Occupational Medicine Prof. Francesco S. Violante

Occupational MedicineProf. Francesco S. Violante

General Concepts

Evolution of Working Conditions

Health and Labour

Occupational Injuries and Diseases

What is Occupational Medicine It is considered to have been founded in 1700 by

Prof. Bernardino Ramazzini's treatise “De Morbis Artificum Diatriba” (b. Carpi – d. Padova)

It was for a long time identified as the medical specialty concerned with the diagnosis, treatment and prevention of occupational diseases

It has developed in Europe since the first half of the XIX century

At the beginning of the XX century, the first “Work Clinic” is established in Milan, and the International Commission on Occupational Health is founded in 1906

What is Occupational MedicineIt is the medical specialty concerned with

the protection and promotion of the working population's health

It is not an “anatomical” specialtyIt is a qualification required by law for

exercising some professional activities (Competent Physician and Authorized Physician)

It has developed and uses peculiar techniques, which have in their turn become operative specialties

Occupational Medicine Specialties

Occupational HygieneOccupational ToxicologyOccupational EpidemiologyErgonomicsMedical Radioprotection (Authorized

Physician)Corporate Medicine (Most specialized

physicians are employed in this sector)

Evolution of Working Conditions

As with many aspects of human life, working conditions remained almost unchanged for centuries

Structured work, as we know it today, is a product of the “Industrial Revolution” (XVIII century)

We are currently living in what is called a “post-industrial society”

Life and Working Conditions before the Industrial Revolution In past centuries, life was dominated by

undernutrition, bad hygienic conditions and lack of effective medical care

In the Middle Ages, life expectancy (today in Italy: 77-83) was about 50 for those who reached adulthood

Food availability and big epidemics have affected the world population rate:- 1000: 300.000.000- 1500: 500.000.000- 1800: 1.000.000.000- 1930: 2.000.000.000- 1975: 4.000.000.000- 2000: 6.000.000.000

World Population Development

Population Developmentin different continent

Anno

Pop

ola

zione in m

ilioni

(s

cala

logari

tmic

a)

Working Conditions before the Industrial Revolution

Most of the population was employed in agriculture and zootechnics; few worked as craftsmen and even less in the service industry

The working life began as soon as children were strong enough

All the work was done by strength of arm, animals and simple machines (levers, block-and-tackles)

The working day lasted from sunrise to sunset Healthcare (mostly ineffective or dangerous) had

to be paid for or was provided by charities (religious organizations)

Health and Labour before the Middle Ages

Hyppocrates (460-377 B.C.): miners, metal craftsmen, dyers, farmers

Lucretius (100-55 B.C.): De Rerum Natura, miners

Plinius the Elder (23-79): minersGalenus (129-200): miners, gladiatorsAl-Razi (850-923): cotton spinning

From the Middle Ages to the Industrial Revolution 1242: Roger Bacon publishes the formula for

black powder, which would lead, in the ensuing centuries, to a change in military technology (and in excavation techniques)

1492: the Discovery of America Ellenbog (1440-1499): metal workers Paracelsus (1493-1541): miners and glazers 1455: Johann Gutenberg puts on sale the first

printed book, a Bible George Bauer, called Agricola (1494-1555): De Re

Metallica, gold and silver metallurgy 1677: van Leeuwenhoek develops the microscope

The Industrial RevolutionIt takes place in England between 1760

and 1830, after the Agricultural Revolution1712: Newcomen's Steam EngineGA Scopoli (1723-1788) is appointed as

physician of the mercury mines in Idrjia, where he works for 16 years. He is author of the De Hydroargyro Idriensi Tentamina, a treatise on mercury poisoning in miners

1768: Arkwright patents the mechanical spinning frame

The Industrial Revolution

1786: John Fitch's Steamboat 1810: Krupp improves the steel production

process (originally developed in 1740 by Huntsmann, in Sheffield), eventually improved by Bessemer (1854) and Martin, by the Siemens in 1866 and by Thomas (1875)

1825: The Locomotion 1 by Robert Stephenson drags the first commercial train in the world from Stockton-on-Tees to Darlington

1840: Samuel Cunard launches a transatlantic service between Great Britain and the United States

Working Conditions during the Industrial Revolution

Safety and Hygiene standards are very poor The population's hygienic and nutritive conditions

are also precarious (though improving) There is no general healthcare The first laws on child labour ban and limit its use

(between 12 and 8 hours depending on age)

Labour in History:the Spinning Mill (1815)

Labour in History: 1800

Working in the Spinning Mill: silkwormsFonte: http://www.provincia.venezia.it/medea/est/frulli/filanda/filande.htm


Working in the Spinning Mill: silkwormsFonte: http://spazioinwind.libero.it/filandeonline/images/7%20Bachi.jpg


Women and Children in the Spinning MillFonte: http://www.bibliolab.it/donne_web/pic/galleria1/1800_Donne%20e%20bambini%20in%20filanda.jpg

Labour in History: ~1900

Factory Workers of the Rasica Spinning Mill in Osio Sotto Source: http://www.lomb.cgil.it/sedi/bg/cdl/2006/8marzo/sommario_foto.htm


Source: http://www.cgil.it/sardegna/foto345.html Argentiera miners (Sassari) at the end of the XIX century

Industrial Development in Italy

On the eve of the First World War, Italy is still an agricultural country with few factories

The first stage of industrial growth dates back to the period between the two World Wars

After the Second World War, Italy emerges first as an industrial economy and later as a post-industrial one (after 1980)


Legler Mechanical Looms in the forties

Source: http://www.lomb.cgil.it/sedi/bg/cdl/2006/8marzo/sommario_foto.htm


Weber Factory: Drilling Machine Operator

Source: Regione Emilia Romagna http://www.form-azione.it/pariopportunita/donnedellaltrosecolo.htm


Factory worker making sweet boxes by hand

Source: Regione Emilia Romagna http://www.form-azione.it/pariopportunita/donnedellaltrosecolo.htm


Ducati Factory WorkerSource: Regione Emilia Romagna http://www.form-azione.it/pariopportunita/donnedellaltrosecolo_06.htm


Sourcehttp://www.stava1985.it/intranet/stava1985_it/www/wo_albums/Index/20050718_152739/20050718_162011/PhotoFolder?display=medium

Miners working in the Prestavel mine (fluorite veins)


Miner working with jack-leg – Mine in Valle Vedra

Source: http://www.wwmm.org/storie/storia.asp?id_storia=252&pagina=9&project=0

The first Italian laws on work safety

1886 Ban on child labour under 9 and ban on night labour under 12

1902 Minimum age for working 12 years

1904 Minimum age for working 14 years

1899-1913 General prevention regulations and regulations for some specific sectors

1898-1934 Mandatory insurance against occupational injuries and (later) diseases

Workforce composition in Italy between 1881 and 2000 (INAIL data)

Year Agriculture Industry Service

1881 65,4% 20,2% 14,4%

1936 52,0% 25,6% 22,4%

1951 43,0% 29,9% 27,1%

1981 11,1% 41,5% 47,4%

2000 5,3% 32,1% 62,6%

Active Population per Sector in Italy (Istat Data, 2001)

Males Females Total

Industry 5.316.779 1.712.202 7.028.981

Trade 2.298.682 1.687.856 3.986.538

Credit and Insurances, services to companies

1.168.507 884.174 2.052.681

Agriculture 739.903 413.775 1.153.678

Transportations and Communications

780.240 198.789 979.029

Other Activities 2.537.860 3.254.965 5.792.825

Total 12.841.971 8.151.761 20.993.732

Relationship between Health and Labour

Work can affect health both negatively and positively

Negative consequences: occupational injuries and diseases, reduction of life expectancy

However, “healthy” work is an important factor in health promotion

Occupational Injuries and Diseases Occupational Injury: damage to an individual's

psychophysical integrity due to a violent causal factor which is concentrated in time during the working activity

Occupational Disease: damage to an individual's psychophysical integrity due to a causal factor which is diluted in time during the working activity

Occupational Injuries and Diseases are, by definition, predictable events

Working is good for our Health It is not yet clear which occupational factors are

associated with an improved health status Income, Social Relations, Identity Physical Activity Abstention from Smoke (in some sectors) Regular Medical Checks (maybe) Healthy Worker Effect: phenomenon described in

Epidemiology whereby workers usually have better health than unemployed people

Mortality and Labour (Turin 1991-96)

Working Condition Relative Risk

Steadily employed 1,00

Intermittently employed 1,52

Unemployed (previously employed)

2,29

Steadily unemployed 2,61

Steadily out of labour force 4,81

Life expectancy according to occupation at 35 (Turin, males, occupation in 1991)

Cleaning and waste collection operators

34,4 Armed Forces 37,9

Postmen 34,8Physicians, dentists, psychologists, pharmacists

37,6

Porters 34,9Lawyers, magistrates, chartered accountants, notaries

37,5

Food Industry workers 35,0 Teachers 37,4

Carpenters 35,2 Technical professions 37,2

Life expectancy according to occupation at 35 (Turin, females, occupation in 1991)

Lawyers, magistrates, chartered accountants, notaries

36,3Physicians, dentists, psychologists, pharmacists

38,9

Waitresses, cooks and barmaids

37,5 Technical professions 38,5

Machine tool operators, mechanics

37,8 Teachers 38,5

Entertainment industry workers and journalists

38,0Transport Vehicle drivers

38,4

Nurses and health technicians

38,0Cleaning and garbage collection operators

38,4

Italian Population divided by age and sex (1-1-2008)

Classi di età

(anni)

Maschi Femmine Totale

0-19 5.837.497 5.512.040 11.349.537

20-64 18.112.441 18.211.326 36.323.767

65 e oltre 4.999.809 6.946.177 11.945.986

Totale 28.949.747 30.669.543 59.619.290

Nati 2007 290.330 273.603 563.933

Morti 2007 279.792 291.009 570.801

Deaths by age and sex class - Italy, 2002Age Classes

(years)Males Females Total

Below 1 1.320 1.017 2.337

1-14 720 469 1.189

15-29 4.257 1.345 5.602

30-44 8.579 4.148 12.727

45-59 24.445 13.591 38.036

60-69 45.516 24.432 69.948

70-79 88.331 64.105 152.436

80-89 79.272 105.664 184.936

90 and over 26.856 66.323 93.179

Total 279.296 281.094 560.390

Deaths by group of causes - Italy, 2002

Cause Males Females Total

Circulatory system diseases 105.726 131.472 237.198

Tumours 93.398 69.672 163.070

Respiratory apparatus diseases 20.617 15.324 35.941

Traumatisms and poisonings 16.026 10.667 26.693

Digestive apparatus diseases 12.485 12.234 24.719

Psychic diseases, diseases of the nervous system and sense organs

9.552 14.765 24.317

Infectious and parasitic diseases 2.145 2.147 4.292

Other morbid conditions … … …

Total 279.296 281.094 560.390

Deaths by group of causes

Mortalità per causa - Per 100.000 abitanti

Deaths due to external causes of traumatisms and poisonings– Italy, 2002

Causa Maschi Femmine Totale

Cadute accidentali 4.035 6.517 10.552

Incidenti stradali 5.577 1.542 7.119

Suicidi 3.145 924 4.069

Annegamento e soffocamento 349 91 440

Omicidio o lesioni provocate intenzionalmente da altri

401 159 560

Incendi 144 131 275

Complicanze di operazioni chirurgiche

199 159 358

Avvelenamento da gas 45 22 67

Altri incidenti … … …

Totale 16.026 10.667 26.693

Major Malignant Tumours causing death, by sex – Italy, 2002

Site Males Females Total

Trachea, bronchus and lung 25.765 6.528 32.293

Colon, rectus and anus 9.164 8.072 17.236

Breast (in women) ― 11.309 11.309

Stomach 6.266 4.686 10.952

Liver and intrahepatic bile ducts 6.661 3.604 10.265

Linfatic and emopoietic tissues 3.887 3.724 7.611

Prostate 7.132 ― 7.132

Leukemias 3.022 2.533 5.555

Death from cancer – Italy, 2002

Occupational Injuries

Occupational Injuries reported to INAIL (2008)

All Lethal

Agriculture(in-itinere injuries)

53.355 (1.259)

121(18)

Industry and Service(in-itinere injuries)

790.278 (88.236)

)

911(249)

Public employees(in-itinere injuries)

31.457 (5.008

88(9)

Total(in-itinere injuries)

875.090(97.201)

1120(276)

Occupational Injuries in the EU (2005)

Economic activity All Lethal

Manufacturing industry 3.505 837

Building sector 6.069 1.236

Trade 2.184 372

Transportations 3.696 701

Agriculture 4.560 4.153

Hotels and restaurants 2.943 61

Electricity, gas, water 1.830 53

Occupational Injuries Industry and Service- type of lesion (INAIL 2008)

Natura della lesione Inabilità temporanea

Inabilità permanente

Morte Totale

Contusione 150.801 4.603 162 155.566

Lussazione 150.830 5.493 5 156.328

Ferita 103.657 2.881 29 106.567

Frattura 49.593 16.872 458 66.923

Altri agenti (calore,..) 12.006 374 91 12.471

Corpi estranei 12.450 130 0 12.580

Lesioni da sforzo (ernie,…) 9.184 239 1 9.424

Altre e indeterminate 6.689 471 161 7.321

Perdita anatomica 1.776 1.085 3 2.864

Lesione da agenti infett. 328 21 1 350

Totale 497.314 32.169 911 530.394

Occupational Injuries - Agriculture- type of lesion (INAIL 2008)

Natura della lesione Inabilità temporanea

Inabilità permanente

Morte Totale

Ferita 8.964 418 4 9.386

Contusione 13.031 706 16 13.753

Lussazione 9.147 773 1 9.921

Frattura 4.898 2.117 51 7.066

Perdita anatomica 169 102 2 273

Da agenti infett. 74 2 - 76

Da altri agenti 596 18 17 631

Da corpi estranei 1.164 17 - 1.181

Da sforzo 616 33 - 649

Totale 38.989 4.236 117 43.342

Occupational Injuries Industry and Service- site of lesion (INAIL 2008)

Sede della lesioneInabilità

temporaneaInabilità

permanenteMorte Totale

Mano 129.803 4.583 2 134.388

Colonna vertebrale 72.918 3.180 39 76.137

Ginocchio 37.320 2.881 1 40.202

Caviglia 37.922 2.444 1 40.367

Cranio 20.841 1.575 439 22.855

Piede 23.735 1.585 1 25.321

Polso 20.716 2.726 0 23.442

Cingolo toracico 22.450 3.248 3 25.701

Occhi 19.178 497 0 19.675

Parete toracica 19.481 1.073 98 20.652

Altro (...) (...) (...) (...)

Totale 497.314 32.169 911 530.394

Occupational Injuries - Agriculture- site of lesion (INAIL 2008)

Sede della lesioneInabilità

temporaneaInabilità

permanenteMorte Totale

Mano 8.542 477 - 9.019

Colonna vertebrale 3.188 455 8 3.651

Ginocchio 4.099 423 - 4.522

Caviglia 2.918 315 1 3.234

Cranio 1.435 133 38 1.606

Polso 1.606 394 - 2.000

Piede 2.014 172 - 2.186

Cingolo toracico 2.460 572 - 3.032

Occhi 2.346 105 - 2.451

Parete toracica 2.899 209 17 3.125

Altro (...) (...) (...) (...)

Totale 38.989 4.236 117 43.342

Injuries: Incidence Rates in the EU (2005)

0 1000 2000 3000 4000 5000 6000 7000

Spagna

Francia

Portogallo

UE - Euro Area

Lussemburgo

Germania

Belgio

UE - 15

Finlandia

ITALIA

Danimarca

Paesi Bassi

Austria

Grecia

Regno Unito

Irlanda

Svezia

Lethal Injuries: Incidence Rates in the EU (2005)

0 1 2 3 4 5 6 7

Spagna

Francia

Portogallo

UE - Euro Area

Lussemburgo

Germania

Belgio

UE - 15

Finlandia

ITALIA

Danimarca

Paesi Bassi

Austria

Grecia

Regno Unito

Irlanda

Svezia

Injury Causes

The ever-present influence of organizational factors on the occurrence of injury events is much more relevant than that of technological factors

Hazardous environments and equipments



Desk-top circular saw

Flexible grind wheel

Specific Causes of Injury

Age below 30Early working hours Less than 5 years experience in a specific taskPerforming unusual tasks Lack of experienceDistractionSleep disorders

Social Determinants of Injury

Schooling levelOccupational conditions (working position and activity)

Psychosocial factors(work stress, relations with colleagues)

Smoke, alcohol and lack of sleep

Repeated Injuries

The second injury is usually less severe than the first one

They are more frequent in males and in young workers

Injury frequency is higher in larger companies

Identifying a risk profile can suggest preventive strategies

Risk Perception

The attitude to act safely is associated with a higher or lower risk perception on the part of workers

Factors affecting risk perception

+ (increasing factors) — (reducing factors)

Severity of effects Voluntary exposure to risk

Irreversibility of effects Controllability of risk

Mediatic attention Familiarity with agent

Personal involvement Known risk/benefit ratio

Previous accidents Natural origin of risk

Occupational Diseases

Recognized Occupational Diseases UE (2003)

Recognized Occupational Diseases: Comparison among European countries

Every year, out of 100.000 insured workers, the followings are recognized

29 occupational diseases in Italy40 occupational diseases in Germany86 occupational diseases in Denmark109 occupational diseases in France113 occupational diseases in Spain128 occupational diseases in Switzerland143 occupational diseases in Belgium

D’Amico F, Mochi S, Salvati A: Le malattie professionali in Italia: evoluzione storica, tendenze in atto e prospettive future. Riv Inf Mal Prof 2002; (1-2): 119-134

Classification of Occupational Diseases in Italy

The occupational diseases recognized in Italy are those contracted in the exercise and because of the working conditions as specified in the tables annexed to D.P.R. 336 (13/4/1994)

Tables report occupational diseases, exposures and working conditions that could cause them

“Tabled” Occupational Diseases reported to INAIL (2005)

Type od disease Agriculture,

Industry and Service

Hypoacusia and Deafness 1.126

Pneumoconiosis 660

Asbestos Neoplasias 642

Skin Diseases 385

Osteoarticular Diseases 148

Bronchial Asthma 143

Allergic Alveolites 11

Others (…)

Total 3.593

“Non-tabled” Occupational Diseases reported to INAIL(2005)

Type od disease Agriculture,

Industry and ServiceHypoacusia 4.155

Tendonitis 2.181

Intervertebral discs ailments 1.800

Respiratory system diseases 1.329

STC 1.288

Osteoarthritis 1.137

Tumours 744

Others (…)

Total 17.620

Epidemiological Data

Every year I.N.A.I.L. receives about 25.000 reports of occupational diseases

Fourth Survey on Workers' Health (European Foundation, Dublin, 2005) :24,7% report back pain22,8% report muscular pain22,3% report stress disorders

Ods compensated in the years1999 – 2002, INAIL data (INDUSTRY AND SERVICE)

Malattie professionali indennizate

-1,0002,0003,0004,0005,000

1998 1999 2000 2001 2002

Tabellate

Non tabellate

Totale

ODs occurred in the years2000 – 2004 in the Italian regions

-

50

100

150

200

250

2000 2001 2002 2003 2004

N°

PIEMONTE VALLE D'AOSTA LOMBARDIA LIGURIA TRENTINO A.A.

VENETO FRIULI V. G. EMILIA ROMAGNA TOSCANA MARCHE

LAZIO ABRUZZO MOLISE CAMPANIA PUGLIA

BASILICATA CALABRIA SICILIA SARDEGNA UMBRIA

VENETO

MARCHEEMILIA ROMAGNA

TOSCANAABRUZZO

UMBRIA

Malattie professionali indennizzate

0

200

400

600

800

1000

1200

1400

1600

1800

2000

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

MALATTIE DA METALLI

MALATTIE CUTANEE CAUSATE DA CATRAME,BITUME, PECE, FULIGGINE, ANTRACENE

MALATTIE OSTEOARTICOLARI E ANGIONEUROTICHE CAUSATE DA VIBRAZIONI MECCANICHE

BRONCOPNEUMOPATIE DA INALAZIONE DI SILICATI O DI CALCARE

BRONCOPNEUMOPATIE (POLVERI,ESALAZIONI): ALLUMINIO,METALLI DURI, SCORIE THOMAS, LEGNI ESOTICI, COTONE

BRONCOPNEUMOPATIE (POLVERI,ESALAZIONI): ANTIBIOTICI,FRUMENTO GOMMA ARABICA, ISOCIANATI

ASBESTOSI

MALATTIE NON TABELLATE O CONTRATTE INLAVORAZIONI NON TABELLATE

ODs reported in Italy

Reported Compensated

non tabled 1999 2000 2001 2002 1999 2000 2001 2002

Ipoacusia 6.535 6.290 4.898 2.119 558 283 186 164

Tendinitis 529 673 794 619 79 79 160 197

Neoplasia 368 366 387 195 33 27 16 20

Respiratory disease

1181 1178 960 852 78 45 44 45

CTS 748 842 779 401 87 90 105 87

Epidemiological Data

Low back pain: INAIL data (1999) Among occupational diseases compensated by

INAIL, musculoskeletal diseases occupy the tenth position (18,1%).

Among non-tabled musculoskeletal diseases accepted by INAIL (about 1000), disc pathology account for 7% of the total

But… 10% of occupational injuries affect the spine (56000

events/year): 38% affect the lumbar rachis 93% of occupational injuries to the lumbar rachis are due

to heavy lifting and to inappropriate movements

(Giuseppe Campo, ISPESL: relazione congressuale 2002)

Dati epidemiologici nazionali

Incidenza MP riconosciute nel quinquennio 1995-1999 per l’industria

WRMSD e INAIL:Numero di casi accolti rispetto ai casi pervenuti (1996-2000)

WRMSD e INAIL Anno 2000MP da WRMSD accolte in SMG nell’anno 2000 (incidenza per patologie)

MP da WRMSD pervenute in SMG - anno 2000 (distribuzione per regioni)

Ripartizioni percentuale dei casi di WRMSD accolti secondo le lavorazioni

INAIL - % MSDs per patologia

0

10

20

30

40

50

60

2000

STC

Spalla

Epicond. /Epitr.

Discopatia rachide

M. De Quervain

Neurop. Ulnare

Tend. Mano/polso

Altro

INAIL - % MSDs per età

0

5

10

15

20

25

30

35

40

45

2000

25 - 3536 - 4546- 55> 55

INAIL - % MSDs per regione

0

5

10

15

20

25

30

35

2000

Emilia R.PiemonteMarcheAbruzzoVenetoFriuli V:G.LazioUmbriaLombardiaToscanaAltre

Tecnopatia 1999 2000 2001 2002 2003 2004 Tot. %Ipoacusie 2859 2108 2376 2378 2283 2253 14257 71,3PMS 341 384 498 696 601 1146 3666 18,3Dermatiti 164 113 160 107 113 109 766 3,8Broncopneumo. 48 41 38 32 41 45 245 1,2Neoplasie 23 35 30 38 78 37 241 1,2Mesoteliomi 17 30 28 37 42 61 215 1,1Asbestosi 11 8 21 18 16 25 99 0,5Epatopatie 58 1 10 5 3 1 78 0,4Asma bronchiale 8 14 11 21 11 10 75 0,4Saturnismo 15 10 12 4 20 9 70 0,4Silicosi 15 6 4 4 2 14 45 0,2Stress/Mobbing 1 1 5 4 9 18 38 0,2Altre 41 14 34 31 34 49 203 1Totale 3601 2765 3227 3375 3253 3777 19998 100

Segnalazioni MP SPSAL Emilia-RomagnaSegnalazioni MP SPSAL Emilia-Romagna

COMPARTOA

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Ali

men

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Alt

ro

Car

ni

Cer

amic

a

Ch

imic

a

Co

mm

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o

Ed

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ia

Ed

it/C

art

Leg

no

MT

M

Mu

n/E

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Pu

bb

lico

San

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Ser

vizi

Tess

/Con

f

Tra

spo

rti

Ipoacusie 594 464 265 242 1436 652 152 3046 160 507 5552 229 204 22 253 171 308

PMS 110 222 64 265 539 193 230 228 47 78 973 43 90 148 149 196 91

Dermatiti 7 24 24 6 46 23 18 145 7 12 204 3 19 143 75 6 4

Broncopn. 19 16 5 3 27 9 3 35 1 20 61 5 7 14 12 3 5

Neoplasie 8 4 4 53 5 20 6 4 61 14 11 29 5 7 10

Mesoteliomi 3 25 6 15 22 6 42 2 5 51 5 7 4 2 6 14

Asbestosi 2 5 3 3 8 18 3 29 12 2 2 2 10

Epatopatie 1 2 1 2 69 1 2

Asma br. 5 8 3 2 1 7 3 3 1 3 14 1 3 11 9 1

Saturnismo 56 9 2 1 2

Silicosi 1 7 1 27 7 1 1

Stress/Mobb 1 1 1 6 3 1 7 1 7 4 5 1

Altre 1 5 4 18 9 15 5 8 4 2 61 4 12 30 9 11 5

Totale 742 779 379 537 2149 993 426 3572 228 635 7023 318 363 477 522 406 449

% 3,7 3,9 1,9 2,7 10,7 5 2,1 17,9 1,1 3,2 35,1 1,6 1,8 2,4 2,6 2 2,2

Segnalazioni MP SPSAL Emilia-Romagna 1999-2004Segnalazioni MP SPSAL Emilia-Romagna 1999-2004

Occupational Diseases

In 1981, Doll and Peto estimated that 4% of annual cancer deaths were caused by occupational exposures

Many countries have developed surveillance systems to correctly identify the origin of occupational diseases

Surveillance Systems (USA)

SENSOR (Sentinel Event Notification System for Occupational Risks)

Surveillance Systems (GB)

THOR (The Health and Occupational Reporting Network)

In the period 2003-2004, the Health and Safety Executive estimated that (prevalence data):

2.223.000 subjects were suffering from diseases whose causes could be traced to occupational factors

Occupational diseases were 5.200 per 100.000 workers

Deaths were 6.000/year and were caused by diseases due to occupational risk factors

HSE. Health and Safety Statistics Highlights 2003/2004. National Statistics, 2004.

Steenland's Study

On the basis of 1997 mortality data, the study estimated: 49.000 deaths/year (range 26.000 -

72.000) due to occupational diseases 6.238 deaths/year due to injuries 55.200 deaths/year (range 32.200 -

78.200) due to occupational causes

Steenland K, Burnett C, Lalich N, Ward E, Hurrell J. Dying for work: The magnitude of US mortality from selected causes of death associated with occupation. Am J Ind Med. 2003 May;43(5):461-82.

Steenland's StudyThe number of death was evaluated

on the basis of 1997 mortality data of USA, calculating the attributable fraction

Attributable Fraction The attributable risk is the proportion of

cases attributable to a specific risk factor (work). Measure the decreasing incidence of the disease if the exposition at this particular risk is completely eliminated

The attributable risk in a population is the proportion of the risk difference between the general population and the non-exposed population, and the risk in the general population

Attributable Fraction

P(E) (RR-1)

––––––––––––––––––P(E) (RR-1) + 1

P(E) = fraction in the general population exposed to a particular risk factor

RR = disease or death relative risck in the exposed vs. non-exposed

Steenland's Study

attributable fraction (AF) of work-related mortality:

Pneumoconiosis (Asbestosis/Silicosis/Berylliosis)

AF 100% 1.087 deaths/year

Asthma AF 15% 784 deaths due to work-related asthma (range 575 -1.099)

COPD AF 14% 14.257 deaths (range 5.092 - 24.440)

Steenland's Study

Tubercolosis AF 5% 60 deaths

Coronary Heart Disease (CHD) AF 6,3-18% of subjects between 20 and 69

years of age range of deaths 4.500-12.900

Steenland's StudyTumoursLung: AF 6,3-13% (>incidence ♂)

= 9.677-19.901 deaths/yearBladder: AF 5,6-19% = 651-2191 deaths/yearMesothelioma: AF ♂ 85-90%, AF ♀ 23-

90% =1.895-2.366 deaths/yearKidney: AF 0-2,3% =57 deaths/yearSkin: AF 1,2-6% =24-92 deaths/year

Steenland's Study

Leukemia: AF 0,8-2% = 152-533 deaths/year

Larynx: AF 1-20% = 30-603 deaths/year

Nose: AF 31-43% = 231-322 deaths/year

Liver: AF 0,4-0,11% = 29-80 deaths/year

Steenland's Study

The study shows the significance of work-related pathologies and deaths, both in terms of human lives and economic costs

A new metrics in the assessment of work-related damage

1996, WHO introduced a new operative unit devoted to the “Global Programme on Evidence for Health Policy” (GPE), with the aim of improving the planning and allocation of health resources

At the same time, the ”International Burden of Disease Network” (including the GPE, which gathers several countries) was launched. The aim was that of providing a rational basis for cost/effectiveness evaluation of health policies

Four criteria for the planning and allocation of health resources

Is this problem sufficiently important? (How many people does it affect; how many healthy years of life have been lost due to this problem?)

Do we have any effective tools to face this problem?

Do we have a good basic knowledge of the problem?

Are developed countries already making efforts in that direction?

Global Burden of Disease (GBD)

The burden of disease measures the gap between the current health status and an ideal situation where everyone lives into old age free of disease and disability

The unit of measurement of GBD is time. This allows to combine the time lived with disability and the time lost due to premature mortality

Health Measures

The HALY (Health Adjusted Life Years) family of measures include, among others:

DALY = Death and Disability-Adjusted Life Years

Years lived minus years lost to disability (and premature death)

QALY = Quality-adjusted Life Years Years lived adjusted for quality of life (years to be

lived in “full health”)

DALY The DALY is the unit of measurement adopted by

WHO to measure the Global Burden of Disease (i.e., the impact of a particular disease on health status)

This measure considers the impact (expressed in

years) on populations of: “early” mortality (mortality below a conventional

age, attainable by all individuals when risk variables are controlled)

Non-fatal consequences of pathologies and accidents

DALY

One DALY can be thought of as the measure, expressed in years, of healthy life lost due to a certain condition

↓disease load attributable to such

condition ↓measure of the impact of a specific

pathology on a population

Graphic representing the case of a subject dying the same age as the previous one, after progressive worsening

Graphic representing the case of a subject dying suddenly after a life in full health

The use of the DALY allows not only a geographic and temporal comparison, but also a comparison among risk factors

It also allows to compare the relative weight of a risk factor on different adverse health phenomena

DALY

Global Deaths (000s) due to Selected Occupational Exposures (2000)

Risk Factor Outcome Males Females Total % of occup

deaths

Agents leading to COPD COPD 240 78 318 37

Risk factors for injuriesUnintentional injuries

293 19 312 37

Beryllium, cadmium, chromium, diesel exhaust, nickel, arsenic, asbestos, silica

Trachea, bronchus, or lung cancer

88 14 102 12

Asbestos Mesothelioma 28 15 43 5

Asthmamagens Asthma 23 15 38 4

CoalCoal workers’ pneumoconiosis

14 14 2

Silica Silicosis 9 9 1

Asbestos Asbestosis 7 7 1

Benzene, ethylene oxide, ionizing radiation

Leukemia 4 3 7 1

Ergonomic stressors Low back pain 0 0 0 0

Noise Hearing loss 0 0 0 0

Total 706 144 850 100

Global DALYs (000s) due to Selected Occupational Exposures (2000)

Risk Factor Outcome Males Females Total% of occup

DALYS

Risk factors for injuriesUnintentional Injuries

9.778 733 10.511 44

Noise Hearing loss 2.788 1.362 4.150 18

Agents leading to COPD COPD 3.020 713 3.733 16

Asthmamagens Asthma 1.110 511 1.621 7



825 144 969 4

Ergonomic stressors Low back pain 485 333 818 3

Asbestos Mesothelioma 356 207 563 2

Silica Silicosis 486 ― 486 2

Asbestos Asbestosis 376 ― 376 2

CoalCoal workers’ pneumoconiosis

366 ― 366 2


Leukemia 66 35 101 0.4

Total 19.656 4.038 23.694 100

Attributable Fractions (%) for Mortality and Morbidity (DALYs) due to Selected Occupational Exposures for the Global Burden of Occupational Disease and Injury

Risk Factor Outcome Males Females Total

Ergonomic stressors Low back pain 41 32 37

Noise Hearing loss 22 11 16

Agents leading to COPD COPD 18 6 13

Asthmagens Asthma 14 7 11

Risk factors for injuriesUnintentional Injuries

12 2 8



10 5 9


Leukemia 2 2 2

Average cost per worker for fatal and all nonfatal injuries and illnesses

Description of detailed industry

Average cost

per worker (USD)

Contribution to GDP per employed worker

(%)

Taxicabs 11.528 21,16

Bituminous coal and lignite mining

8.600 15,78

Logging 7.009 12,86

Crushed and broken stone

4.024 7,38

Oil and gas field services

3.938 7,23

Water transportation services

3.551 6,52

SIC = 1987 standard industrial classification, USD = United States Dollars, GDP = gross domestic product

Total cost for fatal and all nonfatal injuries and illnesses


Description of detailed industry

Total cost (USD) GDP (%)

Trucking and courier services, except air

4.394.408.812 0,0672

Eating and drinking places

3.245.844.489 0,0495

Hospitals 2.755.633.582 0,0421

Grocery stores 2.718.377.125 0,0414

Nursing and personal care facilities

1.943.638.220 0,0297

Motor vehicles and motor vehicle equipment

1.344.070.300 0,0205

Average cost ranking of industries with the lowest costs per worker


Description codeCosts

per worker (USD)GDP per employed

worker (%)

Labor union offices 86 0,16

Security and commodity exchanges

101 0,19

Mortgage bankers and brokers

136 0,25

Security brokers and dealers 137 0,25

Legal services 138 0,25

Passenger transportation arrangements

140 0,26

Classification of Risk Factors

Physical, Chemical and Biological agents, biomechanical and

relational factors

Classification of Risks

HazardIntrinsic characteristic of an activity,substance or physical factor that can cause harm to physical integrityRiskProbability that a hazardous activity,substance or physical factor will actuallycause damage to physical integrity in specificwork situations

Safety risks can be classified as risks deriving from:

Structural deficiencies of the working environment

Safety deficiencies regarding machines and equipment

Handling of hazardous substances Deficiencies in electrical safety Fire and/or explosion



Safety risks can be classified as risks deriving from:

Physical agents Chemical agents Biological agents Biomechanical factors Relational factors

120

Physical Agents

Forms of energy having a physical magnitude as unit of measurement.

Noise Vibrations Ionizing radiations Non-ionizing radiations Electricity Barometric pressure Microclimate

Noise

A series of pressure variances propagating through a medium, that can be perceived by the human ear as sound sensation

Occupational Exposure Building sector, Agriculture, Steel Industry,

etc.

Vibrations

Oscillations of a body around a reference point characterised by: frequency, amplitude and acceleration

Whole-body Vibration

(tractor drivers, lorry drivers, bus drivers, train and underground drivers, crane operators)

Hand-arm Vibration

(workers using compressed air or electrically powered vibrating tools; e.g. construction workers,

lumberjacks)

Ionizing Radiations

Radiations which interact with the matter giving rise to ionization phenomena

Corpuscular radiations

(alpha rays, beta rays, neutrons)

Non-corpuscular radiations

(X rays, gamma rays)

Ionizing Radiations

Occupational Exposure Medical applications

(diagnostic radiology, use of radioactive isotopes, radiotherapy)

Industrial applications

(extraction, production, transformation,

treatment, transportation) Research laboratories

Non-Ionizing Radiations

Radiations that do not carry enough energy to modify atoms and molecules; they form a part of the electromagnetic spectrum and are characterized by several frequency subintervals

Static Fields and Extremely Low Frequencies (ELF)

0Hz-30kHz

Low Frequencies (LF) 30kHz-300kHz

Radio Frequencies (RF) 300kHz-300MHz

Microwaves (MW) 300 MHz-300GHz

Optical Radiation (IR-VIS-UV) 300GHz-3*106GHz



Occupational Exposure Ultraviolet radiations(sterilization, photoinactivation of viruses, blood bacteria and blood products, photobiology,photochemistry, therapy) Visible and infrared radiations(e.g.: analytical techniques, therapy, grass industry) Radio frequencies and microwaves(e.g.: welding, induction furnaces, fusion, electricfurnaces, MNR, marine and aeronautical communications, food processing, disinfection) Low-frequency electromagnetic fields or static

magnetic fields(e.g.: electrical equipment in general)

ElectricityOccupational ExposureElectricians, electrotechnicians

Barometric PressureOccupational ExposureHigh-altitude jobs, underwater jobs.

MicroclimateThermal stress due to high or low temperatures

Occupational Exposuree.g.:outdoor activities, food industry,

iron and steel industry, etc.

Chemical Agents

Any chemical substance used (or already present) alone or in combination in a productive process

(e.g.: solvents, metals, pesticides, resins, etc.)

Dusts Fogs Gases Vapours

Exposure Modes and Absorption Pathways

Respiratory pathway Cutaneous pathway (via skin contact) By ingestion

Occupational Exposure

Several divisions in the agriculture, industry

and service sectors

Chemical Agents

Biological Agents

Risks associated with exposure to pathogenic organisms and microorganisms

Viruses Bacteria Fungi or mycetes Protozoa Parasites

Biological Agents

Occupational ExposuresHealth personnel and clinical and researchlaboratory personnel, farmers, breeders,slaughterhouse operators, waste collectionand disposal personnel

Biological Agents

Transmission Modes

Parenteral pathway(e.g.: hepatitis B,C, HIV)

Aerial pathway(e.g.:TBC, influenza, meningococcal meningitis,

measles)

Transmission by contact(e.g.: scabies)

Transmission by the oral route(e.g.: hepatitis A)

Biomechanical Factors

Forces applied to the body (or generated by the body itself) acting on muscles, tendons, peripheral nerves and blood vessels

Forces applied to the body Repetitive movements Posture Manual handling of loads

Biomechanical Factors

Occupational Exposure

Assembly-line operators, manufacturing

operators, data-entry operators, assistance

to patients, storekeepers, porters,

construction workers, etc.

Forces Applied to the Body

External Forces

Load exerted on the body surface when

performing a task (pushing or grabbing an

object to lift it)

Internal Forces

Tension originating in muscular, tendinous, or

ligamentous structures when making an effort

Repetitive Movements

Identical or very similar movements performed at a high frequency

Posture

Static Postures

Static and prolonged postures

Awkward Postures

Body joints deviate from their optimal area,

which allows effort exertion with minimum

tissue overload

Manual Handling of Loads

Transportation and support operations including:

Lifting Depositing Pushing Pulling Carrying Moving a load

which involve the risk of dorsolumbarinjuries

Relational factors

Factors regarding work organization and social relations, which can affect the psychological and physical health of workers

Worker/occupation relationship (stress, burn out)

Relationships between individuals within the working environment (mobbing)

Relational Factors

Worker/occupation relationshipWork contents:

Task characteristics(lack of variety, short work cycles, no use or under-use of skills, high uncertainty)

Workload, work pacing, work schedule(work overload or underload, lack of control overpacing, time pressure, shift work, lack of scheduleflexibility, overtime work)

Relational factors

Relationships between individuals within the working environment

Working context:

Culture and organizational function, role in the organization, career development, work/family interface, authoritarianism, mobbing, sexual harassment.

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Occupational Medicine Prof. Francesco S. Violante

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