1. ”The Blue Book”, Finnish approach to better health surveillance Helena Taskinen 30 th September 2003 Tallinn

2. 30 th September 2003”Blue Book”/ H. Taskinen Health Examinations Health risks at work – ”Blue Book”, guidelines for health examinations

3. 30 th September 2003”Blue Book”/ H. Taskinen Screening in Occupational Health Services (OHS) Screening: laboratory tests, physical examination, radiologic test or other test performed on asymptomatic patients in hope of discovering subclinical disease (Nielsen et al 1999)

4. 30 th September 2003”Blue Book”/ H. Taskinen The natural progress of diseases Illness processSymptoms Healing beginsstart or death Pre-clinical phase, ident- ifiable by screening symptomless symptoms

5. 30 th September 2003”Blue Book”/ H. Taskinen Prevention of diseases Primary prevention Reduction of risk factors before a disease has occurred. E.g. diminishing exposure to lead, solvents, noise etc. Secondary prevention Early detection and treatment improve the prognosis. E.g. testing blood lead, blood toluene, audiogram Tertiary prevention Minimizing the future negative health effects of the disease

6. 30 th September 2003”Blue Book”/ H. Taskinen The goal of occupational health services To promote the following through cooperation between the employer, the employee and the OHS provider: healthy and safe work environment well-functioning work community the prevention of work-related illnesses the maintenance and promotion of the employees' ability to work (OHS Act 2001, Finland)

7. 30 th September 2003”Blue Book”/ H. Taskinen Health Examination (HE) Act (Finland, 2001) Work entailing specific risk of illness physical, chemical or biological agent new: a risk for reproduction new agents: night work, environmental tobacco smoke, risk of violence at work

8. 30 th September 2003”Blue Book”/ H. Taskinen Types of Health examinations (Finland) Pre-employment Periodical New: HE upon termination of employment especially for carcinogenic exposures advice on further examinations frequency, contents, possible health care units

9. 30 th September 2003”Blue Book”/ H. Taskinen Health examination Act ( 2001, Finland) When new chemicals/processes are introduced if health effects are expected/ unknown symptoms, unusual diseases etc. animal data as reference Information on unknown exposure Precaution: careful handling, minimising exposure

10. 30 th September 2003”Blue Book”/ H. Taskinen Health Examinations at work entailing specific risk to the health HEs are used to identify health hazards at work and produce information for preventive actions recognize the exposure of the worker and health effects due that examine the effects on the health on the suitability to the same work inform the worker about the health risks at work and advice on how to avoid the risks advice the worker to examinations and cure if occupational disease is suspected follow-up the measures to improve the working conditions and their effects On the basis of the obtained data of HEs attempts shall always be made to withdraw the hazard and to prevent the risk to the health of the worker

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18. 30 th September 2003”Blue Book”/ H. Taskinen Examples of hazards Physical agents: noise, vibration (hands, whole body), high pressure, ionising radiation, non-ionising radiation Chemical toxicants: e.g. lead and other metals, organic solvents and other hydrocarbons, toxic inorganic gases, phenols, pesticides, resins, antibiotics, cytostatics, quartz, asbestos, organic dusts.. Biological agents: bacteria, viruses, mold …

19. 30 th September 2003”Blue Book”/ H. Taskinen Goals of health examinations To examine and follow-up workers’ health signs of exposure, early signs of effects late effects (long latency) work ability To give information of health risks and of safe practices personal protective equipment Should lead to treatment and rehabilitation, if needed

20. 30 th September 2003”Blue Book”/ H. Taskinen The Health Examination Process Definition of needs Process: - planning - implementation - health education - recommendations Actions Evaluation

21. 30 th September 2003”Blue Book”/ H. Taskinen 20 Data for HE Work & exposure history Symptoms Biological monitoring, biomarkers Specific tests: questionnaires, audiometry, laboratory tests, lung function, x-ray etc. Other diseases, medication etc. Life style, exposure from hobbies

22. 30 th September 2003”Blue Book”/ H. Taskinen Structure of the guideline book General principles and methods questionnaires, personal protection (EU directive).. proposal for hygienic improvements, follow-up Specific guidelines for certain (listed in the Act) physical, chemical and biological exposures, and for night work and for work with risk of violence Guidelines for certain occupations welders, construction workers, painters, food industry workers, firemen and rescue workers, forest workers, cleaners, hair dressers

23. 30 th September 2003”Blue Book”/ H. Taskinen Structure of the chapter, 1 Description of the agent (CAS-No of chemicals) Exposure: where, how? Occupational exposure limits, biomonitoring data Adverse effects to health How to estimate the need for HE Health examination Pre-placement: at the beginning of work periodical upon the termination of employment

24. 30 th September 2003”Blue Book”/ H. Taskinen Structure of the chapter, 2 Note restrictions/advice e.g. for pregnant workers Informing the workers and employers Actions: What to do if abnormal findings Bibliography/ web sites for further information www.inchem.org/pages/cicads.html

25. 30 th September 2003”Blue Book”/ H. Taskinen Confidentiality Result of health examination is confidential to employer the necessary information for safety improvements suitability of the worker to the work entailing specific risk of illness in the form suitable, suitable with restrictions or suitable Statement of pre-employment examination: worker shall see it first and bring it to employer

26. 30 th September 2003”Blue Book”/ H. Taskinen Carcinogenic exposure Health examinations do not prevent disease Technical and industrial hygienic measures to prevent exposure Health examinations in detection of effects of earlier exposure Information Note: also reproductive effects possible

27. 30 th September 2003”Blue Book”/ H. Taskinen Example of a new agent: Environmental tobacco smoke (ETS) Sidesmoke (from cigarette) 50-90 % Main smoke (exhaled by the smoker) 10- 50% In the tobacco smoke 4000 hazardous compounds; > 40 carcinogenic

28. 30 th September 2003”Blue Book”/ H. Taskinen Health effects of ETS Risk of lung cancer 1.3-1.4 fold heart infarction 1.3-1.4 fold brain stroke 1.3-1.4 fold Estimated: 1-3 work related lung cancer in an year in Finland 5-30 heart infarctions and brain strokes obstructive lung diseases, asthma

29. 30 th September 2003”Blue Book”/ H. Taskinen Laws on tobacco smoking implemented in Finland 1977 1995, work places included 2000, restaurants included ETS classified as carcinogenic

30. 30 th September 2003”Blue Book”/ H. Taskinen Significant exposure to ETS 2-4 hours/d at work on 40 work days a year need of health examinations every 3 years, symptoms, spirometry, X-ray if regarded necessary (suspicion of cancer etc.) notification in the registry of carcinogenic exposure

31. 30 th September 2003”Blue Book”/ H. Taskinen Threat of violence (Finland) In Finland 110 000 employees yearly ”is part of the work” – police, guards etc. ”occasional, unexpected” – hotels, shops, restaurants, banks, health care etc. 500 compensated as work accidents yearly 2 deaths yearly

32. 30 th September 2003”Blue Book”/ H. Taskinen Prevention Recognition of the risk, safety planning at work place, training Pre-employment HE suitability?, information Periodical HE follow-up by qustionnaires or HE

33. 30 th September 2003”Blue Book”/ H. Taskinen ”Traditional risks” present Jobs on municipal engineering Nursing and caring Security work, rescuing, fire fighting Police work Agricultural and forestry work, etc.

34. 30 th September 2003”Blue Book”/ H. Taskinen PHE and intervention

35. 30 th September 2003”Blue Book”/ H. Taskinen Laboratory Animal Allergy Fisher et al. Prevention of laboratory animal allergy. JOEM 1998;40:609-13

36. 30 th September 2003”Blue Book”/ H. Taskinen Laboratory animal allergy and HE Medical surveillance: questionnaire, RAST, physical examination yearly Education, engineering and administrative controls, personal protective equipment Work practice changes: animal-stock density, wet-shaving Filter-topped cages, increased and filtered ventilation, dust-free bedding etc.

37. 30 th September 2003”Blue Book”/ H. Taskinen Health surveillance Health surveillance in milling, baking and other food industry 3 450 employees 19933 asthma, 1 rhinitis 1994 3 -”- 1995 4 -”- 19962 asthma, 2 -”- 19971 -”- 2 -”- Smith TA, Patton J. Occup Med, 1999;49:147-153.

38. 30 th September 2003”Blue Book”/ H. Taskinen HE 7 years before retirement Dutch municipal workers retired for disease 12 % had the main diagnosis in same group of diseases as he/she had stated at health examination 7 years before 17% had some diagnosis in same disease group De Kort: Academic dissertation, University of Amsterdam, -93