SWORD '95: Surveillance of Work-related and Occupational Respiratory Disease in the UK

An estimated 2,741 new cases of occupational respiratory diseaseswere reported by chest and occupational physicians in 1995.Total cases reported by ‘core’ chest physiciansand occupational physicians have risen but cases reported by‘sample’ physicians have fallen by 32%, reducingthe estimated total overall by approximately 16% from 1994.Steps are being taken to reverse this downward trend. Occupationalasthma remains the single most frequently reported disease ofwhich more than two thirds of cases were attributed to sensitization.Non-malignant pleural disease was the next most frequently reported,with pleural plaques predominating in 71% of cases. In a studyof a selected sample of 158 cases of non-malignant pleural disease,81 (51%) were seen for medico-legal reasons; of the remainder13% had signs or symptoms ascribed to the disease.     

Health care workers' exposure to blood-borne pathogens in Lebanon

Background Accidental exposure to blood-borne pathogens (BBPs)is a risk for health care workers (HCWs). Aim To study the pattern of occupational exposure to blood andbody fluids (BBFs) at a tertiary care hospital. Methods This study reports a 17-year experience (1985–2001)of ongoing surveillance of HCW exposure to BBFs at a 420-bedacademic tertiary care hospital. Results A total of 1590 BBF exposure-related accidents werereported to the Infection Control Office. The trend showed adecrease in these exposures over the years with an average ±standard error of 96 ± 8.6 incidents per year. In thelast 6 years, the average rate of BBF exposures was 0.57 per100 admissions per year (average of needlestick injuries alonewas 0.46 per 100 admissions). For 2001, the rates of exposurewere found to be 13% for house officers, 9% for medical student,8% for attending physicians, 5% for nurses, 4% for housekeeping,4% for technicians and 2% for auxiliary services employees.The reason for the incident, when stated, was attributed toa procedural intervention (29%), improper disposal of sharps(18%), to recapping (11%) and to other causes (5%). Conclusions The current study in Lebanon showed that exposureof HCWs to BBPs remains a problem. This can be projected toother hospitals in the country and raises the need to implementinfection control standards more efficiently. Similar studiesshould be done prospectively on a yearly basis to study ratesand identify high-risk groups.     

Nanotechnology and the occupational physician

Nanoparticles differ from the same material at larger scale in chemical and physical properties. Evidence from studies of fibres leads to the conclusion that inhalation of nanotubes could be dangerous and should be regulated. Air pollution research has suggested that particles may be more toxic to cells at the nanoscale. At present the marketing of nanoparticles is advancing more rapidly than research into their safety and toxicology, and one serious inhalation episode has been reported in Germany from apparent use of a nanoproduct. This rapidly developing industry will make an impact on the work of occupational physicians, first in universities and small concerns but later more widely. The future safety of workers and consumers is dependent on research into hazard and risk, an area in which the UK and most other countries are dragging their feet. However, a resource, the Safety of Nanomaterials Interdisciplinary Research Consortium, has been established in the UK to assist those active in this field.     

Health and employment after a diagnosis of occupational asthma: a descriptive study

The objectives of this study were to describe changes in asthmaand employment after diagnoses of occupational asthma reportedto the SWORD project. Questionnaires were sent to 312 physiciansfor all 1,940 cases of occupational asthma reported from 1989–92;1,769 (91%) were returned but information was available foronly 1,317 (68%). Of patients reported by occupational physicians,45% had recovered from asthma compared to only 14% of thosereported by chest physicians (excluding medicolegal cases),presumably because of differences in severity. Proportions withthe same employer were 49% and 48% respectively. Patients exposedfor a year or more after diagnosis recovered from asthma lessfrequently but were more often employed than those exposed forless than a year. Among those whose asthma was attributed tohigh molecular weight agents, smokers had developed asthma earlierafter exposure began than others but had the best prognosis.Asthma developed following a single high exposure in 18 cases(2%), of which 13 were to irritants and five to known sensitizers.     

Evaluation of a workshop on evidence-based medicine for social insurance physicians

Background Evidence-based medicine (EBM), a comprehensive methodto support clinical decision making by using evidence, has beeninstrumental in clinical specialties but not yet in insurancemedicine. Aims We developed and evaluated a workshop on EBM for Dutchsocial insurance physicians who perform disability evaluations. Methods Sixty-six social insurance physicians followed a 1-dayintroductory workshop that focused on teaching two EBM coreskills: to ask answerable questions and to search for the bestevidence. All outcomes were measured before, immediately afterand 3 months after the workshop by means of self-assessment.The primary outcomes were knowledge, skills, attitude and intentionto apply EBM in practice. The secondary outcomes were socialinfluence, self-efficacy and behaviour. Results Immediately after the workshop, a marked and significantimprovement was seen in self-assessed skills (mean difference4.2, 95% CI 3.7–4.6) and in self-efficacy to apply EBM(mean difference 0.7, 95% CI 0.6–0.8). For attitude, knowledgeand intention, the improvements were small. Three months afterthe workshop, the improvements in skills (mean difference 2.3,95% CI 1.8–2.9) and self-efficacy (mean difference 0.5,95% CI 0.3–0.6) remained significant. Conclusions The workshop improved self-assessed EBM skills andself-efficacy both in the short and long term. The workshopalso resulted in limited short-term improvements in self-assessedknowledge and in the intention to apply EBM in practice. TheEBM approach can be successfully taught to social insurancephysicians working in the field of disability evaluation.     

Good medical practice: guidance for occupational physicians

Following a catalogue of serious, highly publicized medical misdemeanours, the General Medical Council (GMC) has introduced plans for a new system of medical licensing in the UK called 'revalidation'. Under this, the onus will fall on individual doctors, including occupational physicians, to demonstrate their continuing fitness to practice. Doctors will need to show that they meet basic minimum standards in terms of the care they provide, their own continuing professional development, and other aspects of professional life like probity and ethical behaviour. As part of the process, the Faculty of Occupational Medicine, Royal College of Physicians, has produced its own guidance on good medical practice for occupational physicians, following an extensive consultation exercise. This paper summarizes the background to the initiative, the development process and the standards that have been recommended to aid professional accountability.     

The changing role of the occupational physician in the private sector: the Canadian experience

The role of the occupational physician in the private sectoris changing. Fewer large corporations maintain medical departmentsfollowing the ‘downsizing’ trend of the late 1980'sand early 1990's and those that do have extensively redefinedthe duties of the corporate medical director, often extendingthese duties to include responsibility for environmental health.Occupational medical services for employees previously coveredby in-house services are now often provided by outsourcing.The private practice of occupational medicine has become themajor growth area of the speciality in both the US and Canada.These trends have been driven primarily by economic imperativesand new management philosophies; the trend may have gone toofar and a ‘rightsizing’ correction may be in progress.However, it is not clear that corporations in general are derivingthe greatest value they can from their physicians or that thecurrent generation of senior managers is utilizing its healthprofessionals as effectively as they might. This is in partbecause the training, qualifications and capabilities of occupationalphysicians are not well understood. At least as important, however,is persistent confusion over desirable and appropriate rolesthat obscures the potential contribution of the medical professionalwithin a management structure. We suggest that the greatestvalue in occupational medical services may be in the anticipationof risk related to health issues and the flexibility this givesthe organization to manage the problem.     

Ethical issues in occupational medicine practice: knowledge and attitudes of occupational physicians

Views on ethical conduct in occupational medicine practice canvary from country to country and even between occupational healthpractitioners. However, there are many areas of common agreement,and this is apparent on comparing guidance documents on ethicsproduced by several different organizations. The usefulnessof these documents will depend in part on how aware practitionersare of their existence. A standardized questionnaire administeredto 70 occupational physicians in the Netherlands, UK, and Singaporeshowed that there was a lack of awareness of guidance documentson ethics, even for publications from their own countries. Onlyfive of the 70 respondents consulted an ethics document in thepast year. In addition to publications, other avenues were usedfor advice on ethical issues. There was a difference in opinionbetween the physicians from Singapore and those from the twoEuropean countries on whether specific occupational health activitieswere ethical. These findings reinforce the need for internationalguidance on ethics to take into account differences in attitudesand practice between countries. On many issues there was nounanimity of opinion, even between occupational physicians fromthe same country. This may be an indication of the complexityof ethical matters, and provides a rationale for publishingguidance on ethics in occupational medicine.     

Sexual health and HIV in travellers and expatriates

Travellers engaging in sexual contact with a new partner abroad may be at high risk of acquiring a sexually transmitted infection. This review examines the impact of travel on sexual health and provides prevention, management and treatment recommendations to practising occupational health physicians.     

The impact of the COSHH regulations on workers with occupational asthma

In the UK, the COSHH Regulations give specific guidance thatemployers have duties to inform, instruct and train their employeesabout occupational risks and provide them with suitable healthsurveillance. The aim of the study was to evaluate the impactof the Regulations on employees with occupational asthma. Onehundred consecutive patients attending an occupational lungdisease clinic completed a questionnaire assessing the implementationof the COSHH Regulations in their workplace. Twenty-eight percent had a pre-employment inquiry about asthma, 31% had regularhealth surveillance by questionnaires and 19% had regular lungfunction assessment at work. Pre-employment spirometry was carriedout in 44% of the workers who were exposed to one of the originalseven prescribed agents, significantly more than those who wereexposed to other agents (19%) (p < 0.05). Moreover, figuresfor spirometry during employment were 31% and 8% respectively(p < 0.05). The patients who worked after ‘COSHH’but before ‘MS25’ had a tendency to be providedwith health surveillance more than those who worked after both‘COSHH’ and ‘MS25’. Ninety-one per centof the patients had never been informed about the risks of gettingasthma at work and 73% had never seen the safety data sheets.The workers who (1) worked after ‘COSHH’ introduction;(2) worked in larger firms and (3) were exposed to one of theoriginal seven prescribed agents, had a tendency to be informed,instructed and trained more than the rest. However, there wereonly significant statistical differences (p<0.05) in termsof the safety data sheet provision between the cases who workedbefore the time of the legislation and those employed afterwards.     

A Survey of Respiratory and Dermatological Disease in the Chrome Plating Industry in the West Midlands, UK

Between 1993–1995 a cross-sectional survey of 20 chromeplating companies in the West Midlands was undertaken to assessthe prevalence of respiratory and dermatological disease inplaters. By means of a questionnaire and clinical examination71 platers were examined of whom 23% were found to have dermatitisat the time of the visit and 45% of companies had at least onecase of dermatitis in their plating workforce. Twenty-threeper cent of platers had evidence of old chrome ulceration and13% had evidence of new and healing chrome ulcers. When thenasal passages of platers were examined 17% had inflammationand 14% had septal perforation. Those with perforations wereaged less than 35 years at the time of perforation which hadusually occurred in the first 10 years of exposure. Lower respiratorysymptoms were rare. Guidance on the prevention of disease inthis occupational group which does not always have ready recourseto experienced occupational medical advice will be discussed.     

Incidence and suspected cause of work-related musculoskeletal disorders, United Kingdom, 1996-2001

BACKGROUND: Musculoskeletal conditions are the most common self-reported work-related disease, with high costs incurred from long-term disability. In the United Kingdom, occupational physicians and rheumatologists have been reporting new cases of work-related musculoskeletal disorders to voluntary surveillance schemes since 1996. AIMS: To estimate population incidence rates for work-related musculoskeletal disorders reported by rheumatologists and occupational physicians by occupation and industry, in relation to tasks and movements suspected as causal. METHODS: Estimated average annual incidence rates were calculated for nine main job categories and eight industrial groups; Labour Force Survey figures were used as the denominator for rheumatologists, and a special survey for the occupational physicians. These were then related to tasks and movements reported as causal. RESULTS: Between October 1997 and the end of 2001, an estimated 2,599 new cases/year were reported by rheumatologists, and from January 1996, 5,278 cases/year by occupational physicians. Average annual rates overall were 94 per million for rheumatologists and 1,643 per million for occupational physicians (a 17-fold difference). Jobs at highest risk for the upper limb were primarily clerical, craft-related and machine work. Tasks associated with upper limb disorders and with neck and back problems were predominantly keyboard work and heavy lifting, and in craft-related occupations with gripping or holding tools. CONCLUSIONS: Jobs at risk and the associate tasks were identified which should assist prevention, but the extent to which these factors were causal or aggravating previous injury requires further study. The much higher rates reported by occupational physicians reflect, in part, the type of industries they served.     

Improving mental well-being in the workplace

Occupational physicians, who are in a key position to influencecompany policy on mental health, have limited access to educationon mental health. This paper discusses the results of a postalsurvey of occupational physicians that was designed to identifythe mental health information needs of occupational physicians,determine the way in which this information should be disseminatedand measure the extent to which occupational physicians encountermental health problems in the workplace.     

Work Related Injuries in Danish Fishermen

A one-year retrospective study among Danish commercial fishermenrevealed that the overall rate of injury was 20.4 per 100 personsper year. There were no significant differences in injury ratesrelated to age. The overall rates of injury related to the differenttypes of vessels—trawlers, gill-netters and Danish seiners—diddiffer statistically when the number of man-days at sea wastaken into account. There was, however, a significant increasein the number of injuries on trawlers over 100 gross registertons. The overall number of days lost due to injury among allfishermen was 47 days per 1,000 days at sea. The highest numberof days lost for work was on trawlers of 100–199 grossregister tonnage. Preventive measures should be implementedin all age groups and in all the main types of fishing vessels.     

Hydrogen Sulphide

Hydrogen sulphide (H₂S is the primary chemical hazard in naturalgas production in ‘sour’ gas fields. It is alsoa hazard in sewage treatment and manure-containment operations,construction in wetlands, pelt processing, certain types ofpulp and paper production, and any situation in which organicmaterial decays or inorganic sulphides exist under reducingconditions. H₂S dissociates into free sulphide in the circulation.Sulphide binds to many macromolecules, among them cytochromeoxidase. Although this is undoubtedly an important mechanismof toxicity due to H₂S, there may be others. H₂S provides littleopportunity for escape at high concentrations because of theolfactory paralysis it causes, the steep exposure-response relationships,and the characteristically sudden loss of consciousness it cancause which is colloquially termed ‘knockdown.’Other effects may include mucosal irritation, which is associatedat lower concentrations with a keratoconjunctivitis called ‘gaseye’ and at higher concentrations with risk of pulmonaryoedema. Chronic central nervous system sequelae may possiblyfollow repeated knockdowns: this is controversial and the primaryeffects of H₂S may be confounded by anoxia or head trauma. Treatmentis currently empirical, with a combination of nitrite and hyperbaricoxygen preferred. The treatment regimen is not ideal and carriessome risk.     

Disability management through positive intervention in stakeholders' information asymmetry. A pilot study

BACKGROUND: One increasingly attractive hypothesis to account for prolonged sickness absence from work is the presence of 'information asymmetry' among stakeholders. Information asymmetry refers to a situation in which critical information is not (appropriately) exchanged, in this case among those involved in disability management. AIM: The purpose of this study was to intervene positively in the information asymmetry that currently exists between social insurance physicians and occupational physicians in Belgium. METHODS: We developed a novel model aimed at improving information exchange, and a pilot study protocol based on the model. Our first objective was to investigate feasibility of implementing the study protocol. Our second and main objective was to obtain preliminary results on whether improving information exchange between physicians would facilitate work resumption of employees out on sickness absence. RESULTS: Of 126 patients recruited, 91 were eligible and assigned to one of two groups: a control group, whose physicians used the standard Belgian evaluation protocol, and an intervention group, whose physicians used our new protocol. Outcome parameters from the 15 patients assigned to the intervention group revealed that enhanced inter-physician information exchange produced favourable work resumption rates (73%), suggesting that both the model and study protocol show promise. CONCLUSIONS: The issue of sharing information among all stakeholders involved in disability management is an important one. Moreover, professional reintegration of employees after a sickness absence is universally important to occupational health practitioners. Our preliminary results suggest that reducing information asymmetry among physicians should be investigated further in larger intervention trials.     

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.     

The suicide mortality of working physicians and dentists

BACKGROUND: Some studies have shown that physicians and dentists have elevated risks of suicide, while other studies have not. AIMS: Using all deaths and corresponding census data in 26 US states, we examine the suicide risk for working physicians and dentists. METHODS: Death and census data for working people were obtained from 1984 through 1992. Directly age-standardized suicide rate ratios (SRRs) were calculated for white male and white female physicians and white male dentists. RESULTS: For white female physicians, the suicide rate was elevated compared to the working US population (SRR = 2.39, 95% CI = 1.52-3.77). For white male physicians and dentists, the overall suicide rates were reduced (SRR = 0.80, 95% CI = 0.53-1.20 and 0.68, 95% CI = 0.52-0.89, respectively). For older white male physicians and dentists, however, observed suicide rates were elevated. CONCLUSIONS: White female physicians have an elevated suicide rate. Only older white male physicians and dentists have elevated suicide rates, which partially explains the varied conclusions in the literature.     

Chemical, biological, radiological and nuclear terrorism: an introduction for occupational physicians

BACKGROUND: Chemical, biological, radiological and nuclear terrorism poses considerable threat throughout the world. AIM: To provide occupational physicians with an understanding of this threat and its main forms and what action can be taken to counter this threat. METHODS: Presenters at a conference on chemical, biological, radiological and nuclear terrorism were asked to contribute their evidence-based opinions in order to produce a review article. RESULTS: This paper presents a summary of the different forms of chemical, biological, radiological and nuclear terrorism and the effective counter-measures and also provides a review of current scientific literature. CONCLUSION: The threat of chemical, biological, radiological and nuclear terrorism is present throughout the world and is one that occupational physicians should be aware of, as well as the action that can be taken to counter it.     

Quality Improvement by Means of 'Differential' Occupational Health Care: An Experiment in a Regional Occupational Health Centre

From a general policy of quality improvement, the regional OccupationalHealth Centre Eastern Gelderland has developed a method of companyhealth care based on the particular demands and needs of companies.A procedure of care ‘made to measure’ based on companyand work characteristics was designed. For one year, an experimentwas carried out in seven companies, to investigate if this ‘differentialcare’ is feasible, and if its quality is better than thetraditional ‘standard’ form. After the experiment,the companies' satisfaction proved to have increased. The influenceof the Occupational Health Centre on working conditions wasestimated more important than before. The increased satisfactionis considered to be an indication of better quality of care,compared with the traditional ‘standard’ care. Thedifferential approach appeared to be feasible. The method requiresskills of professionals in the field of planning, cooperation,estimating costs and negotiating.