Peer-group risk assessment: a post-traumatic management strategy for hierarchical organizations

BACKGROUND: Organizations have moral and legal duties to consider the psychological needs of their workforce following exposure to potentially traumatic events related to the workplace. Additionally, it makes economic sense to avoid loss of valuable personnel to the effects of psychological trauma. There have been attempts to provide a range of psychological interventions for staff after exposure to potentially traumatizing events, but recent evidence-based medicine publications have questioned their effectiveness and, indeed, some studies show that single-session psychological debriefings may be harmful. AIM: This paper presents a post-traumatic management strategy based upon peer-group risk assessment which was developed by the British military and is in use with other hierarchical organizations. The presented model keeps employees functioning after traumatic events and provides support and education to those who require it. Additionally, the strategy aims to identify those who are unable to cope after potentially traumatizing events and aims to refer them for early intervention, which has been shown to be of benefit.     

Improving the quality of peak flow measurements for the diagnosis of occupational asthma

INTRODUCTION: Serial measurements of peak expiratory flow (PEF) are recommended in the evidence-based review list as the first stage in objective confirmation of occupational asthma. Different centres have reported widely different success in obtaining records of sufficient data quantity for diagnosis. We investigated different methods of instruction and determined the return rate and quality of the resulting record for the diagnosis of occupational asthma. METHODS: Consecutive new referrals were recruited from a specialized occupational lung disease clinic and requested to carry out serial PEFs for the assessment of suspected occupational asthma. Requests to carry out the records were either from written postal instructions or personal instruction from a PEF specialist. Record quality received from other clinicians was also analysed separating those using dedicated occupational forms, and those submitting on graph type forms. RESULTS: The postal return rate was 56% and the personal rate 85%. The number of records fulfilling all the data quality criteria were similar in the postal and personal groups (55 and 59%, respectively). Pre-existing records from other clinics plotted from graph charts (fulfilling all criteria) were only adequate in 23%, compared with 61% adequate for pre-existing records plotted from occupational forms. Failure of the record to contain consecutive work periods of > or =3 workdays was the most common failure. CONCLUSION: The return rate of PEFs for diagnosing occupational asthma is better when patients have been given specific instructions from a PEF specialist and the data quantity better when recorded on a dedicated form.     

Risk assessment and risk management of nanomaterials in the workplace: translating research to practice

In the last decade since the rise in occupational safety and health (OSH) research focusing on nanomaterials, some progress has been made in generating the health effects and exposure data needed to perform risk assessment and develop risk management guidance. Yet, substantial research gaps remain, as do challenges in the translation of these research findings to OSH guidance and workplace practice. Risk assessment is a process that integrates the hazard, exposure, and dose-response data to characterize risk in a population (e.g. workers), in order to provide health information needed for risk management decision-making. Thus, the research priorities for risk assessment are those studies that will reduce the uncertainty in the key factors that influence the estimates. Current knowledge of OSH in nanotechnology includes the following: (i) nanomaterials can be measured using standard measurement methods (respirable mass or number concentration), (ii) workplace exposures to nanomaterials can be reduced using engineering controls and personal protective equipment, and (iii) current toxicity testing and risk assessment methods are applicable to nanomaterials. Yet, to ensure protection of workers' health, research is still needed to develop (i) sensitive and quantitative measures of workers' exposure to nanomaterials, (ii) validation methods for exposure controls, and (iii) standardized criteria to categorize hazard data, including better prediction of chronic effects. This article provides a state-of-the-art overview on translating current hazard research data and risk assessment methods for nanomaterials to the development and implementation of effective risk management guidance.     

Occupational toxicology and the control of exposure to pharmaceutical agents at work

BACKGROUND: The pharmaceutical industry employs >350 000 people worldwide in operations including research and development (R&D), manufacturing, sales and marketing. Workers employed in R&D and manufacturing sectors are potentially exposed to drug substances in the workplace that are designed to modify physiology and also to chemical precursors that are potentially hazardous to health. Pharmaceutical workers are at risk from adverse health effects, including occupational asthma, pharmacological effects, adverse reproductive outcomes and dermatitis. AIM: This study aimed to describe the approaches taken by pharmaceutical companies for identifying and communicating potential adverse health effects that may result from workplace exposures and in setting 'in-house' exposure control limits and to highlight the challenges in controlling workplace exposures to increasingly potent compounds. METHOD: The literature was reviewed by searching the Medline and HSELine databases. RESULTS: The findings are presented in five sections, covering: test methods and approaches to occupational toxicology; hazard communication; approaches to setting health-based occupational exposure limits for pharmaceutically active agents; recent approaches to risk control; and occupational hygiene and exposure controls. CONCLUSION: Significant efforts have been directed at predicting and evaluating potential occupational health hazards in the pharmaceutical industry. The pharmaceutical industry has provided leadership in controlling exposure to hazardous substances. Much of this work has been driven by a real need to control occupational exposures to substances that can have profound adverse health effects in exposed employees and that are becoming increasingly more potent.     

The design of hazard risk assessment matrices for ranking occupational health risks and their application in mining and minerals processing

Two hazard risk assessment matrices for the ranking of occupational health risks are described. The qualitative matrix uses qualitative measures of probability and consequence to determine risk assessment codes for hazard-disease combinations. A walk-through survey of an underground metalliferous mine and concentrator is used to demonstrate how the qualitative matrix can be applied to determine priorities for the control of occupational health hazards. The semi-quantitative matrix uses attributable risk as a quantitative measure of probability and uses qualitative measures of consequence. A practical application of this matrix is the determination of occupational health priorities using existing epidemiological studies. Calculated attributable risks from epidemiological studies of hazard-disease combinations in mining and minerals processing are used as examples. These historic response data do not reflect the risks associated with current exposures. A method using current exposure data, known exposure-response relationships and the semi-quantitative matrix is proposed for more accurate and current risk rankings.     

Evaluation of an occupational health service for general practitioners and their staff in a primary care trust

BACKGROUND: An occupational health service was set up in 2002 for general practitioners (GPs) and their staff in a London primary care trust (PCT). The service was based on a needs assessment undertaken in the locality in 1998. AIMS: To evaluate awareness, usage and perceived helpfulness of the service amongst GPs and practice managers, and to ascertain current perceived priorities for what to include in the service. METHODS: Questionnaire survey sent postally and electronically to 199 named GPs and 69 practice managers in 78 practices in the PCT. RESULTS: Overall 119/268 (44%) responses were received from 54/78 practices (69%). Awareness of the existence of the service was high (76%), and although uptake had been poor, this was not related to a perception that the service was unlikely to be helpful. Almost all those who had used the service had found it helpful. Nineteen (16%) respondents asked for more information about the service. Advice on health and safety law and fitness for work assessments were the highest priorities and hepatitis B immunization lowest, as in the 1998 needs assessment. However, a discrepancy between GPs and practice managers with regard to the perceived relative importance of pre-employment health screening and counselling/stress management emerged. CONCLUSIONS: The service is valued by users but could be developed by exploring new ways to disseminate information about the service and deliver it.     

Physicians' beliefs in the assessment of work attribution when reporting musculoskeletal disorders

BACKGROUND: There is considerable uncertainty about work-relatedness and musculoskeletal disorders in general, and it is also not clear how physicians decide whether work has caused a disorder in an individual patient. AIMS: To investigate physicians' beliefs about assessment of occupational attribution for work-related musculoskeletal disorders. METHODS: A questionnaire survey was sent to 526 occupational physicians and 248 rheumatologists on: characteristics of cases seen, assessment of work attribution, definition of work-relatedness and threshold for case reporting. Continuous variables were analysed by mean, standard deviation, an independent two-sample t-test and the Mann-Whitney test. Mean and median values were calculated and Spearman's rank test was applied to ranked data. RESULTS: Questionnaires were completed by 68% occupational physicians and 64% rheumatologists. Both groups of physicians believed that 'history of onset in relation to workplace changes' and 'symptoms consistent with work exposure' were the most important factors suggesting work attribution. They considered that the most important objective of a reporting scheme was detection of trends in disease incidence and that the most suitable criteria for defining work-relatedness was the probability that exposure at work 'more likely than not' caused the condition (mean 0.73; SD=0.17), in a perceived likelihood scale (0-1). CONCLUSION: There was a strong agreement between occupational physicians and rheumatologists on questions about work-relatedness and musculoskeletal disorders. The level of probability for concluding work-relatedness has been quantified.     

Review of objective tests for the hand--arm vibration syndrome

The Health and Safety Executive has recommended health surveillancefor all workers in jobs identified as giving rise to significantrisk of the hand-arm vibration syndrome. Objective tests arenot routinely recommended for workplace surveillance but mayhave a role in the assessment of accurate staging or if decisionson an individual's continuing exposure is in question. Thispaper covers the use of multiple objective tests, the collectionof routine data, a proposed scoring system for the sensorineuralcomponent and discusses the role of cold provocation testingin the diagnosis of the vascular component.     

Silica exposure, smoking, silicosis and lung cancer--complex interactions

Background Establishing a clear relationship between workplaceexposures and cancer is often difficult. The latent period forcancer development can make it difficult to establish a definitecause–effect relationship. The picture is further complicatedby variable job histories, concomitant exposure to other carcinogensand other factors such as genetic susceptibility and poor nutrition.The lack of accurate and detailed record keeping may potentiallymask informative differences among group of workers. Removingor reducing exposures to probable and known carcinogens, however,can prevent workplace cancer. Aim This paper gives an overview of the literature reportinginvestigations of the relationship between exposure to silicaand development of lung cancer with a focus on the controversyconcerning the roles of silicosis and smoking in the developmentof cancer. Method A literature search was conducted to identify epidemiologicpapers on silica, silicosis and lung cancer using electronicdatabases (MEDLINE, PubMed, Web of Science) from 1996 onwardsand paper bibliographies. Results If silicosis were the necessary step leading to lungcancer, enforcing the current silica standards would protectworkers against lung cancer risk as well. Alternatively, a directsilica–lung cancer association that has been suggestedimplies that regulatory standards should be revised accordingly. Conclusion Further research is needed in order to understandthe complex pattern of interactions leading to lung cancer amongsilica-exposed workers (and cancers and workplace exposuresin general) and to understand whether and to what extent otherworkplace lung carcinogens, total respirable dust and totalsurface size and age of silica particles affect the carcinogenicpotential of silica. In addition, the apparent paradox of alower lung cancer risk in some workplaces with high-level silicaexposure needs further investigation.     

Sickness absence due to influenza

In addition to its recognized health effects, influenza has socio-economic consequences, most notably sickness absence and associated work disruption. It may account for 10-12% of all sickness absence from work. Data on the impact of influenza on work are limited. Most research has assessed the impact of an intervention, usually influenza immunization. Within the available literature, there are five randomized controlled trials in the workplace that have assessed the effectiveness of influenza immunization as an intervention: two in the general working population and three in the health sector. If the benefit desired is a reduction in sickness absence as a cost-effective measure, the likely outcome is a modest gain in years when incidence of influenza is increased in the community. There are some distinctive factors in the health care industry: health care workers may exhibit different absence behaviour, they may be more exposed to infection at work and they may pose a risk as a source of nosocomial infection. From the occupational health perspective, how do we best inform employers currently? The cost-effectiveness case has not been absolutely proven. More research appears necessary, including assessment of those factors that influence uptake of influenza immunization. In the interim, a targeted approach to certain job categories may be the way forward.     

Occupational groups at risk of voice disorders: a review of the literature

BACKGROUND: Occupational voice health is becoming more important as more people rely on their voices for their work. A number of studies have identified certain occupational groups at increased risk of developing occupational voice disorders, namely teachers, singers and aerobics instructors. Aim The paper aims to review the literature on occupational groups at risk of voice disorders and identify areas for future research. METHOD: A literature review of key databases using key words such as 'occupational', 'voice health', 'voice loss', 'dysphonia' and 'work related' was undertaken. RESULTS: The review identified case reports, studies of attendees at hospital voice clinics and a few cross-sectional studies of occupational groups in the workplace. There were no longitudinal studies found or intervention studies looking at reduction of risk. CONCLUSION: Further research on occupational voice disorders needs to be based in the workplace, and to look at the risk factors for the development of voice problems and for the efficacy of controls.     

Saved by a material safety data sheet

BACKGROUND: We present the case of a young female laboratory worker who developed acute hepatic encephalopathy. OBJECTIVE: To show that knowledge of occupational exposures to causative agents can alter therapeutic management. METHODS: Although the patient was in a deep coma, her family members examined the workplace material safety data sheet, revealing exposure to chloroform. Since most chemical-induced hepatitis is self-limiting, a scheduled liver transplantation was postponed. RESULTS: The patient recovered. Subsequent air sampling suggested that the patient had been exposed to chloroform at a concentration of more than 15 ppm for 2 weeks. CONCLUSION: Our case report demonstrates the importance of obtaining an occupational history and how the patient's family can be important in this process.     

Prevalence, management and impact of urinary incontinence in the workplace

BACKGROUND: The few prior studies of urinary symptoms in the workplace have been small investigations of women in specific occupations (e.g. nursing) or industries (e.g. pottery manufacture). In this study, the aims were to describe the prevalence, management and impact of urinary incontinence for a large cross-section of employed women in the USA. METHODS: Five-page questionnaires were mailed to 5130 American households selected from the National Family Opinion survey panel during the spring of 2004. Usable questionnaires were returned by 3364 women in the target age range of 18-60 years. RESULTS: About 37% of the 2326 employed respondents reported urine loss during the last 30 days. The most common strategies for managing incontinence at work included frequent bathroom breaks and wearing pads. The use of urine control methods increased with the severity of urine loss. The effect of incontinence on workplace activities also increased with the severity of urine loss: 88% of employed women with the most severe symptoms reported at least some negative impact on concentration, performance of physical activities, self-confidence or the ability to complete tasks without interruption. CONCLUSION: Urinary incontinence is prevalent among employed women. Those who experience severe symptoms report that it has a negative effect on aspects of work. Programs on the prevalence and impact of urinary incontinence would help educate both employers and employees, and may lead to the development of better management techniques in the workplace.     

Current best practice for the health surveillance of enzyme workers in the soap and detergent industry

This study defines current best practice for the health surveillance of workers who are potentially exposed to enzymes in the manufacture of enzymatic detergent products. It is recommended that health surveillance is performed 6-monthly for the first 2 years and annually thereafter. The health surveillance programme should include a respiratory questionnaire to detect symptoms, assessment of lung function to detect pre-symptomatic changes and an immunological test to detect specific immunoglobulin E (IgE) to enzymes. The International Union Against Tuberculosis and Lung Disease respiratory questionnaire should be used since it has been validated extensively for detecting asthma. Operators should observe the American Thoracic Society performance criteria for spirometers and standardized procedures for conducting spirometry. Since current airborne monitoring techniques for enzymes do not detect short-duration peak exposures, the incidence of employee sensitizations remains the most reliable measure of the integrity of environmental control. The Pepys skin prick test has been validated as a sensitive, specific and practical test for detecting specific IgE to many inhalant allergens including enzymes. For newly sensitized workers, a multi-cause investigation should be conducted to identify potential sources of exposure. Group results of immunological test results assist in the evaluation of workplace control measures, and should be used to monitor the effectiveness of hygiene and engineering programmes and to help prioritize areas for improvement. Positive responses to a questionnaire or abnormal spirometry should be assessed further. Occupational asthma should be excluded in any case of adult-onset asthma that starts or deteriorates during working life. This is particularly important because an accurate diagnosis of occupational asthma with early avoidance of exposure to its cause can result in remission of symptoms and restoration of lung function.     

Health surveys in the workplace: comparison of postal, email and World Wide Web methods

Health surveys in the workplace are an important part of epidemiology, needs assessment and health promotion. Since the workplace is changing rapidly with the use of computer networks, we examined the feasibility, validity and cost of health surveys using e-mail and the World Wide Web (WWW). Five hundred systematically sampled university staff in a convenience sample of 10 English universities were surveyed using either e-mail alone, e-mail plus a WWW form or postal questionnaire. Response rates, speed of response, validity and costs were examined. The postal survey obtained the best response rate: 72% as compared with 34% for e-mail alone and 19% for the WWW, but it was also the most expensive at 92p per reply, with 35p for e-mail, and 41p for the WWW. Most of the electronic responses were made within five days. In 1997, the increased response rate justified the higher cost of postal questionnaires. e-mail and WWW surveys are easy, quick and inexpensive to administer, and despite low response rates may be useful for pilot studies. The rapid changes in the spread and use of information technology means we have to keep reassessing the methods we use for health surveys in the workplace.     

Irritant contact dermatitis due to 1-bromo-3-chloro-5,5-dimethylhydantoin in a hydrotherapy pool. Risk assessments: the need for continuous evidence-based assessments

A physiotherapist working in hydrotherapy presented to occupational health with irritant contact dermatitis. Subsequent investigation revealed that the likely causative agent was 1-bromo 3-chloro 5,5 dimethylhydantoin which was used to disinfect the hydrotherapy pool. A COSHH risk assessment had been performed which failed to take full account of current knowledge and this agent had been introduced into the workplace. The development of adverse health effects among staff and other pool users lead to a review of this risk assessment and eventually a return to less hazardous chlorine-based disinfection. Had an evidence-based approach been combined with an appropriate COSHH assessment prior to and following changes in the workplace then unnecessary risk to employees would not have occurred.     

Report of a system for diagnosis, categorizing and recording occupational mental ill-health

BACKGROUND: UK statutory systems for occupational disease recording do not include mental illness resulting from occupational stress. The issue is included within physician reporting systems, but there is no agreed set of criteria for diagnosis of occupational causation and no agreed system of categorization in terms of type of causation by workplace factors. METHOD: A multidisciplinary group of occupational health professionals, in conjunction with human resources staff, developed a system for the diagnosis, categorization and recording of occupational mental ill-health. RESULTS: The developed system was applied as a pilot and the outcome from its first year of use is presented. CONCLUSIONS: The system is considered to have operated well in pilot, and has now been adopted as a standard operating procedure by the occupational health provider who developed it. The system is proposed as a tool in the development of standardized NHS or UK national systems for the recording of occupational mental ill-health.     

Dog noise as a risk factor for hearing loss among police dog handlers

AIM: To determine the sources of noise exposure among police dog handlers and to examine whether these levels might lead to noise-induced hearing loss. METHODS: We conducted a cross-sectional study at four Royal Air Force bases using a noise survey, a postal questionnaire and medical record review. The noise survey was conducted following task analysis. We surveyed police dog handlers and a comparison group of police who had never been dog handlers, using a postal questionnaire on noise exposures and confounders. Audiometric and otological data were extracted from medical records. RESULTS: The noise survey revealed significant exposures due to dogs, travelling in vans and aircraft noise during foot patrol. The overall response rate to the questionnaire was 56% (29 police dog handlers, 24 police officers). Five subjects (9.4%) had age-corrected hearing loss exceeding 10 dB, averaged over the 4 and 6 kHz frequencies, affecting the left ear only, but there were no differences between dog handlers and controls. CONCLUSION: Although the measured noise exposures of police dog handlers did not exceed current legal limits, the noise levels at times are such that the proposed Physical Agents (Noise) Directive has implications for employers who use dogs for security purposes.     

Impairment of colour vision in patients with n-hexane exposure-dependent toxic polyneuropathy

The aim of this study was to investigate the effects of n-hexane on visual function and to determine the duration of any symptoms related to workplace exposure. The study involved 26 workers diagnosed as having polyneuropathy following n-hexane exposure. The FM-100 Hue test was used to determine colour discrimination in study volunteers. Their results were compared with a control group of 50 people who had not been exposed to n-hexane. The mean total error score for the exposed group was 168.3 (SD = 70.5) for the right eye and 181.5 (SD = 103.0) for the left eye. The mean total error scores for the control group for the right and left eyes were 36.0 (SD = 19.8) and 35.6 (SD = 18.2), respectively. Differences between total and partial error scores for exposed and control groups were statistically significant (P < 0.001). These results may indicate a relationship between n-hexane exposure and development of defects in colour vision, and would support a recommendation for periodic assessment of workers exposed to n-hexane and chemically related solvents.     

Air blast circuit breaker noise and hearing loss: a multifactorial model for risk assessment

The assessment of the risk to hearing from impulse noise exposure may be a problem for the occupational physician because existing legislative and international noise exposure standards deal primarily with continuous noise, and are not valid in excess of the peak exposure limit of 200 pa (140 dB). Noise exposure in excess of this level, for example that due to firearms, is frequently perceived as harmful, but this is not necessarily the case, as impulse noise standards do, in fact, allow exposure with a maximum in the order of 6.3 kPa (170 dB). To illustrate this, a cross-sectional group of electrical transmission workers have been studied who were exposed to significant levels of impulse noise from air blast circuit breakers and firearms. Important hearing loss factors have been identified by means of a specially designed questionnaire. Using the Health & Safety Executive definition, the risk of hearing loss was determined by calculating prevalence odds ratios (ORs) for exposure to these factors. The OR for those with fewer than eight unprotected air blast circuit breaker exposures was 2.27 (95% confidence interval (CI), 1.01-5.08), whilst for those with more than eight exposures the OR was 2.10 (95% CI, 0.97-4.54). For firearm exposure, ORs of 1.61 (95% CI, 0.95-2.74) were noted in the medium exposure group and 2.05 (95% CI, 1.08-3.86) in the high exposure group. When all the factors were included in the model, the most significant factor was age. The study gives support to the impulse noise exposure criteria, confirming the borderline risk from air blast circuit breaker noise exposure and the relative safety of moderate gunfire exposure.