Transcript Diapositiva 1

Occupational Medicine
Prof. Francesco S. Violante
General Concepts
Evolution of Working Conditions
Health and Labour
Occupational Injuries and Diseases
What is Occupational Medicine




It is considered to have been founded in 1700 by
Prof. Bernardino Ramazzini's treatise “De Morbis
Artificum Diatriba” (b. Carpi – d. Padova)
It was for a long time identified as the medical
specialty concerned with the diagnosis, treatment
and prevention of occupational diseases
It has developed in Europe since the first half of
the XIX century
At the beginning of the XX century, the first
“Work Clinic” is established in Milan, and the
International Commission on Occupational Health
is founded in 1906
What is Occupational Medicine
It is the medical specialty concerned with
the protection and promotion of the
working population's health
 It is not an “anatomical” specialty
 It is a qualification required by law for
exercising some professional activities
(Competent Physician and Authorized
Physician)
 It has developed and uses peculiar
techniques, which have in their turn
become operative specialties

Occupational Medicine Specialties
Occupational Hygiene
 Occupational Toxicology
 Occupational Epidemiology
 Ergonomics
 Medical Radioprotection (Authorized
Physician)
 Corporate Medicine (Most specialized
physicians are employed in this sector)

Evolution of Working Conditions
As with many aspects of human life,
working conditions remained almost
unchanged for centuries
 Structured work, as we know it today, is a
product of the “Industrial Revolution”
(XVIII century)
 We are currently living in what is called a
“post-industrial society”

Life and Working Conditions before the
Industrial Revolution



In past centuries, life was dominated by
undernutrition, bad hygienic conditions and lack
of effective medical care
In the Middle Ages, life expectancy (today in
Italy: 77-83) was about 50 for those who
reached adulthood
Food availability and big epidemics have affected
the world population rate:
-
1000:
1500:
1800:
1930:
1975:
2000:
300.000.000
500.000.000
1.000.000.000
2.000.000.000
4.000.000.000
6.000.000.000
World Population Development
Popolazione in milioni
(scala logaritmica)
Population Development
in different continent
Anno
Working Conditions before the
Industrial Revolution





Most of the population was employed in
agriculture and zootechnics; few worked as
craftsmen and even less in the service industry
The working life began as soon as children were
strong enough
All the work was done by strength of arm,
animals and simple machines (levers, block-andtackles)
The working day lasted from sunrise to sunset
Healthcare (mostly ineffective or dangerous) had
to be paid for or was provided by charities
(religious organizations)
Health and Labour before the Middle
Ages
Hyppocrates (460-377 B.C.): miners,
metal craftsmen, dyers, farmers
 Lucretius (100-55 B.C.): De Rerum
Natura, miners
 Plinius the Elder (23-79): miners
 Galenus (129-200): miners, gladiators
 Al-Razi (850-923): cotton spinning

From the Middle Ages to the Industrial
Revolution







1242: Roger Bacon publishes the formula for
black powder, which would lead, in the ensuing
centuries, to a change in military technology (and
in excavation techniques)
1492: the Discovery of America
Ellenbog (1440-1499): metal workers
Paracelsus (1493-1541): miners and glazers
1455: Johann Gutenberg puts on sale the first
printed book, a Bible
George Bauer, called Agricola (1494-1555): De
Re Metallica, gold and silver metallurgy
1677: van Leeuwenhoek develops the microscope
The Industrial Revolution
It takes place in England between 1760
and 1830, after the Agricultural Revolution
 1712: Newcomen's Steam Engine
 GA Scopoli (1723-1788) is appointed as
physician of the mercury mines in Idrjia,
where he works for 16 years. He is author
of the De Hydroargyro Idriensi Tentamina,
a treatise on mercury poisoning in miners
 1768: Arkwright patents the mechanical
spinning frame

The Industrial Revolution




1786: John Fitch's Steamboat
1810: Krupp improves the steel production
process (originally developed in 1740 by
Huntsmann, in Sheffield), eventually improved by
Bessemer (1854) and Martin, by the Siemens in
1866 and by Thomas (1875)
1825: The Locomotion 1 by Robert Stephenson
drags the first commercial train in the world from
Stockton-on-Tees to Darlington
1840: Samuel Cunard launches a transatlantic
service between Great Britain and the United
States
Working Conditions during the
Industrial Revolution




Safety and Hygiene standards are very poor
The population's hygienic and nutritive conditions
are also precarious (though improving)
There is no general healthcare
The first laws on child labour ban and limit its use
(between 12 and 8 hours depending on age)
Labour in History:the Spinning Mill
(1815)
Labour in History: 1800
Working in the Spinning Mill: silkworms
Fonte: http://www.provincia.venezia.it/medea/est/frulli/filanda/filande.htm
Labour in History: 1800
Working in the Spinning Mill: silkworms
Fonte: http://spazioinwind.libero.it/filandeonline/images/7%20Bachi.jpg
Labour in History: 1800
Women and Children in the Spinning Mill
Fonte:
http://www.bibliolab.it/donne_web/pic/galleria1/1800_Donne%20e%20bambini%20in%20filanda.jpg
Labour in History: ~1900
Factory Workers of the Rasica Spinning Mill in Osio Sotto
Source: http://www.lomb.cgil.it/sedi/bg/cdl/2006/8marzo/sommario_foto.htm
Labour in History: ~1900
Argentiera miners (Sassari) at the end of the XIX century
Source:
http://www.cgil.it/sardegna/foto345.html
Industrial Development in Italy
On the eve of the First World War, Italy is
still an agricultural country with few
factories
 The first stage of industrial growth dates
back to the period between the two World
Wars
 After the Second World War, Italy emerges
first as an industrial economy and later as
a post-industrial one (after 1980)

Labour in History: ~1940
Legler Mechanical
Looms in the forties
Source: http://www.lomb.cgil.it/sedi/bg/cdl/2006/8marzo/sommario_foto.htm
Labour in History: 1950
Weber Factory: Drilling Machine Operator
Source: Regione Emilia Romagna http://www.form-azione.it/pariopportunita/donnedellaltrosecolo.htm
Labour in History: 1950
Factory worker making sweet boxes by hand
Source: Regione Emilia Romagna http://www.form-azione.it/pariopportunita/donnedellaltrosecolo.htm
Labour in History: 1950
Ducati Factory Worker
Source: Regione Emilia Romagna http://www.form-azione.it/pariopportunita/donnedellaltrosecolo_06.htm
Labour in History: 1960
Miners working in the Prestavel mine (fluorite veins)
Sourcehttp://www.stava1985.it/intranet/stava1985_it/www/wo_albums/Index/20050718_152739/20050718
_162011/PhotoFolder?display=medium
Labour in History: 1965
Miner working with jack-leg – Mine in Valle Vedra
Source: http://www.wwmm.org/storie/storia.asp?id_storia=252&pagina=9&project=0
The first Italian laws on work safety
1886
Ban on child labour under 9 and ban
on night labour under 12
1902
Minimum age for working 12 years
1904
Minimum age for working 14 years
1899-1913 General prevention regulations and
regulations for some specific sectors
1898-1934 Mandatory insurance against
occupational injuries and (later)
diseases
Workforce composition in Italy
between 1881 and 2000 (INAIL data)
Year
Agriculture
Industry
Service
1881
65,4%
20,2%
14,4%
1936
52,0%
25,6%
22,4%
1951
43,0%
29,9%
27,1%
1981
11,1%
41,5%
47,4%
2000
5,3%
32,1%
62,6%
Active Population per Sector in Italy
(Istat Data, 2001)
Males
Females
Total
Industry
5.316.779
1.712.202
7.028.981
Trade
2.298.682
1.687.856
3.986.538
Credit and Insurances,
services to companies
1.168.507
884.174
2.052.681
Agriculture
739.903
413.775
1.153.678
Transportations and
Communications
780.240
198.789
979.029
2.537.860
3.254.965
5.792.825
Total 12.841.971 8.151.761
20.993.732
Other Activities
Relationship between Health and
Labour
Work can affect health both negatively
and positively
 Negative consequences: occupational
injuries and diseases, reduction of life
expectancy
 However, “healthy” work is an important
factor in health promotion

Occupational Injuries and
Diseases



Occupational Injury: damage to an individual's
psychophysical integrity due to a violent causal
factor which is concentrated in time during the
working activity
Occupational Disease: damage to an individual's
psychophysical integrity due to a causal factor
which is diluted in time during the working
activity
Occupational Injuries and Diseases are, by
definition, predictable events
Working is good for our Health






It is not yet clear which occupational factors are
associated with an improved health status
Income, Social Relations, Identity
Physical Activity
Abstention from Smoke (in some sectors)
Regular Medical Checks (maybe)
Healthy Worker Effect: phenomenon described in
Epidemiology whereby workers usually have
better health than unemployed people
Mortality and Labour (Turin 1991-96)
Working Condition
Relative Risk
Steadily employed
1,00
Intermittently employed
1,52
Unemployed (previously
employed)
Steadily unemployed
2,29
Steadily out of labour force
4,81
2,61
Life expectancy according to occupation
at 35 (Turin, males, occupation in 1991)
Cleaning and waste
collection operators
34,4 Armed Forces
37,9
Postmen
Physicians, dentists,
34,8 psychologists,
pharmacists
37,6
Porters
Lawyers, magistrates,
34,9 chartered accountants,
notaries
37,5
Food Industry workers
35,0 Teachers
37,4
Carpenters
35,2 Technical professions
37,2
Life expectancy according to occupation
at 35 (Turin, females, occupation in 1991)
Lawyers, magistrates,
chartered accountants,
notaries
Physicians, dentists,
36,3 psychologists,
pharmacists
38,9
Waitresses, cooks and
barmaids
37,5 Technical professions
38,5
Machine tool operators,
mechanics
37,8 Teachers
38,5
Entertainment industry
workers and journalists
38,0
Transport Vehicle
drivers
38,4
Nurses and health
technicians
38,0
Cleaning and garbage
collection operators
38,4
Italian Population divided by age and
sex (1-1-2008)
Classi di
età
(anni)
0-19
Maschi
5.837.497
20-64
65 e oltre
Femmine
Totale
5.512.040 11.349.537
18.112.441 18.211.326 36.323.767
4.999.809
6.946.177 11.945.986
Totale 28.949.747 30.669.543 59.619.290
Nati 2007
Morti 2007
290.330
279.792
273.603
291.009
563.933
570.801
Deaths by age and sex class - Italy, 2002
Age Classes
(years)
Below 1
Males
Females
Total
1.320
1.017
2.337
720
469
1.189
15-29
4.257
1.345
5.602
30-44
8.579
4.148
12.727
45-59
24.445
13.591
38.036
60-69
45.516
24.432
69.948
70-79
88.331
64.105
152.436
80-89
79.272
105.664
184.936
90 and over
26.856
66.323
93.179
279.296
281.094
560.390
1-14
Total
Deaths by group of causes - Italy, 2002
Cause
Males
Circulatory system diseases
Females
Total
105.726
131.472
237.198
Tumours
93.398
69.672
163.070
Respiratory apparatus diseases
20.617
15.324
35.941
Traumatisms and poisonings
16.026
10.667
26.693
Digestive apparatus diseases
12.485
12.234
24.719
Psychic diseases, diseases of the
nervous system and sense organs
9.552
14.765
24.317
Infectious and parasitic diseases
2.145
2.147
4.292
…
…
…
Other morbid conditions
Total
279.296
281.094 560.390
Deaths by group of causes
Mortalità per causa - Per 100.000 abitanti
Deaths due to external causes of
traumatisms and poisonings– Italy, 2002
Causa
Maschi
Femmine
Totale
Cadute accidentali
4.035
6.517
10.552
Incidenti stradali
5.577
1.542
7.119
Suicidi
3.145
924
4.069
Annegamento e soffocamento
349
91
440
Omicidio o lesioni provocate
intenzionalmente da altri
401
159
560
Incendi
144
131
275
Complicanze di operazioni
chirurgiche
199
159
358
45
22
67
…
…
…
16.026
10.667
26.693
Avvelenamento da gas
Altri incidenti
Totale
Major Malignant Tumours causing
death, by sex – Italy, 2002
Site
Trachea, bronchus and lung
Males
Females
Total
25.765
6.528
32.293
9.164
8.072
17.236
―
11.309
11.309
Stomach
6.266
4.686
10.952
Liver and intrahepatic bile ducts
6.661
3.604
10.265
Linfatic and emopoietic tissues
3.887
3.724
7.611
Prostate
7.132
―
7.132
Leukemias
3.022
2.533
5.555
Colon, rectus and anus
Breast (in women)
Death from cancer – Italy, 2002
Occupational Injuries
Occupational Injuries reported to
INAIL (2008)
All
Agriculture
(in-itinere injuries)
Industry and Service
(in-itinere injuries)
Public employees
(in-itinere injuries)
Total
(in-itinere injuries)
Lethal
53.355
121
(1.259)
(18)
790.278
911
(88.236)
)
(249)
31.457
88
(5.008
(9)
875.090
1120
(97.201)
(276)
Occupational Injuries in the EU
(2005)
Economic activity
All
Lethal
Manufacturing industry
3.505
837
Building sector
6.069
1.236
Trade
2.184
372
Transportations
3.696
701
Agriculture
4.560
4.153
Hotels and restaurants
2.943
61
Electricity, gas, water
1.830
53
Occupational Injuries Industry and
Service- type of lesion (INAIL 2008)
Natura della lesione
Inabilità
temporanea
Inabilità
permanente
Morte
Contusione
150.801
4.603
162
155.566
Lussazione
150.830
5.493
5
156.328
Ferita
103.657
2.881
29
106.567
Frattura
49.593
16.872
458
66.923
Altri agenti (calore,..)
12.006
374
91
12.471
Corpi estranei
12.450
130
0
12.580
Lesioni da sforzo (ernie,…)
9.184
239
1
9.424
Altre e indeterminate
6.689
471
161
7.321
Perdita anatomica
1.776
1.085
3
2.864
328
21
1
350
497.314
32.169
911
530.394
Lesione da agenti infett.
Totale
Totale
Occupational Injuries - Agriculture
- type of lesion (INAIL 2008)
Natura della lesione
Inabilità
temporanea
Inabilità
permanente
Morte
8.964
418
4
9.386
Contusione
13.031
706
16
13.753
Lussazione
9.147
773
1
9.921
Frattura
4.898
2.117
51
7.066
169
102
2
273
74
2
-
76
596
18
17
631
1.164
17
-
1.181
616
33
-
649
38.989
4.236
117
43.342
Ferita
Perdita anatomica
Da agenti infett.
Da altri agenti
Da corpi estranei
Da sforzo
Totale
Totale
Occupational Injuries Industry and
Service- site of lesion (INAIL 2008)
Inabilità
temporanea
Inabilità
permanente
Morte
129.803
4.583
2
134.388
72.918
3.180
39
76.137
Ginocchio
37.320
2.881
1
40.202
Caviglia
37.922
2.444
1
40.367
Cranio
20.841
1.575
439
22.855
Piede
23.735
1.585
1
25.321
Polso
20.716
2.726
0
23.442
Cingolo toracico
22.450
3.248
3
25.701
Occhi
19.178
497
0
19.675
Parete toracica
19.481
1.073
98
20.652
(...)
(...)
(...)
(...)
497.314
32.169
911
530.394
Sede della lesione
Mano
Colonna vertebrale
Altro
Totale
Totale
Occupational Injuries - Agriculture
- site of lesion (INAIL 2008)
Inabilità
temporanea
Inabilità
permanente
Morte
Mano
8.542
477
-
9.019
Colonna vertebrale
3.188
455
8
3.651
Ginocchio
4.099
423
-
4.522
Caviglia
2.918
315
1
3.234
Cranio
1.435
133
38
1.606
Polso
1.606
394
-
2.000
Piede
2.014
172
-
2.186
Cingolo toracico
2.460
572
-
3.032
Occhi
2.346
105
-
2.451
Parete toracica
2.899
209
17
3.125
(...)
(...)
(...)
(...)
38.989
4.236
117
43.342
Sede della lesione
Altro
Totale
Totale
Injuries: Incidence Rates in the EU
(2005)
Svezia
Irlanda
Regno Unito
Grecia
Austria
Paesi Bassi
Danimarca
ITALIA
Finlandia
UE - 15
Belgio
Germania
Lussemburgo
UE - Euro Area
Portogallo
Francia
Spagna
0
1000
2000
3000
4000
5000
6000
7000
Lethal Injuries: Incidence Rates in the
EU (2005)
Svezia
Irlanda
Regno Unito
Grecia
Austria
Paesi Bassi
Danimarca
ITALIA
Finlandia
UE - 15
Belgio
Germania
Lussemburgo
UE - Euro Area
Portogallo
Francia
Spagna
0
1
2
3
4
5
6
7
Injury Causes

The ever-present influence of
organizational factors on the occurrence of
injury events is much more relevant than
that of technological factors
Hazardous environments and equipments
Hazardous environments and equipments
Hazardous environments and equipments
Desk-top circular saw
Flexible
grind wheel
Specific Causes of Injury







Age below 30
Early working hours
Less than 5 years experience in a specific task
Performing unusual tasks
Lack of experience
Distraction
Sleep disorders
Social Determinants of Injury
Schooling level
 Occupational conditions

(working position and activity)

Psychosocial factors
(work stress, relations with colleagues)

Smoke, alcohol and lack of sleep
Repeated Injuries




The second injury is usually less severe than the
first one
They are more frequent in males and in young
workers
Injury frequency is higher in larger companies
Identifying a risk profile can suggest
preventive strategies
Risk Perception

The attitude to act safely is associated with
a higher or lower risk perception on the
part of workers
Factors affecting risk perception
+ (increasing factors)
— (reducing factors)
Severity of effects
Voluntary exposure to risk
Irreversibility of effects
Controllability of risk
Mediatic attention
Familiarity with agent
Personal involvement
Known risk/benefit ratio
Previous accidents
Natural origin of risk
Occupational Diseases
Recognized Occupational Diseases UE
(2003)
Recognized Occupational Diseases:
Comparison among European countries

Every year, out of 100.000 insured
workers, the followings are recognized

29
40
86
109
113
128
143






occupational
occupational
occupational
occupational
occupational
occupational
occupational
diseases
diseases
diseases
diseases
diseases
diseases
diseases
in
in
in
in
in
in
in
Italy
Germany
Denmark
France
Spain
Switzerland
Belgium
D’Amico F, Mochi S, Salvati A: Le malattie professionali in Italia: evoluzione storica,
tendenze in atto e prospettive future. Riv Inf Mal Prof 2002; (1-2): 119-134
Classification of Occupational Diseases
in Italy

The occupational diseases recognized in
Italy are those contracted in the exercise
and because of the working conditions as
specified in the tables annexed to D.P.R.
336 (13/4/1994)

Tables report occupational diseases,
exposures and working conditions that
could cause them
“Tabled” Occupational Diseases reported
to INAIL (2005)
Type od disease
Hypoacusia and Deafness
Pneumoconiosis
Asbestos Neoplasias
Skin Diseases
Osteoarticular Diseases
Bronchial Asthma
Allergic Alveolites
Others
Total
Agriculture,
Industry and Service
1.126
660
642
385
148
143
11
(…)
3.593
“Non-tabled” Occupational Diseases
reported to INAIL(2005)
Type od disease
Hypoacusia
Tendonitis
Intervertebral discs ailments
Respiratory system diseases
STC
Osteoarthritis
Tumours
Agriculture,
Industry and
Service 4.155
2.181
1.800
1.329
1.288
1.137
744
Others
(…)
Total
17.620
Epidemiological Data

Every year I.N.A.I.L. receives about 25.000
reports of occupational diseases

Fourth Survey on Workers' Health (European
Foundation, Dublin, 2005) :
 24,7% report back pain
 22,8% report muscular pain
 22,3% report stress disorders
Ods compensated in the years
1999 – 2002, INAIL data (INDUSTRY AND SERVICE)
Malattie professionali indennizate
5,000
4,000
3,000
2,000
1,000
-
Tabellate
Non tabellate
Totale
1998
1999
2000
2001
2002
ODs occurred in the years
2000 – 2004 in the Italian regions
250
200
EMILIA
ROMAGNA
MARCHE
N°
150
ABRUZZO
100
UMBRIA
50
VENETO
TOSCANA
-
2000
2001
2002
2003
2004
PIEM ONTE
VALLE D'AOSTA
LOM BARDIA
LIGURIA
TRENTINO A.A.
VENETO
FRIULI V. G.
EM ILIA ROM AGNA
TOSCANA
M ARCHE
LAZIO
ABRUZZO
M OLISE
CAM PANIA
PUGLIA
BASILICATA
CALABRIA
SICILIA
SARDEGNA
UM BRIA
Malattie professionali indennizzate
2000
1800
1600
1400
1200
1000
800
600
400
200
0
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
MALATTIE DA METALLI
MALATTIE CUTANEE CAUSATE DA CATRAME,BITUME, PECE, FULIGGINE, ANTRACENE
MALATTIE OSTEOARTICOLARI E ANGIONEUROTICHE CAUSATE DA VIBRAZIONI MECCANICHE
BRONCOPNEUMOPATIE DA INALAZIONE DI SILICATI O DI CALCARE
BRONCOPNEUMOPATIE (POLVERI,ESALAZIONI): ALLUMINIO,METALLI DURI, SCORIE THOMAS, LEGNI ESOTICI, COTONE
BRONCOPNEUMOPATIE (POLVERI,ESALAZIONI): ANTIBIOTICI,FRUMENTO GOMMA ARABICA, ISOCIANATI
ASBESTOSI
MALATTIE NON TABELLATE O CONTRATTE INLAVORAZIONI NON TABELLATE
ODs reported in Italy
Epidemiological Data
Reported
Compensated
non tabled
1999 2000 2001 2002 1999 2000 2001 2002
Ipoacusia
6.535 6.290 4.898
2.119
558
283
186
164
Tendinitis
529
673
794
619
79
79
160
197
Neoplasia
368
366
387
195
33
27
16
20
1181
1178
960
852
78
45
44
45
748
842
779
401
87
90
105
87
Respiratory
disease
CTS
Low back pain: INAIL data (1999)


Among occupational diseases compensated by
INAIL, musculoskeletal diseases occupy the
tenth position (18,1%).
Among non-tabled musculoskeletal diseases
accepted by INAIL (about 1000), disc pathology
account for 7% of the total
But…
 10% of occupational injuries affect the spine (56000
events/year): 38% affect the lumbar rachis
 93% of occupational injuries to the lumbar rachis are due
to heavy lifting and to inappropriate movements
(Giuseppe Campo, ISPESL: relazione congressuale 2002)
Dati epidemiologici nazionali
Incidenza MP riconosciute nel quinquennio 1995-1999 per l’industria
WRMSD e INAIL:
Numero di casi accolti rispetto ai casi pervenuti
(1996-2000)
WRMSD e INAIL Anno 2000
MP da WRMSD accolte in SMG nell’anno 2000 (incidenza per
patologie)
MP da WRMSD pervenute in SMG - anno 2000 (distribuzione per
regioni)
Ripartizioni percentuale dei casi di WRMSD accolti secondo le lavorazioni
INAIL - % MSDs per patologia
60
50
STC
Spalla
40
Epicond. /Epitr.
30
Discopatia rachide
M. De Quervain
20
Neurop. Ulnare
Tend. Mano/polso
10
Altro
0
2000
INAIL - % MSDs per età
45
40
35
30
25 - 35
36 - 45
46- 55
> 55
25
20
15
10
5
0
2000
INAIL - % MSDs per regione
35
30
25
20
15
10
5
0
2000
Emilia R.
Piemonte
Marche
Abruzzo
Veneto
Friuli V:G.
Lazio
Umbria
Lombardia
Toscana
Altre
Segnalazioni MP SPSAL Emilia-Romagna
Tecnopatia
1999 2000 2001 2002 2003 2004
Tot.
Ipoacusie
2859 2108 2376 2378 2283 2253
PMS
341
384
498
696
601 1146
Dermatiti
164
113
160
107
113
109
Broncopneumo.
48
41
38
32
41
45
Neoplasie
23
35
30
38
78
37
Mesoteliomi
17
30
28
37
42
61
Asbestosi
11
8
21
18
16
25
Epatopatie
58
1
10
5
3
1
Asma bronchiale
8
14
11
21
11
10
Saturnismo
15
10
12
4
20
9
Silicosi
15
6
4
4
2
14
Stress/Mobbing
1
1
5
4
9
18
Altre
41
14
34
31
34
49
Totale
3601 2765 3227 3375 3253 3777
14257
3666
766
245
241
215
99
78
75
70
45
38
203
19998
%
71,3
18,3
3,8
1,2
1,2
1,1
0,5
0,4
0,4
0,4
0,2
0,2
1
100
Ipoacusie
PMS
Dermatiti
Broncopn.
Neoplasie
Mesoteliomi
Asbestosi
Epatopatie
Asma br.
Saturnismo
Silicosi
Stress/Mobb
Altre
Totale
%
Trasporti
Tess/Conf
Servizi
Sanita'
Pubblico
Mun/Ener
MTM
Legno
Edit/Cart
Edilizia
Commercio
Chimica
Ceramica
Carni
Altro
Alimentare
COMPARTO
Agricolo
Segnalazioni MP SPSAL Emilia-Romagna 1999-2004
594 464 265 242 1436 652 152 3046 160 507 5552 229 204 22 253 171 308
110 222 64 265 539 193 230 228
47
78
973
43
90 148 149 196 91
7
24
24
6
46
23
18
145
7
12
204
3
19 143 75
6
4
19
16
5
3
27
9
3
35
1
20
61
5
7
14
12
3
5
8
4
4
53
5
20
6
4
61
14
11
29
5
7
10
3
25
6
15
22
6
42
2
5
51
5
7
4
2
6
14
2
5
3
3
8
3
29
12
2
2
2
10
2
69
1
2
3
11
9
1
1
5
8
3
2
2
1
1
1
1
5
4
18
1
7
56
9
1
3
7
1
1
6
3
18
9
15
5
3
1
3
27
8
14
1
2
1
7
4
2
1
1
1
7
1
7
4
5
1
2
61
4
12
30
9
11
5
742 779 379 537 2149 993 426 3572 228 635 7023 318 363 477 522 406 449
3,7 3,9 1,9 2,7 10,7
5
2,1 17,9 1,1 3,2 35,1 1,6 1,8 2,4 2,6
2
2,2
Occupational Diseases
In 1981, Doll and Peto estimated that 4%
of annual cancer deaths were caused by
occupational exposures
 Many countries have developed
surveillance systems to correctly identify
the origin of occupational diseases

Surveillance Systems (USA)
 SENSOR
(Sentinel Event Notification
System for Occupational Risks)
Surveillance Systems (GB)

THOR (The Health and Occupational Reporting

In the period 2003-2004, the Health and
Safety Executive estimated that (prevalence
data):



Network)
2.223.000 subjects were suffering from diseases
whose causes could be traced to occupational
factors
Occupational diseases were 5.200 per 100.000
workers
Deaths were 6.000/year and were caused by
diseases due to occupational risk factors
HSE. Health and Safety Statistics Highlights 2003/2004.
National Statistics, 2004.
Steenland's Study

On the basis of 1997 mortality data, the
study estimated:
 49.000 deaths/year (range 26.000 72.000) due to occupational diseases
 6.238 deaths/year due to injuries
 55.200 deaths/year (range 32.200 78.200) due to occupational causes
Steenland K, Burnett C, Lalich N, Ward E, Hurrell J. Dying for work: The
magnitude of US mortality from selected causes of death associated with
occupation. Am J Ind Med. 2003 May;43(5):461-82.
Steenland's Study
 The
number of death was evaluated
on the basis of 1997 mortality data of
USA, calculating the attributable
fraction
Attributable Fraction
The attributable risk is the proportion of
cases attributable to a specific risk
factor (work). Measure the decreasing
incidence of the disease if the
exposition at this particular risk is
completely eliminated
 The attributable risk in a population is
the proportion of the risk difference
between the general population and the
non-exposed population, and the risk in
the general population

Attributable Fraction
P(E) (RR-1)
––––––––––––––––––
P(E) (RR-1) + 1
P(E) = fraction in the general population
exposed to a particular risk factor
RR = disease or death relative risck in the
exposed vs. non-exposed
Steenland's Study
attributable fraction (AF) of work-related
mortality:
Pneumoconiosis (Asbestosis/Silicosis/Berylliosis)
 AF 100%


1.087 deaths/year
Asthma
 AF 15%

784 deaths due to work-related asthma
COPD
 AF 14%

14.257 deaths
(range 5.092 - 24.440)
(range 575 -1.099)
Steenland's Study
Tubercolosis
 AF 5%

60 deaths
Coronary Heart Disease (CHD)
 AF 6,3-18% of subjects between 20 and 69

years of age
range of deaths 4.500-12.900
Steenland's Study
Tumours

Lung: AF 6,3-13% (>incidence ♂)
= 9.677-19.901 deaths/year

Bladder: AF 5,6-19%
= 651-2191 deaths/year
Mesothelioma: AF ♂ 85-90%, AF ♀ 2390% =1.895-2.366 deaths/year
 Kidney: AF 0-2,3%

=57 deaths/year

Skin: AF 1,2-6%
=24-92 deaths/year
Steenland's Study

Leukemia: AF 0,8-2%
= 152-533 deaths/year

Larynx: AF 1-20%
= 30-603 deaths/year

Nose: AF 31-43%
= 231-322 deaths/year

Liver: AF 0,4-0,11%
= 29-80 deaths/year
Steenland's Study

The study shows the significance of workrelated pathologies and deaths, both in
terms of human lives and economic costs
A new metrics in the assessment of
work-related damage
1996, WHO introduced a new operative unit
devoted to the “Global Programme on
Evidence for Health Policy” (GPE), with the
aim of improving the planning and
allocation of health resources
 At the same time, the ”International Burden
of Disease Network” (including the GPE,
which gathers several countries) was
launched. The aim was that of providing a
rational basis for cost/effectiveness
evaluation of health policies

Four criteria for the planning and
allocation of health resources
Is this problem sufficiently important?
(How many people does it affect; how
many healthy years of life have been lost
due to this problem?)
 Do we have any effective tools to face this
problem?
 Do we have a good basic knowledge of the
problem?
 Are developed countries already making
efforts in that direction?

Global Burden of Disease (GBD)
The burden of disease measures the gap
between the current health status and an
ideal situation where everyone lives into
old age free of disease and disability
 The unit of measurement of GBD is time.
This allows to combine the time lived with
disability and the time lost due to
premature mortality

Health Measures

The HALY (Health Adjusted Life Years) family of
measures include, among others:

DALY = Death and Disability-Adjusted Life Years
Years lived minus years lost to disability (and
premature death)

QALY = Quality-adjusted Life Years
Years lived adjusted for quality of life (years to be
lived in “full health”)
DALY

The DALY is the unit of measurement adopted by
WHO to measure the Global Burden of Disease
(i.e., the impact of a particular disease on health
status)

This measure considers the impact (expressed in
years) on populations of:
 “early” mortality (mortality below a conventional
age, attainable by all individuals when risk
variables are controlled)
 Non-fatal consequences of pathologies and
accidents
DALY
One DALY can be thought of as the
measure, expressed in years, of
healthy life lost due to a certain
condition
↓
disease load attributable to such
condition
↓
measure of the impact of a specific
pathology on a population


Graphic representing the
case of a subject dying
suddenly after a life in full
health
Graphic representing the
case of a subject dying
the same age as the
previous one, after
progressive worsening
DALY
The use of the DALY allows not only a
geographic and temporal comparison, but
also a comparison among risk factors
It also allows to compare the relative
weight of a risk factor on different adverse
health phenomena
Global Deaths (000s) due to Selected
Occupational Exposures (2000)
Risk Factor
Outcome
Males
Females
Total
% of occup
deaths
Agents leading to COPD
COPD
240
78
318
37
Risk factors for injuries
Unintentional
injuries
293
19
312
37
Beryllium, cadmium,
chromium, diesel exhaust,
nickel, arsenic, asbestos,
silica
Trachea,
bronchus, or
lung cancer
88
14
102
12
Asbestos
Mesothelioma
28
15
43
5
Asthmamagens
Asthma
23
15
38
4
Coal
Coal workers’
pneumoconiosis
14
14
2
Silica
Silicosis
9
9
1
Asbestos
Asbestosis
7
7
1
Benzene, ethylene oxide,
ionizing radiation
Leukemia
4
3
7
1
Ergonomic stressors
Low back pain
0
0
0
0
Noise
Hearing loss
0
0
0
0
706
144
850
100
Total
Global DALYs (000s) due to Selected
Occupational Exposures (2000)
Outcome
Risk factors for injuries
Unintentional
Injuries
9.778
733
10.511
44
Noise
Hearing loss
2.788
1.362
4.150
18
Agents leading to COPD
COPD
3.020
713
3.733
16
Asthmamagens
Asthma
1.110
511
1.621
7
Beryllium, cadmium, chromium,
diesel exhaust, nickel, arsenic,
asbestos, silica
Trachea,
bronchus, or
lung cancer
825
144
969
4
Ergonomic stressors
Low back pain
485
333
818
3
Asbestos
Mesothelioma
356
207
563
2
Silica
Silicosis
486
―
486
2
Asbestos
Asbestosis
376
―
376
2
Coal
Coal workers’
pneumoconiosis
366
―
366
2
Benzene, ethylene oxide,
ionizing radiation
Leukemia
66
35
101
0.4
19.656
4.038
23.694
100
Total
Males
Females
Total
% of occup
DALYS
Risk Factor
Attributable Fractions (%) for Mortality and Morbidity
(DALYs) due to Selected Occupational Exposures for
the Global Burden of Occupational Disease and Injury
Risk Factor
Outcome
Males
Females
Total
Ergonomic stressors
Low back pain
41
32
37
Noise
Hearing loss
22
11
16
Agents leading to COPD
COPD
18
6
13
Asthmagens
Asthma
14
7
11
Risk factors for injuries
Unintentional
Injuries
12
2
8
Beryllium, cadmium,
chromium, diesel exhaust,
nickel, arsenic, asbestos,
silica
Trachea,
bronchus, or
lung cancer
10
5
9
Benzene, ethylene oxide,
ionizing radiation
Leukemia
2
2
2
Average cost per worker for fatal
and all nonfatal injuries and illnesses
Description of
detailed industry
Taxicabs
Average cost
per worker (USD)
Contribution to GDP
per employed worker
(%)
11.528
21,16
Bituminous coal and
lignite mining
8.600
15,78
Logging
7.009
12,86
Crushed and broken
stone
4.024
7,38
Oil and gas field
services
3.938
7,23
Water transportation
services
3.551
6,52

SIC = 1987 standard industrial classification, USD = United States Dollars,
GDP = gross domestic product
Total cost for fatal and all nonfatal
injuries and illnesses
Description of
detailed industry
Total cost (USD)
GDP (%)
Trucking and courier
services, except air
4.394.408.812
0,0672
Eating and drinking
places
3.245.844.489
0,0495
Hospitals
2.755.633.582
0,0421
Grocery stores
2.718.377.125
0,0414
Nursing and personal
care facilities
1.943.638.220
0,0297
Motor vehicles and
motor vehicle
equipment
1.344.070.300
0,0205

SIC = 1987 standard industrial classification, USD = United States Dollars,
GDP = gross domestic product
Average cost ranking of industries with
the lowest costs per worker
Description code
Labor union offices
Costs
per worker (USD)
GDP per employed
worker (%)
86
0,16
Security and commodity
exchanges
101
0,19
Mortgage bankers and
brokers
136
0,25
Security brokers and
dealers
137
0,25
Legal services
138
0,25
Passenger transportation
arrangements
140
0,26

SIC = 1987 standard industrial classification, USD = United States Dollars,
GDP = gross domestic product
Classification of Risk Factors
Physical, Chemical and Biological
agents, biomechanical and
relational factors
Classification of Risks
Hazard
Intrinsic characteristic of an activity,
substance or physical factor that can cause
harm to physical integrity
 Risk
Probability that a hazardous activity,
substance or physical factor will actually
cause damage to physical integrity in specific
work situations

Classification of Risks

Safety risks can be classified as risks
deriving from:





Structural deficiencies of the working
environment
Safety deficiencies regarding machines
and equipment
Handling of hazardous substances
Deficiencies in electrical safety
Fire and/or explosion
Classification of Risks

Safety risks can be classified as risks
deriving from:





Physical agents
Chemical agents
Biological agents
Biomechanical factors
Relational factors
120
Physical Agents








Forms of energy having a physical
magnitude as unit of measurement.
Noise
Vibrations
Ionizing radiations
Non-ionizing radiations
Electricity
Barometric pressure
Microclimate
Noise

A series of pressure variances propagating
through a medium, that can be perceived
by the human ear as sound sensation
Occupational Exposure
Building sector, Agriculture, Steel Industry,
etc.

Vibrations

Oscillations of a body around a reference
point characterised by:
frequency, amplitude and acceleration
Whole-body Vibration
(tractor drivers, lorry drivers, bus drivers, train and
underground drivers, crane operators)
 Hand-arm Vibration
(workers using compressed air or electrically
powered vibrating tools; e.g. construction workers,
lumberjacks)

Ionizing Radiations


Radiations which interact with the matter
giving rise to ionization phenomena
Corpuscular radiations
(alpha rays, beta rays, neutrons)

Non-corpuscular radiations
(X rays, gamma rays)
Ionizing Radiations
Occupational Exposure
 Medical applications
(diagnostic radiology, use of radioactive
isotopes, radiotherapy)
 Industrial applications
(extraction, production, transformation,
treatment, transportation)
 Research laboratories

Non-Ionizing Radiations

Radiations that do not carry enough energy
to modify atoms and molecules; they form
a part of the electromagnetic spectrum and
are characterized by several frequency
subintervals
Non-Ionizing Radiations
Static Fields and Extremely
Low Frequencies (ELF)
0Hz-30kHz
Low Frequencies (LF)
30kHz-300kHz
Radio Frequencies (RF)
300kHz-300MHz
Microwaves (MW)
300 MHz-300GHz
Optical Radiation (IR-VIS-UV) 300GHz-3*106GHz
Non-Ionizing Radiations

Occupational Exposure

Ultraviolet radiations
(sterilization, photoinactivation of viruses, blood
bacteria and blood products, photobiology,
photochemistry, therapy)

Visible and infrared radiations
(e.g.: analytical techniques, therapy, grass industry)

Radio frequencies and microwaves
(e.g.: welding, induction furnaces, fusion, electric
furnaces, MNR, marine and aeronautical communications,
food processing, disinfection)

Low-frequency electromagnetic fields or static
magnetic fields
(e.g.: electrical equipment in general)
Electricity

Occupational Exposure
Electricians, electrotechnicians
Barometric Pressure

Occupational Exposure
High-altitude jobs, underwater jobs.
Microclimate
Thermal stress due to high or low temperatures

Occupational Exposure
e.g.:outdoor activities, food industry,
iron and steel industry, etc.
Chemical Agents

Any chemical substance used (or already
present) alone or in combination in a
productive process
(e.g.: solvents, metals, pesticides, resins, etc.)




Dusts
Fogs
Gases
Vapours
Chemical Agents

Exposure Modes and Absorption
Pathways

Respiratory pathway
Cutaneous pathway (via skin contact)
By ingestion


Occupational Exposure
Several divisions in the agriculture, industry
and service sectors

Biological Agents
Risks associated with exposure to
pathogenic organisms and microorganisms






Viruses
Bacteria
Fungi or mycetes
Protozoa
Parasites
Biological Agents
Occupational Exposures
Health personnel and clinical and research
laboratory personnel, farmers, breeders,
slaughterhouse operators, waste collection
and disposal personnel

Biological Agents

Transmission Modes

Parenteral pathway
(e.g.: hepatitis B,C, HIV)

Aerial pathway
(e.g.:TBC, influenza, meningococcal meningitis,
measles)

Transmission by contact
(e.g.: scabies)

Transmission by the oral route
(e.g.: hepatitis A)
Biomechanical Factors

Forces applied to the body (or generated by
the body itself) acting on muscles, tendons,
peripheral nerves and blood vessels

Forces applied to the body
Repetitive movements
Posture
Manual handling of loads



Biomechanical Factors
Occupational Exposure
Assembly-line operators, manufacturing
operators, data-entry operators, assistance
to patients, storekeepers, porters,
construction workers, etc.

Forces Applied to the Body
External Forces
Load exerted on the body surface when
performing a task (pushing or grabbing an
object to lift it)

Internal Forces
Tension originating in muscular, tendinous, or
ligamentous structures when making an effort

Repetitive Movements

Identical or very similar movements
performed at a high frequency
Posture
Static Postures
Static and prolonged postures

Awkward Postures
Body joints deviate from their optimal area,
which allows effort exertion with minimum
tissue overload

Manual Handling of Loads

Transportation and support operations
including:

Lifting
Depositing
Pushing
Pulling
Carrying
Moving a load





which involve the risk of dorsolumbar
injuries
Relational factors



Factors regarding work organization and
social relations, which can affect the
psychological and physical health of
workers
Worker/occupation relationship (stress,
burn out)
Relationships between individuals within
the working environment (mobbing)
Relational Factors
Worker/occupation relationship
Work contents:

Task characteristics
(lack of variety, short work cycles, no use or underuse of skills, high uncertainty)

Workload, work pacing, work schedule
(work overload or underload, lack of control over
pacing, time pressure, shift work, lack of schedule
flexibility, overtime work)

Relational factors
Relationships between individuals
within the working environment
Working context:


Culture and organizational function, role in the
organization, career development, work/family
interface, authoritarianism, mobbing, sexual
harassment.