriate
clothing, physical activity and breaks in warm environments will coun-
42
AFS 2005:6
teract the cooling down of the body. Exposure to cold air, particularly
on the face, can trigger or aggravate problems in the event of vascular
spasms. This occurs because the blood pressure increases, which
increases the load on the heart while at the same time there is no in-
creased blood flow to the cardiac muscle. There are certain indications
that long-term work in both intense cold and intense heat may contri-
bute to the appearance of hardening of the arteries (arteriosclerosis) due
to the strains on the body that these types of exposure entail.
Persons with a tendency to vasoconstriction in the fingers – white fin-

gers or Raynaud’s Syndrome – may experience increased suffering from
this even with moderate chilling. Previous local frostbite also increases
the risk of peripheral sensitivity to cold.
Work involving the risk of strain injuries
Certain types of work involve particular risks of strain injury. This can
be the case when there is heavy manual handling, frequently repeated
movements, or work performed in twisted or otherwise extreme body
positions. Even stationary or monotonous work with a static muscle
strain or, conversely, an extremely low strain can cause problems. The
risks of strain problems increase if the work also involves mental ten-
sion. An exposure which in itself brings unfavourable strain factors, and
where simultaneous exposure to vibrations further amplifies the effect
is another example for which increased attention may need to be paid to
the risk of strain injuries.
The biological damage mechanisms behind strain injuries are only part-
ly known. The pinching of nerve fibres, excessive strain on certain mus-
cle fibres and/or the accumulation of certain chemical substances which
cause more pain and further release of chemical substances so that vi-
cious circles occur are all explanation models for complaints to do with
muscles and other soft parts. Symptoms can include pain and stiffness,
numbness and loss of feeling. If a joint becomes too heavily strained it
can lead to its cartilage wearing down (arthrosis).
Strain injuries have a tendency to become very protracted once they

have become established. Medical examinations can be used to discover
43
early signs of trouble so that the work environment can be improved
both for the individual employee and – when necessary – for his or her
colleagues. Examinations can also show that the work itself needs to be
adapted. For example, a certain piece of equipment may need to be
adapted to the employee’s body size, physical strength or possible dis-
abilities.
Work which for safety reasons places high demands on employees’

physical working capacity is subject to compulsory medical supervision
under rules included in these provisions. Other comparable types of
work without a general requirement for medical supervision include
overhead work other than that done on masts and poles, and work in-
volving climbing using a rope.
Work involving severe mental stress
Being subjected to high demands in one’s work environment does not

have to imply negative health effects – on the contrary, it can have a
stimulating effect, as long as the strain feels manageable and is at its
most severe for only relatively short periods of time, and as long as
there are opportunities for recuperation. But when demands feel over-
whelming or when we experience long-term frustration for other rea-
sons, a number of negative mental and physical reactions can appear.
These include anguish/anxiety, muscle tension, depression, high blood
pressure, high blood lipids and a weakened immune system. In recent
years, researchers in the area have begun to explore the possibility of
measuring biomarkers for stress due to work environment conditions
(Åkerstedt, T and Theorell, T). These markers include certain hormones
such as cortisol in saliva and measurements of the heart rate, blood
pressure and muscle activity. The methods used are hard to apply in
practice as there is considerable individual variation, both between and
within individuals. More knowledge is needed about normal values by
gender, age etc., and about how measured changes correlate with the
appearance of illness. Still, stress biomarkers could be an interesting
complement to other measurements of shortcomings in the mental work
environment, if the study were run as a research and development
44
AFS 2005:6
project and the results were assessed at the group level. Health check-
ups with questionnaires could be a valuable tool for diagnosing stress-
related ill health, as long as the questions are properly validated and
suited for the purpose.
The section on night work contains rules and information regarding the
special strains of working at night.
Work involving the risk of accidents
Some types of work involve particular accident risks. These include

driving vehicles or controlling machinery, handling dangerous instru-
ments or substances, and work involving the risk of falls. Medical con-
ditions that lower consciousness or judgement, as well as reduced vi-
sion and hearing, may need to be considered for such work. The abuse
of medicines or drugs that affect the nervous system and the sensory
organs is a particular problem in this context. In some workplaces em-
ployers and employees have agreed to drugs testing of employees in
order to prevent accidents. Drugs testing can be regarded as an in-
fringement of the tested employee’s personal integrity, which must be
weighed against the accidents the employer is trying to prevent. Under
the provisions on work adaptation and rehabilitation, employers and
employees must draw up a policy for how to deal with any drug abuse
problems in the workplace. A cornerstone of such a policy should be
that addicts are given support to overcome their addiction and if possi-
ble remain in their job. If drugs testing is to be used, the methods used
in these analyses should be quality assured in order to avoid incorrect
results. Workplaces can seek advice about alcohol and drugs issues at
ALNA, which is a coordinating body for employers’ and employees’
organisations.
Risks of damage to reproductive functions and foetal injury
Damage to reproductive functions is the overall term for negative ef-

fects on women’s or men’s ability to reproduce, and for injuries to the
already formed foetus. Factors causing such damage can occur in the
work environment as well. Some chemical substances may pose a risk
45
through various effects on men’s or women’s sex cells, or through direct
effects on the foetus via the pregnant woman.
Damage to the sex cells can consist of changes to the genetic material in
the cell caused by mutagens, while effects on the foetus may be caused
both by mutagens and by substances which damage the foetus directly,
affecting the foetus without damaging the genetic material (teratogens).
Some substances damage reproductivity directly by dramatically reduc-
ing the number of sperm cells in the man, which can lead to reduced
fertility or in serious cases to sterility.
Injuries to the foetus may lead to miscarriage, deformities or other deve-

lopmental impairments or illness, e.g. child cancer. Certain
carcinogenic substances can also damage reproductivity. The foetus is
most sensitive to the effects of chemical substances at the beginning of
the pregnancy, when it may not yet have been confirmed. The foetus is
more sensitive than the mother to organic mercury, for example.
Substances on the list of limit values which have been classified as da-
maging to reproductivity are specified in the provisions on occupation-
al exposure limit values and measures against air contaminants.
Aside from chemical factors, exposure to biological and physical factors

can also pose risks during pregnancy. Examples include certain infec-
tion risks and noise leading to hearing loss.
Very high mental stress, or intense anxiety that one’s pregnancy might
be at risk, may in itself pose risks to the pregnancy through accompany-
ing hormonal imbalances. Night work can also pose risks if combined
with other risk factors.
The connections between foetal injuries and work-related exposure are

very difficult to study, however. The conditions under which exposure
occurred are often unclear and information about e.g. miscarriages
which happen early in the pregnancy can be very uncertain. Reproduc-
tivity-damaging factors can furthermore cause different effects depend-
ing on when the exposure takes place.
46
AFS 2005:6
As far as can be judged at this time, work environments in Sweden rare-

ly pose risks to pregnancy or the foetus as long as the existing work
environment rules are carefully followed. However, suspicions about
risks to the foetus and to pregnancy often give rise to intense anxiety. If
suspicions are put forward about risks posed by certain toxic factors, or
if a woman feels worried because of several miscarriages or children
with deformities among her colleagues, and if the suspicions are diffi-
cult to assess, it might be a good idea to ask the advice of toxicological
or epidemiological expertise.
In the provisions on pregnant and breast-feeding employees there are

examples of physical, chemical and biological risk factors, and stipula-
tions on the employer’s obligation to carry out a risk assessment and
apply work environment measures when an employee has informed the
employer that she is pregnant. Some types of work are completely for-
bidden for pregnant or breast-feeding employees. These include work
involving lead, diving work or work in other hyperbaric environments,
rescue work in smoke-filled or chemically contaminated conditions, and
work which could involve the risk of toxoplasma or rubella infection,
unless the employee has immune protection against these. Other factors
could also amount to damaging exposure. More detailed information is
available in the above-mentioned provisions.
For pregnant or breast-feeding employees who have been forbidden to

continue their work and for whom it has not been possible to arrange a
transfer to risk-free work, the possibility exists for time off with preg-
nancy benefit under the provisions of the National Insurance Act. Local
social insurance offices can provide further information.
Cancer risks
Cancer involves a cell or group of cells in the body changing in such a

way that they begin to grow uncontrollably. It is an illness in both hu-
mans and animals, and occurred even in dinosaurs. One in three
Swedes develops cancer during their lifetime, and the risk generally
increases greatly with increasing age. The development of a normal cell
into a cancer cell usually takes a long time – from 5-10 up to over 40
years. The reasons why animals and humans develop cancer are com-
47
plex and not fully known. Both genetics and environment can play a
role in the appearance of cancer. A higher dose of/exposure to the car-
cinogenic factor normally increases the risk. Dietary habits and smoking
are by far the most important factors contributing to the occurrence of
cancer in Sweden. UV radiation in sunlight (skin cancer) and radon in
homes (lung cancer) also contribute to the occurrence of a number of
cancer cases.
Within the work environment a number of chemical substances and

ionising radiation have been identified as carcinogenic factors. Inhala-
tion of carcinogenic chemical substances can cause cancer in the respira-
tory tracts and the lungs, sometimes also in the liver and urinary tracts
in connection with the breakdown and excretion of the substances.
Some substances, e.g. soot and tar, can cause skin cancer following
long-term direct contact with the skin. Radiation and chemical sub-
stances can also contribute to the occurrence of leukemia. The occur-
rence of other types of cancer may also occasionally be related to work
environment conditions.
For several decades the WHO’s International Agency for Research on

Cancer (IARC) has published monographs on chemical substances,
classifying them into risk groups, which has contributed to increased
knowledge about carcinogenic substances. The publication programme
has been broadened and the monographs now also cover exposure to
mixtures of chemicals and to other agents such as radiation and viruses
(IARC Monographs on the Evaluation of Carcinogenic Risks to Hu-
mans).
The Swedish Cancer Committee estimated at the beginning of the 1980s

that approximately 2 per cent of new cancer cases at that time had work
environment conditions as a contributing factor. Since that time, expo-
sure to (known) carcinogenic substances in the work environment has
been reduced. Still, in some workplaces there may be risks that need to
be prevented by means of occupational hygiene measures.
The Swedish Work Environment Authority’s provisions on occupation-

al exposure limit values and measures against air contaminants also
contain a list of known carcinogenic substances. Some of these may not
be used at all professionally, others only following a dispensation from
48
AFS 2005:6
the Swedish Work Environment Authority. Exposure to the rest is con-

trolled by means of applying limit values for levels in the air.
If several cases of cancer occur in a workplace it often causes great an-

xiety. Demands may come to be made for general health check-ups of
the rest of the staff in order to discover any possible further cancer cas-
es. The medical value of such a control is often debatable. In order to
establish whether the number of cancer cases in a workplace has in-
creased and whether it can have any connection with the work envi-
ronment, a complete epidemiological investigation is usually required,
preferably in collaboration with experts in the area, e.g. at a clinic of
occupational medicine. Such an investigation will take the exposure
conditions into account and also the amount of time which the em-
ployees in question were exposed to the suspected carcinogenic factor.
Differences in sensitivity
People vary in their sensitivity to risks in the work environment. Swe-

dish work environment regulations are intended to protect all em-
ployees. However, it is difficult to establish with scientific certainty the
limit beyond which damage results from strain, be it physical, chemical,
psychological etc. Sometimes technical shortcomings or financial con-
straints come in the way of regulations which would have provided
sufficient margins. For this reason it may be advisable to determine if
there is a need for specially adapting work routines in certain situations.
Such adaptation measures – e.g. improved lighting or acoustic condi-
tions – often result in a better work environment for all employees.
For most normally sighted people, the elasticity of the eye’s lens has
been so reduced by the age of around 40 that they experience some dif-
ficulty in seeing clearly at close range and in shifting quickly between
seeing at close range and at farther distances. With increasing age the
lens becomes more dense and may develop small areas of cloudiness.
This increases the need for good lighting conditions and also increases
sensitivity to blinding and light reflexes.
The risks of persistent strain injuries due to bad ergonomic conditions

increases after the age of 30, but particularly after the age of 50-55.
49
However, adaptation measures can be used to eliminate unsatisfactory
ergonomic conditions. Many people find that the strain of working at
night and of shifting between working at different times of the day and
night becomes harder to bear after the age of 45-50. Irregular working
hours and night work can also be unsuitable for people with hormone
imbalances such as in the case of diabetes or thyroid disorders.
Low blood count and iron deficiency are not uncommon in women of
child-bearing age. Aside from tiredness and lack of energy, iron defi-
ciency anaemia can cause an increased uptake of toxic metals such as
lead and cadmium – if they are present in the environment – as a side
effect of the increased need for iron. If inappropriate dietary habits are
the cause of the iron deficiency, it is often accompanied by deficiencies
of other metals and of various vitamins. This reduces the body’s ability
to repair damaged tissue and detoxify chemical substances. There are
thus both general health reasons and work environment reasons for
identifying and treating persons with iron deficiency or other deficien-
cies which are known to weaken the general state of health and the im-
mune system.
The significance of certain other medical conditions for the risk of occu-
pational injury is described in the special provisions on some types of
work with a particularly high risk level.
Under-age and pregnant or breastfeeding employees are groups which

may run particular risks of ill health and accidents, and for which there
are special work environment provisions. Hypersensitivity and the
hypersensitive are described under their own heading.
Allergy risks
Work-related allergies most often appear as contact dermatitis in the

form of hand or face eczemas or as respiratory complaints (allergic rhi-
nitis, asthma or alveolitis). Allergic contact dermatitis is due to an ac-
quired allergy against one or several specific substances in the envi-
ronment. The substances that most often cause contact dermatitis are
the metals nickel, chrome and cobalt, preservatives, fragrance sub-
stances, certain medicines, monomers of plastic, rubber chemicals and a
50
AFS 2005:6
large number of natural products (e.g. various terpenes). Contact der-

matitis (mainly hand eczemas known as irritant eczemas) can also be
caused by repeated skin contact with substances that irritate the skin,
such as work in wet conditions (most common) or work which involves
contact with solvents, oils, dry dust or dirt. The occurrence (one-year
prevalence) of hand eczemas in adults of working age has been esti-
mated at 10 per cent. Younger women are the most susceptible.
Most adults with asthma or allergic rhinitis have developed the com-
plaint during childhood or adolescence, but about 10 percent of new
adult occurrences of asthma are regarded as work-related. Common
respiratory allergens (which cause allergic rhinitis or asthma) in work
environments include bakery dust, thermosetting plastics, certain furry
animals, and organic dust in agricultural environments.
People with respiratory allergy problems, including problems which

have appeared outside of the work environment, often have difficulties
handling environments with irritant substances, not least tobacco
smoke, large amounts of dust, cold air with strong smells e.g. from fra-
grance substances. This is even if they are not allergic to any of the men-
tioned irritants. What they suffer from is known as a general hyper-
reactivity of the mucous membranes of the respiratory passages and the
eyes. Animal hairs in clothes can cause problems for colleagues with
allergies to furry animals.
The occupational exposure limit values for airborne contaminants are

intended to protect against the occurrence of new allergies, even if this
can sometimes be difficult in practice due to considerable individual
variations in sensitivity of the population. However, a person who has
already developed an allergy to a certain substance will become so sen-
sitive that air allergen levels far below the set limit levels will cause a
reaction. It is therefore urgent to avoid further exposure to the allergen
once hypersensitivity problems have developed. In some cases (e.g.
work involving certain thermosetting plastics) there is a direct ban on
further exposure.
Persons with allergies can have problems choosing certain types of

work. In some cases, e.g. respiratory exposure to many animal and
plant substances, an atopic individual runs a higher risk of reacting. On
51
the other hand it is often possible to protect oneself against sensitisation
by means of good working methods and good occupational hygiene in
the workplace – both things the employer is responsible for maintain-
ing. Atopic or allergic persons should not be excluded from jobs with
potential risks; instead the environment and the conditions for their
working there should be improved.
A good approach to dealing with persons judged to run a particular risk

of developing allergy problems in the workplace is to inform them tho-
roughly about the risks as well as the possibilities for preventive meas-
ures, and then let them make the assessment themselves as to whether
they are prepared to work there or not.
Environments with large amounts of micro-organisms and organic dust

are a special case. These might be e.g. animal stables, wood-drying
plants or hay barns. If exposures are high enough, employees may de-
velop an acute toxic inflammation of the pulmonary alveoli (alveolitis).
Repeated exposures can cause a chronic inflammation. In these situa-
tions it will be necessary to apply measures as specified in the provi-
sions on microbiological work environment risks, organic dust in agri-
cultural activities or wood mould.
A medical examination of employees with allergy problems or who are

going to work in an environment with allergy risks can, if it is judged to
be justified, be modelled on the basic medical examination described in
the section on thermosetting plastics.
52
AFS 2005:6
Medical supervision can sometimes be justified even in situations where
the provisions do not require it. This might apply e.g. for employees
working at night but for shorter periods than those specified in the pro-
visions on night work, or for individuals exposed to certain types of
vibrations. See the Comments on Section 3 also.
Additionally there are stipulations on medical supervision in other pro-

visions from the Swedish Work Environment Authority:
- for exposure to noise (hearing test),
- for work with display screen equipment (eye test),
- for work with laboratory animals (medical examination),
- for minors (medical examination in some situations),
- for microbiological work environment risks and
- for work with lasers (eye test).
As can be seen under the heading “Information from the Swedish Work
Environment Authority”, other government authorities also have provi-
sions on medical examinations or other medical supervision.
The advice to the patient can e.g. include information about the appro-
priate working method, the need for protective equipment, symptoms
which could be a sign of adverse effects, and possible interaction be-
tween work risks and lifestyle factors such as smoking. It is recom-
mended that the employee be given information and advice about con-
tinued medical supervision even after exposure has ceased, if this is
justified on medical grounds.
Provided the person examined has been informed of the purpose and
consequences of a medical examination, the examining doctor is at li-
berty to pass on information about employability or the results of the
biological exposure control to the employer or supervising authority.
Any diagnoses or other medical information are subject to professional
secrecy by the doctor pursuant to Chapter 2, Sections 8-9 of the Act on
Professional Activities in Health and Medical Services (SFS 1998:531) or
to secrecy pursuant to Chapter 7, Section 1 of the Secrecy Act (SFS
1980:100) and may not be disclosed to the employer without the ex-
amined person’s consent.
53
In the rehabilitation plan which must be drawn up in connection with
work adaptation and rehabilitation there is the option of specifying that
certain work tasks may not be carried out by the patient, but the inclu-
sion of any information about the diagnosis is strictly subject to the
patient’s consent.
As specified in Section 2, medical supervision may comprise various
measures such as medical examinations, analyses of biological samples,
interviews or questionnaires.
There can be many different explanations and reasons for illnesses and
complaints in examined employees, both in the work environment and
outside it. The increased occurrence of a disorder/illness in a group of
employees with a common risk factor in the work environment can of
course strengthen suspicions of a workplace connection. An investiga-
tion of working conditions may be necessary in order to assess any risks
and to determine what measures need to be applied. There can also be a
need to extend medical supervision in terms of scope or the number of
employees examined. Results of medical supervision can also indicate a
need for work adaptation measures for individual employees.
Health and safety representatives are entitled to receive any informa-

tion which is relevant to the exercise of their duty.
Medical examination
For the purposes of these provisions, a medical examination is an ex-
amination governed by health and medical services legislation and do-
cumented pursuant to the Patient Records Act (SFS 1985:562). The doc-
tor is responsible for the examination and the final medical assessments
and decisions that follow from it. A condition of the examination is that
the doctor meets the patient and makes the final employability assess-
ment which it often leads to. Certain elements of the examination may
be carried out by other staff, e.g. the collection of laboratory samples,
spirometry and interviews using questionnaires. The results of these are
54
AFS 2005:6
documented in the patient record along with health data. It is also the
examining doctor’s duty to follow up previously observed pathological
changes.
The doctor who makes the employability assessment also determines

the extent of any examinations deemed necessary in addition to the
requirements of the provisions. The employee is either declared fit for
work or unfit for work. See the comments on Section 2 also. If there is
uncertainty as to whether the employee’s state of health is an impedi-
ment to employability, it is recommended that the advice of an occupa-
tional health care clinic be sought. See the comment on the definition of
employability assessment also.
In addition to fulfilling the formal qualification requirements, any doc-

tor carrying out medical examinations pursuant to these provisions
must possess good knowledge of the patient’s occupational situation
and the risks associated with the work in question, as well as of the
patient’s state of health. For medical supervision which includes a re-
quirement for an employability assessment, the decision can have con-
siderable ramifications for the patient’s situation as he or she may risk
losing his or her job. This must be weighed against the perceived health
benefits underlying the requirement for an employability assessment.
That is why doctors carrying out such employability assessments must
possess special qualifications.
Medical examinations related to diving require special qualifications,

but no specialisation in diving medicine for doctors exists in Sweden at
the present time. In collaboration with the Karolinska University Hos-
pital and the Karolinska Institute, the Armed Forces offer annual
courses in diving medicine which have been quality assured by the
European Diving Technology Committee (EDTC) in collaboration with
the European Committee for Hyperbaric Medicine (ECHM) regarding
the “Medical Assessment of Working Divers”. Similar training is of-
fered in several EU member states.
Data on registered physicians and their specialities is available in a cata-

logue published by the National Board of Health and Welfare which
can be ordered from order.fritzes@nj.se Data on doctors and dentists
who have completed training in diving medicine can be obtained from
55
the Armed Forces or from the Swedish Society for Hyperbaric Medicine
(SHMS).
Most of the prescribed examinations are recurrent at varying intervals.

In order to be able to monitor the course of an illness over an extended
period of time – and as this is also valuable for a possible assessment of
an occupational injury – it is recommended that patient records be arc-
hived for at least ten but preferably fifty years, or for the patient’s life-
time. It is advisable that documentation of the medical supervision (e.g.
copies of the patient record) accompany the patient if her or she
changes occupational health services or other medical entity in charge
of carrying out the supervision.
Register
Regarding registered data as specified in a), b), c) and d) there are pro-
visions in Section 3 of the Work Environment Ordinance (1977:1166)
about storage for forty years, and regarding data as specified in e) for
ten years.
As specified in the provisions on occupational exposure limit values

and measures against air contaminants, employers must keep a register
of employees who are exposed to carcinogenic substances in work and
where exposure could pose a risk of ill health. It is advisable to coordi-
nate such a register with the register specified in Section 9.
Section 3 of the Work Environment Ordinance stipulates that a register

must be kept by the employer for a certain minimum time. If the activi-
ty is transferred to new ownership, the register must be handed over to
the new owner. Under the Personal Data Act (SFS 1998:204) each em-
ployee must have access to the data in the register that concerns him or
her personally.
There is no legal obstacle to the register being kept, at the employer’s

request, by e.g. occupational health services. This is on condition, how-
ever, that access to the register by the supervising authority is not re-
stricted e.g. in connection with a change of occupational health services.
56
AFS 2005:6
It is important that extracts from the register can be presented when the
Swedish Work Environment Authority makes pre-announced
workplace visits.
Information to send to the Swedish Work Environment Authority
Reports are to be sent to the Swedish Work Environment Authority in
the district where the activity is located.
The submitted information should include data on the number of em-

ployees who have undergone periodic medical examinations as well as
their distribution in the following categories:
- employable for the work in question and
- not employable for the work in question.
The data submitted on periodic biological exposure control on blood

levels of lead or cadmium is to be divided by gender (for women also
by the age categories Under/Over 50 years of age) and by different
blood levels of lead and cadmium. The name of the laboratory that car-
ried out the tests must also be given.
Suggested report format
The report should follow the template available on the Swedish Work
Environment Authority’s website www.av.se Suggestions for report
formats are also provided in Appendixes 5 and 6.
Copies of the reports may be sent in electronic format provided the

employer has made sure beforehand that the Swedish Work Environ-
ment Authority is able to receive and read it.
Doctor’s reporting of illness
Under Section 2a of the Work Environment Ordinance, doctors must
report to the Swedish Work Environment Authority any such illnesses
as may be connected with work and are of interest from a work envi-
57
ronment perspective. The purpose of these reports is to bring to the
Swedish Work Environment Authority’s attention risks in the work
environment which have caused ill health or accidents. This is so that
the Swedish Work Environment Authority be able to assess what meas-
ures may be needed in order to prevent further cases. It could e.g. be a
matter of increasing supervision in the area, of revising or issuing new
regulations.
In judging what is new, unusual, more than expected, etc. it is reasona-

ble for the doctor to refer to his or her general appraisal of the condi-
tions based on his or her own knowledge and experience in the area.
The report is not expected to be preceded by any mathematical calcula-
tions or analyses of research in the area. Such calculations are of course
welcome anyway from those who have the possibility of making them.
Doctors may of course also report other types of illness if they regard
this as justified. The doctor must also be prepared to give information
and assistance to the Swedish Work Environment Authority.
The report is to be sent to the Swedish Work Environment Authority,

171 84 Solna. The template in Appendix 7 offers a suitable format. The
report should be de-identified if possible and may concern individual
cases of illness/ill-health as well as more general observations of e.g. an
increase in certain diagnoses in certain types of work or in certain types
of worksites.
It is important to distinguish this report from the occupational injury

report that he employer must send to the social insurance office
(Forsäkringskassan) and from the report the employer must send, pur-
suant to Section 2 of the Work Environment Ordinance, to the Swedish
Work Environment Authority in the case of serious injuries and acci-
dents.
Obligatory medical supervision
Work involving lead and cadmium
Health risks
58
AFS 2005:6
Lead
Work involving inorganic lead occurs in metal foundries, smelting

works, in battery manufacture, scrap metal handling, painting with
paints containing lead, the manufacture of enamel, brass, tin and bronze
goods, the manufacture of certain plastics, the manufacture of glass and
ceramics, and in the manufacture and use of ammunition.
Acute lead poisoning can occur following the inhalation of lead smoke
or dust with a high concentration of lead, e.g. when cutting red lead or
other materials with a high lead content. Symptoms include stomach
pain (lead colic) and headaches, irritability and other symptoms from
the nervous system. Acute occupational lead poisoning is a rare occur-
rence in Sweden today.
Long-term exposure may affect, above all, the blood and blood forma-
tion, the peripheral and central nervous system, and the kidneys. Early
signs of lead effects include a disturbance of the production of the blood
pigment haemoglobin and damage to the red blood vessels, to which
the lead primarily binds. Anaemia can be a consequence of this. Proven
effects of longer-term lead exposure include damage to the central
nervous system with effects on memory, reaction times and perception.
Absorbed lead accumulates in the skeleton, which can hold up to 90 per

cent of the body’s total lead content. Deposition in the skeleton can lead
to a prolonged half-life period in the blood of older lead workers who
have had long-term exposure. The release of lead from bone increases
during periods of increased bone demineralisation, e.g. in connection
with pregnancy and breast-feeding.
Children are more sensitive to lead than adults, especially with regard
to the functions of the brain. Foetuses are a particular risk group. The
lead is passed across the placenta to the blood of the foetus. Conse-
quences such as effects on the nervous system and a risk of mental ef-
fects on the child are proven and may occur even at lower exposure
levels. This is the reason behind the special limit values for women who
work with lead. Lead is also released in breast milk. Under the provi-
sions on lead, pregnant and breast-feeding employees may not be en-
gaged in work involving lead.
59
Some studies indicate that lead exposure can cause genetic damage and
possibly affect reproductive functions, though the results are not unam-
biguous.
Lead poisoning can also occur through lead intake via the mouth. There
have been cases of poisoning when people have stored e.g. juice in ce-
ramic vessels with glazing that contains lead.
Organic lead compounds such as tetraethyl lead generally have a higher

toxicity than inorganic ones. They primarily affect the nervous system
and its mental functions. Sleeplessness, lack of appetite and psychotic
states have been reported. Death has also been known to follow on
acute poisoning, though not recently in Sweden as far as is known.
Following several measures to limit the use of lead in various contexts,

the spread of lead in the Swedish environment has been reduced and
the blood lead levels of people who are not occupationally exposed
have thereby also been reduced.
Cadmium
Use of cadmium has lessened, and occupational exposure is no longer

as extensive as it was. Cadmium compounds are used as paint pigments
and in the manufacture of batteries. The biggest use of cadmium in
Sweden is in rechargeable NiCd batteries. Soldering metal used for
soldering tools and in goldsmiths’ may contain cadmium. Cadmium
also occurs as a contaminant in phosphate fertilisers, and some cad-
mium intake can occur via food.
Exposure to cadmium can cause damage to the lungs, kidneys and ske-
leton, and some studies indicate a connection with the occurrence of
cancer. The principal exposure route in work involving cadmium is
inhalation of dust or smoke containing cadmium. The uptake of cad-
mium may increase with iron or calcium deficiencies, for example.
Blood cadmium levels can therefore be higher in persons with low body
iron.
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AFS 2005:6
Lung damage
Inhalation of cadmium oxide smoke (around or exceeding 0.5–1 mg
Cd/m3) during a few hours can cause chemical pneumonia and, in se-
rious cases, lung oedema. Deaths have occurred following exposure to
very high concentrations of cadmium oxide smoke (around or exceed-
ing 1–5 mg Cd/m3) in connection with welding and soldering. Long-
term exposure to lower concentrations of cadmium (around 150 μg
Cd/m3) can cause a permanent reduction of the lung function.
Kidney damage
The earliest effect of long-term – as a rule, several years’ – exposure to
cadmium is a specific type of kidney damage (tubular kidney injury).
This injury can appear after many years’ exposure to atmospheric levels
of around 20-50 μg Cd/m3. If the exposure is much higher, the injury
can appear after a shorter time. In serious cases, such kidney injury can
lead to reduced urine filtering (glomerural filtration) and in rare cases
urine poisoning (uremia). The injury can probably also contribute indi-
rectly to the development of kidney stones.
Osteoporosis
Several scientific studies have indicated a connection between cadmium
exposure – both in the work environment and in the general population
–, reduced bone density and an increased risk of fractures.
Medical examination
An important aim of the medical examination is to prevent any em-
ployee who has an illness or debility which can be associated with an
increased risk of ill health following lead or cadmium exposure from
doing work involving lead or cadmium respectively.
Another important aim of both the medical examinations and the peri-
odic biological exposure controls is to discover, at an early stage, an
increased uptake and accumulation in the body of lead and cadmium
respectively. In such cases, ill health effects can be prevented by lower-
ing or interrupting exposure. In some cases it is appropriate for the
medical examination to be done more frequently than every third year,
61
e.g. if there are signs of disruptions to the kidney function or if blood or
urine levels of lead or cadmium are high or increasing.
It is appropriate during the medical examination to provide information

about the health risks associated with work involving lead or cadmium.
It is important to stress the significance of good personal hygiene, since
lead or cadmium dust on the hands when eating, applying cosmetics or
smoking can increase exposure. It is also important that smokers be
informed about the special risks they may be exposed to because of
tobacco’s cadmium content.
Lead
The nervous system, both central and peripheral, is a critical target or-
gan. There is also reason to examine heart and vascular functions in-
cluding blood pressure, as well as the kidney function. Other conditions
which may also draw the doctor’s attention include any signs of disrup-
tions to haemosynthesis. Other blood diseases must be noted. Porphy-
ria, which implies difficulties in establishing possible lead effects, is a
strong reason against employment in work involving lead. The analysis
can further include any examination the doctor deems to be justified by
lead exposure.
Cadmium
It is appropriate for the medical examination of employees in work in-
volving cadmium to be focused principally on the kidney function. An
early sign of tubular kidney effects is increased release into the urine of
low-molecular proteins, e.g. α1-microglobulin (protein HC), ß2-
microglobulin or of the tubular enzyme N-acetyl-ß-glucosaminidase
(NAG). In order to avoid diurnal variations, all urine samples can be
collected at the same time of day. It may be justified to examine blood
and liver status and the lung function following high cadmium expo-
sure. The analysis can further include any examination the doctor
deems to be justified by cadmium exposure.
If there is uncertainty as to whether the employee’s state of health is an

impediment to employability in work involving cadmium, it is recom-
mended that the advice of an occupational health care clinic be sought.
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AFS 2005:6
Below are comments and guidelines regarding the assessment of the

urine levels of cadmium and low-molecular proteins, and of low-
molecular proteins and creatinine in serum.
Cadmium in urine
The urine level of cadmium is usually dependent on the body burden
and thereby also on the cadmium content in the cortex of the kidney.
Following high exposure levels, however, urine levels can increase
dramatically, which is then more likely to be a reflection of the ongoing
exposure. Urine levels can also increase dramatically if a kidney injury
occurs. Persons who are not occupationally exposed usually have a
release which is lower than 1 μmol Cd/mol creatinine in their urine.
Smoking and advanced age increases the body burden and thereby also
the urine levels of cadmium. In some cases, kidney damage will only
appear several years after exposure ended. This is probably due to
cadmium being stored in the liver, from where it is slowly released and
then accumulates in the kidneys. It is important to keep exposure so
low that kidney damage is prevented, since tubular kidney effects can
deteriorate into permanent damage, in particular if exposure continues.
Recent data indicate a slightly increased risk of tubular kidney damage
at urine levels as low as 1–3 μmol Cd/mol creatinine.
When the urine level of cadmium exceeds 2 μmol Cd/mol creatinine it

is important to analyse the reason for this and to apply measures to
reduce cadmium uptake. It is a good idea to repeat the test and to sup-
plement it with a measurement of e.g. low-molecular proteins in the
urine, and possibly with further kidney function examinations. When
the urine level of cadmium exceeds 5 μmol Cd/mol creatinine it is ap-
propriate to contemplate a transfer to another post. In the assessment of
such a transfer it is important to consider the individual’s current and
earlier exposure to cadmium, the accumulation rate of cadmium in the
body, as well as other biological factors such as age, smoking etc. Be-
cause cadmium has such an extended release period, it can take a very
long time before the urine levels of cadmium drop.
Markers for kidney effects in urine

As has been mentioned, the currently most sensitive method of disco-
vering early cadmium effects is the measurement of low-molecular pro-
teins, e.g. α1-microglobulin (protein HC), ß2-microglobulin or retinol-
63
forming proteins in urine. A very small reduction of the tubular re-
resorption function causes a marked increase in e.g. microglobulins in
urine. The marker ß2-microglobulin, which was previously the most
used, is broken down at a low pH (≤ 5.6). The marker protein HC (α1-
microglobulin) is not as pH dependent (stable down to pH 4.5) and is
today used more often as a first-hand indicator for tubular kidney dam-
age. It is advisable to contact the analysing laboratory for instructions
prior to taking samples. The release of ß2-microglobulin in persons who
are not occupationally exposed is generally less than 0.034 mg/mmol
creatinine (equivalent to 290 mg/l in urine at a density of 1.023 g/m3).
Correspondingly, the release of α1-microglobulin in persons who are
not occupationally exposed is ≤ 0.7 mg/mmol creatinine (equivalent to
≤ 10 mg/l in urine).
If the urine release of α1-microglobulin or ß2-microglobulin is above

these levels, an investigation of present and previous cadmium expo-
sure should be carried out urgently, as should any measures to improve
the work environment that the investigation implies. It is also important
that the individual’s uptake of cadmium is promptly reduced, e.g. by
means of a transfer to work which does not involve cadmium exposure.
Low-molecular proteins and creatinine in serum

A determination of low-molecular proteins and creatinine in serum
provides some basis for an assessment of the glomerular filtration rate.
For persons exposed to cadmium who do not have increased levels of
markers for kidney damage in their urine, or who do not run an ele-
vated risk of kidney damage, it can be appropriate to examine the glo-
merular filtration rate approximately every six years, and in other cases
more frequently. However, it is essential to take into account that even
in serious cases of chronic cadmium poisoning, the filtration rate can be
relatively good.
Periodic biological exposure control for work involving lead
Comments to Sections 17-20

In applying Sections 18 and 19, the blood lead level control prior to
employment is included in the three-month controls. A summary of the
measures applied for different lead levels is provided in Appendix 2. In
order to avoid women of child-bearing age accumulating a lead deposit
64
AFS 2005:6
in their bodies, biological exposure controls are expanded for women

under the age of 50, so that even those with the lowest exposure will be
regularly controlled. This allows for lead exposure to be monitored and
for measures to be applied in order that the risk of effects on the foetus
in a possible pregnancy are reduced.
The analyses must be carried out by a laboratory that uses appropriate

analysis methods. Accredited analytical laboratories generally use relia-
ble analysis methods. It should be observed, however, that accreditation
often only covers certain analyses. Other laboratories can also have ap-
propriate and reliable analysis methods. It is essential that analytical
laboratories practice quality management which should include both
internal and external quality control.
The lead level in the work environment is monitored principally by

controlling the atmospheric concentration, so that the concentration is
acceptable in relation to the occupational exposure limit levels. If the
blood lead level of any woman under the age of 50 were still to exceed
1.0 μmol/l, or the level of any woman above the age of 50 or of any man
exceed 1.8 μmol/l, it is important to investigate the causes. Such inves-
tigations should include a discussion with the employee about working
methods and protective equipment, as well as a review of personal hy-
giene conditions, possible leisure exposure to lead, etc.
If no explanation is found for the high blood lead level, or if increased

levels have been observed in several employees in the same worksite, it
is important that the investigation is broadened to include a general
review of technical equipment, work routines and other work environ-
ment conditions.
In addition to measures to improve the work environment, a temporary

measure prompted by Section 21 could be a reduction of the number of
hours spent in work involving lead exposure, along with the possibility
of compensation for any associated loss of income.
65
Periodic biological exposure control for work involving cadmium
Comments on Sections 22-25

The blood cadmium level primarily reflects the body’s uptake over the
past few months. However, if earlier exposure was high compared to
current exposure, the blood cadmium level may be a reflection of the
body burden rather than the current exposure level.
Studies show that the blood cadmium level of persons not occupational-
ly exposed varies on average from 1–4.5 nmol/l for non-smokers and
up to 9–10 nmol/l for smokers. However, older heavy smokers can
reach much higher blood levels of cadmium. Older non-smoking per-
sons also have higher blood cadmium levels than younger persons at
similar current exposure.
The purpose of the periodic controls is to detect, at an early stage, an

increased uptake of cadmium and thereby prevent its adverse health
effects. The intervals indicated apply to both full-time and part-time
work. In order to avoid adverse health effects of cadmium it is impor-
tant that the blood cadmium level does not exceed 50 nmol/l. If the
blood cadmium level of anyone exceeds 50 nmol/l the causes for this
must be urgently investigated and any necessary measures to reduce
uptake applied. A summary of measures for different cadmium levels is
provided in Appendix 2.
For information regarding analytical laboratories, see the comments on

Sections 17-20.
A high blood cadmium level can in some cases also be due to previous
exposure conditions and an associated sharp increase in the body bur-
den of cadmium, which can mean that older persons will have higher
blood cadmium levels than younger persons at similar current expo-
sure. An investigation should include an analysis of previous exposure,
current working methods and use of safety appliances and personal
protective equipment, as well as a review of personal occupational hy-
giene conditions and working habits. It may also be appropriate to de-
termine urine levels of cadmium and possibly of α1-microglobulin or
other markers for kidney damage.
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AFS 2005:6
It may also be important to note other types of exposure besides occu-

pational exposure, e.g. a high intake via food. In older heavy smokers
the blood cadmium level can be very high, approaching 50 nmol/l in
extreme cases. Blood cadmium levels that high in non-smokers would
be extraordinary. In cases where an increased blood cadmium level can
be explained by smoking habits, the Section’s requirement for an inves-
tigation does not imply any extensive work environment measures, but
suggestions for such measures as improved hand hygiene may contri-
bute to reduced exposure.
If an investigation does not produce any explanation for observed in-

creased blood cadmium levels in individual employees, or if increased
blood cadmium levels have been observed in a number of employees in
the same worksite, it is important that the investigation is broadened to
include a general review of technical equipment, safety regulations and
work routines as well as other work environment conditions.
In addition to measures to improve the work environment, a temporary

measure could be the reduction of the number of hours spent in work
involving cadmium exposure.
Dispensation
Some employees who have been exposed to lead or cadmium over a
prolonged period of time may have accumulated such large quantities
of lead or cadmium in their bodies that a return to acceptable blood lead
or cadmium levels will take a very long time. For such persons the
Swedish Work Environment Authority may exceptionally grant an in-
dividual dispensation from the rules on interruption of work, prefera-
bly following consultation with occupational medicine expertise. Such a
dispensation may also lead to a need for extra or more frequent medical
supervision.
If, as a consequence of these provisions, a person may no longer be em-

ployed in work involving lead or cadmium, and the employer is unable
to offer work without lead or cadmium exposure with maintained sala-
ry benefits, the social insurance office may, following a review, grant
67
compensation pursuant to the stipulations in Chapter 6, Section 4 of the
Occupational Injury Insurance Act (SFS 1976:380).
Applications for dispensation must be sent to the Swedish Work Envi-

ronment Authority in the district where the activity is located.
Work involving dust which may induce fibrosis: asbestos, quartz

and certain synthetic inorganic fibres
Health hazards
The health effects of dust particles are determined by a number of the

particles’ characteristics. Size, shape, components, bioaccessibility and
biopersistence are all significant. Irritations to the skin, eyes and upper
respiratory tracts are primarily caused by articles bigger than approx. 5
μm, while particles smaller than that can penetrate deeper into the res-
piratory tracts and be deposited in the smallest bronchi and the alveoli.
Irritation to the eyes and upper respiratory tracts can be the earliest
effect (which occurs at the lowest dose). This applies in particular for
work involving synthetic inorganic fibres and often occurs by means of
a direct mechanical effect on the mucous membrane. Deposited par-
ticles have been shown to cause direct damage to mucous membrane
cells. They also affect the stability of the tear film’s surface layer.
The body’s normal reactions to foreign material deposited in pulmo-

nary tissue include local sensory nerve irritation and inflammatory
reactions. These are acute defence mechanisms and are generally of a
temporary nature. The symptoms are itching and irritation of the muc-
ous membranes.
Long-term or repeated exposure can give rise to more lasting reactions

such as the fibrotisation of pulmonary tissue and tumours.
How long the particles remain in the tissue is decided to a large extent
by their form and chemical composition. The cilia in the respiratory
tract epithelium are important in removing deposited dust and fibres
and transporting them to the throat, were they are mostly swallowed.
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AFS 2005:6
For this reason, the damage caused by smoking to mucous membranes

and cilia in the respiratory tracts has a notable effect on their ability to
protect against and purge deposited particles and fibres.
Persons with sensitive respiratory tracts in the case of e.g. asthma may
experience considerable difficulties with irritation caused by dust in
certain types of work. Examples include construction workers, electri-
cians and insulators.
Other effects than those on respiratory tracts can also occur. Skin irrita-
tions are caused mainly by direct skin contact with dust, and can be
avoided with appropriate protective clothing. Skin reactions can also be
caused by the additives that exist in certain materials. For example, the
epoxy resin and urea-formaldehyde resin additives to mineral wool can
cause allergic reactions. Persons with a tendency to develop eczemas,
e.g. persons with atopic eczema, may experience considerable difficul-
ties when exposed to dust.
Asbestos
Asbestos did not begin to be used on an industrial scale until the early
20th century. In Sweden its importation and use was at its highest in the
1960s. A ban on using asbestos in certain areas of the building sector
from 1976 was followed by a general ban in 1982, with specified excep-
tions that required a permit. Examples of occupations in which asbestos
exposure used to occur/occurs include construction work, plumbing
insulation, shipyards, furnace renovation, ventilation service (older)
and brake lining work.
There are a number of illnesses of the lower respiratory tracts which are
associated with asbestos exposure. These are pleural plaque, pleurisy
(acute and chronic), pulmonary fibrosis-asbestosis, bronchial cancer and
mesothelioma. Pleural plaque occurs in the parietal pleura and has a
latency of 20–50 years after exposure has begun. It is a clear marker for
asbestos: 90 percent of sufferers have been exposed in work or leisure
time. Another pulmonary sac manifestation is pleurisy, which can ap-
pear after a few years’ latency. Compared with pleurisy caused by other
factors, the asbestos-related kind often has few symptoms and is often
69
detected as a secondary condition. It frequently recurs and can become
chronic, leading to a thickening of the pulmonary sac and a reduction of
the lung function.
Asbestosis involves a fibrotisation of the lungs. The clinical symptoms

are exertion dyspnoea and rale from the lung bases on inhalation. Spi-
rometry will indicate restrictive lung disease. Reduced diffusion capaci-
ty, lung stiffening and reduced compliance can also occur. Lung biopsy
samples will show diffuse interstitial fibrosis (fibrotisation). Exertion
tests with blood oxygenation testing may show reduced oxygen levels.
Typical pneumonography changes for asbestos are:

- reticular interstitial pattern which typically begins at the base and
progresses upwards,
- possible occurrence of pleural plaque as a marker for asbestos
exposure
- if the illness is advanced, high resolution computed tomography
(HRTC) will show a honeycomb appearance of the pulmonary tissue.
There is a relatively clear connection between asbestos exposure and a

reduction of the lung function. The cumulative dose is often measured
in fibre-years/ml. There are research compilations in which reduced VC
(Vital Capacity) is estimated in per cent per fibre-year/ml. According to
a Swedish compilation this reduction of VC is estimated at 0.1 % per
fibre-year/ml, but varies in the literature between 0.01 and 0.3 %. As a
rule, asbestosis is a high-exposure illness.
Lung cancer caused by asbestos exposure is usually bronchial cancer,

and smoking raises the cancer risk considerably. As with asbestosis, the
risk is proportional to the (cumulative) dose. Latency is often 20-30
years. It is not clear if different types of asbestos imply different lung
cancer risks. Smoking in combination with asbestos exacerbates the risk,
but if the smoker stops smoking there is a reduction in risk even if
he/she has previously been exposed to asbestos.
Mesothelioma is another form of cancer which (in 90 per cent of cases)

is related to asbestos exposure. The latency is often very extended, 30–
60 years. Since this form of cancer is very unusual among people who
have not been exposed to asbestos, it may be assumed that a majority of
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AFS 2005:6
the cases in Sweden today (about 100 new cases a year) are due to earli-
er asbestos exposure.
Quartz
Exposure to quartz dust occurs in the processing of materials containing

quartz or through exposure to quartz dust e.g. in mining work, tunnel
driving, sandblasting, furnace repairs and at foundries. The lung dis-
ease silicosis or Potter’s rot, which is caused by quartz, was the most
common occupational lung disease in Sweden during the first part of
the 20th century, with 100-150 new cases a year around the middle of the
century. Exposure to quartz has been shown to imply an increased risk
of lung cancer as well. The inhalation of quartz dust does not cause any
acute disorders such as coughing or irritation of the respiratory tracts.
Instead the symptoms appear insidiously, usually after extended expo-
sure. Symptoms of silicosis include shortness of breath on exertion and
sometimes a dry cough. The typical pneumonography change is pro-
gressing irregular patches of induration, mainly located in the upper
half of the lung area.
Pulmonary physiology does not follow a characteristic pattern. There

can be major pneumonography changes with only a minor reduction of
the lung function. Clinically physiological finds are reduced vital capac-
ity and total lung capacity (restrictive picture). Increased lung stiffness,
reduced diffusion capacity and lowered arterial blood gas level (during
exertion) can also occur.
There are a number of conditions that worsen the prognosis for quartz
exposure. It is important to diagnose these conditions during the medi-
cal examination of new employees in order to avoid sensitive persons
being subjected to hazardous exposure. The conditions are obstructive
or restrictive lung disease, thorax deformities, rheumatoid arthritis
(Caplan’s syndrome) and tuberculosis.
Certain synthetic inorganic fibres
The Swedish Work Environment Authority’s provisions on synthetic

inorganic fibres specifies what level of fibre exposure is covered by
71
medical supervision. For synthetic inorganic vitreous fibres it is expo-
sure to refractory ceramic fibres and special purpose fibres, as well as
exposure to synthetic inorganic crystalline fibres that require medical
supervision to be carried out.
Inhalation studies in rats have shown that refractory ceramic fibres can
cause lung cancer, mesothelioma, pleural plaque and fibrotisation. Stu-
dies in humans have shown the development of pleural plaque and a
reduction of the lung function, particularly in employees who smoke.
Crystalline silicon carbide fibres have been shown in animal studies to

cause fibrotisation of the lungs and lung cancer. Occupational epidemi-
ological studies suggest a risk for fibrotisation of the lungs and lung
tumours.
A fibre with a crystalline structure can more easily split longitudinally,

increasing its surface area per unit of weight, which is believed to affect
its bioactivity. There are examples of synthetic inorganic crystalline
fibres which in animal studies have proven more important for fibroti-
sation and tumour development than asbestos, among them fibres of
potassium titanate. Aside from the shape, which determines bioaccessi-
bility and biopersistence, the chemical composition can have direct toxic
effect on cells and cell organelles.
Medical examination
In the anamnesis it is important to take the work history into account
and focus in particular on exposure to fibre-containing or other dust
that can cause fibrotisation in the lungs. It is furthermore advisable that
the anamnesis covers illnesses of the respiratory organs as well as earli-
er and present habits regarding smoking.
In terms of clinically physiological examination methods when looking

at silicosis, it is important to carry out an examination with simple spi-
rometry (vital capacity, VC, and forced expiratory volume during the
first second, FEV1).
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It is of great importance that the lung function examinations are carried

out in a standardised manner by specially trained staff and with quality
control. This means that an examination should include at least three
repeated measurements with less than 5 per cent deviation between the
curves. The curves should be measured in the same body position. Cali-
bration of the equipment should be done regularly, and the measure-
ments should all be carried out in a similar environment in terms of
temperature and humidity.
In addition the investigation can include any examinations that the doc-
tor deems to be justified by the exposure to substances harmful to the
lungs.
It is important that the medical examination includes information about

the health risks, not least the risk posed by smoking.
The purpose of periodic medical examination is to establish, as early as
possible, any pathological changes, primarily in lung tissue or pulmo-
nary sac, and to ascertain if in individual cases there is a need to for
further medical analysis with reference to examination finds.
The periodicity given here also applies to employment which is inter-

rupted and then resumed. In those cases where the exposure has ex-
ceeded about ten years it may be appropriate for the periodic medical
examinations to continue even after the exposure has ceased complete-
ly. Following the end of exposure or the cessation of employment, the
employer no longer has an obligation to arrange medical examinations.
They are nevertheless recommended since illnesses can develop after
20–40 years’ latency.
Besides the medical examination as specified in Section 29, the most

indicated further examination to complement the periodic medical ex-
amination when effects on the lung function are suspected is an ex-
panded lung function examination, possibly in consultation with a lung
specialist, physiologist or a specialist in occupational medicine.
If there are any doubts in the interpretation of the radiograph, specialist

help can be sought from a clinic of occupational medicine, a lung clinic
73
or a radiography diagnosis department. All lung radiographs should be
controlled by a doctor who is familiar with the kind of changes that the
exposures in question can cause.
Such illness or debility would primarily be a lung disease at an active
stage, or one which had caused a remaining reduction to lung function.
It would not, however, be a well healed tubercular primary complex or
an uncomplicated pleural plaque.
Smoking in itself, as well as such uncomplicated chronic bronchitis

which is conditioned solely by smoking would not, either together or
separately, normally be regarded as an impediment to work, while to-
bacco-conditioned changes to pulmonary tissue, e.g. chronic obstructive
pulmonary disease (COPD), need to be considered in the employability
assessment. However, the examined person should always be carefully
informed about the considerable synergism (reinforcing effect of two
simultaneously occurring factors) which often obtains between smoking
and exposure to lung-harming environmental factors with regard to the
risk of developing serious lung disease. See the section on health ha-
zards as well.
Work involving thermosetting plastics
Health hazards
In general terms, ready manufactured thermosetting plastics, or ther-

mosets – which have cured completely – do not imply any health ha-
zards in normal use. However, certain residues of thermoset compo-
nents may remain in the cured product and can in rare cases cause
complaints in already sensitised persons.
Many of the key substances used for the manufacture of thermosets are
very reactive and frequently biologically active, which can lead to irrita-
tion and allergy reactions of the skin and mucous membranes. The same
risks may be present in the handling of thermosets which have not
cured completely, and thermoset waste.
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On thermal degradation of thermosets and some thermoset compo-

nents, and of blocked isocyanates, degradation products are formed
which, if absorbed via the respiratory organs, can pose a serious health
hazard.
Most acrylate components cause irritation of the eyes, skin and respira-
tory tracts. Irritation may occur in the event of exposure to vapour,
aerosol and dust from such products. Asthma can also occur. Dust gen-
erated by the machining of cured acrylate plastic can also produce simi-
lar effects, due to residues of some uncured component in the end
product. It is the acrylate component's content of acrylate monomers
which poses the greatest health hazard, but this hazard can also be
compounded by the component’s content of oligomers and prepoly-
mers.
Acrylate components, as a rule, are sensitising on coming into contact

with the skin, i.e. they can cause allergic contact dermatitis. Metacry-
lates are generally less sensitising than the corresponding acrylates.
Dental care personnel are a particularly vulnerable occupational catego-

ry. Although they handle only small quantities of material for each fill-
ing, this work is repeated a number of times every day. The uncured
acrylate components used in dental care are often highly allergenic.
Ultraviolet radiation (UV radiation), which is used to cure certain acry-

lates, can be hazardous primarily to the skin and eyes. Ozone, which is
formed in UV furnaces above all when the UV lamps are switched on,
can cause irritation to the eyes and respiratory tracts even at low con-
centrations. The ozone thus formed is normally removed by means of
the ovens’ built-in ventilation system.
In the production of polyurethane plastics, diisocyanates often consti-

tute the biggest health hazard. These hazards occur above all when
isocyanates are inhaled in the form of vapour, dust or aerosol (mist).
Inhalation can cause irritation of the mucous membrane followed by
asthma or bronchitis-like symptoms from the respiratory tracts and
reduced lung function. There is a high risk of hypersensitivity. A sensi-
tised person can experience considerable problems even at concentra-
tions below the occupational exposure limit values. For this reason,
75
work involving isocyanates is covered by the requirement for periodic
medical examinations with employability assessment as specified in
Sections 36-38.
Isocyanates can also cause irritation to the eyes and skin. Repeated skin
contact with isocyanates can lead to eczemas and skin sensitisation.
Isocyanate hypersensitivity usually develops simultaneously with res-

piratory tract hyper-reactivity. Hyper-reactivity means that a person
reacts even to strong smells, e.g. perfume, to generally irritating sub-
stances such as tobacco smoke and vehicle exhaust fumes or to cold air.
Such a person can thus become severely functionally disabled even
outside of work. Hyper-reactivity can also remain after the exposure to
isocyanate has ceased. Exposure to tobacco smoke can sustain a pre-
viously established hyper-reactivity.
In the urethane plastic industry, amines are often added to the compo-
nent mixture as a means of catalysing the polymerisation reaction. Ex-
posure to high concentrations of amines can cause eye, skin and respira-
tory disorders including asthma. Uncontrolled exposure to amines can
thus imply considerable health hazards.
The most common health hazards in the production and handling of

epoxy plastic are skin sensitisation and allergic contact dermatitis. The
production of certain types of epoxy plastic makes use of certain organic
acid anhydrides. These can cause allergic reactions in the respiratory
tracts, such as rhinitis and asthma, even at very low atmospheric con-
centrations. For this reason, work involving organic acid anhydrides is
included in the category requiring regular medical examinations with
an employability assessment.
Information on the risks of work involving reinforced ester plastic is

provided in the comments on Sections 39-40.
Medical examination

The stipulations on medical examinations are aimed at detecting em-
ployees who could more easily experience adverse effects to their health
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AFS 2005:6
if they were exposed to a thermoset component or to air contaminants

formed in the thermal degradation of thermosets. It is very important
that persons with asthma and bronchitis are informed of the risk that
these conditions will deteriorate in the event of exposure to certain
thermoset components. Nose disorders (rhinitis) can also be a sign of
damaging effects.
Spirometry should include the determination of vital capacity (VC) and

forced expiratory volume during one second (FEV1). The technical pro-
cedure for spirometry is described in the comments on Section 29. It is
important to pay special attention to changes to the lung function in
relation to previous examinations.
Note that early asthmatic changes can sometimes be difficult to estab-

lish and that asthmatics in many cases return a completely normal re-
sult in a spirometry examination. It is therefore important to be obser-
vant of persons who experience breathing difficulties at night, at the
end of the working day or on exertion, since these symptoms may be a
sign of effects on the respiratory tract. An additional investigation with
repeated measurements of the peak expiratory flow (PEF) over the
course of several days and nights, both during work and leisure time, is
advisable. It is a good idea to carry out such an investigation in collabo-
ration with a specialist in occupational medicine or pulmonary medi-
cine, or with an allergy specialist.
Sometimes the result of the spirometric examination can deviate some-

what from the norm without being indicative of obstructivity. It may be
appropriate to complement the spirometric examination with what is
know as a reversibility test. This involves repeating the spirometry after
the patient has been given an inhalant to widen the bronchial tubes.
Certain thermoset components cause irritation to the skin. Since all

forms of hand eczemas can worsen on contact with skin-irritating sub-
stances, it is inappropriate for persons with frequently recurring or on-
going hand eczemas to be employed in the handling of skin-irritating
thermoset components.
Allergic contact dermatitis from thermoset components is not uncom-

mon. An allergic contact dermatitis manifests itself as itching, redden-
77
ing, pimples 1 mm across and possibly blisters. If the reaction is intense,
swelling and discharge can occur. The hands and lower arms are the
most commonly affected areas. Sometimes the eczema can also occur on
the face. Substance transmission can be via direct contact or by diffusion
of dust or mist through the air. The symptoms can therefore either be a
sign of problems in occupational hygiene conditions or of personal hy-
giene.
Allergic contact dermatitis can also be acquired outside of working life.

It is therefore important for the cause of frequently recurring or ongoing
hand eczemas to be established. Hand eczemas or other skin changes
suspected of being associated with work are best analysed at a derma-
tology clinic capable of analysing a possible allergic contact dermatitis
using epicutaneous testing which includes suspected work materials. A
facial eczema can also be a sign of harmful effects.
It is very inappropriate for persons with e.g. allergic contact dermatitis

to epoxy to be employed in work involving contact with epoxy resin,
particularly of the low-molecular variety.
The questionnaire in Appendix 4 can be a useful aid to the medical ex-

amination.
Periodic medical examination with employability assessment

The purpose of periodic medical examinations is to detect, as early as
possible, any injury or damage which as occurred as a result of work.
Reduction of the lung function can appear without the patient noticing
anything to begin with. This is true especially of exposure to diisocya-
nates, where obstructivity can be present without any typical asthma
symptoms in the patient.
Persons with lung disease are in a worse position if they should also
become hypersensitive in their respiratory tracts or if they should dam-
age their lungs in any other way. The aim of the medical examination is
to prevent such persons from being employed in work where they
might be harmed through contact with diisocyanate, phenyl isocyanate,
cyanoacrylate or certain organic acid anhydrides. A person who already
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AFS 2005:6
suffers from asthma often runs an elevated risk of developing asthma

attacks on contact with these substances, due to the hyper-reactivity of
the bronchi which is a consequence of asthma.
Besides asthma, any lung disease which has caused or may cause re-
duced lung function is an example of an illness or debility which may
mean that it is inappropriate to be exposed to these thermosets.
The presence of moderate or serious COPD is an impediment to em-

ployment. However, pre-clinical or mild COPD, which is due only to
smoking, is not normally regarded as an impediment.
Disorders triggered by acid anhydrides are often caused by an allergic

reaction conveyed by IgE. In these cases, specific antibodies can be es-
tablished.
Atopy in itself is no longer regarded as implying an increased risk of

developing hypersensitivity to isocyanates. However, persons with
hyper-reactive mucous membranes are more prone to suffer from irrita-
tive disorders when they are exposed to isocyanates or to certain organ-
ic anhydrides.
Contact with components containing diisocyanate or certain organic

anhydrides can also cause skin irritation. Diisocyantes were previously
regarded as only rarely causing skin sensitisation, but more recent stu-
dies have indicated that this may be more common than what was
thought. In these cases, too, it is unsuitable to employ persons with
allergic contact dermatitis in work which implies a high risk of contact
with such components.
See the comments on Sections 32-35 also.
Medical examination for work involving ester plastic

Large amounts of styrene are used in the production of ester plastic.
The styrene serves both as a solvent for the unsaturated ester plastic
component and as cross-linking agent. Uptake of styrene is mostly
through inhalation. Between 60 and 70 per cent of the inhaled amount
79
can be absorbed. How much is absorbed depends on the concentration
in the inhaled air and on how heavy the work is. Styrene can also be
absorbed via the skin and the intestinal canal. The high fat-solubility of
styrene means that the substance is stored in fatty tissue.
Exposure to styrene at concentrations above the occupational exposure

limit value can cause acute irritation of the mucous membranes of the
respiratory tract and the eyes. Effects on the central nervous system can
occur at about the same concentration. Because styrene has such a
strong locally irritating effect, the risk is non-existent that anyone could
be exposed to potentially fatal concentrations of styrene without being
aware of it.
Long-term exposure to high concentrations of styrene can cause injuries

to the central nervous system (toxic encephalopathy). Isolated cases of
asthma and skin allergy have also been reported. In work carried out
inside tanks, the skin uptake can be considerable. For work with rein-
forced ester plastic which could involve atmospheric exposure to sty-
rene in concentrations approaching the occupational exposure limit
value it is important that the medical examination focuses on symptoms
from the nervous system such as tiredness, irritability, memory disrup-
tion, and pricking sensations and numbness – solvent effects. Styrene
exposure can also be measured with biological sampling by means of
analysing mandelic acid and phenylglyoxylic acid in urine. See also the
general recommendations for Section 3, the passage “Measuring expo-
sure using biological samples”. If the anamnesis and status raises suspi-
cions of chronic solvent effects it is advisable for the patient to be re-
ferred to an occupational medicine clinic for assessment and further
analysis.
Organic peroxides – which occur in the production of ester plastic, cause

irritation of the skin, mucous membranes and eyes. Repeated skin con-
tact with organic peroxides implies a certain risk of allergic contact
dermatitis. At high concentrations they have a locally tissue-damaging
effect and can on direct contact cause ulceration of e.g. the cornea.
Fillers, pigments and reinforcing materials can cause disorders or inju-

ries, in particular if they are handled in such a way that dust is pro-
duced. If reinforced ester plastic is treated (sanded, cut etc.), dust is
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AFS 2005:6
produced which is mostly made up of ester plastic and to a lesser extent

of e.g. fibreglass or carbon fibre. Fibreglass dust is mechanically irritant
and can cause irritation of the skin and respiratory tracts.
Overhead work on masts and poles
Health hazards
Work on and around masts, poles and similar carries special hazards.
Work done high above the level of the surrounding ground constitutes
a particular hazard. The definition of overhead work is included in the
provisions on mast and pole work. The most evident hazards are falls
from a high height and injuries from falling ice, tools or other objects,
but there are also other, more indirect hazards. For example, access to
the worksite is often associated with climbing up ladders, which in-
volves extreme physical strain and considerable exertion on the heart
and other circulatory organs. This physical strain is aggravated in cold
weather and/or very windy conditions. Another special hazard of mast
and pole work has to do with the fact that access to the worksite is often
difficult, which in turn makes it difficult quickly to provide aid to an
employee who has had an accident or fallen acutely ill.
For pregnant employees it is important to point out the employer’s ob-

ligation to carry out a risk assessment according to the provisions on
pregnant and breast-feeding employees, and then to apply the neces-
sary measures.
Medical examination
Overhead work, and climbing in particular, makes high demands on
physical work capacity. The exposed nature of the worksite and the
difficulty in gaining access to it make it important also that sudden and
unforeseen illness be avoided to the greatest extent possible. Medical
supervision is an aid to this end.
81
The medical examination is intended to prevent the employment in
overhead work of anyone suffering from an illness or debility which
increases the risk of suffering ill health or accidents in overhead work.
In order to serve as a basis for an employability assessment, the anam-
nesis may also need to include:
- perceived vision, hearing and balance disturbances,
- use or abuse of medical and recreational drugs or doping agents
affecting alertness, judgement or blood pressure, and
- previous contacts with psychiatric care.
For the same reason, the physical examination may also need to focus
on:
- visual acuity and hearing,
- organs of balance and locomotion,
- neurological status, and
- the presence of glucose and pharmacologically active substances or
their metabolites in body fluids.
The predictive value of deviations in exercise ECG results is regarded as

quite low, which means that findings of this kind may need to be fol-
lowed up by an examination in greater depth.
The more frequent ECG tests for older employees are motivated by the
fairly steep increase in the risk of cardiovascular disease from the age of
45–50. Employees who have turned 50 therefore need an annual ECG
test of the heart during exertion (exercise ECG) in order to maximise the
chances of discovering such early or latent cardiovascular disease as
may pose a risk during maximum physical exertion. See the comments
on Sections 47–50 also.
Rescue work in smoke-filled or chemically contaminated condi-

tions
Health hazards
Personnel from the rescue services who work in smoke-filled or chemi-

cally contaminated conditions are exposed to considerable hazards, in
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AFS 2005:6
part because of operating in extreme heat but also because of the risk of
explosions, falling building debris, sharp objects and similar. The exten-
sive use of chemicals in society has meant that burnt gases have become
more health-hazardous in recent decades. Additionally there are ha-
zards in connection with rescue operations at sites of chemical acci-
dents. The risk of accidents is further increased as visibility becomes
reduced or disappears when entering smoke from a fire. However, the
actual risk scenario during a rescue operation is difficult to predict, as
conditions at the site often change as work is going on.
Smoke from a fire contains carbon monoxide and a large number of

other hazardous gases in unknown concentrations. Besides their toxic
effects, they can also cause a lack of oxygen. The hazard level has been
raised further due to the widespread use of plastic in building materials
and furniture, which means that smoke intensity increases and that
more hazardous substances form in the smoke. Additionally, personnel
are often subjected to extreme heat at the same time as they are carrying
out physically very demanding work and wearing heavy and often
unwieldy personal protection equipment. This means that breathing
apparatus firefighters have to protect themselves both against the heat
from the fire and from the heat that builds up inside their suits due to
dense clothing and heavy physical work. The personal protection
equipment prevents the normal evaporation of sweat, which means that
the body’s temperature regulation system cannot function properly.
The crucial functions of breathing are to oxygenate the blood and re-
move the carbon dioxide which forms. Inhaling oxygen-free or very
oxygen-deficient inert gas (non-toxic and non-reactive gas), e.g. nitro-
gen and/or noble gases, is very treacherous as these gases wash out
both oxygen and carbon dioxide from the blood and respiratory organs.
Unconsciousness can then occur without any warning whatsoever.
Carbon monoxide is formed whenever organic material is combusted

without sufficient oxygen, and has a specific toxic effect by blocking
those bonding sites for oxygen in the blood’s haemoglobin that are re-
sponsible for transporting oxygen out into the organism. Carbon mo-
noxide poisoning can hereby lead to a lack of oxygen in the tissues and
to death.
83
The demands for physical work capacity made on employees are pri-
marily based on the strain of working in smoke-filled conditions and
operating at chemical accident sites since it is normally the same em-
ployees who carry out both types of work.
The provisions on rescue work in smoke-filled or chemically contami-

nated conditions proscribe pregnant or breast-feeding employees from
being employed in such work. For further information, see the provi-
sions on pregnant and breast-feeding employees as well.
Medical examination

Working in smoke-filled or chemically contaminated conditions implies
extreme physical strain in part due to exterior thermal pressure and in
part due to the body’s own heat production. It follows that the work
places high demands on health and working capacity as well as on
mental stability.

rescue work in smoke-filled or chemically contaminated conditions of
anyone suffering from an illness or debility which increases the risk of
suffering ill health or accidents in such work.
The exercise ECG must done under maximum exertion since that is
often required in “severe” operations in smoke-filled or chemically con-
taminated conditions. Traditionally, this test is carried out by pedalling
on a cycle ergometer since ECG registration and blood pressure mea-
surements are usually easier to do on a cycle. Additionally, ECG regis-
tration on a cycle suffers less from movement artefacts (disturbances to
the ECG curve) than ECG registration on a treadmill. Maximum exer-
tion (until exhaustion) presupposes preparedness for medical treatment
of the employee being tested. It is advisable to monitor the development
of the ECG curve continuously towards the end of the test.
It is also important that muscle strength and the ability to withstand

heat are judged to be satisfactory for the type of work.
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AFS 2005:6
It might also be appropriate to consider a spirometric examination if it

emerges in connection with the medical examination and anamnesis
that the examined employee has a respiratory tract disorder.
The more frequent ECG tests for older employees are motivated by the
increased risk of cardiovascular disease. Employees who have turned 50
therefore need an annual exercise ECG test.
Requirements for physical work capacity
As stated in the interim provisions, an older test method – pedalling on
a cycle ergometer – applies until 1 January 2008 in parallel with a
treadmill test. In terms of strain, the two test methods – the modern one
of walking on a treadmill and the older one of pedalling on a cycle er-
gometer – are comparable at the group level but not at the individual
level. In a treadmill test, the test person bears his or her own body
weight and also wears full personal protective gear, which makes the
test better suited to the demands of the job. For that reason, the possibil-
ity of testing on a cycle ergometer will be discontinued. The cycle ergo-
meter is nonetheless an excellent exercise appliance.
As mentioned, the test method for physical work capacity for rescue
work in smoke-filled or chemically contaminated conditions is walking
on a treadmill dressed in full working gear (rescue suit). However, in
order for the tester to be able to observe the test person’s face during the
test, the breathing mask is not used. For safety reasons, boots may be
substituted for training shoes. The treadmill test consists of walking at
an upward incline for six minutes. The incline must be set at a 8.0º angle
against the horizontal plane and at a speed of 4.5 km/h, or to another
combination of speed and inclination which gives the same load (oxy-
gen absorption capacity, VO2, measured in mi/min x body weight). The
total weight of the equipment worn during the test is 24±0.5 kg. In order
to reach this equipment weight, ballast weights may be attached to the
belt or placed in pockets. Note that the load on a treadmill, as opposed
to on a cycle ergometer, will be dependent on the test person’s own
body weight. This means that when setting the incline and speed to
other values than the above-mentioned 8.0º and 4.5 km/h, the body
85
weight will need to be taken into account. This should be explained and
listed in the tables provided by the maker of the treadmill.
The older test method requires pedalling on a cycle ergometer for six
minutes with a 200 W load, which is more or less equivalent to an abso-
lute oxygen absorption capacity of 2.8 l/min for a person weighing 70
kg. The recommended way of carrying out the test is for the test person
to warm up by gradually increasing the load to the final load of 200 w
and then keep that load for six minutes. There is no particular clothing
requirement for this test, which is typically carried out in training
clothes.
The exercise ECG (which is a medical test for excluding latent heart
disease) and the test of physical work capacity (which is a way of con-
trolling the lowest permissible physical fitness of employees) should be
kept strictly apart. If the two tests are to be carried out on the same oc-
casion, e.g. during the medical examination, it is best to do the physical
work capacity test first.
In those cases where the work capacity test is done on a cycle ergometer
(the older method), the ECG electrodes and the blood pressure cuff may
be applied before the test begins. After the test person has completed
the work capacity test (200 W for six minutes) it is recommended that he
or she pedals at a low load (100 W) for one to two minutes before the
test is carried out at maximum load and with exercise ECG registration.
Since physical work capacity declines with age it is appropriate to com-

pensate for this fact in the first examination of younger new employees.
It may therefore be a good idea for people under about the age of 30
who are new employees to do 5.6 km/h at an inclination of 8º on a
treadmill, or 250 W on a cycle ergometer, for six minutes. There is noth-
ing to stop employees striving to continue achieving these higher loads.
Routines and programmes to this end can usefully be developed by the
employer in consultation with the responsible doctor.
Diving work and other work at elevated pressure
Health hazards
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AFS 2005:6
Work under water and work under elevated pressure, such as work in
tunnel driving, implies very specific and high physical demands. For
this reason there is a requirement for a medical examination to identify
persons with an illness or a debility which implies an increased risk of
injury or accident in diving work and other work at elevated pressure.
The elevated pressure causes both mechanical effects on the body and
altered partial pressures of gases in the body tissues. Injuries from ele-
vated pressure can occur in the middle ear, sinuses, lungs and teeth,
particularly in connection with defective fillings.
Increased partial pressure of oxygen has toxic effects on the respiratory

tracts and nervous system. Nitrogen gas has narcotic effects at high
pressure. Gas mixtures with inert gases other than nitrogen can be used,
e.g. helium, whereby the narcotic effects of the breathing gas decrease.
The increased density of breathing gas at increased pressure means, in

combination with a number of other physical circumstances, that the
pattern of breathing becomes altered. This in turn can lead to an accu-
mulation of carbon dioxide in the body, with the added risk of head-
aches, consciousness effects and an intensification of the narcotic effect
of the nitrogen.
An uncontrolled or overly rapid ascent implies a risk of decompression

sickness as the inert gases dissolved in the body form bubbles as a result
of the decompression. These bubbles can in themselves produce symp-
toms, but they can also cause tissue damage which may also give rise to
symptoms of decompression sickness. The mildest form of decompres-
sion sickness causes pain in larger joints such as the hip, knee or shoul-
der (“the bends”). Skin symptoms such as itching and marbling may
also occur. More serious forms cause dizziness, symptoms from the
central nervous system and dyspnoea (“the chokes”) due to gas bubbles
in the brain and pulmonary capillaries, respectively.
Professional women divers have existed for a long time in Japan and
Korea, where they are known as “amas”. They dive down to a depth of
30 m, holding their breath, to collect mussels and algae. Much of the
existing knowledge of physical diving effects on women comes from
87
these women, since other research in diving medicine has almost exclu-
sively dealt with male military personnel. Available data does not sup-
port any significant gender differences with respect to decompression
sickness or other complications.
However, the engagement of pregnant or breast-feeding employees in

diving work or other work in a hyperbaric environment is forbidden
under the provisions on diving work. For further information, refer also
to the provisions on pregnant and breast-feeding employees.
Medical examination
diving work of anyone who runs an increased risk of suffering ill health
in such work. The medical examination requires qualified assessments
of a number of medical factors. It is therefore important that the exami-
nation and assessments are carried out by a doctor who is familiar with
the health effects of diving work and who is trained in and has expe-
rience of carrying out diving medicine analyses.
The exception regarding single instances of work at elevated pressure in

pressure chambers should be applied particularly restrictively. If work
in pressure chambers is a recurring task, e.g. in connection with re-
search or health care work, the principal rule on a medical examination
before work applies.
It is important for anyone engaged in diving work to be observant of

their state of health and to keep their employer continuously informed
about matters which could lead to increased health hazards at work.
The medical examination should normally include:

- illness anamnesis,
- physical status,
- heart/lung radiography,
- spirometry,
- exercise ECG,
- determination of physical work capacity,
- determination of blood pressure,
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AFS 2005:6
- determination of blood haemoglobin content (B-Hb)

- qualitative control of the presence of glucose or protein in urine,
- dental and maxillary examination,
- audiological examination,
- eye examination and
- radiographic examination of the skeleton in case of special indica-
tion.
It is important that the anamnesis include hereditary diseases, previous

illnesses and surgery, medical problems in connection with previous
diving work, and naturally current medical conditions including ongo-
ing medication, alcohol consumption and use of other drugs. It is im-
portant also to investigate factors which may have a bearing on safety in
connection with diving work, e.g. mental illnesses and phobias, in par-
ticular claustrophobia, and substance abuse problems.
Persons with an anamnesis which includes the following diseases, inju-

ries and surgery may run an increased risk of ill health in connection
with diving work:
Lung diseases
- chronic lung disease (restrictive lung disease, asthma, chronic
obstructive pulmonary disease [COPD], pneumoconioses and other
abnormal reduction of the lung function),
- perforated thorax injuries or thoracotomy, and
- previous pulmonary rupture (spontaneous or traumatic) or pneu-
mothorax.
Cardiovascular diseases
- angina pectoris or previous myocardial infarction,
- certain types of vitium cordis (organic heart disease)
- pathological arrhythmias, and
- serious hypertension and hypertension being treated with beta
blockers.
Other illnesses and disorders

- other serious illnesses which have had permanent effects on respire-
tory and circulatory organs,
- balance disorders,
89
- diabetes mellitus and other endocrine diseases and disorders,
- epilepsy and other neurological diseases, and
- kidney stones and other serious diseases of the kidneys and urinary
tract.
Excess weight increases the risk of ill health in connection with diving
work. Excess weight which is more than negligible should be consi-
dered in the employability assessment. Obesity can be regarded as ob-
taining when the BMI (Body Mass Index), i.e. the body weight (in kg)
divided by the square of the body height (in m) exceeds 30 kg/m2.
The examination of physical status should usefully include an assess-

ment of the general condition, signs of cardiac insufficiency and auscul-
tation of the heart and lungs. Diving work typically requires fully satis-
factory musculoskeletal function and normal muscle strength.
If there are any signs of gastritis, gastric ulcers, chronic intestinal dis-
ease or disease of the liver, bile ducts or pancreas, it is important that
the condition’s bearing on employability for diving work is carefully
evaluated in each individual case.
Severe psoriasis and other serious skin disorders generally constitute an

impediment to diving work.
It is important that the eardrums are intact and that air can be pressed
to the middle ear via the auditory tube without discomfort. Balance
disorders generally constitute an impediment to diving work.
Heart and lung radiography needs to be done in the standing position

during maximum inhalation, from both front and side. In some situa-
tions a radiograph may also need to be taken during maximum exhala-
tion, since that type of image is regarded as better for detecting possible
air-retaining alveolar dilatations. It is important that the images are
examined with special regard to diving work. Uncomplicated pleural
plaques are not generally an impediment to diving work.
ECG should be taken with at least a six-channel recorder. It is important

to investigate any signs of previous myocardial infarction and arrhyth-
mias. If there is any doubt, an exercise ECG is advisable.
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AFS 2005:6
Physical work capacity measured with a cycle ergometer should be at

least 200 W for six minutes up the age of 40 and at least 150 W for six
minutes above that age. If there is any doubt, an exercise ECG is advis-
able.
If there is any doubt about the interpretation of the Hb value, a full

analysis of haematological status is advisable.
If there is any doubt about the indication of glucose and protein in

urine, a more comprehensive assessment of the renal function and glu-
cose tolerance is advisable.
It is important that the spirometric examination is carried out using a

proven method and properly calibrated apparatus. See also the com-
ments on Section 29.
It is essential for any necessary dental treatment to be performed cor-

rectly and for fillings to be intact. Dentition should be such that, where
relevant, a mouthpiece can be firmly retained in the mouth. Any den-
tures should be firmly secured.
Dentists who have undergone training in barodontalgia, receiving a

pass grade, are qualified to carry out a diving odontology examination.
Information on dentists with barodontalgia training can be obtained
from the chief dentistry officer of the Swedish Armed Forces.
It is important that a person employed in diving work can comprehend

normal speech and that he or she does not have a speech impediment
which could make communication difficult.
Visual acuity and field of vision should be examined. It is important

that a person employed in diving work is able to read instruments
without difficulty, even in adverse lighting conditions. Glasses and
contact lenses my be unsuitable for use in diving work.
Skeletal radiography should be carried out in consultation with a radi-

ologist who is familiar with the skeletal changes which can occur in
connection with diving work. For persons who regularly work under
91
elevated pressure for more than 20 hours per week or are engaged in
saturation diving, mixed gas diving or diving to depths of more than 30
m it is advisable that the responsible diving doctor considers the indica-
tions for carrying out a skeletal radiography to reveal asymptomatic dysbaric
osteonecrosis.
The periodic medical examination should focus anamnesis on that
which has occurred since the previous examination. Radiographic ex-
amination of the heart and lungs, and of the skeleton, should be re-
served for those in whom there are clinical or anamnestic suspicions
that some change which can only be radiologically diagnosed, and
which could be decisive for the employability assessment, has occurred
since the previous examination. In other respects the periodic medical
examination should normally include the same elements as the medical
examination as specified above.
Work involving exposure to vibrations
Health hazards
Extensive exposure to vibrations from hand-held tools can cause symp-

toms as a result of damage to nerves, blood vessels, muscles and the
skeleton. Damage to blood vessels implies an increased tendency to
vasoconstriction. Nerve damage manifests itself in the form of numb-
ness, reduced sense of touch, fine motor ability and strength. Damage to
blood vessels and nerves can both further cause a feeling of increased
intolerance to cold. Blood vessel damage appears as pale patches on the
skin when cold, also known as “white fingers”, while intolerance to
cold due to nerve damage mainly expresses itself as pain. This can make
outdoor activities much more difficult during the cold part of the year
and can impede activities such as fishing and swimming. There are also
studies that indicate a connection between exposure to vibrations and
nerve compression in the wrist (Carpal Tunnel Syndrome), with numb-
ness, pricking sensations and a reduced tactile sense on the inside of the
hand. The symptoms often appear during the night.
Drivers of various kinds of vehicles, particularly in mining, construction

and installation, are sometimes exposed to powerful whole body vibra-
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AFS 2005:6
tions. Vibrations transferred to the human body are amplified, at certain

frequencies, in different parts of the body and organs, and may then to
varying degrees cause stretching and compression of tissue. Vibrations
can affect joints, muscular attachments and the discs in the vertebral
column. Research suggests that vibrations, e.g. from vehicles, bring an
increased risk of back problems. Exposure to whole body vibrations can
also cause tiredness.
There is also a connection between exposure to vibrations and hearing

damage. Noise and vibrations often occur together.
Research suggests that whole body vibrations, e.g. from vehicles, bring
an increased risk of back problems.
Medical examination
The examination of new employees is intended to diagnose illnesses or
injuries he or she might have which would imply an increased risk of
vibration injury, and to consider the precautions that this would call for.
For instance, a person with a known previous nerve injury might need
further protection in addition to what is considered sufficient for com-
pletely healthy persons. Medical conditions that carry an increased risk
of neuropathies (nerve injuries) include diabetes, hypothyroidism (in-
sufficiency of the thyroid gland), alcohol abuse and vitamin B12 defi-
ciency. Other conditions which justify caution in exposure to vibrations
include primary and secondary Raynaud’s disease. Connective tissue
diseases and medication with vasoconstrictor drugs may also imply
increased risk due to impaired circulation.
Among other things, the examination involves an inspection in order to
detect signs of reduced peripheral circulation, joint alterations and atro-
phied muscles. It is advisable to check the peripheral circulation and
blood pressure. Neurological statues includes tendon reflexes, muscle
strength, coordination, two-point discrimination, vibration sense, pain
sense, temperature sense and touch. The musculoskeletal examination
includes movement pattern, joint status, muscle strength, tendinitis test
93
and back status. It is also important to be attentive to symptoms or signs
of Carpal Tunnel Syndrome.
A special back examination can include assessment of incorrect posture,

mobility, pain, pressure tenderness as well as signs of muscular weak-
ness and nerve root compression.
The purpose of the periodic medical examination is to discover early
signs of vibration injury and thereby be able to apply the appropriate
measures to reduce the exposure and prevent further injury.
A medical interview is regarded as the best method for classifying the

severity of vibration white finger. The interview should include ques-
tions about bouts of pale fingers. A suggested assessment model for
determining the severity of vasospastic vibration injury is provided in
Appendix 3, Table 1.
Vibration injury syndrome also gives rise to neurological symptoms,

which can be both more common than white finger and appear earlier.
For these, too, there is an assessment model in Appendix 3, Table 2.
Since there are a number of illnesses that can produce the same symp-
toms, testing for a differential diagnosis is a valuable tool. Patients suf-
fering from Raynaud conditions should always be recommended to
stop nicotine intake.
If the employee shows signs of a more pronounced vibration injury,

Raynaud symptoms as in Stage 1, Table 1 or vibration neuropathy Stage
2SN as in Table 2, he or she should normally not continue in work with
exposure to vibrations. However, an individual assessment always
needs to be made. With older persons who are able to limit their expo-
sure to vibrations, a different assessment – from a holistic perspective –
may sometimes be justified. If the employee shows new signs of vibra-
tion injury since the previous examination, the periodic examination
should be brought forward. It may also make sense to impose medical
examinations or health check-ups with shorter intervals, perhaps 1-2
years, for all employees under similar exposure conditions who on ex-
amination have shown signs of rapidly progressing injuries.
94
AFS 2005:6
Persons with symptoms and signs of vibration-related injuries may in

individual cases need to go through an in-depth assessment by a doctor
with special qualifications in vibration-related disorders. It is inadvisa-
ble to continue in work involving exposure to vibrations if a there is any
suspicion or confirmation about a more serious vibration injury, since
the symptoms will be aggravated by continued exposure.
Night work
Health hazards
Human beings have a natural circadian rhythm which is governed by

light. We are active during the day and we rest during the night. Much
of the body’s repair work occurs during the nightly rest. Among other
things, the production of growth hormone and testosterone (male sex
hormone) increases during sleep, and the activity of the immune system
increases. The circadian rhythm makes it harder to stay awake at night
and to sleep during the day.
Sleep is a prerequisite for waking activities in the short term, and in the
long term we would not survive without sleep. A large body of research
has shown that 7-8 hours of sleep per 24 hours is necessary for recupe-
ration, health and safety. In the short term, a reduction of sleep from 8
to 6 hours on a single night has only a marginal effect on wakefulness
and achievement ability the following day. Further sleep reduction,
however, produces clearer negative effects.
The hazards of tiredness due to sleep deficiency include reduced atten-

tiveness and impaired judgement, with the risk of accidents. Such risks
are apparent for drivers of vehicles. Tiredness is normally at its greatest,
as is the concomitant accident risk, towards the end of the night at 3-5
a.m. Longer-term effects of work that causes sleep problems include
raised blood pressure, cardiovascular disease, stomach and intestinal
disorders and probably diabetes. It is possible that night work can also
contribute to carcinogenesis.
Night work in combination with pregnancy and breastfeeding is not

normally regarded as a risk increaser. In some cases, however, night
95
work can become too much of a strain. However, this must be deter-
mined individually through consultation between the doctor and the
employee. In such circumstances it is urgent that the employee is of-
fered daytime work. If this is not possible, leave can be obtained in ac-
cordance with current regulations.
Any differences that might exist in terms of accident and illness risks
between men and women as a result of night or shift work have not
been much researched. However, disturbances to social life as a result
of night work appear to be worse for women than for men. States of
anxiety and stress may also mean that sleeping becomes even more
difficult. The risk of sleep problems and illness related to night work
appears to increase with increasing age, in particular after the age of 45-
50.
When drawing up shift schedules, the rest period between shifts should
be long enough to allow for recuperation. Since time is required for
transportation to the place of rest, for eating, hygiene etc., in addition to
sleeping time, it has been judged that an 11-hour break between two
shifts should normally be the minimum in order to maintain health and
safety. To prevent fatigue, regularly recurring recuperation should be
given priority over many consecutive shifts followed by a longer period
of leave. In rotating shift schedules it is often appropriate to include a
longer recuperation period after no more than two or three night shifts.
Gradually bringing working hours forward should be avoided as this
generally leads to disturbed sleep.
The time at which work begins in the morning can be relatively signifi-
cant. To begin work at 7 or 8 a.m. is would thus seem preferable to be-
ginning at 5 or 6 a.m.
With respect to the length of work shifts, eight-hour shifts are preferable
to twelve-hour shifts. On the other hand there are examples of twelve-
hour solutions which are positive if the number of working periods are
reduced and few periods are worked consecutively. A prerequisite for
this, however, is that the employee him- or herself is in control of the
work load, and that breaks and rests can be taken as needed.
96
AFS 2005:6
The health hazards of work which affects nightly rest and sleep are
often reduced if the employee him- or herself has been able to choose
working hours. i.e. if the employee can be regarded as having chosen
the working conditions voluntarily. The above recommendations on
scheduling are intended to create acceptable conditions for the majority
of employees.
Definition of night work

The definition of night work with a requirement for medical supervi-
sion follows, in some respects, from Article 2 of the EC directive on the
organisation of working time (93/104/EC). From a medical point of
view there is no clearly defined concentration of the health hazards of
night work to the categories of employees covered by the definition. For
this reason it may in some cases be appropriate to offer medical super-
vision also to other employees who work at night for a considerable
proportion of their man-year, e.g. employees with rolling shifts, time-
tabled or duty work. For employees on duty or in preparedness, whose
share of night work is governed by events, the share of night work over
a man-year is hard to predict. In such cases, calculations have to be
based on previous experiences of the average frequency and duration of
disturbances/events at night.
The definition of night also follows from the above-mentioned article,

which means that the total length of the night is regarded as limited to
seven hours, but that it can occur with a flexibility of two hours. Thus
every continuous seven-hour period falling between 10 p.m. and 7 a.m.
is regarded as night. Examples of such seven-hour periods include 10
p.m. – 5 a.m., 11 p.m.- 6 a.m. and midnight – 7 a.m. If at least three of
the daily working hours of a job fall within such a period, that job is
regarded as night work under these provisions.
If the distribution of working hours between day and night varies, the
share of night work is calculated over a longer period of time which can
be regarded as representative of the division between night and day
work periods. If the share of night work during such a period is 38 per
cent or more, the job is defined as night work. Since the night (seven
hours) constitutes about 29 per cent of the 24-hour period, employees
97
whose working hours are evenly distributed between day and night,
e.g. three-shift workers, will not normally be regarded as night workers.
For night work which may be assumed to be non-recurring and which

lasts for less than three months, there would appear to be no medical
justification for a medical examination. If the same employee returns to
night work at a later date, it is assumed that a new assessment of the
need for a medical examination will be made.
In accordance with what has been stated above, employers are free to
use a more generous definition of night work and to offer medical ex-
aminations to employees who do not fulfil the minimum definition for
night work.
Medical examination

Medical supervision of night workers is intended to reduce the risks of
employees suffering ill health or accidents as a result of night work. It
should therefore focus primarily on such factors as serious sleep disrup-
tion with follow-up research into any accidents connected with reduced
wakefulness, the incidence of cardiovascular disease or abdomin-
al/intestinal disease, but also on such factors as use or abuse of alcohol,
tobacco, medication or illegal drugs, as well as eating habits and social
situation.
Anyone who is shown to have health problems which are judged to be

due to night work should not be employed in such work. The same
applies to employees who have evinced an illness or debility that would
make them particularly vulnerable to ill health caused by night work. If
there is any doubt as to whether the state of health is an impediment to
night work or not, it is advisable to contact a clinic of occupational med-
icine or the equivalent for guidance. Issues of transferring employees
from night work into work with different tasks/hours usually require
individual assessments which take a number of factors into account –
not just the physical state of health. In this context it is relevant to reite-
rate the employer’s responsibility for work adaptation and the rehabili-
tation of employees.
98
AFS 2005:6
Comments on entry into force and interim provisions
When these Provisions on Occupational Medical Supervision enter into

force, the Provisions on Medical Supervision of Night Workers (AFS
1997:8) and Medical Supervision of Work Involving Cadmium (AFS
2000:7) will be repealed, and rules on medical supervision in the follow-
ing provisions will be altered in accordance with new provisions from
the Swedish Work Environment Authority:
AFS 1992:16 Quartz

AFS 1992:17 Lead
AFS 1993: 57 Diving Work
AFS 1995:1 Rescue Work in Smoke-filled or Chemically Contami-
nated Conditions
AFS 1996:4 Thermosetting Plastics
AFS 1996:13 Asbestos
AFS 2000:6 Mast and Pole Work
AFS 2004:1 Synthetic Inorganic Fibres
Periodic medical examination in work without previous medical super-

vision requirements
Example (work involving exposure to vibrations): A person has had a

job involving exposure to vibrations for the past ten years and has never
undergone any medical supervision. Under current rules, periodic med-
ical examinations must be carried out every three years. The next medi-
cal examination will then need to be done in two years’ time, twelve
years (3 x 4) after the job was begun.
If the person has some complaint that could be a sign of vibration in-
jury, he or she has the right to a medical examination as soon as he/she
has notified the employer of this.
Medical supervision in work for which there are applicable rules, but
now with a new periodicity
Example (night work): A person aged 40 has had a night job for the past
eight years. Previously, medical examinations were done before new
employment and then after five years. The new rule is that periodic
99
medical examinations must be done every six years for employees who
have not yet turned 50. As three years have passed since the last exami-
nation, the next one must be done after another three years.
Glossary
A
ACGIH – American Conference of Governmental Industrial Hygienists.

American organisation that makes recommendations for occupational
exposure limit values.
Allergy – a hypersensitivity condition in which the body reacts against

a specific substance or substances, and in which the immune system is
involved. An allergy can be against biological substances such as pollen
or fur/skin scrapings, but also against chemical substances, e.g. nickel
or certain medicine. Common allergic reactions include blocked/runny
nose, asthma and eczemas.
Anamnesis – a patient’s account of his or her medical history.
Atopy – hereditary tendency to develop hypersensitivity.
Atopic – condition or person characterised by atopy.
Alveolitis – inflammation of the terminal air sacs of the lungs. Can be

either an allergic reaction or the effect of a toxin.
Auscultation – listening. Clinical examination method, usually done

with a stethoscope.
Bioactivity – ability to have an effect on or cause a reaction in living

tissue.
100
AFS 2005:6
BMI – Body Mass Index. A measure of deviations in body weight. Cal-

culated by dividing the body weight (in kg) with the square of the body
height (in m). Should be between 19 and 26 kg/m2. BMI>30 kg/ m2
indicates obesity.
Cardiac insufficiency – insufficient reserve capacity of the heart to

handle the demands of the body.
Cataract – a clouding of the lens of the eye.
Cell organelle – specific part of a cell.
Central nervous system – the brain and spinal cord.
COPD – Chronic Obstructive Pulmonary Disease. A condition in which

the function of the lungs is gradually reduced due to a growing con-
striction of the respiratory tracts. The most common cause of COPD is
smoking.
Critical effect –limit values for exposure are set well below the critical
effect, a reference value which is usually the effect which first manifests
itself (i.e. at the lowest dose) in dose-effect studies.
Cumulative dose – the total, accumulated dose.
Dysbaric – collective term for the negative effects on the body of large
pressure differences.ECHM – European Committee for Hyperbaric
Medicine.
EDTC – European Diving Technology Committee.
Endotoxin – toxic substances that form inside certain bacterial cells and
are released when the cell dies.
101
Epicutaneous test – a test of the skin’s reaction to a substance by apply-
ing the substance to the skin.
FEV 1.0 – Forced Expiratory Volume 1 second. A spirometry term.

Measures the maximum volume of air that can be exhaled in one
second.
Fibrosis – pathological increase of connective tissue in the lungs (or

other organs).
Glomerular – from glomerulus, the part of the kidney where the first
filtration of the urine occurs.
Haemosynthesis – the body’s formation of the red blood pigment hae-

moglobin during blood production.
Hyperbaric – at greater than atmospheric pressure.
Hyperbaric medicine – area of medicine dealing with the body’s physi-

cal and pathological reactions in an environment with raised atmos-
pheric pressure.
Hyper-reactive – overreacting. Can apply e.g. to an increased tendency

of the respiratory tracts to swell up and become constricted following
exposure to irritant substances.
IARC – International Agency for Research on Cancer, within the World

Health Organisation.
Intermittent – occurring at irregular intervals, in sudden fits or bouts.
102
AFS 2005:6
Latency – the time between exposure and the appearance of effects.

Often used in connection with cancer.
Lung oedema – accumulation of fluid in the alveoli. Usually a conse-

quence of a weak heart, but may also follow on the exposure to toxic
substances through inhalation.
Mutagen – something which causes a change in the genetic material, a

mutation.
Necrosis – the death of tissue.
Organic acid anhydride – some organic acid anhydrides are used as

hardeners in the manufacture of special types of epoxy plastic. These
anhydrides are often sensitising. They are either listed in Group B (=
handling requires a permit from the supervising authority) or Group D
(= sensitising substance) in Appendix 3 of the Provisions on Occupa-
tional Exposure Limit Values and Measures Against Air Contaminants;
see the provisions on thermosetting plastics as well.
Orthostatic reaction / Orthostatism – term for a symptom which can

occur when the body is in an upright position, having to do with insuf-
ficient reflux of blood to the heart and, secondarily, insufficient blood
flow to the brain which can produce faintness, dizziness and uncons-
ciousness.
Ototoxic substances – chemical substances that can damage or alter

hearing by having a toxic effect on the eighth brain nerve (Nervus ves-
tibulo-cochlearis), which can produce acute or chronic reduction in
hearing and/or balance disorders.
103
P
PAH – polyaromatic hydrocarbons made up of several condensed ben-

zene rings, e.g. pyrene and benzopyrene. Often oxidize in the body into
carcinogenic degradation products.
Partial pressure – physical term used for gas mixtures. Indicates the
proportion of the total pressure of the gases in a mixture exercised by a
specific gas in that mixture.
Particle – small, limited mass in fluid and/or solid form.
PEF – Peak Expiratory Flow. A spirometry term. Measures the top

speed of exhaled air at the fastest possible exhalation and reveals if
there are any obstacles to the air’s passage out of the body.
Peripheral nervous system – collective term for the nerves that connect
the brain and spinal cord to the body’s various organs.
Phalanxes – the two or three joined bones that together make up a fin-
ger or a toe. In these Provisions, the term is used for fingers of people
who work with hand-held vibrating tools.
Physical status – the result of an examination of the body by a doctor

using basic instruments such as a stethoscope, a reflex hammer and a
torch.
Population – in these Provisions, a statistical term indicating a specified

group of individuals.
Porphyria – a condition involving the increased formation of porphy-

rines. There are different kinds that produce different symptoms, e.g.
light sensitivity, liver effects or pigmented skin.
Predictive value – a measure of the ability to predict something, e.g. the

risk of becoming ill with a specific disease.
104
AFS 2005:6
Prevalence – a statistical term indicating the proportion of sufferers of a

specific disease in a specific population at a given point in time.
Reproduction – in these Provisions, indicating human procreation.

Restrictive lung disease – a reduction of the lungs’ flexibility and com-
pliance in breathing, with a reduced share of functioning active lung
tissue.
Respiratory tract epithelium – the superficial lining of cells covering

the mucous membranes of the respiratory tracts.
Rubella – German measles, a rash-forming illness primarily in children,

caused by the rubella virus.
Sensitisation – to produce a sensitivity, in particular an allergic hyper-

sensitivity.
Sensory-neuronal – indicates the part of the nervous system that con-

veys sensory information.
Spirometry – breathing measurement. A test of the bellows function of

the lungs using an instrument called a spirometer.
Tactile discrimination ability – the ability to discern the type and de-
gree of touch using the tactile sense.
Tear film – a film of tear fluid protecting the eye against irritant sub-
stances and drying out.
Tinnitus – a sensation of ringing or buzzing in the ears.
Toxic – poisonous.
105
Toxoplasma – a species of single-cell organism that can parasite on
human cells.
Trophic skin change – a skin change due to a nutritional imbalance.
Validated – confirmation of the reliability of a measured sample or a

method, i.e. that the measurement really is of what was intended.
VC – Vital Capacity. A spirometric term measuring the volume of the

lungs.
VO2 – volume of oxygen, or oxygen uptake capacity. A measure of

physical work capacity. May be expressed as absolute VO2 (for one in-
dividual) in litres/min or, as relative VO2, in ml/min x kg of body
weight.
106
AFS 2005:6
Appendix 1
Overview of obligatory medical supervision
Exposure or Time of Sampling/ Employ- Results

work medical laboratory ment pro- summary
examination examination scription for to be
non- submit-
approved* ted
Lead and Before Regular bio- Yes Yes

cadmium work; logical sam-
every 3 pling
years
Fibrosis- Before Spirometry Yes Yes
inducing dust work; Lung radio-
every 3 graphy
years
Thermoset- Before Spirometry No No
ting plastics work; if
disorder
occurs
Thermoset- Before Spirometry Yes No

ting plastics work; after
with em- 3-6 months;
ployability every 2
assessment years of if
requirement disorder
occurs
Reinforced** Before Spirometry No No
ester plastic work; if
disorder
occurs;
every 6
years an
107
examina-
tion of
nervous
system
Physically Med. Exam Exercise ECG Yes No
straining before Special ex-
work: mast work; then amination for
and pole each year divers
work, rescue or every
work in 5 or 2 years
smokefilled depending
or chem. con- on age or
taminated work
conditions
Rescue work Annual Physcial work Yes No
in smoke- physical capacity test
filled or condition
chemically examina-
contaminated tion
conditions
Vibrations** Before Recommend- No No

work; every ed if doctors
3 years and find injuries
if disorder
occurs
Night work** Before Determined No No
work; every by examining
6 years; doctor
>50 years
old
every 3
years
** obligatory for employer to offer medical supervision. No employabil-

ity assessment required.
108
AFS 2005:6
This summary is intended to provide guidance about statutory medical

supervision. The examinations are described in detail under each head-
ing.
If a risk assessment has shown that medical supervision is justified, the

following measures may be considered:
– for work with allergy-inducing substances other than thermosetting
plastics, carry out an examination like the one for exposure to thermo-
setting plastics,
– for work involving extreme physical strain other than mast and pole
work, rescue work in smoke-filled or chemically contaminated condi-
tions, or diving work involving high accident risks, carry out supervi-
sion like that for mast and pole work,
– for work which may involve toxic exposure to the nervous system,
e.g. due to the handling of organic solvents, apply some of the controls
for work involving reinforced ester plastic,
– for work involving severe mental stress, apply the rules and rec-
ommendations for night work. See also the general recommendations
for Section 3, under the heading “Work involving severe mental stress”.
Appendix 2
Summary of medical supervision for lead and cadmium
A. Medical examination before work involving lead and cadmium is

begun for the first time.
B. Periodic medical examinations at three-year intervals.
C. Periodic biological exposure control of blood concentrations accord-

ing to the following tables.
109
Lead
For women aged over 50 and all men:
Blood lead level, Measure

μmol/l
< 0.8 No recurring control if

three consecutive < 0.8.
0.8–1.5 Six-monthly control of blood lead.
> 1.5–2.0 Three-monthly control of blood lead.
> 1.8 Investigation required under Section 20.

Suspension if three consecutive tests are
>1.8.
> 2.0 Suspension. Return to lead-exposed work

when level is under 1.8.
110
AFS 2005:6
For women aged under 50:
Blood lead level, Measure

μmol/l
< 0.8 Six-monthly control of blood lead.
> 0.8 Three-monthly control of blood lead.
> 1.0 Investigation required under Section 20.

Suspension if three consecutive tests are > 1.0.
Return to lead-exposed work when level is
under 1.0.
> 1.2 Suspension. Return to lead-exposed work when

level is under 1.0.
Cadmium
Blood cadmium Measure

level, nmol/l
< 50 Annual control of blood cadmium.

If three consecutive six-monthly controls
have been under 50, annual controls can
follow.
> 50 Investigation required under Section 23.
50–75 Six-monthly control of blood cadmium.
> 75 Suspension. Medical examination under

Section 14. Return to cadmium-exposed
work when level is under 50.
111
Appendix 3
Classification of disorders and symptoms caused by vibrations
Table 1 Classification of white finger disorders according to the Stockholm

scale
Stage* Degree Symptoms
0 – No bouts of white finger.
1 Mild Occasional bouts that affect the

outer phalanx of one or more
fingers.
2 Medium Occasional bouts that affect the

outer and middle phalanx of one
or more fingers.
3 Severe Frequent bouts that affect all t

the phalanxes on most fingers.
4 Very As Stage 3 but with trophic
severe skin changes.
* If different fingers have different stages, describe finger by finger.
Table 2 Classification of sensory-neuronal symptoms according to the

Stockholm scale
Stage* Symptoms
0SN exposed to vibrations but without symptoms.
1SN intermittent numbness, with or without pricking sensations.
2SN intermittent or lasting numbness, reduced sense of touch.
3SN intermittent or lasting numbness, reduced tactile discrimina

tion ability and/or reduced fine motor ability.
* State the grading separately for each hand.
112
AFS 2005:6
Appendix 4
Questionnaire about allergy problems in working with thermosetting

plastics
1. Over the past 12 months, have you had problems with bouts of:
(Note that common colds are not be considered)
Yes No
– Itchy, runny or sore eyes □ □

– Runny nose □ □
– Blocked nose □ □
– Sneezing and/or itching in the nose □ □
– Nosebleeds □ □
– Soreness and dryness of the throat □ □
– Wheezing, shortness of breath and/ □ □
or chest pressure
– Severe hacking cough □ □
2. Have you had bouts of any of the following problems since the
end of your childhood but before your employment with the compa-
ny?
Yes No
– Itchy, runny or sore eyes □ □

– Runny nose □ □
– Blocked nose □ □
– Sneezing and/or itching in the nose □ □
– Nosebleeds □ □
– Soreness and dryness of the throat □ □
113
–Wheezing, shortness of breath □ □
and/or chest pressure
– Severe hacking cough □ □
3. Do you have bouts of wheezing, shortness of breath and/or chest

pressure when you are subjected to:
Yes No
– Physical exertion □ □
– Cold □ □
– Strong smells (perfume, solvents etc.) □ □
– Any form of smoke or spray
4. Do you have or have you had any of the following conditions:
Yes No
– Asthma □ □
– Hay fever □ □
– Chronic bronchitis/emphysema □ □
– Flexural eczema □ □
If Yes, did you have the condition before the age of 15?
Yes No
– Asthma □ □
– Hay fever □ □
– Chronic bronchitis/emphysema □ □
– Flexural eczema □ □
5. Have you been diagnosed with asthma by a doctor?
Yes No
114
AFS 2005:6
If Yes, in what year? □ □
6. Have you, after the age of 15, ever woken up with dyspnoea?
Yes No
If Yes, in what year did it first occur?
7. Have you, after the age of 15, ever had whistling or wheezing
sounds in your chest?
Yes No
If Yes, in what year did it first occur?
8. Has your breathing been normal between these occasions of

dyspnoea and/or whistling or wheezing sounds in your chest?
Yes No
9. Do you easily become short of breath on exertion?

(E.g. dyspnoea walking uphill at a normal pace, dyspnoea
during walks on level ground with people of the same age?)
Yes No
10. If you have respiratory problems do you regularly

take medicine?
Yes No
If Yes, which medicines?
115
11. Are you or have you ever been a smoker?
Yes No
If Yes, during what period of time?
Information from the Work Environment Authority
It should be noted that documents on the Internet are liable to contain

inaccuracies and that the printed version alone is legally binding.
For updates on current provisions it is also appropriate to visit the Au-

thority's website, www.av.se subheading Law & Provisions, to check
which rules apply to a particular activity.
116

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AFS 2005:6

The Work Environment Authority´s Statute Book

The Swedish Work Environment Authority´s provisions on occupa-

Provisions on fines ......................................................................................... 27

The Swedish Work Environment Authority´s general recommenda-

Appendix 1 Overview of obligatory medical supervision .......................... 106

The Swedish Work Environment Authority issues the following provi-

Medical supervision a medical measure in support of improv-

Medical examination individual examination of each employee,

Health check-up an examination in which a doctor does not

Employability assessment a doctor’s assessment of whether an ex-

Arrange (medical supervision) the employer’s obligation to arrange med-

Offer differs from “Arrange” in that there is no

General rules for medical supervision

lent of two years’ full-time service within civilian occupational health

Doctor’s reporting of illness

Obligatory medical supervision

Work involving lead and cadmium

Periodic biological exposure control for work involving lead

Periodic biological exposure control for work involving cadmium

Work involving dust which may induce fibrosis: asbestos, quartz

Work involving thermosetting plastics

Periodic medical examination with employability assessment

Medical examination for work involving ester plastic

Work involving extreme physical strain

Overhead work on masts and poles

Rescue work in smoke-filled or chemically contaminated condi-

Physical employability requirements

- before diving work is resumed, if more than five years – or in the

ic examination – but not the first one – may be replaced by a simplified

Entry into force and interim provisions

Transitionally, but not beyond 1 January 2008, physical capacity to

On 1 July 2005 the following provisions issued by the National Board of

Yvonne Strempl Maria Hagberg Forss

The Swedish Work Environment Authority issues the following general

General recommendations are of a different juridical status than provi-

The fundamental document for employers’ responsibilities for the work

Stipulations on medical supervision have previously been included in

Under Sections 3 and 4 the employer is responsible for arranging medi-

Environment Act is applicable to any work carried out in Sweden, re-

Biological exposure control

Arrange (medical supervision)

General rules on medical supervision

Under Chapter 3, Section 2 of the Work Environment Act the employer

In order for medical supervision to be useful as an element of work

Medical supervision can also be preventive by making the risks in-

At the same time it is important to bear in mind that he human body

In order to facilitate the assessment of symptoms it may be appropriate

If the results of medical supervision in accordance with Section 3 show

An idea of the health and accident risks in a given work environment

It is unusual in Sweden today for exposure to chemical substances to be

Measuring exposure using biological samples

Biological exposure control involves measuring the body’s absorption

One uncertain factor, however, is the variation in metabolism between

Because measured values from biological exposure controls also reflect

Other situations for which biological exposure controls can be useful

Before a biological exposure control is carried out it is crucial that the