1. PHYSICAL AGENTS

2. Objectives: To know the definition of physical agents To identify the physical agents as risk factors in the work and work environment To explain the main effects of physical hazards on health To know, roughly, the threshold values of physical hazards To recognize the main occupational diseases because of physical hazards exposure and to know when to refer the patient to an occupational physician To explain the specific role, tasks and responsibilities of the occupational health services and occupational physician at the workplaces with physical hazards exposure (prevention, treatment)

4. Which are the physical agents? Noise Vibrations Radiations Temperature Lighting Pressure

5. The 5th European Working Conditions Survey shows that the physical hazards have remained a problem for the European workers in the last few years.

6. Which are the main characteristics? We cannot see We cannot touch We can feel them by the neuro-sensorial organs (except radiation) We can measure them in the occupational workplace/environment We cannot measure them in the human body (except ionizing radiation)

7. Which are the effects? Time of exposure Level of exposure Source Worker - occupational diseases - occupational related diseases - accident of work Workplace - days of incapacity of work - a new worker - risk insurance

8. How can we protect ? Source Worker I.Reduces the PA at the source Eg: -isolation -change the device

9. How we can protect ? Source Worker II. Reduce exposure time Increase the distance

10. How can we protect ? Source Worker III. At the Worker Level E.g.: - isolation (special cabin) - individual equipment protection

11. What is the Role of the OH Physician? OH physicianPrevention Identifies the physical hazards Screening at pre-employment Monitoring health Periodical examination Treatment First aid specific/supportive

12. Noise What is noise? – a group of unwanted or/and wanted sounds which produce an unpleasant hearing sensation, sometimes disturbing, which impede communication – an annoying sound The perception depends on the listener and the circumstances (e.g. rock music can be pleasant for a person, but uncomfortable in a surgery room).

13. What is occupational noise? a complex of sounds, of variable intensities and pitches, having different characteristics, rhythmic or rhythmless, produced continuously or discontinuously by machines, tools, devices, means of transportation, the human voice, etc, during the performance of the professional activity

14. Characteristics of sounds Frequency = the peach of sound Hertz High pitches>3000 Hz Low pitches<500 Hz E.g. the woman’s voice and the man’s voice 500 and 2000 Hz are the most important for understanding speech 3000 Hz and 4000 Hz are the first to be affected by noise Intensity = the level of the sound or the sound pressure dB “0” dB does not mean the lack of any sound, but a sound level where the sound pressure is equal to that of the reference level which corresponds to 0.02 mPa. E.g. if the noise produced by a machinery is 97 dB (A), when doubling the source of noise (if we have 2 identical machineries), the noise will increase by 3 dB, it will not be doubled! Loudness = the subjective human response to sound dependent on sound pressure and, then, on frequency

15. What is the Threshold Limit Value? The Threshold Limit Value (TLV) depends on the work specificity (International Standard, ISO 1999-1990). The Law establishing this is the Directive 2003/10/EC of the European Parliament and of the European Council. This directive is to be transposed into the national legislation of all Member States. In the European countries the maximum admitted values (Leq - weekly equivalent acoustic level) at the workplace with normal neural-sensorial solicitation are between 85 and 90 dB (A).

17. What are the Health Effects? http://www.hse.gov.uk/noise/vid eo/hearingvideo.htm

18. What are the Health Effects? Auditory Acute : tinnitus acoustic trauma Chronic: hypoaccousia Noise Induced Hearing Loss (NIHL) Non-auditory sleep disturbances general effects (cardiovascular, metabolic changes) behavioural effects

19. The audiogram - records both ways of sound transmission: air and bone conduction Normal audiogram

20. NIHL

21. Treatment 1. Ceasing the exposure to noise and other toxic substances (Hg, SC2, toluene, Gentamycin, Kanamycin etc) 2. Medication: antioxidants, vitamins 3. Hearing aids in severe cases

22. How can we protect from noise? Source I.Reduces the N at the source E.g.: -isolation -change the device Technical and organizational measures Worker III. At the worker level E.g.: - isolation (special cabin) - individual equipment protection (ear plugs or ear muffs) II. Reduce exposure time Increase the distance

23. How can you protect from noise? Medical measurements Pre-employment examination Periodical examinations – Audiometric testing Risk assessment Risk management

24. Ultrasounds and infrasound Ultrasounds > 20000 Hz = inaudible Where to be found? (workplaces) - industry (used in detecting defects, cleaning of pieces etc) medicine (ultrasounds, dental scaling, therapy) devices against thieves, pests etc Infrasound 1-20 Hz = inaudible Where to be found? (workplaces) natural sources: – geological (earthquakes, landslides, avalanches) or – meteorological events (storms, tornadoes) artificial sources: – industrial machines – ventilation systems, air conditioning – aircraft – rail traffic

25. What are the health effects of ultrasounds and infrasound? Ultrasounds Acute effects: 18-30 kHz headache, fatigue at the end of the day, sleepiness during day time, the feeling of pressure inside the ear, walking disturbances, numbness, and sensitivity disturbances. Chronic effects: vascular disturbances, increase of the central and skin temperatures, hyperglycemia, increased number of eosinophiles Infrasound Acute exposure: to intensities high enough to be heard, it can determine a decrease in vigilance Chronic exposure: to normal levels present in the environment, there is not enough evidence

26. How do we protect from ultrasounds and infrasound? By respecting the technical prophylactic measurements concerning noise exposure In case of ultrasounds, wearing rubber cotton gloves may be of help

27. Vibration Vibrations are the mechanical oscillations of an object reported to an equilibrium point. Vibrations enter the body through the organ in contact with the vibrating equipment. There are two situations: – the hand-arm vibration exposure, when a worker operates hand-held equipment such as a chain saw or jackhammer, the vibrations affect the hands and the arms; – the whole body vibration exposure, when a worker sits on a vibrating seat or stands on a vibrating floor, the vibrations exposure affect almost the entire body.

28. How do you measure vibrations? The measurement of vibrations is made with a special device similar to the sonometer and the established parameter according to legal standards is the acceleration http://www.occup-med.com/content/3/1/13 Legal framework: European Directive 2002/44/ CE

29. What are the workplaces with vibrations? Mining, constructions, forestry work, car driving (tractor, excavator, and bulldozer), helicopter, etc. Sources of vibrations: pneumatic tools, chain saw and other vibrating tools.

30. What are the health effects? Hand-arm vibration exposure Whole body vibration exposure 20-500 HZ< 20 Hz Target organs: - blood vessels of the fingers - sensitive nerves of the hand - bone-muscle-articulation - structures of the hand-arm system Target organs: - organs of the abdominal cavity - circulatory system - vertebral column - nervous system

31. What are the health effects? Hand-arm vibration exposure Whole body vibration exposure Vascular changes: - Vibration – Induced White Finger (VWF) - Hand – Arm Vibration Syndrome (HAVS) - Carpal Tunnel Syndrome Neurological changes: - night numbness, tactile sensitivity decrease, alteration of the superficial thermal pain sensitivity Osteo-musculo-skeletal disorders: -cysts at the carpal bones -Osteoarthritis of the metacarpal- trapeze bone articulation -Kienbock disease (aseptic necrosis of the semilunar bone) -Dupuytren disease (retraction of the superficial palmar aponevrosis) Motion sickness: (0,1-2 HZ) Gastro-intestinal disorders: (4-8 Hz) Circulatory disorders: (4-8 Hz) Visual disorders: (5-20 Hz) Osteo-musculo-skeletal disorders: - especially back pain with disc or arthrosis modifications

32. Laboratory investigations Hand-arm vibration exposure Whole body vibration exposure Cold provocation test Vascular Doppler test Infrared thermograph test Vibration perception test Other investigations: - Bone X –ray - Biological Bone X ray (lumbar vertebral column) RMN Biological investigations Gastric examination Renal examination

33. Treatment Cessation to vibrations exposure Symptomatic treatment Medical prevention Pre-employment examination Periodical medical examination Increased caution for people with cardiovascular diseases and musculo-skeletal disorders

34. How can we protect from vibrations? Source I.Reduce the V at the source E.g.: -Design an ergonomic tool to attenuate the V -Change the device Technical and organizational measures Worker III. At the worker level E.g.: - individual protection equipment (special gloves) II. Reduce exposure time Avoid exposure to cold Vibration damping system

35. Radiation What do we know about radiation? Radiation is a complex process through which the energy emitted by a source is transmitted through different media and then absorbed by a support. According to the ionizing capacity of the matter, we have ionizing and non-ionizing radiation.

36. Visible Light Enough energy to produce ionization

37. Classification according to the ionizing capacity of the matter Ionizing radiationNon-ionizing radiation Electromagnetic: - X rays - Gamma rays Corpuscular : - Alpha particles - Beta particles - Neutrons Electromagnetic fields Infrared (IR) Ultraviolet (UV) Visual radiation (V) Laser Microwave

38. Characteristics of radiation Source Energy deposit The first interaction Transport

39. Ionizing radiation How can we measure radiation? The radiation dose is the most important measure from the medical point of view. The radiation dose can be expressed as: Absorbed dose (D) - the amount of energy absorbed per unit weight of the organ or tissue; - measured in Gray (Gy). Equivalent dose (H) - Absorbed dose in Gy multiplied by a weighing radiation factor (W R ) which expresses the biological effectiveness of radiation; - measured in Sievert (Sv). The equivalent dose takes into consideration the radiation type, because the equal doses of all types of ionizing radiation are not equally harmful. Effective dose (E) E =  T w T.H T where w T.= weighing tissue/organ factor and H T = equivalent dose in tissue/organ

40. What are the limits of exposure to radiation? The Threshold Limit Values (TLVs) published by the ACGIH (American Conference of Governmental Industrial Hygienists) are: – 20 mSv - average annual dose for radiation workers, over an average of five years – 1 mSv - annual dose limit recommended for general public (ICRP - International Commission on Radiological Protection) The risk of radiation-induced diseases depends on the total radiation dose that a person receives over the time. Legal framework: there are specific standards for each type of radiation.

41. Where we can find ionizing radiation? Sources of radiation: natural (85%): cosmic, the natural radioactivity of the earth, the natural radioactivity of the air (Radon), the natural radioactivity of the water, vegetation, and food; artificial (15%): medical, occupational, and from other sources such as: industrial, nuclear research, nuclear accident (Chernobyl, Fukushima). Workplaces: the medical sector (X-ray examinations ~ 1mSv/year, nuclear medicine ~ 1-2mSv/year), research (operating accelerators ~ 4-5mSv/year), industry (industrial X- ray examination, radioisotopes production, manufacturing of luminescent products), nuclear industry, natural sources (Radon in the uranium mining activity, the cosmic radiation during plane flights).

42. What are the Health Effects? TYPES OF EFFECTS CELL DEATH DETERMINISTIC Somatic Clinically attributable in individual exposure E.g. acute radiation disease, burns Existence of a threshold (under this, no observable effects) Severity increased by dosage CELL TRANSFORMATION STHOCASTIC Somatic and hereditary Epidemiological attributable in large population E.g. cancer, mutations No threshold Probability of the effect increases by dosage BOTH ANTENATAL Somatic and hereditary Expressed in the foetus, newborn or descendants

43. Radiosensitivity (RS) High RSMedium RSLow RS Bone marrow Spleen Thymus Lymphatic nodules Gonads Crystalline Lymphocytes Skin Mezodermic tissue of organs (e.g. liver, heart, lung etc) Muscles Bones Nervous system

44. Clinical Aspects ACUTECHRONIC GENERAL Radiation Acute Syndrome (RAS) LOCAL Acute radio dermatitis Eye impact Infertility GENERAL Chronic radiation disease LOCAL Chronic radio dermatitis Skin cancer

45. Treatment In case of over-exposure: Identify the affected people, select, isolate and monitor them Proper protection of the personnel involved in the rescue and in the research !!! Reconstruct the accident through physical and biological measurements and clinical data Symptomatic treatment (antivomitives, sedative drugs, etc) In local exposure the prognosis is better.

46. How can we protect from ionizing radiation ? Technical and organizational measures Increase the distance from the source Reduce exposure time Protect exposed people Fundamental concepts of radioprotection: Justification Optimization Dosage limitation

47. How can we protect from ionizing radiation ? Medical measures - blood count !!! - nucleoli test - ophthalmological examination - psychological test

48. Non-ionizing radiation Non-ionizing radiation: electro-magnetic fields, infrared, ultraviolet (UV), visual radiation, laser, microwave How do we measure non-ionizing radiation? Measure unit: frequency – Hz (cycle/second), wavelength – λ (m)

49. Non-ionizing radiation UltravioletVisibleInfrared SourceNatural: sunlight Artificial: welding activities, cutting with plasma, laser with UV, incandescent metals, lamp with Hg vapours, etc Natural: sunlight Artificial: electric lamp, lamps with high intensity, flashes, laser, video terminals, etc Natural: sunlight Artificial: any object with temperature higher than 0 degrees absolute Microwave radiation and radiofrequency wave Source: in radio communications, industry (heating), drying, hardening of metal, food sterilization, display screen, in medicine (diathermy) Very low frequency radiation (<200Hz, especially 50-60 Hz) include the frequencies used for the high voltage electric lines and the domestic electric lines Laser (Light Amplification by Stimulated Emission of Radiation ) Source: cutting of metals, plastics, in communications, in medicine

50. Non-ionizing radiation What are the Health Effects? Two types: - thermal effect - non-thermal effect (genetic, phototoxic, and photo-allergic) Main affected organs: - eyes (Laser exposure) - skin Clinical effects of exposure to very low frequency are very controversial. Research has focused on possible carcinogenic, reproductive, and neurological effects. Other suggested health effects include cardiovascular, brain, behaviour, hormonal and immune system changes.

51. Non-ionizing radiation Treatment: Restriction or cessation to the exposure Specific treatment of the eye and skin lesions

52. Non-ionizing radiation How can we protect from non-ionizing radiation? Medical measures People having mechanical or cardiac implants are not allowed on/ around electromagnetic fields !!! We can not employ people with: – eye conditions – central nervous system condition – cardio-vascular condition – skin diseases

53. How can we protect from non- ionizing radiation? Source Technical and organizational measures Worker III. At the worker level E.g.: - individual protection equipment (proper clothing, special eye protection) - protection cream II. Reduce exposure time Increase source distance Use protective shields

54. Lighting What do you know about lighting? Light is a key element for our capacity to see and it is necessary to appreciate the form, the colour and the perspective of the objects that surround us. Light or visible light is electromagnetic radiation that is visible to the human eye, and is responsible for the sense of sight.

55. Good lighting implies: – uniform illumination – optimal luminance – no glare – adequate contrast conditions and use of correct colours as detail and background – absence of stroboscopic effect or intermittent light

56. How do we measure lighting? The device for measuring lighting is the lux meter. The measuring unit for lighting is “lux” (luminance) i.e. the luminous flux per unit area at any point, on a surface exposed to incident light. Legal framework: according to the European legislation A good lighting level is necessary to be sufficient (at least equal with the specific values)

57. What are the sources and workplaces? Sources: natural: the sunlight, artificial: lighting by incandescence, fluorescence, high-pressure sodium or mercury lamp, low-pressure sodium or tungsten lamp, mixed lighting (i.e. natural and artificial). The sunlight is composed of: 40% visible radiation, 59% infrared visible radiation, 1% ultraviolet visible radiation. Workplaces: agriculture, constructions, sailing activities, foundries, office work. Professions: workers in outdoor activities in summer and winter, inside activities with visual solicitation (jeweler, watchmaker, etc).

58. What are the Health Effects? Poor lighting may affect the workers' Health Visual trouble (visual fatigue, tearing, and other visual problems) Fatigue Headache Musculoskeletal disorders Performance Errors Accidents

59. Treatment WorkplaceWorker Solving the technical problems of inadequate lighting: - type of light - position - distances - organization of work - 10 minutes breaks every 1 hour (e.g. fine, very fine, computer work) Against visual disorders: - ophthalmologic eyewash, vitamins, protection or correction glasses Against fatigue: - vitamins - antioxidants Against MSD: - physiotherapy - swimming - NSAID It is recommended to use natural lighting!

60. How can we prevent the effects of poor lighting? Technical measures For good lighting it is necessary to have an ergonomic organization of the workplace and to take into consideration: – the precision required for the performed tasks – the amount of work – the mobility of the worker – the characteristics of the workplace (windows, type of lighting and the season)

61. How can we prevent the effects of poor lighting? Medical measures Monitoring the visual capacity of employees before employment and after that, through periodical examination (usually, a screening examination per year).

62. Microclimate (cold and warm climate) The microclimate is characterized by: - temperature (dry) - relative humidity - air current speed - surface temperature - caloric radiation Very cold and very hot temperatures could be dangerous to health.

63. Temperature action and worker reaction Temperature Air movement Humidity Cold/warm environment Worker Proper insulation (protective clothing) Physical activity Controlled exposure to cold or warm

64. How do we measure temperature? Measuring device: globe thermometer Measuring unit: temperature in degrees Celsius or Fahrenheit Legal framework: according to the European legislation

65. Cold exposure What are the workers exposed to cold? Outside: road builders, construction workers, police officers, fire fighters, emergency response workers, military personnel, transport workers, bus and truck drivers, fishermen, hunters and trappers, etc Inside: workers in refrigerated warehouses, meat packaging and meat storage workers, etc.

66. What are the Health Effects to cold exposure? Heat Loss Local effects: FROSTBITE General effects: HYPOTHERMIA Heat production + Heat retention

67. Treatment FROSTBITEHYPOTHERMIA EMERGENCIES FIRST AID INCREASE THE BODY TEMPERATURE GRADUALLY !!!

68. How can we prevent frostbite and hypothermia? Cold environment Worker Proper insulation (protective clothing) Proper resting periods in a warm area Balanced meals and adequate warm tea intake NO alcohol !!! Insulated Cabine Technical measures

69. How can we prevent frostbite and hypothermia? Medical measures: pre-employment periodical medical examinations People presenting the following conditions are not allowed to work in cold environments: cardiovascular diseases Reynaud’s syndrome otitis, sinusitis nephropathy

70. Heat environment What are the workplaces with warm/hot exposure? Outdoor occupations, such as: constructions, road repairing, open-pit mining and agriculture - summer sunshine being the main source of heat. Inside occupations, such as: foundries, steel mills, bakeries, smelters, glass factories, and furnaces - extremely hot or molten material being the main source of heat; in laundries, restaurant kitchens, and canneries, high humidity adds to the heat burden.

71. Heat environment What is acclimatization? The temporary adaptation of the body to work in heat conditions and to which a person is exposed over time. Complete heat acclimatization generally takes 6 to 7 days, but some individuals may need longer. When a person gets acclimatized, the central temperature decreases with up to 1 degree Celsius and the cardiac frequency decreases with 10-14 beats/minute, compared to a non-acclimatized person in the same conditions. This is a consequence of the increased sweating process and a good vaso-motor control.

72. How does warmth act? What are the Health Effects? Body heat (generated by working) Clothing requirements Warm environment Heat stress Heat oedema Heat rashes Heat cramps Heat exhaustion Heat syncope Heat stroke and hyperpyrexia

73. Treatment Removal from the heated environment Resting in a cool area ± consumption of cool salted drinks Heat stroke and hyperpyrexia require immediate first aid and medical survey !!!

74. How can we protect from heat exposure? Source I. Reduces the radiant from hot surfaces Insulation of hot surfaces Technical and organizational measures Worker III. Protection clothing Eyes protection II. Reduce exposure time Increase the distance Shielding Ventilation Reducing the humidity

75. How can we protect from heat exposure? Medical measures: Acclimatization !!! a decrease in heat tolerance occurs even after a long weekend. This is the reason for which it is often not advisable for anyone to work under very hot conditions on the first day of the week. Also, the new employees should acclimatize before assuming a full workload. People with cardiovascular diseases are not allowed to work in heat conditions.

76. Air pressure The activities performed in conditions of abnormal pressure are grouped into two categories: activities performed in hyperbarism (atmosphere compression or decompression) activities performed in hypobarism (pressure below that of the ground level atmospheric pressure)

77. Air pressure HyperbarismHypobarism - underwater activities - scuba divers (the pressure exceeds with at least 0.1 atmospheres the normal value) - pilots - lift workers - workers in store-rooms with modern fire protection systems where the oxygen content of the air is reduced to 13 % What are the Workplaces and Workers ?

78. Air pressure the trauma of the ears and the sinuses during compression period the toxic effect of nitrogen and CO 2 while working in increased pressure caisson disease during decompression period HYPERBARISM What are the Health Effects and Treatment? Treatment : acute forms are medical emergencies and require Oxygen administration and modifying the pressure

79. Air pressure the decompression disease at high altitude (pilots, aircraft personnel) the altitude hypoxia (pilots, aircraft personnel) the lift workers disease the high altitude disease Hypobarism What are the Health Effects and Treatment? The effects that occur depend on: how quick the transfer from normal pressure to decreased pressure is, how trained the person is and whether he adapts to the pressure. Treatment: returning to the level of the ground; specific treatment according to the condition of the patient.

80. How can we prevent the effects of exposure to hyperbarism and hypobarism? HyperbarismHypobarism Technical measures: - by assuring good quality and good temperature of compressed air - by respecting the decompression protocol - by reducing the work time ~ deep - availability of a special room for relaxing and clothing Technical measures: - by pressurizing the planes - by climbing in stages Medical measures: - pre-employment examination - periodical examinations - adaptive control Medical measures: - pre-employment examination - periodical examinations - adaptive control