Occupational Health and Occupational Medicine

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Occupational Health and Occupational Medicine
David A. Compton MD, MPH
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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.

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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.

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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

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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.

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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?

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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.

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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

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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

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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

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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

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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
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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

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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

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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

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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).

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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

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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
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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

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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

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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

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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
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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?
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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?

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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?

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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

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The 10,000 Foot View Of Occupational Health

• Identification
• recognition
• assessment
• Control
• eliminate
• manage
• personal protection
• Prevention

Intervene and Treat
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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
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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?

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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.

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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.
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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.

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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.
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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.

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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.