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Title: Occupational Health and Occupational Medicine


1
Occupational Health and Occupational Medicine
David A. Compton MD, MPH
2
Work Related Disease Issues Have Been Identified
For A Long Time
  • Hippocrates (460-377 BC)
  • Described symptoms of lead poisoning among miners
    and metallurgists.
  • Pliny the Elder (23-70 AD)
  • Roman senator who wrote about workers who
    protected themselves from dust by tying animal
    bladders over their mouths.
  • He also noted hazards of asbestos and cinnabar
    (mercury ore)
  • Ulrich Ellenborg (1473)
  • A German physician, he recognized the dangers of
    metal fumes, described symptoms and preventive
    measures.

3
Influential People
  • Paracelsus (1493-1541)
  • Known by several names
  • Born Phillip von Hohenheim
  • A Swiss physician, he wrote a treatise on
    occupational diseases
  • Described lung diseases among miners and
    attributed the cause to vapors and emanation from
    metals
  • Paracelsus is best known today as the Father of
    Toxicology because of his observations of dose
    and response
  • All substances are poisons there is none which
    is not a poison. The right dose differentiates a
    poison and a remedy.

4
Observant People
  • Agricola (1494-1555)
  • Born Georg Bauer, he was a physician appointed to
    the mining town of Jochimstral in the Swiss
    mountains
  • Wrote De Re Metallica, a comprehensive discourse
    addressing every aspect of mining, smelting and
    refining.
  • He noted the need to provide ventilation for
    miners, and described asthma among workers who
    toiled in dusty mines

5
De Re Metallica
  • Some mines are so dry that they are entirely
    devoid of water and this dryness causes the
    workmen even greater harm, for the dust, which is
    stirred and beaten up by digging, penetrates into
    the windpipe and lungs, and produces difficulty
    in breathing and the disease the Greeks call
    asthma. If the dust has corrosive qualities, it
    eats away the lungs and implants consumption in
    the body. In the Carpathian mountains women are
    found who have married seven husbands, all of
    whom this terrible consumption has carried off to
    a premature death.

6
Perceptive People
  • Bernardino Ramazzini (1633-1714)
  • Italian physician, known as the patron saint of
    industrial medicine.
  • His book De Morbis Artificium Diatriba (The
    Diseases of Workmen) described the symptoms of
    mercury and lead poisoning and other occupational
    diseases.
  • He wrote about the pathology of silicosis and
    recommended precautions to avoid hazards
  • Advised physicians to learn about occupational
    diseases by studying the work environment, and
    exhorted them to always ask their patients Of
    what trade are you?

7
Investigative People
  • Sir George Baker (1722-1809)
  • Discovered that Devonshire colic was caused by
    lead contamination in cider.
  • Percival Pott (1714-1788)
  • A London physician, he was the first to link
    occupational exposure to cancer.
  • Scrotal cancer among chimney sweeps, caused by
    soot
  • Later linked to Polycyclic Aromatic Hydrocarbons
    in Coal Soot
  • Sir Humphrey Davy (1788-1829)
  • Investigated problems of mine explosions and
    developed the first miners safety lamp.

8
American People
  • Dr. Alice Hamilton (1869-1970)
  • First woman faculty member at Harvard University
    (1919).
  • A social activist who worked to improve
    occupational health and safety.
  • Her autobiography Exploring the Dangerous
    Trades details her experiences in the mines and
    mills across America

9
Tragedies Stimulated Change
  • Workplace Disasters of the early 1900s led to
    outrage and subsequently to legislation to
    protect workers
  • The Triangle Shirtwaist Fire probably was the
    most important event leading to the regulation of
    occupational safety
  • The Triangle Shirtwaist Company was a New York
    City sweatshop where dozens of mostly young
    female immigrant workers crowded together to cut
    and sew shirtwaists
  • Shirtwaists were a popular ladies garment of the
    time, especially for working women
  • Sweatshops workers are paid low wages as they
    work excessively long hours in unsanitary and
    unsafe conditions

10
Triangle Shirtwaist Company
  • 1911 - The Triangle Shirtwaist Company Caught
    Fire
  • 146 workers died from fire in the upper floors of
    this fireproof building
  • Fire exits were inadequate or locked to keep the
    workers at their work stations
  • Unable to flee, many victims jumped from the
    windows to their deaths
  • The tragedy led to 36 laws reforming the state
    labor codes

11
Ill Take Any Job That Pays
  • 1930 - Gauley Bridge Disaster
  • Also known as the Hawks Nest tragedy, this was
    Americas worst industrial disaster
  • Construction of the Hawks Nest tunnel near Gauley
    Bridge, West Virginia, caused massive exposures
    to silica dust
  • At least 476 men died and 1500 disabled by
    silicosis. Silica exposures were so high men were
    dying from acute silicosis from only two months
    of exposure
  • Pneumatic drilling equipment and rock high in
    silica content magnified the risk
  • Economic factors of the Great Depression forced
    the men to work in unhealthy conditions

12
Everyday Tragedies
It took a tragedy to get attention, since death
on the job was a normal every-day event. In this
single Pennsylvania county, 524 workers died in
one year.
MMWR, June 11, 1999 / Vol. 48 / No. 22
13
Social Factors
  • Organized Labor
  • Labor unions did much to influence improvements
    in workplace health and safety by influencing
    legislation as well as forcing concessions from
    management.
  • The International Ladies Garment Workers Union
    (ILGWU) was established in1900 and took on the
    task of promoting comprehensive safety and
    workers compensation laws
  • Professional Organizations Were Formed
  • American Society of Safety Engineers, 1911
  • National Safety Council, 1913
  • American Industrial Hygiene Association, 1939

14
What Changed?
  • Other countries led the United States in adoption
    of workplace regulation
  • Laws in Great Britain regulated conditions and
    limited child labor
  • 1802 Factory Act
  • Health and Morals of Apprentices Act, it
    established minimum working conditions and
    regulated child labor
  • 1833 Factory Act
  • Further restricted child labor
  • 1842 Mines Act
  • Prohibited boys less than 10 years old and all
    females from working underground. Before this
    act, children as young as 7 years were harnessed
    with chains to haul heavy coal containers
    underground
  • 1844 Factory Act
  • Reduced work hours for children, extended
    coverage to women

15
US Laws and Regulations
  • Early U.S. Laws and Regulations
  • United States Bureau of Labor established in 1884
    to study employment and labor
  • Laws and regulations to protect US workers first
    began to appear in the early 1900s
  • 1911- New York and New Jersey passed workmens
    compensation laws.
  • 1913 - New York State Department of Labor
  • Established a Division of Industrial Hygiene
  • 1916 - 1930 Forty-seven states enacted workmens
    compensation laws to guarantee wages and medical
    care for injured workers

16
More US Laws and Regulations
  • 1935 - The Social Security Act
  • Made funds available for public health programs.
  • 1936 - The Walsh Healey Public Contracts Act
  • Required organizations supplying goods or
    services to the U.S. government to maintain a
    safe and healthful working environment
  • 1948 - All states had workers compensation laws
  • 1970 - The Occupational Safety and Health Act
  • Established NIOSH and OSHA to carry out its
    mandate to ensure a workplaces free of recognized
    hazards.
  • 1977 - The Federal Mine Safety Health Act
  • Consolidated all federal health and safety
    regulations of the mining industry, strengthened
    and expanded the rights of miners, established
    the Mine Safety and Health Administration (MSHA).

17
What About Medical Care For Workers?
  • By the 1930s, a medical specialty was formed
    Industrial Medicine
  • Physicians in this area of practice were
    generally self-taught or taught on the job until
    the late 1940s when specialty training, testing,
    and board certification were developed and the
    resulting new specialty was renamed Occupational
    Medicine

18
What Do Occupational Medicine Practitioners
Strive For In Daily Practice?
The highest degree of physical, mental and
social well-being of workers in all occupations.

International Labor Organization Committee on
Occupational Health, 1950
19
Occupational Medicine
  • Recognized Specialty For Over 50 Years,
    certification is under the American Board of
    Preventive Medicine
  • Combines Clinical Skills With Toxicology,
    Epidemiology, Safety, Rehabilitation, and
    Business Operations
  • Tightrope Walker Responsible to Patients,
    Business, and the Community

20
Occupational Health Services
  • Detecting, Evaluating, and Treating Medical
    Conditions
  • Emergency Response
  • Medical Surveillance
  • Chronic Disease Management
  • Fitness and Wellness
  • Work-Life Management
  • Disability Management and Accommodation
  • Employee Assistance and Advocacy
  • Absence Management
  • Training
  • Consultant to Workers, Managers, Unions, and the
    Community

21
Occupational Medicine Staff
  • In addition to the physician, physician
    assistant, or nurse practitioner who are the main
    providers of service, multiple other roles must
    be filled.
  • These can be filled by individuals with a single
    skill, or individuals who have been trained in
    multiple areas.
  • It is important to note that governmental
    regulations or industry standards prescribe many
    types of evaluations and require that they are
    performed by trained and certified staff.
  • Potential Ancillary Staff
  • Certified Audiometric Technicians
  • Occupational Health Nurses
  • Medical Assistants
  • Physical Therapists
  • Radiology Technologists
  • Behavioral Health Counselors
  • Disability Case Managers
  • Certified Pulmonary Function Technicians
  • Emergency Responders (EMT or Paramedic) in
    manufacturing locations

22
Why a Special Practice Model?
  • Occupational Diseases are Hard to Distinguish
    From Ones Unrelated to the Workplace
  • Is the asthma arising from workplace dust, or
    tree pollen?
  • Absences from Work Have Multiple Causes (not all
    are medical)
  • See the CCH survey
  • Economic Implications of Maintaining a Healthy
    Workforce are Large

CCH Group, Wolters and Kluver 2015
23
Since It Is Hard To Differentiate Occupational
Diseases From Naturally Occurring Diseases, How
Do You Know For Sure That The Disorder Is Or Is
Not Associated To The Work Environment Or
Activities?
24
Important Considerations When Considering Linkage
Of A Disease To Work Activities
  • Strength of association - The greater the impact
    of an exposure on the occurrence or development
    of a disease, the stronger the likelihood of a
    causal relationship - dependent on epidemiologic
    and/or toxicological data
  • Consistency - Do all of the research reports have
    similar conclusions?
  • Specificity - Has it been shown that exposure to
    a specific risk factor results in a clearly
    defined pattern of disease or diseases?
  • Temporality or time sequence - Did the exposure
    precede the disease by a period of time
    consistent with proposed biological mechanisms?

25
More Considerations For Occupational Disease
Linkage
  • Biological gradient - Has it been shown that the
    greater the level and duration of exposure, the
    greater the severity of diseases or their
    incidence?
  • Biological plausibility - Does it make biological
    sense to suggest that exposure leads to the
    disease?
  • Coherence. Does review of the evidence lead to
    the conclusion that there is a causeeffect
    relationship in a broad sense and in terms of
    common sense?
  • Interventional studies. Have there been trials
    where removing the hazard from the workplace
    eliminates the development of the disease?

26
What Does It Mean To Have An Occupational Health
Program?
  • The Goal is to Enable Employees to Safely Attend
    Work and Successfully Perform Their Tasks Without
    Interference from Health Based Issues. Thus, a
    successful occupational health situation
    represents dynamic equilibrium between the worker
    and his or her occupational environment.
  • Health and safety consideration must be given to
    work processes and how they impact employees,
    their contacts, and the environment
  • If an employee is absent (for any reason),
    occupational health practitioners should
    facilitate receipt of effective and efficient
    medical interventions with a goal of return to
    work as soon as practicable

27
The 10,000 Foot View Of Occupational Health
  • Identification
  • recognition
  • assessment
  • Control
  • eliminate
  • manage
  • personal protection
  • Prevention

Intervene and Treat
28
The 1000 Foot View of Occupational Health
  • Awareness Of Potential Hazards
  • Qualitative Assessment
  • Exposure
  • Health (Worker Eval)
  • Hazard Judgment
  • Acceptable
  • Unacceptable
  • Uncertain
  • Quantitative Assessment
  • Exposure
  • Health
  • Risk communication

Interventions Medical Engineering Administrative
29
Employee Evaluations
  • Medical evaluations of employees should be
    conducted as prevention and health promotion
    sessions with special attention to health factors
    related to the job or to known hazards. They are
    NOT a substitute for controlling workplace
    hazards or using personal protective equipment.
  • Employers often view physical examinations, and
    purchase these services, as a commodity where low
    cost wins out but the evaluations need to be so
    much more. . .
  • Can The Employee Physically do the Job?
  • Are There Medical Conditions Impacted by the
    Jobs Requirements?
  • Can We Control The Conditions in the Worksite or
    are They Better Controlled in the Employee?
  • Are There Regulatory Mandates?
  • What are Past Practices by This Employer and in
    Similar Industries?

30
If We Are To Intervene And Prevent, How Do We
Know What To Address?
  • Remain vigilant for activity or incident trends,
    changes in people, worksites, or regulatory
    requirements. When all else fails - ask the
    workers
  • Develop relationships with people who control
    workplace change (engineers, supervisors,
    purchasing agents)
  • Evaluate potential or suspected issues early
  • Involve all stakeholders - management, safety,
    human resources, industrial hygiene, engineering,
    and medical personnel.
  • Balance the individuals rights and needs with
    the rights and needs of the employer but injury
    and illness prevention is paramount.

31
Example - Firefighters
  • A 2007 Harvard study heart disease kills more on
    duty firefighters than anything else (45 of
    on-duty deaths)
  • Epidemiologically, the majority of on-duty heart
    disease deaths in firefighters appear to be
    precipitated by physical and toxic factors
  • General reviews have shown that heart disease is
    less prevalent in firefighters than the general
    public
  • However this is work in adverse environments,
    wearing cumbersome equipment, generating high
    levels of stress, and involving exposure to
    chemical toxins that may aggravate cardiac risk
  • Is this epidemiologic association plausible?
    Lets look at some data

New England Journal of Medicine 20073561207-15.
32
Firefighter Heart Disease
  • Comparisons of on duty time and activities to Off
    Duty Time and Activities Revealed
  • Firefighters are 12 to 136 times more likely to
    die of heart disease when putting out a fire.
  • Firefighters are 3 to 14 times more likely to die
    of heart disease while responding to an alarm.
  • Firefighters are 2 to 10.5 times more likely to
    die of heart disease while returning from an
    alarm.
  • Firefighters are 3 to 7 times more likely to die
    of heart disease during physical training.

33
What is The Occupational Medicine Response?
  • Based on the study findings, the best approach is
    to work with professional and volunteer (70 of
    firefighters) fire departments to educate
    firefighters and the medical community about the
    special issues involving firefighters and cardiac
    disease.
  • Specifically work to implement
  • Wellness and fitness programs for firefighters
    and their families to reduce heart disease risk
    factors
  • Encourage adoption of a requirement for
    firefighters to undergo entrance and annual
    medical examinations by a provider well-versed in
    the requirements of firefighting
  • Encourage implementation of an annual physical
    performance test for all firefighters
  • A general understanding that, if heart disease is
    diagnosed in a firefighter, a very open and
    careful discussion must be undertaken in advising
    this person whether it is safe to return to duty

NFPA 2003. NFPA 1582 Standard on
comprehensive occupational medical program for
fire departments. Quincy, MA National Fire
Protection Association. NFPA 2000.
NFPA 1583 Standard on health-related fitness
programs for fire fighters. Quincy, MA National
Fire Protection Association.
34
Even If You Have A Successful Program Of
Prevention And Intervention, Employers Often Ask
What About These Absences?
  • Absences happen. An important point to remember
    is that even problem employees get sick.
  • Another important point is that each day an
    individual is out of work, they may lost income
    and the employer may lose productivity or have to
    hire a substitute
  • The medical providers must work within company
    policies, any regulatory requirements, and
    applicable privacy rules to address both points.
  • Programs must use competent and objective
    personnel for case evaluation and absence
    management.
  • Success occurs when you obtain optimum
    intervention for the individual and coordinate
    their return with the worksite.
  • Providers are not through when the individual
    returns to work, they should monitor outcomes and
    prevention efforts after full return to work.

35
Final Thoughts
  • Occupational Medicine practice is rooted in
    prevention. Workers who develop occupational
    diseases or receive injuries in the workplace
    represent a failure of prevention.
  • Many places that have Occupational Medicine
    listed as a service on their signage are
    frequently only practicing Workers Compensation
    Medicine and have little to offer in the way of
    prevention - know your service providers.
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