Occupational Medicine S. Salehpour M.D. Occupational Medicine Specialist

Salehpour2 About 45% of the world’s population and 58% of the population over 10 years of age belong to the global workforce. Importance: –Health –productivity –Socioeconomic issues –Sustainable development.

Salehpour3 Only 5ـ10% of workers in developing countries and 20 ـ 50% of workers in industrialized countries have access to occupational health services. approximately eight out of 10 of the worlds workers live in newly industrialized countries.

Salehpour4 Rapid change of the modern working life: Increasing demands of learning new skills Need to adapt to new types of work Pressure of higher productivity and quality of work Time pressure Growing psychological workload Stress

Scope of the Occupational Health and Safety Challenges Priority areas for research have changed over time as disease patterns have been altered by economics and change in work processes. Asbestos use has decreased in developed nations and asbestosis is far less common. Vinyl chloride- induced liver cancers and byssinosis have almost been eliminated. Since 1970, fatal injury rates in coal miners have been reduced by more than 75%, and the prevalence of coal workers' pneumoconiosis has had a general downward trend. However, silicosis persists, especially in foundries and mines, and lead poisoning continues to be reported.

Occupational lung diseases persist. Nearly 30% of chronic obstructive pulmonary disease and adult asthma may be attributable to occupational exposure, and 9 million workers are occupationally exposed to known sensitizers and irritants associated with asthma. Salehpour6

Allergic and irritant dermatitis (contact dermatitis) are overwhelmingly the most important cause of occupational skin diseases, and they account for 15% to 20% of all reported occupational diseases. Latex in protective gloves causes contact dermatitis or urticaria in 10% of exposed health care workers. Prevention is critically important since 75% of patients with occupational contact dermatitis may develop chronic skin disease.

Research on the effects of various chemicals on reproduction, including birth defects, stillbirths, low birth weight, developmental disorders, and impotence, remains meager. Noise is the most important occupational cause of hearing loss resulting from acute trauma or, more likely, chronic exposure to ototraumatic agents. Factors such as heat and chemicals may interact in causing hearing loss. Salehpour8

The Role of Surveillance in Occupational Health Occupational health surveillance entails the systematic monitoring of health events and exposures in working populations in order to prevent and control occupational hazards and their associated diseases and injuries.

Occupational health surveillance systems, has four essential components :  Gather information on cases of occupational diseases and injuries and on workplace exposures  Analyze the data  Disseminate organized data to necessary parties, including workers, unions, employers, governmental agencies, and the public  Intervene on the basis of data to alter the factors that produced these health events and hazards

Surveillance in occupational health has been more concisely described as counting, evaluating, and acting. The word surveillance derives from the French word surveiller, watch over, which encompasses the twin notions of careful observation and timely intervention. It is important to emphasize that the enumeration and documentation of cases of occupational disease and injury is inseparable from the obligation to attempt to alter the conditions that led to the described occupational health morbidity and mortality.

This obligation to take preventive action on the basis of surveillance data stems from a well-defined series of moral, ethical, and legal responsibilities of employers, governmental agencies, and unions.

Medical surveillance refers to the ongoing application of medical tests and procedures to individual workers who may be at risk for occupational morbidity to determine whether an occupational disorder may be present. Medical surveillance is generally broad in scope and represents the first step in ascertaining the presence of a work-related problem.

A medical surveillance program applies tests and procedures to a group of workers with common exposures for the purpose of identifying individuals who may have occupational illnesses and for the purpose of detecting patterns of illness among the program participants, which may be produced by occupational exposures.

In occupational health, there are two kinds of surveillance activities: (a) public health and medical surveillance (b) hazard surveillance Hazard surveillance is the monitoring of exposure to chemical agents, physical hazards, or radiation in the workplace. The two types of surveillance data complement each other.

The main purpose of occupational health surveillance is to identify the incidence and prevalence of known occupational diseases and injuries. Gathering descriptive epidemiologic data on disease incidence and prevalence on an accurate and comprehensive basis is an essential prerequisite for establishing a rational approach to the control of occupational disease and injury.

Collection of incidence and prevalence data permits an analysis of trends of occupational disease and injury among different groups, at different places, and during different time periods. Detecting such trends is useful for determining control and research priorities and strategies as well as for evaluating the effectiveness of any intervention undertaken

Finally, occupational health surveillance is an important means of discovering new associations between occupational agents and accompanying diseases. The potential toxicity of approximately 80% of the chemicals used in the workplace has not been evaluated in humans.

Occupational Sentinel Health Events NIOSH defined the occupational sentinel health event as a disease, disability, or untimely death which is occupationally related and whose occurrence may: (a) provide the impetus for epidemiologic or industrial hygiene studies; (b) serve as a warning signal that materials substitution, engineering control, personal protection, or medical care may be required.

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The goal of a multidisciplinary occupational health and safety team is to design, implement, and evaluate a comprehensive health and safety program that will maintain and enhance health, improve safety, and increase productivity. Such programs often provide similar results for the families of workers, with resultant financial and other benefits for the corporation.

Occupational health and safety professionals include: –Occupational medicine physicians –Industrial hygienists –Safety professionals –Occupational and environmental health nurses –Occupational health psychologists –Other related members of the multidisciplinary team: Ergonomists Toxicologists Epidemiologists Human resource specialists Industrial/organizational psychologists

Safety and health statistics Indicators of safety and health at work: –Indicators of outcome –Indicators of capacity and capability –Indicators of activities Salehpour23

Work-related ill health and occupational disease (HSE) Over deaths each year are estimated to have been caused by past exposure at work - primarily exposure to chemicals and dusts. An estimated 1.1 million people who worked in 2011/12 were suffering from a work-related illness, of which were new cases which started in the year. Salehpour24

Around 80% of the new work-related conditions in 2011/12 were musculoskeletal disorders or stress, depression or anxiety. Other work-related illnesses include skin disease, respiratory disease, hearing loss and vibration-related disorders 25

Global estimates of occupational burden of disease (WHO) Salehpour26

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Salehpour29 According to the estimates by the International Labour Organization (ILO) for accidents and diseases, there are globally about 2.2 million work-related deaths annually. Of this total, about 350,000 deaths are due to fatal occupational injuries The largest share of work related fatalities is made up by fatal diseases: 1.7 ـ 2 million deaths annually. Almost half of these fatalities occur in Asian countries.

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In a 2005 report, the ILO utilizes a variety of national reports to generate estimates, and states that the global workforce of 2.8 billion persons suffer some 270 million serious non-fatal injuries and 160 million work-related diseases. Salehpour31

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Occupational risk factors such as the following, contribute markedly to global illness and injury:  37% of back pain  16% of hearing loss  13% of Chronic Obstructive Pulmonary Disease (COPD)  11% of asthma  9% of Trachea, bronchus lung cancer  8% of injuries  2% of leukemia 33

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35 History of Occupational Diseases

Salehpour36 Silicosis- Ancient Disease of Miners  Detected among Mummies of workers in Egypt (1500 BC)  Described by Hyppocrites as disease of metal miners (400 BC)  In the 16 th century Agricora wrote of mines in Carpathian Mountains in Europe: “ women are found who have married seven husbands, all of whom this terrible consumption has carried off to a premature death.”

Salehpour37 Ancient Greeks were familiar with lung disease in quarry workers (Hippocrates) and the fact that respirators could prevent the disease (Pliny). Agricola (1566) described disease in stone cutters as later did Ramazini (1713). By 1917, the U.S. Public Health Service identified sand blasters and foundry workers to be at high risk of silicosis. The Gauley Bridge disaster with 475 deaths in 1931 focused public attention on silicosis in America. Lawsuits in the 1920s and 1930s resulted in workers' compensation coverage for occupational disease.

Salehpour38 The World-wide Problem There can be no question that the risks of injury and lung illness were realized to be a part of the miner’s life, even in 16 th century.

Salehpour39 Ancient times Egypt, Greece and Rome –Mining one of the oldest industries –miners – slaves, criminals –work = punishment –miners used bags, sacks, animal bladders as masks to decrease dust exposure

Salehpour40 Late 19 th, early 20 th century Development of government agencies and professional associations ILO –created 1919 – declared anthrax occupational disease –1925 – 1 st list of Occupational Diseases

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Salehpour42 According to the principles of the United Nations, WHO and ILO, every citizen of the world has a RIGHT to healthy and safe work and to a work environment that enables him or her to live a socially and economically productive life.

Salehpour44 Occupational Health The definition of occupational health has broadened considerably and there has been a transition from the strict concept of “prevention of occupational injuries and diseases” to “overall protection and promotion of workers’ general health”.

Salehpour45 بيماري هاي شغلي بيماري هاي مرتبط با كار (سل در يك پرستار) بيماري هاي ناشي از كار (سيليكوزيس، آزبستوزيس) بيماري هاي مرتبط با كاربيماري هاي ناشي از كار

Salehpour46 Occupational diseases

Salehpour47 قانون كار براي صيانت نيروي انساني و منابع مادي كشور رعايت دستورالعمل هايي كه از طريق شوراي عالي حفاظت فني(جهت تامين حفاظت فني) و وزارت بهداشت، درمان و آموزش پزشكي (جهت جلوگيري از بيماري هاي حرفه اي و تامين بهداشت كار و كارگر و محيط كار) تدوين مي شود، براي كليه كارگاه ها ، كارفرمايان، كارگران و كارآموزان الزامي است. ( ماده 85 )

Salehpour48 ماده 92 كليه واحدهاي موضوع ماده 85 اين قانون كه شاغلين در آنها به اقتضاي نوع كار در معرض بروز بيماري هاي ناشي از كار قرار دارند بايد براي همه افراد مذكور پرونده پزشكي تشكيل دهند و حداقل سالي يك بار توسط مراكز بهداشتي، درماني از آنها معاينه و آزمايش هاي لازم را به عمل آورند و نتيجه را در پرونده مربوطه ضبط نمايند.

Salehpour49 تبصره 1 ماده 92: چنانچه با تشخيص شوراي پزشكي نظر داده شود كه فرد معاينه شده به بيماري ناشي از كار مبتلا يا در معرض ابتلا باشد، كارفرما و مسئولين مربوطه مكلفند كار او را بر اساس نظريه شوراي پزشكي مذكور بدون كاهش حق السعي ، در قسمت مناسب ديگري تعيين نمايند. تبصره 2 ماده 92: در صورت مشاهده چنين بيماراني، وزارت كار و امور اجتماعي مكلف به بازديد و تاييد مجدد شرائط فني و بهداشت و ايمني محيط كار خواهد بود.

Salehpour50 ماده 175 متخلفان هر يك از موارد مذكور در مواد 78، 80 ، 81 ، 82 و 92 براي هر مورد تخلف حسب مورد علاوه بر رفع تخلف يا تاديه حقوق كارگر يا هر دو، در مهلتي كه دادگاه با كسب نظر نماينده وزارت كار و امور اجتماعي تعيين خواهد كرد، به ازاي هر كارگر به ترتيب ذيل محكوم خواهند شد: 1) براي تا 10 نفر ، 30 تا 100 برابر حداقل مزد روزانه يك كارگر.

Salehpour51 ماده175 (ادامه...) 2) براي تا 100 نفر نسبت به مازاد 10 نفر، 10 تا30 برابر حداقل مزد روزانه يك كارگر. 3) براي بالاتر از 100 نفر نسبت به مازاد 100 نفر، 5 تا 10 برابر حداقل مزد روزانه يك كارگر. در صورت تكرار تخلف ، متخلفان مذكور به 1/1 تا 5/1 برابر حداكثر جرائم نقدي فوق و يا به حبس از 91 روز تا 120 روز محكوم خواهند شد.

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Salehpour53 Early detection of occupational diseases

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Salehpour55 نظام مراقبت از بيماري ها Surveillance سيستمي پويا براي جمع آوري، تحليل و تفسير اطلاعات مرتبط با سلامتي است كه براي برنامه ريزي، اجرا و ارزيابي خدمات سلامت ضروري بوده و با توزيع به موقع اين اطلاعات به افراد ذي نفع همراه است.

Salehpour56 What is Occupational Surveillance? Systematic monitoring of: –Hazardous exposures –Adverse health events FOR THE PURPOSE OF Prevention and control of: –Occupational hazards –Occupational diseases and injuries

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Salehpour58 Types of Prevention Primary – Target: those with potential for exposure; no disease yet. Goal: change exposure conditions Secondary – Target: those with early stage of disease, no symptoms yet Goal: reverse disease, delay symptom onset Tertiary – Target: those with clinical disease Goal: cure or control of disease.

Salehpour59 HealthyAsymptomaticSymptomatic Worker Disease Disease PrimarySecondaryTertiary PreventionPreventionPrevention Opportunities for Prevention time

Salehpour60 Why might you start an occupational surveillance program? Identify a problem and estimate its magnitude Identify groups at risk Monitor illness/injury trends in time and geography Identify cases, workplaces, and industries for attention Identify new illnesses Identify new hazards

Salehpour61 How might you use a surveillance program? Prioritize health problems Determine whether you need an intervention program Evaluate progress, success, or failure of an intervention program Provide planning data for cost- effectiveness and benefit analysis

Salehpour62 How would you organize surveillance? HAZARD BASED Characterize hazards –Observation/checklist Monitor environment Test workers HEALTH BASED Acute or chronic injuries/illnesses List of insurance claims Death certificates Health questionnaire Physical examination Lab testing for disease markers

Salehpour63 What are the components of a surveillance system? Gather information on exposure & disease Analyze data Disseminate data in an organized form Use data to target or evaluate an intervention On-going

Salehpour64 غربالگري شاغلين غربالگري انجام هرگونه معاينه يا آزمايشي به منظور شناسايي اختلال عملكرد در ارگانهاي بدن يا بيماري، قبل از ظهور آن اختلال و بيماري است، در زماني كه مداخله پزشكي موثر و مفيد واقع گردد.

Salehpour65 غربالگري در واقع بررسي افراد بدون علامت براي شناسائي احتمال وجود بيماري مورد نظر است. افرادي كه در آنها احتمال بيماري وجود داشته باشد ، جهت بررسي بيشتر معرفي شده و آزمايشات تكميلي براي ايشان انجام مي گيرد.

Salehpour66 Designing & Implementing a screening program 1.Assessment of workplace hazards 2.Identification of target organ toxicities for each hazard 3.Selection of a test for each screenable health effect 4.Development of action criteria 5.Performance of testing

Salehpour67 Designing & Implementing a screening program 6. Interpretation of test results 7. Test confirmation 8. Determination of work status 9. Notification 10. Diagnostic evaluation 11. Evaluation and control of exposure 12. Record-keeping

Salehpour68 Following conditions should be considered before a screening test is adopted:

Salehpour69 Moreover…

Sensitivity Sensitivity : measures the proportion of actual positives which are correctly identified as such (e.g. the percentage of sick people who are correctly identified as having the condition). Sensitivity relates to the test's ability to identify positive results. Salehpour70

Specificity Specificity measures the proportion of negatives which are correctly identified (e.g. the percentage of healthy people who are correctly identified as not having the condition). Specificity relates to the test's ability to identify negative results. A sign or symptom with very high specificity is often termed pathognomonic.pathognomonic Salehpour71

Salehpour72 انواع معاينات شغلي  Preplacement Examinations  Periodic Examinations  Return to Work Assessments  Exit Examinations  Evaluation for Specific Occupational Exposures or Diseases …

Salehpour73 پايش بيولوژيك Biologic Monitoring اندازه گيري و ارزيابي عوامل شيميايي محيط كار و متابوليت هاي آنها در نمونه هاي بيولوژيك بدن (هوای بازدمی،خون، ادرار، مو) به منظور ارزيابي مواجهه و جذب مواد از راههاي مختلف (استنشاق، بلع يا جذب پوستي). پايش محيطي عبارت است از ارزيابي مواجهه خارجي با يك ماده شيميايي موجود در محيط كار.

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Salehpour75 Environmental Monitoring  TLV* Biologic Monitoring  BEI BEI یا شاخص بیولوژیک تماس، حدود مجاز مرجع برای پایش بیولوژیک هستند. شاخص های بیولوژیکی تماس معمولاً مقادیری هستند که در نمونه های بیولوژیک کارگر سالم با تماس شغلی در حد TLV یافت می شوند. مگر...

Salehpour76 کاربرد پایش بیولوژیک مستدل نمودن پایش هوا ارزیابی اثربخشی وسایل حفاظت فردی تعیین قابلیت نفوذ مواد از راه پوستی و گوارشی تعیین تماس های غیر شغلی

Salehpour77 آيا پايش بيولوژيك و پايش محيطي الزاماً يك نتيجه را نشان مي دهند؟ خير ، به دلائل زير: روش هاي انجام كار در كارگران مختلف، متفاوت است. راهها و سرعت جذب و متابوليسم مواد در افراد مختلف ممكن است متفاوت باشد. استفاده از وسائل حفاظت فردي، جذب مواد را تحت تأثير قرار مي دهد. ميزان جذب استنشاقي با تفاوت در ميزان تهويه، متغير خواهد بود. افراد با بافت چربي بيشتر، به ميزان بيشتري مواد محلول در چربي را در بدن تجمع مي دهند.

Salehpour78 منابع اصلی تناقض بین پایش بیولوژیک و پایش محیطی وضعیت فیزیولوژیک و بهداشتی فرد شرایط تماس شغلی منابع تماس محیطی غیر شغلی شیوه زندگی فرد (Life style) روش کار نمونه برداری و تحلیل نتایج زمان نمونه گیری

Salehpour79 آيا براي تمام مواد شيميايي پايش بيولوژيك انجام پذير است؟ خير، بايد واجد خصوصيات زير باشند: ماده مورد نظر در محيطهاي بيولوژيك موجود و براي نمونه گيري مناسب بوده و نيز روش نمونه گيري براي جمعيت مورد نظر قابل قبول باشد. روش هاي آناليز عملي بوده و داراي نتايج معتبر و قابل تكرار باشد. نتايج قابل تفسير باشند. با توجه به نتايج، مداخله مناسب از قبل تعريف شده باشد.

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