浅析职业卫生监督的主要问题和对策

《职业病防治法》实施二年多,各级卫生部门认真履行职责,依法监督,职业病防治工作取得了一定的成效.然而,在摸索和实践中也暴露出不少问题,制约了职业卫生工作的开展.     

Particulate air pollution and health in Valencia [Spain] 1994-1996

OBJECTIVE: To estimate the short-term association between levels of air pollution due to suspended particulates and several indicators of morbidity and mortality in the city of Valencia, Spain. METHODS: We performed an ecological time-series study. Daily levels of air pollution from black smoke were related to indicators of mortality, hospital admissions, and visits to emergency departments in the city of Valencia between 1994 and 1996. The magnitude of the association was estimated through Poisson autoregression using generalized additive models. The form of the relationship, the delayed effect of pollution, and the possible modification of this effect by other pollutants or periods of the year were assessed. RESULTS: A significant association was found between levels of suspended particulates and several of the indicators analyzed in Valencia. The form of this relationship was linear. An increment of 10 microg/m3 in the daily levels of black smoke was associated with an increase of 1.8% (95% confidence interval: 0.9-2.7%) in the number of deaths on the following day. The same increment in pollutant levels was associated with an increase of 1.5% (0.1-2.8%) in deaths from all cardiovascular causes, an increase of 1.3% (0.0-2.6%) in admissions for all cardiovascular diseases and in an increase of 5.4% (0.6-10.4%) in the number of emergency visits for asthma. This association was not confounded by levels of other pollutants. Black smoke was not associated with mortality from respiratory diseases, with hospital admissions for cerebrovascular diseases, or with emergency visits for chronic obstructive pulmonary disease. CONCLUSIONS: This study provides evidence that levels of suspended particles in Valencia are associated with emergency visits for asthma, hospital admissions for cardiovascular diseases, and daily deaths. The association found is consistent with the results of previous studies and fits with recent knowledge of psychopathological mechanisms.     

Tubal sterilization in the United States, 1994-1996

CONTEXT: Although the number and rate of tubal sterilizations, the settings in which they are performed and the characteristics of women obtaining sterilization procedures provide important information on contraceptive practice and trends in the United States, such data have not been collected and tabulated for manyyears. METHODS: Information on tubal sterilizations from the National Hospital Discharge Survey and the National Survey of Ambulatory Surgery was analyzed to estimate the number and characteristics of women having a tubal sterilization procedure in the United States during the period 1994-1996 and the resulting rates of tubal sterilization. These results were compared with those of previous studies to examine trends in clinical setting, in the timing of the procedure and in patient characteristics. RESULTS: In 1994-1996, more than two million tubal sterilizations were performed, for an average annual rate of 1 1.5 per 1,000 women; half were performed postpartum and half were interval procedures (i. e., were unrelated by timing to a pregnancy). All postpartum procedures were performed during inpatient hospital stays, while 96% of interval procedures were outpatient procedures. Postpartum sterilization rates were higher than interval sterilization rates among women 20-29 years of age; interval sterilization procedures were more common than postpartum procedures at ages 35-49. Sterilization rates were highest in the South. For postpartum procedures, private insurance was the expectedprimary source of payment for 48% and Medicaid was expected to pay for 41 %; for interval sterilization procedures, private insurance was the expected primary source of payment for 68% and Medicaid for 24%. CONCLUSIONS: Outpatient tubal sterilizations andprocedures using laparoscopy have increased substantially since the last comprehensive analysis of tubal sterilization in 1987, an indication of the effect of technical advances on the provision of this service. Continued surveillance of both inpatient and outpatient procedures is necessary to monitor the role of tubal sterilization in contraceptive practice.     

An assessment of occupational health care in the Netherlands (1996-2005)

BACKGROUND: The extensive Dutch occupational health care system of the past decade has not led to the desired outcomes, namely, a decrease of work absenteeism and the associated costs. AIM: To assess the differences between in-house and external occupational health care services in the process quality of occupational health care provided. METHODS: In total, 26 interviews were conducted with chief executive officers of occupational health services (OHS). The responses and other relevant policy documents were analysed and described. A key component of this process was to compare differences between in-house and external services. RESULTS: Notable differences in quality were found to exist between in-house and external occupational health care systems, with the in-house occupational health care services offering the highest process quality. CONCLUSION: Our findings suggest that the effectiveness of OHS is mainly dependent on their structure (in-house versus external) and on economic factors (profit driven versus not for profit).     

The incidence of work-related disease reported by occupational physicians, 1996-2001

In the course of six calendar years, 1996-2001, 5491 new cases of work-related disease were reported by a 1-in-12 random sample of occupational physicians throughout the UK. This represented an estimated total of almost 66 000, or 11 000 cases per annum. These cases have now been analysed by sex, occupation (nine categories) and industry (eight categories), and annual average incidence rates calculated in five main disease groups against a similarly classified denominator of 3.2 million employees served by the same physicians. The overall average annual estimated rate (342 per million) was eight times higher than that reported by clinical specialists, calculated in a similar manner against the entire employed population of the UK (28 million), but 17 times higher for musculoskeletal disease. For men employed in mines and quarries, and both men and women in metallic and automotive manufacture, rates for most types of disease were very high. Occupations with the highest rates were craftsmen and female associate professionals. In all these occupational and industrial groups with high rates, musculoskeletal complaints were the main cause, and skin, respiratory or stress diseases were next in importance. In each type of disease, there was a wide range in incidence rates, suggesting important differences in risk by occupation or industry.     

The financial performance of community health centers, 1996-1999

This paper presents recent financial health trends of community health centers (CHCs) between 1996 and 1999, a time characterized by fiscal and operating challenges. Results show that many individual CHCs have been subject to large changes in payer-mix among uninsured and Medicaid users. Troubling is the finding that more than half of all CHCs reported operating deficits in 1997, 1998 and 1999. CHCs experiencing large increases in the share of uninsured users and those participating in Medicaid managed care appear to have been disproportionately affected. The analyses presented support recommendations for enhanced data collection and for further monitoring of CHCs' financial health.     

National health expenditure projections, 1994-2005

Using 1993 as a baseline and assuming that current laws and practices continue, the authors project U.S. health expenditures through the year 2005. Annual spending growth has declined since 1990, and, in the scenario reported here, that trend continues in 1994. Growth of health spending increases thereafter, but remains below the average experience of the past decade. Even so, health expenditures grow faster than the gross domestic product (GDP), and by 2005, account for 17.9 percent of the GDP. Unless the system changes, Medicare and Medicaid are projected to pay for an increasing share of total spending during the next decade.     

Analysis of infant mortality in coverage areas of health centers in Belo Horizonte, Minas Gerais, Brazil (1994-1996)]

Geographic analysis of health conditions highlights regional and intra-urban inequalities. This study aims to identify intra-urban discrepancies in the city of Belo Horizonte, studying the infant mortality coefficients (IMC) in the various areas of the metropolitan area and evaluating their evolution from 1994 to 1996. The study uses data from 1994 to 1996 regarding birth and death records (from the SINASC and SIM registries). It also uses "thematic maps" related to geographic coverage areas of municipal health centers to demonstrate differences in infant mortality coefficients. The empirical Bayesian method was applied to correct possible random fluctuation in IMC due to small and unstable numbers. A 24.4% reduction in the overall coefficient was observed in the city from 1994 to 1996. Decreases also occurred in the health center coverage areas. In 1994, eight areas presented an IMC above 50/1,000, while in 1996 no area reached that coefficient. In 1994, 29 areas presented an IMC from 35 to 50/1,000, as compared to only four areas in 1996. In 1996 there were more areas with IMC below 35/1,000 as compared to 1994. In 1996, more homogeneity was observed in IMC distribution and hence a reduction in intra-urban inequalities.     

Surveillance for influenza--United States, 1994-95, 1995-96, and 1996-97 seasons.

PROBLEM/CONDITION: Influenza epidemics occur nearly every year during the winter months and are responsible for substantial morbidity and mortality in the United States, including an average of approximately 114,000 hospitalizations and 20,000 deaths per year. REPORTING PERIOD: This report summarizes U.S. influenza surveillance data from October 1994 through May 1997, from both active and passive surveillance systems. DESCRIPTION OF SYSTEM: During the period covered, CDC received weekly reports from October through May from a) state and territorial epidemiologists on estimates of local influenza activity, b) approximately 140 sentinel physicians on their total number of patient visits and the number of cases of influenza-like illness (ILI), and c) approximately 70 World Health Organization (WHO) collaborating laboratories in the United States on weekly influenza virus isolations. WHO collaborating laboratories also submitted influenza isolates to CDC for antigenic analysis. Throughout the year, vital statistics offices in 121 cities reported deaths related to pneumonia and influenza (P&I) weekly, providing a measure of the impact of influenza on mortality. RESULTS: During the 1994-95 influenza season, 25 state epidemiologists reported regional or widespread activity at the peak of the season. Cases of ILI reported by sentinel physicians exceeded baseline levels for 4 weeks, peaking at 5%. Influenza A(H3N2) was the most frequently isolated influenza virus type/subtype. The longest period of sustained excess mortality was 5 consecutive weeks, when the percentage of deaths attributed to P&I exceeded the epidemic threshold, peaking at 7.6%. During the 1995-96 season, 33 state epidemiologists reported regional or widespread activity at the peak of the season. ILI cases exceeded baseline levels for 5 weeks, peaking at 7%. Influenza A(H1N1) viruses predominated, although influenza A(H3N2) and influenza B viruses also were identified throughout the United States. P&I mortality exceeded the epidemic threshold for 6 consecutive weeks, peaking at 8.2%. The 1996-97 season was the most severe of the three seasons summarized in this report. Thirty-nine state epidemiologists reported regional or widespread activity at the peak of the season. ILI reports exceeded baseline levels for 5 consecutive weeks, peaking at 7%. The proportion of respiratory specimens positive for influenza peaked at 34%, with influenza A(H3N2) viruses predominating. Influenza B viruses were identified throughout the United States, but only one influenza A(H1N1) virus isolate was reported overall. The proportion of deaths attributed to P&I exceeded the epidemic threshold for 10 consecutive weeks, peaking at 9.1%. INTERPRETATION: Influenza A(H1N1), A(H3N2), and B viruses circulated during 1994-1997. Local surveillance data are important because of geographic and temporal differences in the circulation of influenza types/subtypes. PUBLIC HEALTH ACTIONS: CDC conducts active national surveillance annually from October through May for influenza to detect the emergence and spread of influenza virus variants and monitor the impact of influenza-related morbidity and mortality. Surveillance data are provided weekly throughout the influenza season to public health officials, WHO, and health-care providers and can be used to guide prevention and control activities, vaccine strain selection, and patient care.     

Fire- and flame-related occupational fatalities in the United States, 1980-1994

The National Traumatic Occupational Fatalities surveillance system recorded 1518 fire- and flame-related occupational fatalities among the civilian workforce in the United States between 1980 and 1994. The fatalities resulted from 1221 separate incidents, of which 122 involved more than one victim and accounted for 419 of 1518 deaths. Nearly 4 of 10 fatalities resulting from a multiple-victim fire were workers in the manufacturing industry. Similarly, the highest frequency of fatalities in single-victim events, over one fourth, were in manufacturing. For one fourth of the fatalities within each event category, the usual occupation of the deceased was a precision production, craft, and repair worker. Although this study sheds light on selected characteristics of these fatalities, additional research on the causal factors associated with single- and multiple-victim events is needed to present specific recommendations for prevention efforts.     

Fatal occupational injuries associated with forklifts, United States, 1980-1994.

BACKGROUND: This paper describes deaths of American workers involving forklifts during the 15-year period from January 1, 1980 to December 31, 1994. METHODS: Death certificate data were obtained from the National Institute for Occupational Safety and Health's (NIOSH's) National Traumatic Occupational Fatality (NTOF) surveillance system. The narrative fields on the death certificate were searched for keywords indicating that a powered industrial vehicle (PIV) or forklift was involved in the death. This study examined the circumstances of the forklift-related deaths, the nature of the injury, and the decedent's age, gender, race, occupation, and industry. Average annual employment data from the Bureau of the Census were used to calculate civilian fatality rates by age, gender, industry, and occupation. RESULTS: A total of 1,021 deaths were identified. The average age of the fatally injured worker was 38 years; the 1,021 forklift-related deaths resulted in a total of 27,505 years of productive life lost. The three most common circumstances of the fatalities were forklift overturns (22%), pedestrian struck by forklifts (20%), and worker crushed by forklift (16%). The greatest proportion of the fatalities (37%) occurred to workers in Manufacturing, followed by Transportation, Communication, and Public Utilities, (TCPU), (17%), Construction (16%), Wholesale Trade (8%), and Agriculture, Forestry, and Fishing (AFF) (7%). The highest forklift-related fatality rates per ten million workers occurred among transport operatives (34.0) and laborers (32.0). CONCLUSIONS: Many of the fatalities resulting from forklift "overturns" might have been prevented if the operator had been restrained with a lap/shoulder belt. Careful consideration should be given to separating pedestrian and forklift traffic, and restricting the use of forklifts near time clocks, exits, and other areas where large numbers of pedestrians pass through an area in a short time. Additionally, systematic traffic control, including rules for pedestrian and forklift traffic, will be necessary to reduce the enormous injury and death toll associated with forklifts. Am. J. Ind. Med. 36:504-512, 1999. Published 1999 Wiley-Liss, Inc.     

A cohort study to estimate occupational mortality risks in Navarra

BACKGROUND: Few studies on occupational mortality have been conducted in Spain. The objective of this work was to analyse inequalities on global mortality and on mortality due to specific causes according to occupation in a historical cohort of males from the province of Navarra, Spain. METHODS: The base population for this historical cohort comprised all employed men over age 34 from Navarra in the 1986 population register. Age-standardised point estimates and confidence intervals for occupational-specific mortality risks were computed. RESULTS: There exist differences in mortality risks with respect to the overall risk of Navarra in certain occupational activities for several major causes of mortality. Some of the results corroborate previous findings in other works, such as the significant high risk that presents in leather, clothing workers and shoemakers when analysing kidney, bladder and other urinary malignant tumours, while others present a certain degree of novelty. CONCLUSION: This work contributes to filling the gap in the lack of works on occupational mortality in Spain. It also complements the information that other monitoring systems may provide on occupational health.     

Patterns of individual health insurance coverage, 1996-2000

Information about patterns of individual health insurance coverage is limited. Knowledge gaps include the extent to which individual insurance provides transitional versus long-term coverage, and participants' insurance status before and after being covered by an individual plan. In this study we use data from the 1996-2000 Survey of Income and Program Participation (SIPP) to examine how long the individually insured maintain their coverage; sources of coverage before and after enrolling in an individual health plan; and characteristics of those who rely on individual insurance coverage. Understanding the dynamics of this market will better inform federal and state insurance reform efforts.     

Farmers' occupational health programme in Finland, 1979-1987

At the beginning of 1985, the National Board of Health in Finland issued directives for the initiation of farmers' occupational health services in municipal health care centres. The directives were based on the evaluation study on farmers' occupational health services in Finland. The main aim of this study is to analyse the current problems of the farmers' occupational health care system and to analyse how effective the system is. The efficiency of the occupational health services has been surveyed with postal inquiries twice, first in 1982 and later in 1986. The farmers' knowledge of appropriate means for reducing hazardous exposures had improved significantly since the initiation of the occupational health services. The effect of the occupational health services was evident particularly in the more effective use of personal safety devices. The limited resources at the municipal health care centres form the main obstacle in the provision of occupational health services for all farmers who would like to have them. 25-35% of the farmers in Finland (total 45,000 farmers) are willing to participate in the occupational health care system. Participation is voluntary for self-employed farmers.     

Food consumption patterns in Italy: the INN-CA Study 1994-1996

OBJECTIVES: The present study was aimed at surveying the Italian food consumption patterns in the 90s. It represented the second nationwide food intake survey that was carried out by the Istituto Nazionale di Ricerca per gli Alimenti e la Nutrizione (INRAN). DESIGN: Cross-sectional study. SETTING: Free-living households. SUBJECTS: Sampled subjects: 1147 households randomly selected to be representative of the four main geographical areas (North-West, North-East, Centre, South). Analysed subjects: 1978 individuals out of 2734 initially collected in 15 Collaborative Centres strategically scattered through the national territory. METHODS: A mixed 7-day based survey technique was applied in order to survey both individual and household consumption. At individual level, food intake was recorded by a self-compiled diary. At household level food data collection was by compilation of a food inventory by the dietician, a purchased/wasted foods diary and a recipes form both compiled by the person responsible for food related activities (decision of purchase, purchase, preparation of meals) in the household. All recorded data were monitored by the dieticians who visited the households participating in the study, at least three times. Household members were interviewed in order to collect socio-demographic, lifestyle and motivational information. Furthermore, field-workers performed the food coding and the input of data by an ad hoc developed software. The survey design allowed an internal quantitative check of food data. Several check steps were centrally performed RESULTS: The complex methodology caused the 46.8% response rate and afterwards a reduction of the analysed units (72% of the surveyed individuals). However, the analysed sample provided sufficiently reliable data for outlining the most relevant aspects of dietary patterns in Italy. In order to better interpret the results, controversial aspects are also illustrated and discussed in the text. The disparity analysis found that traditional diversities among Italian regions are still alive. In general, males eat more than females. Analysis according to the age class (children: 1-9 years old; adolescents: 10-17; adults: 18-64; elderly: >64) showed differences especially between the group of children vs all the others, but also in the two groups of young individuals vs adults and the elderly, that could represent clues of an incorrect way of eating. CONCLUSIONS: Taking into account the different methodology, the comparison with previous results showed changes in the Italian average diet complying with an increasing attention to healthy aspects by large sectors of the population, but also opposite tendencies that should be carefully monitored. SPONSORSHIP: Minister delle Politiche Agricole e Forestali (Mi.P.A.F.).     

Reported incidence of occupational asthma in France, 1996-99: the ONAP programme

Aims: To estimate the general and specific incidence of occupational asthma in France in 1996–99; and to describe the distribution of cases by age, sex, suspected causal agents, and occupation.     

Non-typhoid salmonellosis in in a basic health area of Navarra, Spain

BACKGROUND: Salmonella gastro-enteritis is a Zoonoses transmitted by the ingestion of food products and water or fomites contaminated by the faeces of infected people or animals. At present, constitutes a world-wide pandemic. The aim of the present study has been to in progress examine cases of non-typhoidal salmonellosis in the Health Area I of Navarra (376,079 inhabitants). METHODS: 39,697 outpatient specimens submitted for culture during 1993-2000 were analysed retrospectively. Standard procedures to isolate enteropathogens were employed. The Salmonella strains were serotyped. Data was collected on age, sex, specimen date and result of culture and antimicrobial susceptibility testing for all isolates. RESULTS: 2,924 salmonellae were isolated (7.4%) with the most frequent serotype being Salmonella Enteritidis (62%). The highest isolation rate was associated with children, particularly infants (1,117.3 per 100,000 inhabitants). Salmonella Typhimurium was typically more resistant than Salmonella Enteritidis, although resistance rates in both have increased in recent time. CONCLUSIONS: In spite of the socio-economic improvements, the incidence of gastro-enteritis associated with Salmonella spp. has continued to increase in recent years, mainly affecting infants, and constitutes an important public health problem.