Prevalence of fatigue among commercial pilots

BACKGROUND: Short-haul pilots have largely been neglected in studies of fatigue, sleep loss and circadian disruption created by flight operations, but anecdotal evidence from pilots suggests that with the increasing amount of low-cost air travel, commercial pilots working short-haul operations may be becoming seriously fatigued. AIMS: This study attempted to ascertain how much subjective fatigue short-haul pilots reported, and makes comparisons between low-cost and scheduled airline pilots. METHODS: Pilots completed anonymous questionnaires (encompassing aviation factors, flight experience and a fatigue scale) posted on the Professional Pilots' Rumours Network website. RESULTS: Data were collected from 162 short-haul pilots and statistical adjustment for operational factors was made. Seventy-five percent reported severe fatigue and 81% reported the fatigue to be worse than 2 years ago. Eighty percent considered their thought processes were reduced while flying. Severe fatigue was reported more frequently by low-cost airline pilots than scheduled airline pilots (P = 0.05) and fatigue ratings were higher in this group (P = 0.03). Pilots who reported regularly flying into their 'discretion' hours had lower physical and psychological health, and overall fatigue scores, and poorer self-rated general health. Flying into discretion time occurred no more frequently in low-cost airline pilots than scheduled airline pilots. CONCLUSIONS: Identifiable fatigue problems are reported by short-haul pilots, but this cannot be attributed solely to the work schedules of low-cost airlines as regular use of discretion time appears to be associated with fatigue regardless of airline.     

Working conditions in international seafaring

BACKGROUND: Seafaring is a global profession and seafarers have their second home on board and live there for several months at a time. AIM: To assess self-rated health status and the main characteristics of seafarers' working conditions. METHODS: Questionnaire study concerning the most recent tour of duty. RESULTS: A total of 6,461 seafarers in 11 countries responded. In general, the seafarers' self-rated health was good, but it declined significantly with age. Seafarers from South-East Asian countries spent longer time periods at sea, and had lower numbers of officers and older seafarers than found among seafarers from western countries. Most seafarers worked every day of the week, and on average for 67-70 h a week during periods of 2.5-8.5 months at sea. CONCLUSIONS: Seafarers' self-rated health was generally good but varied significantly by country. Working conditions also differed by country but did not reflect working conditions in general. Further studies are necessary to describe more closely the influence of work schedules on the health and social life of seafarers.     

What is the risk associated with being a qualified military parachutist?

Military parachuting has been recognized as a hazardous activity since it was first introduced in World War II. Other risks associated with military service include actual war-fighting, training with weapons and explosives, operating with armoured vehicles or deployment to climatic extremes. These other hazards should be considered in any assessment of the additional risk associated with military parachuting. The aim of this study was to identify the risk attributable to parachuting amongst US Army enlisted soldiers. This study identified a cohort of infantry soldiers who served between 1990-94. They were separated by receipt of parachute hazardous duty pay. There was a total of 329,794 person-years (PY) available for study of which 18% were in the exposed group. The rate of hospitalization was very similar in both groups [123.9 per 1,000 PYs for the exposed group, 127 in the non-exposed group: relative risk (RR) = 0.98, 95% confidence interval (CI) = 0.96-1.00). The exposed group was 1.49 times (CI = 1.42-1.57) more likely to be admitted as a result of an injury as compared with the non-exposed group. Military parachuting was 20 times (CI = 16.6-24.3) more likely to be the cause of an injury. This study has shown that receipt of hazardous duty pay for military parachuting can be used as a marker in identifying significant additional risks to the health of infantry soldiers associated with military parachuting. This was reflected in an increased incidence of admission for acute injury and musculoskeletal trauma (particularly a trauma pattern associated with parachuting) as a result of military parachuting. Other risks, which are associated with parachute pay, are admission for the effects of heat, battle injury and helicopter accidents.     

The duty of care of the occupational physician in assessing job applicants.

Where an occupational physician carries out a medical assessment of a job applicant, he or she owes a duty to the employer but not to the applicant, unless actual physical harm is caused. If the applicant is unsuccessful as a result of an assessment which is alleged to be negligent, he or she cannot sue the physician. This is essentially because (i) the relationship between the physician and the applicant is insufficiently close, and (ii) the physician might be faced with a conflict of interest since differing duties might be owed to the employer and to the applicant.     

Comparison of outcomes of untreated carpal tunnel syndrome and asymptomatic controls in meat packers

Our objectives were to determine the reporting of symptoms, the medical outcome and the work status of meat plant workers diagnosed with clinical carpal tunnel syndrome (CTS). Forty-seven cases of CTS were identified from a previously reported study, and were matched by age, gender and hand use. Cases and controls were followed up for 24 months. The Provincial Workers' Compensation Board and company health records were used to determine the reporting of symptoms, interventions and work status. Thirty-one study cases and all control cases were followed for the full 24 months (16 study cases were lost to follow-up). In total, 12 cases reported symptoms of CTS during the 24 months (eight study cases and four controls). Of the eight study cases, one required surgical release of the carpal tunnel. After a period of work modification, five of the eight study cases returned to regular duty and the remainder were placed on permanent job restrictions. Of the four controls, one subject had a surgical release and returned to regular work, two subjects' jobs were permanently modified, and the fourth returned to regular duty. Occupation-related CTS in meat packers appears to be transient and responsive to conservative measures, with a surgical rate comparable to other occupations.     

Clinical governance in UK commercial occupational health providers

BACKGROUND: Clinical governance has been introduced into health care in the United Kingdom as a means to improve quality. At present there is no legal duty for commercial occupational providers to implement this model. AIM: This preliminary study examined how commercial occupational health providers had implemented clinical governance. METHODS: The senior clinical manager of commercial occupational health providers completed a questionnaire. RESULTS: Fourteen of 17 organizations asked to participate completed the survey. Most of these had implemented some form of clinical governance. Patient and public involvement was attributed the least importance of potential components of clinical governance. Organizations were more likely to have systems to address poor clinical performance than encourage excellent performance. CONCLUSIONS: Commercial occupational health providers have implemented clinical governance. Its focus appears to be avoidance of failures rather than clinical excellence and patients. However, further work is needed to explore this more fully.     

Hepatitis B--are surgeons putting patients at risk?

The 1993 Department of Health guidelines permit a surgeon who is hepatitis B surface antigen (HBsAg) positive but e-antigen (HBeAg) negative to perform exposure prone procedures, unless demonstrated to have infected patients. However, there is increasing evidence of transmission of hepatitis B to patients from health care workers in this supposedly low infectivity category. The Occupational Physician must decide whether existing guidelines represent an adequate risk assessment and indeed whether this is an acceptable risk for patients. If an NHS Trust continues to follow these guidelines it may be in breach of its duty of care to patients. Yet refusing to allow such carriers to operate without testing for additional serological markers may be unlawful discrimination. Further research is clearly needed as well as an urgent review of the guidelines.     

Incidence of self-reported occupational injuries in seafaring--an international study

AIMS: Seafaring is known as a high-risk industry. The aims were to describe the incidence of non-fatal injuries among seafarers, including testing the hypothesis that long working hours might result in higher injury rates. METHODS: A questionnaire study of injury on the latest tour of duty was carried out among seafarers in 11 countries with 6461 participants. The seafarers were asked if they were injured during the latest tour of duty and what was the number of hours worked. RESULTS: During the latest tour of duty, 9.1% of all seafarers were injured and 4.3% had an injury with at least 1 day of incapacity. The injury incidence rates for cargo ships and tankers: 39.5 per 1 million work hours and 37.6 per 100,000 days. Multivariate analyses: incidence rate ratios (IRR) for >70 working hours per week compared with <57 h: 0.90 [95% confidence interval (95% CI) = 0.61-1.32]; non-officers compared with officers: IRR = 1.57 (95% CI = 1.14-2.15); seafarers <35 years compared with > or =35 years of age: IRR = 2.11 (1.57-2.86); tour lengths > or =117 days compared with <117 days: IRR = 0.27 (0.19-0.39). Main work area on the deck and in the service area compared with work in the engine room: IRR = 0.37 (0.27-0.52) and IRR = 0.49 (0.26-0.91), respectively. CONCLUSIONS: There was no evidence that long working hours alone resulted in higher injury rates. Low self-perceived health, lack of use of personal protection and lack of occupational safety on board were significantly related to an increase in the injury risk.     

Investigating and analysing workplace clusters of diseases: a Health & Safety Executive perspective

BACKGROUND: Clusters of disease arising in workplaces cause concern among the management of the company, the workers affected and their families and friends. Chance is the most likely explanation for their occurrence, although a number of real workplace hazards have been identified through their observation and investigation. Employers have a duty to investigate such occurrences in order to assess whether some unknown or unidentified hazard is at work and to take the appropriate action. Several papers have been published over the last 15 years or so that set out a method for investigating workplace clusters of disease. Aims This paper presents the steps in the approach taken by the Health & Safety Executive in Great Britain. METHOD: An initial step identifies the relevant stakeholders at the outset, in order to maintain a realistic expectation of what the investigation can hope to achieve and to open a dialogue. The main steps in the assessment are: (1) identifying cases; (2) determining the other parameters of the investigation; (3) statistically assessing the cluster; (4) examining potential exposures and assessing their biological plausibility; and (5) determining the overall significance of the cluster. The approach is illustrated throughout by examples.     

Shift work,safety and productivity

The arguments in favour of introducing shift work clearly depend on productivity and safety being maintained at an acceptable level. However, the evidence reviewed in this paper clearly indicates that both productivity and safety may be compromised at night. More specifically, safety declines over successive night shifts, with increasing hours on duty and between successive rest breaks. The only known way to minimize these problems is to improve shift systems with respect to these factors. However, these factors need to be considered in combination with one another since, for example, a long night shift that includes frequent rest breaks might well prove safer than a shorter night shift with less frequent breaks.     

Status and development of critical incident stress management services in the United Kingdom National Health Service and other emergency services combined: 1993-1996

Surveys conducted amongst members of the Association of NHSOccupational Physicians indicate few changes in the status anddevelopment of Critical Incident Stress Management Services(CISMS) in the United Kingdom National Health Service between1993 and 1996. Limited CISMS are confirmed by the majority ofrespondents in the two surveys with developments having typicallyoccurred within long-established staff care services such ascounselling. In 1996 NHS provision is typically based on theindependent use of own resources. A 1996 comparison of NHS withpooled returns from Ambulance Services, Fire Brigades and SocialServices Departments indicates few variations in status, provisionand levels of expertise in the delivery of CISMS. Other emergencyservices co-operate to a greater extent with each other thandoes the health care sector. Occupational Health Departmentresponders confirm availability of expertise resources to provideCISMS, but low priority status frustrates delivery of CISMS.Survey results indicate the NHS is at risk of not fulfillingits duty to care for staff after major incidents. The establishmentof regional centres of CISMS excellence with local and nationalresponsibilities is advocated.     

Improved communication between doctors and with managers would benefit professional integrity and reduce the occupational medicine workload

BACKGROUND: Professional expectations for communication skills are explicit. These skills are needed for professional integrity and personal morale. Nevertheless, occupational physicians see doctors as patients for whom communication among between doctors and with their managers are the principal cause of their presenting health problems. AIM: To describe the frameworks of professionalism in medicine and the duty to care for good communication; present issues surrounding competency in communication skills; identify health problems among doctors associated with poor communication; and consider roles of economic appraisal and preventive strategies. METHOD: A literature review identified key publications of professional expectations and requirements of doctors for their communication skills. Health problems among doctors associated with poor communication and presenting at least twice in a National Health Service (NHS) occupational health (OH) department during January-December 2002, were sought by manual retrieval of all doctor-patient records. The categories of communication difficulty were agreed in the focus group discussion of the presenting problems with occupational physicians. RESULTS: Nine categories of communication difficulties among doctors resulting in their presentation in OH departments with health problems were identified. CONCLUSIONS: Personal health problems caused by poor communication involve considerable time and potential litigation costs. Doctors need to be reminded of their responsibilities. Opportunity cost studies would help to strengthen an evidence base for the need of doctors to adhere to the professional requirements of good communication skills.     

Susceptibility to Varicella Zoster Virus Infection in Health Care Workers

Varicella zoster virus (VZV) is an occupational hazard for apercentage of health care staff. Nine hundred and seventy staffmembers attending the Occupational Health Department at CorkUniversity Hospital took part in the survey. A latex agglutinationassay was used to determine the health care workers immune statusto VZV. Of the 970 workers tested, 928 (95.7%) were immune toVZV. The sensitivity, specificity and predictive value of anenquiry regarding a history of chicken-pox was determined ona sample of 206.health care workers: The positive predictivevalue was 95% (119/125) and the negative predictive value was11% (4/35). The sensitivity of the enquiry was 79% (119/150).the specificity was 40% (4/10), reducing to 61% (119/195) and36% (4/11) respectively when individuals with uncertain hitorieswere included in the calculations. The advantages and disadvantagesof selective staff screening are discussed. In the authors opinionall health care workers involved in the clinical care of patientsshould be screened by serology for past VZV infection beforetaking up duty and those who are susceptible to VZV should bemade aware of the risks and health effects associated with VZVif contracted.     

Ethical requirements for occupational health research--compliance arrangements for a single company in relation to a recent major nuclear industry study.

The media coverage given to occupational health studies in the field of ionizing radiation has, on occasion, been the cause of very real distress to radiation workers and their families. In response to this situation the Chief Medical Officers of the major UK nuclear companies developed an ethical policy for future involvement in research, based on the duty of care which researchers owe to a key customer of such studies: the worker. The policy consists of four principal elements: medical confidentiality; worker information; worker consent and the guarantee of the availability to the workers of pre-publication knowledge of the results. The policy issued in 1991/92 has achieved growing acceptance among researchers and medical journals, though the medical officers involved have been aware of some scepticism, particularly in relation to the practicalities of the dissemination of pre-publication information. The Record Linkage Study published in November 1997 marked a major piece of research work involving data from 120,000 radiation workers that had been carried out since the development of the policy. This paper reports on the successful compliance arrangements to meet the ethical requirements of that study within a single UK nuclear company, and is published to demonstrate that with commitment from researchers, the journal and occupational health staff such ethical requirements, and particularly the need for pre-publication information can be met in full.     

A medical assessment process for a large volume of medico-legal compensation claims for hand-arm vibration syndrome

BACKGROUND: The judgement on preliminary issues of nine lead cases of suspected hand-arm vibration syndrome (HAVS) in former coal miners in the UK ruled that there was evidence of damage and breach of duty of care (Armstrong and Others v. British Coal, 1996). In anticipation of > 120 000 cases and at significant cost, a handling agreement was prepared in 1999. This recommended a single medical assessment process (MAP) to determine general damages for which almost 200 doctors attended 2 days of training. AIMS: This paper outlines the assessment process and the results to date. METHODS: Seventeen test centres across the UK were commissioned. Standardization of the performance by both the doctors and technicians within individual examination centres and across all centres was necessary. A pragmatic solution using 'best available assessment techniques', whilst at the same time coping with the large number of claimants, was required. Doctors were trained to administer questionnaires for clinical symptoms, past medical history and occupational history, and a standardized clinical assessment pro-forma. Three standardized tests were used: vibrotactile thresholds, thermal aesthesiometry and cold water provocation testing. A modification of the Stockholm Workshop Scales and scoring system was adopted. At time of writing, 52 490 claimants had been assessed by the MAP. RESULTS: Analysis of results showed that 5% were assessed at 0SN, 15% at 1SN, 18% at 2SN (early), 28% at 2SN (late), 33% at 3SN, 21% at 0V, 13% at 1V, 38% at 2V and 28% at 3V. CONCLUSION: It is concluded that the MAP is a practical and time-efficient tool for assessing a large volume of claimants with suspected HAVS. Further analysis of the process and staging is required to confirm its validity as a medico-legal examination.     

Workers' right-to-know legislation: does it work?

Workers' right-to-know (WRTK) laws and regulations were established to empower workers to protect their health by providing them with information about the hazards to which they are exposed while at work. The present study was conducted to examine the implementation of WRTK regulations in Israel. We interviewed 552 workers and 33 safety officers from a random sample employed at 50 industrial plants. The workers' questionnaire included items on awareness and self-management of workplace hazards, and the safety officers answered questions about job experience and hazards communications to workers. In 36% of cases workers and their safety officers disagreed about the existence of hazards in the workplace (p < 0.001). Most (78%) of the workers' knowledge about work hazards was based on informal sources, i.e., not those stipulated by the regulations. There were also discrepancies between worker and safety officer reports regarding the provision of safety training upon employment (p < 0.001), recent instructions about special risks and distribution of relevant printed material. We found that more than 5% of workers were unable to read the language in which the hazards material was written and 22% had levels of education below that required to comprehend the technical terms used. There are serious problems in the implementation of WRTK regulations in Israel. We recommend that employers be made aware of the importance of these laws and of their proactive duty to comply with them and that the material distributed to workers be written in simpler terms and/or explained orally in a language they understand. These findings have important implications for all countries with similar legislation and should form the basis for further and more comprehensive studies world-wide.     

Future advances in work-related asthma and the impact on occupational health

Work-related asthma (WRA) and WRA-like conditions refer to all situations in which asthma or asthma-like syndromes occur or worsen in the workplace. This occurs in approximately 10% of all adult-onset asthma subjects. Occupational asthma (OA) is a specific type of WRA that is 'caused' by the workplace, being mediated either by an allergic process with a latency period or by a non-allergic irritant-induced mechanism. Personal asthma can also 'worsen' at work (work-aggravated or exacerbated asthma), the reasons, mechanisms, extent and consequences of this situation being unknown. The author reviews various aspects of WRA with an emphasis on OA (about which more is known) and proposes key issues that need to be further studied, proposed and applied in at-risk workplaces in order to improve recognition, diagnosis and management of this condition. OA represents a unique situation that, unfortunately, is only very rarely provided to health-care providers: affected workers can be cured with minimal impact on quality of life. All efforts should be made to achieve this goal at an affordable socio-economic cost.     

Shift work, health, the working time regulations and health assessments.

Shift work and night work in particular have been associated with sleep difficulties, general malaise, fatigue, peptic ulceration, ischaemic heart disease, cigarette smoking and adverse pregnancy outcome. The medical conditions previously regarded as making individuals unsuitable for shift work show wide ranging patho-physiological activity and there is no published evidence for any such condition to be regarded an absolute reason to exclude an individual from shift work. The fulfilment of the legal obligations of the Working Time Regulations 1998 is neither prescribed nor constrained in any way. It is advisable therefore to build on existing health procedures where they are in effect. Periodic health questionnaires can offer health professionals an opportunity to detect any disorder likely to be aggravated by shift work or by a combination of shift work, job demands and workplace conditions. A further purpose of the questionnaire is the assessment of ability to undertake shift work duties. However, health questionnaires are neither sensitive nor specific enough to be used to select applicants or employees for shift work, since they do not consistently predict tolerance of shift work or subsequent health problems. Whether employers should offer anything more than a simple questionnaire will depend on the culture of the company and accessibility of health services. Screening programmes affect many people relative to the few who benefit and with existing knowledge, periodic general health examinations performed in asymptomatic subjects have limited predictive or preventive value.     

Work-related bilateral osteoarthritis of the first carpometacarpal joints

BACKGROUND: A 44-year-old industrial worker produced panels for folding doors for 9 years. During this period, he developed osteoarthritis (OA) of both first carpometacarpal joints. Surgery was performed without improvement. METHODS: Clinical examination, demonstration and recording of work conditions, with photos and videos. The literature concerning first carpometacarpal OA was reviewed using PubMed. RESULTS: The observation of work conditions demonstrated unusual forceful and repetitive ulnar flexion of both first fingers. No competing causes of OA could be identified. CONCLUSION: This patient had specific and intense work-related strain of both first carpometacarpal joints. A good temporal relation between work exposure and disease development was demonstrated and it appears likely that the OA was caused by work. However, there is very limited epidemiological evidence relating first carpometacarpal OA to work exposure.