Occupational issues in episodic care populations

BACKGROUND: Much care for non-emergency problems is provided at "episodic care" settings (e.g., urgent care and emergency room). METHODS: Ninety-four subjects, without known occupational disease, who were seeking care for a chronic or sub-acute problem in an episodic care location, were interviewed to assess the frequency and types of occupational health concerns. They were asked whether work probably "caused" or "made worse" their illness and whether their illness "made work difficult." RESULTS: Categorized hierarchically, 20% reported causation, 15% worsening, and 15% interference of illness with work. (Each was categorized in one category only). Only 50% reported absence of a workplace-health interaction. One-third reported that workplace changes could improve their functional status. Nevertheless, workplace factors were discussed only 21% of the time in physician-patient encounters. CONCLUSIONS: This study suggests that occupational health issues are frequent in episodic care settings and that the definition of occupational health issues should be broadened to include "made worse" and "illness makes work difficult" as well as the traditional workplace causation definition. Further, episodic care settings present unique opportunities for prevention.     

Cohort mortality study among French asphalt workers

BACKGROUND: In conjunction with the European cohort study among asphalt workers coordinated by the International Agency for Research on Cancer (IARC), we studied the mortality of 15,011 French men who were followed for 17 years for a total of 175,062 persons-years. This group contained 2,506 subjects who had ever been employed as asphalt workers: they contributed 30,692 person-years of risk. A reference group was composed of 6,675 subjects (i.e., 61,856 persons-years) who had been employed only in building or ground construction. METHODS: Mortality ratios standardized for age and period were computed with their 95% confidence intervals (CI) from the age and period mortality rates of all French men for the years covered by the study (1979-1996). We also compared the mortality of exposed workers and the reference group with Poisson regression models after adjustment for age, calendar period, and either duration of employment or length of follow-up. RESULTS: Mortality from lung cancer was equivalent to the expected rate [SMR = 1.01 95% CI (0.6-1.6)], but was 40% greater than among the non-exposed reference group [RR = 1.4 95% CI (0.7-2.8)]. We also found an excess of gastrointestinal cancers, especially of the esophagus [SMR = 1.94, 95% CI (0.9-3.6)] and stomach [SMR = 2.2, 95% CI (0.8-4.7)]. Comparison with the internal reference group confirmed these findings, especially for stomach cancer [RR = 2.8, 95% CI (0.7-11.4)]. CONCLUSIONS: Although our results are not statistically significant, they suggest that road-paving workers may have a slightly higher rate of lung cancer and a moderately higher rate of stomach cancer than their non-exposed counterparts. The excess of lung cancer may be due to potential confounding factors, including the occupational risk factor of coal tar exposure and the lifestyle risk factor of smoking. A nested case-control study is under way that will make it possible to control for smoking and other potential carcinogenic exposures; this is necessary before any definitive conclusions can be drawn.     

Association of expired nitric oxide with urinary metal concentrations in boilermakers exposed to residual oil fly ash

BACKGROUND: Exposure to metal-containing particulate matter has been associated with adverse pulmonary responses. Metals in particulate matter are soluble, hence are readily recovered in urine of exposed individuals. This study investigated the association between urinary metal concentrations and the fractional concentration of expired nitric oxide (F(E)NO) in boilermakers (N = 32) exposed to residual oil fly ash (ROFA). METHODS: Subjects were monitored at a boiler overhaul site located in the New England area, USA. F(E)NO and urine samples were collected pre- and post-workshift for 5 consecutive workdays. Metals investigated included vanadium (V), chromium (Cr), manganese (Mn), nickel (Ni), copper (Cu), and lead (Pb). RESULTS: The median F(E)NO was 7.5 ppb (95% CI: 7.4-8.0), and the median creatinine-adjusted urinary metal concentrations (mug/g creatinine) were: vanadium, 1.37; chromium, 0.48; manganese, 0.30; nickel, 1.52; copper, 3.70; and lead, 2.32. Linear mixed-effects models indicated significant inverse exposure-response relationships between log F(E)NO and the log-transformed urinary concentrations of vanadium, manganese, nickel, copper, and lead at several lag times, after adjusting for smoking status. CONCLUSIONS: Urine samples may be utilized as a biomarker of occupational metal exposure. The inverse association between F(E)NO and urinary metal concentrations suggests that exposure to metals in particulate matter may have an adverse effect on respiratory health.     

Occupational asthma (OA) with sensitization to diphenylmethane diisocyanate (MDI) presenting at the onset like a reactive airways dysfunction syndrome (RADS)

BACKGROUND: Two types of OA are distinguished: immunological (OA with sensitization) and non-immunological, i.e., irritant induced asthma or reactive airways dysfunction syndrome (RADS). METHODS: We describe the case of a worker who developed respiratory symptoms after a spill of diphenylmethane diisocyanate (MDI) at the workplace. RADS was initially diagnosed and the worker resumed working. The progressive worsening of symptoms and the appearance of symptoms-work relationship one year later, when concentrations of isocyanates were no longer "irritant," suggested immunological OA. RESULTS: The diagnosis was confirmed by specific inhalation challenge test, followed by removal from exposure and complete recovery. CONCLUSIONS: In the case of RADS due to an agent with both irritant and sensitizing properties, history should be repeatedly assessed for a possible symptom-work relationship. If this is found, further investigations should be carried out, including specific inhalation challenges, to confirm the possibility of immunological OA.     

Exposure assessment in epidemiology: Does gender matter?

BACKGROUND: The pathway from potential hazards in the work environment to the measurement or estimation of personal exposure for epidemiologic studies comprises many steps, each of which can be influenced by factors that may or may not differ by gender. This article explores this pathway to address the question, "Should the potential for gender differences be taken into account in the activity of exposure assessment for epidemiologic studies?" METHODS: Evidence from previously published studies and data from the investigators' own research were examined to explore whether or not several theoretical sources of gender 'bias' in exposure assessment have been found in actual studies. Sources of bias examined included: differences in job tasks despite same job titles; differences in delivered exposure due to differences in protective equipment, body size, or other relationships to exposure sources; and differences in estimated exposure arising from study methods or design. RESULTS AND CONCLUSIONS: Evidence was found for gender differences (and thus potential bias) from all these sources, at least in some studies. We conclude that the answer to the question posed, "Does gender matter, in exposure assessment for epidemiology?" is a qualified 'yes,' but that the magnitude and direction of the potential bias cannot be predicted, a priori. Am. J. Ind. Med. 44:576-583, 2003.     

Acute effects from occupational exposure to antineoplastic drugs in a para-professional health care worker

BACKGROUND: While health risks from occupational exposure of nursing and pharmacy staff have been recognized, exposure of para-professional health care workers (HCW) has received little attention. METHODS: This case report describes a patient care assistant who developed allergic reactions subsequent to exposure to urine of oncology patients who had been treated with antineoplastics. RESULTS: The patient care assistant on two occasions developed a pruritic, disseminated rash shortly after emptying commodes containing the urine of oncology patients treated with Vincristine and Adriamycin (doxorubicin). CONCLUSIONS: Increased attention should be focused on the occupational exposures of para-professional HCWs to potentially hazardous antineoplastics.     

Occupational injury and illness among migrant and seasonal farmworkers in New York State and Pennsylvania, 1997-1999: pilot study of a new surveillance method

BACKGROUND: Traditional worksite injury surveillance methods are often ineffective for Northeastern farms employing seasonal harvest labor. Many are small farms, exempt from mandatory injury reporting. The high proportion of foreign workers and the temporary nature of the work further discourages reporting. Therefore, an alternative migrant health center-based occupational injury and illness surveillance system was piloted during 1997-1999. METHODS: Anonymous medical chart data from nine migrant health centers and four regional hospital emergency rooms was collected during 1997-1999. RESULTS: There were 516 injury/illness cases over two seasons. Joint/muscle straining (31%), falling (18%), poison ivy contact (10%), and object strikes (8%) were most common injurious events. The participation rate of health care was 75%; 130 cases were reported by hospital emergency rooms; and optimal health center participation was associated with: being a farmworker-dedicated program, and including the chart reviewer in the health center's decision to participate. CONCLUSIONS: Further development of a medical records-based surveillance system should include hospital emergency rooms and focus on identified health center performance factors.     

Cancer incidence and mortality in workers employed at a transformer manufacturing plant: update to a cohort study

BACKGROUND: This study is an extension of a previously published analysis of cancer mortality in a transformer manufacturing plant where there had been extensive use of mineral oil transformer fluid. The objectives of the present study were to update the mortality analysis and include deaths for the past 6 years as well as to do an analysis of cancer incidence of the cohort. METHODS: A cohort of 2,222 males working at a transformer manufacturing plant between 1946 and 1975 was constructed. Using a classical historical cohort study design, cancer incidence and mortality were determined through record linkage with Canadian provincial and national registries. The rates of cancer incidence and mortality experienced by this cohort were compared to that of the Canadian male population. RESULTS: A statistically significant increased risk of developing and dying of pancreatic cancer was found but not an increase in overall cancer mortality. This was consistent with the previous report from this group. Interestingly, the cohort demonstrated a statistically significant risk of overall cancer incidence and specific increased incidence of gallbladder cancer. CONCLUSIONS: This study contributes further evidence to the growing body of literature indicating the carcinogenic properties of mineral oils used in occupational settings, in particular those used prior to 1970s.     

Teaching of occupational medicine to undergraduates in UK schools of medicine

OBJECTIVES: To assess any recent change in the commitment to occupational medicine teaching in UK undergraduate medical curricula. DESIGN: A questionnaire survey of the teaching of occupational medicine to undergraduates in all medical schools listed in the UK Universities and Colleges Admissions Service prospectus for 1999-2000 (n = 24). RESULTS: Nineteen UK schools medical schools returned a completed questionnaire, giving a response rate of 79%. A comparison of results from this survey with previous surveys of teaching of occupational medicine to undergraduates in the UK shows that fewer schools now provide lectures, project work or ward-based tuition in the subject. Workplace visits were not undertaken by any institution. Only two of the schools setting an examination question also had a syllabus. CONCLUSION: Despite the prominence given to issues related to occupational health in recent UK government policy, this study suggests a declining commitment to occupational medicine on the part of UK medical schools. Urgent action needs to be taken to address the lack of training in occupational medicine in UK medical schools.     

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.