World Health Organization Regional Office for the Eastern Mediterranean WHO-EM/OCH/85/E/L Distribution: Limited OccupaIional healIh A nnnun o nn) IcntI cnc \oc: THO-IM,OCH,S5,I,I IIstrIIutIon: IInItcd Tod HcntI Ognnznton Icgonn Occ o tIc In:tcn Mcdtcnncnn Cno 21 WorId HeaIth OrganIzatIon 200T ThIs document Is not Issued to the generaI pubIIc and aII rIghts are reserved by the WorId HeaIth OrganIzatIon (WHO). The document may not be revIewed, abstracted, quoted, reproduced or transIated, In part or In whoIe, wIthout the prIor wrItten permIssIon oI WHO. No part oI thIs document may be stored In a retrIevaI system or transmItted In any Iorm or by any means-eIectronIc, mechanIcaI or other-wIthout the prIor wrItten permIssIon oI WHO. The vIews expressed In documents by named authors are soIeIy the responsIbIIIty oI those authors. DesIgn by ]ohn ShImweII, EDR]EMRO Document WHO-EM]OCH]085]E]L]04.0T]2000 Contents Foreword 7 PreIace 9 ntroductIon T3 TraIner`s CuIde 2T ModuIe 1 Work environment 27 T. ObjectIves 27 2. ntroductIon and basIc concepts 27 3. RecognItIon oI heaIth hazards 28 4. EvaIuatIon oI HeaIth Hazards 36 5. ControIIIng hazards 39 6. Tasks Ior traInees 40 AppendIx T.T PotentIaIIy hazardous operatIons and assocIated aIr contamInants 4T AppendIx T.2 An occupatIonaI hygIene survey check IIst 42 ModuIe 2 Occupational and other workrelated diseases 45 T. ObjectIves 45 2. ntroductIon and basIc concepts 46 3. OccupatIonaI dIseases 47 4. WorkreIated dIseases 69 5. Tasks Ior traInees 74 ModuIe 3 Early detection of occupational diseases 77 T. ObjectIves 77 2. ntroductIon and basIc concepts 77 3. EarIy detectIon oI occupatIonaI dIseases caused by physIcaI Iactors 79 4. EarIy detectIon oI occupatIonaI dIseases caused by bIoIogIcaI agents 80 5. EarIy detectIon oI occupatIonaI dIseases caused by chemIcaIs 80 6. Tasks Ior traInees 86 ModuIe 4 Occupational ergonomics 87 T. ObjectIves 87 2. ntroductIon and basIc concepts 87 3. ErgonomIcs: a muItIdIscIpIInary scIence 89 4. Tasks Ior traInees 95 ModuIe 5 Stress and adverse psychological factors at work 97 T. ObjectIves 97 2. IntroductIon and basIc concepts 97 3. preventIon and controI oI stress T00 4. PrIncIpIes oI job desIgn T0T 5. Tasks Ior traInees T02 ModuIe b Occupational safety and accident prevention 103 T. ObjectIves T03 2. ntroductIon and basIc concepts T03 3. RecordIng and InvestIgatIng accIdents T07 4. AccIdent rates T08 5. PreventIon and controI oI occupatIonaI accIdents T09 6. Tasks Ior traInees TT0 ModuIe 7 First aid and its practice 113 T. ObjectIves TT3 2. mportance oI IIrst aId TT3 3. njurIes TT3 4. Fractures TT6 5. ThermaI InjurIes TT7 6. PoIsonIng TT9 7. Haemorrhage TT9 8. Shock T20 9. mpaIred breathIng T20 T0. Tasks Ior traInees T20 ModuIe Health education in occupational health 121 T. ObjectIves T2T 2. OccupatIonaI dIseases T2T 3. OccupatIonaI accIdents T22 4. Work envIronment and controI measures In the workpIace T24 5. PreventIon oI occupatIonaI dIseases and accIdents T26 6. LegIsIatIon T27 7. EIIects oI IIIestyIe and behavIour on heaIth T27 8. HeaIth educatIon In the workpIace T28 9. HeaIth educatIon methods and aIds T30 T0. CommunIcatIon skIIIs In heaIth educatIon T32 TT. Tasks Ior traInees T33 ModuIe 9 Epidemiology and biostatistics in occupational health 135 T. ObjectIves T35 2. deIInItIons T35 3. IostatIstIcaI data T37 4. Types oI epIdemIoIogIcaI study T38 5. Common measures oI dIsease Irequency T39 6. Tasks Ior traInees T40 ModuIe 1U Record keeping 143 T. ObjectIves T43 2. Purpose and types oI record T43 3. Record keepIng T45 4. Tasks Ior traInees T46 ModuIe 11 Occupational health in special areas 147 T. MInIng T47 2. SmaIIscaIe Industry T50 3. AgrIcuIturaI and ruraI areas T52 ModuIe 12 Occupational health for women and children 159 T. WorkIng women T59 2. ChIId Iabour T65 Further readIng T73 lOREWORD A heaIIhy workIorce Is vIIaI Ior susIaInabIe socIaI and economIc deveIopmenI on a gIobaI, naIIonaI, and IocaI IeveI. The cIassIc approach Io ensurIng heaIIh and saIeIy In Ihe workpIace has depended maInIy on Ihe enacImenI oI IegIsIaIIon and InspecIIon oI workpIaces Io ensure compIIance wIIh heaIIh and saIeIy sIandards. WhIIe IhIs approach has been eIIecIIve In conIroIIIng many specIIIc occupaIIonaI hazards sInce Ihe IndusIrIaI RevoIuIIon, II has noI been very eIIecIIve In Ihe pasI severaI decades, parIIcuIarIy In deveIopIng counIrIes, Ior severaI reasons. IIrsI, Ihe deveIopmenI oI prIvaIe enIerprIse, resuIIIng In a proIIIeraIIon oI smaII and medIumsIzed workpIaces, has meanI IhaI In many InsIances producIIon occurs In Ihe workers' own homes where Ihere can be serIous heaIIh hazards, IncIudIng harmIuI dusI, chemIcaIs, noIse and heaI. InspecIIon oI such workpIaces Is IargeIy ImpossIbIe In vIew oI Ihe Iarge numbers and wIde dIsIrIbuIIon. Second, wIIh Ihe InIroducIIon oI new agrIcuIIuraI IechnIques, agrIcuIIure has become an IndusIry Ior whIch sysIems based on InspecIIon are InadequaIe. There Is a need Io deveIop oIher sysIems Io proIecI Ihe heaIIh oI agrIcuIIuraI workers. ThIrd, occupaIIonaI heaIIh probIems have graduaIIy Increased In Iype and magnIIude and have Ied Io or aggravaIed dIseases resuIIIng Irom exposure Io severaI rIsk IacIors, onIy one oI whIch beIng Ihe work envIronmenI. LxampIes IncIude chronIc obsIrucIIve puImonary dIsease whIch Is maInIy caused by smokIng buI may be aggravaIed by IrrIIanI gases or dusIs In Ihe workpIace. Lowback paIn syndrome has severaI rIsk IacIors IncIudIng rheumaIIc dIsorders, scoIIosIs and InapproprIaIe posIure aI work. The DecIaraIIon oI AImaAIa In 1978 Ied Io Ihe recognIIIon oI Ihe ImporIance oI prImary heaIIh care (PHC) workers and communIIy heaIIh workers In brIngIng heaIIh care Io where peopIe IIve and work. PHC and communIIy heaIIh care workers In mosI deveIopIng counIrIes are noI IraIned In Ihe specIaI needs oI workers nor In Ihe sImpIe measures IhaI can be Iaken Io prevenI or overcome and conIroI many workers' heaIIh probIems. WorId HeaIIh AssembIy resoIuIIon WHA 40.28 (1987) requesIed Ihe DIrecIor GeneraI oI Ihe WorId HeaIIh OrganIzaIIon "Io deveIop guIdeIInes on IraInIng oI PHC workers In occupaIIonaI heaIIh". The RegIonaI CommIIIee Ior Ihe LasIern MedIIerranean aI IIs S8Ih sessIon In 1991 passed resoIuIIon LM/RC.S8/R.8 urgIng Member SIaIes In Ihe RegIon Io "IncIude In prImary heaIIh care servIces eIemenIs oI occupaIIonaI heaIIh". In response, Ihe RegIonaI OIIIce, Ihrough a RegIonaI ConsuIIaIIon (Amman, |ordan, 26-29 May, 1997) caIIed Ior Ihe deveIopmenI oI a IraInIng manuaI whIch wouId enabIe PHC workers and communIIy heaIIh workers Io recognIze Ihe mosI common hazards In Ihe workpIace, know how Io prevenI and conIroI Ihem and use Ihe supporI sysIem avaIIabIe Io Ihem Ior reIerraI and consuIIaIIon. HIghIy quaIIIIed experIs In Ihe IIeId oI occupaIIonaI heaIIh have conIrIbuIed Io Ihe deveIopmenI oI IhIs manuaI, whIch we hope wIII meeI Ihe needs oI Member SIaIes OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers In IheIr eIIorIs Io IncIude occupaIIonaI heaIIh In Ihe PHC servIces. I hope IhIs sImpIe, IaskorIenIed pubIIcaIIon wIII be useIuI noI onIy Ior PHC workers and IheIr IraIners aI aII IeveIs buI aIso Ior aII specIaIIsIs and InIeresIed auIhorIIIes. HusseIn A. GezaIry MD, IRCS WHO RegIonaI DIrecIor Ior Ihe LasIern MedIIerranean PRElACE WHO poIIcy has, sInce IIs IoundaIIon, aIways IncIuded eIemenIs oI occupaIIonaI heaIIh Issues. Numerous key WHO documenIs and bodIes, e.g. Ihe WHO ConsIIIuIIon, Ihe DecIaraIIon oI AIma AIa, Ihe HeaIIh Ior AII SIraIegy, Ihe GeneraI Programmes oI Work and severaI resoIuIIons oI Ihe WorId HeaIIh AssembIy, WHO's GIobaI HeaIIhy Work Approach (HWA), Ihe meeIIngs oI Ihe neIwork oI WHO CoIIaboraIIng CenIres In OccupaIIonaI HeaIIh, Ihe LxecuIIve Board, Ihe RegIonaI CommIIIee Ior Ihe LasIern MedIIerranean RegIon and oIher RegIonaI CommIIIees, have aII emphasIzed Ihe need Io proIecI and promoIe heaIIh and saIeIy aI work Ihrough Ihe prevenIIon and conIroI oI hazards In Ihe work envIronmenI and Ihrough Ihe promoIIon oI heaIIh and Ihe work capacIIy oI workIng peopIe. The WHO GIobaI SIraIegy Ior OccupaIIonaI HeaIIh Ior AII, deveIoped Ihrough Ihe gIobaI neIwork oI Ihe WHO CoIIaboraIIng CenIres In OccupaIIonaI HeaIIh provIdes an ImporIanI mechanIsm Ior proIecIIng and promoIIng heaIIh aI work. AccordIng Io Ihe DecIaraIIon oI AImaAIa, 1978: "PrImary heaIIh care ... Is Ihe IIrsI IeveI oI conIacI oI IndIvIduaIs, Ihe IamIIy and communIIy wIIh Ihe naIIonaI heaIIh sysIem brIngIng heaIIh care as cIose as possIbIe Io where workers IIve and work, and consIIIuIes Ihe IIrsI eIemenI oI a conIInuIng heaIIh care process." Workers are IhereIore an InIegraI parI In Ihe body oI Ihe DecIaraIIon. In addIIIon, Ihe WorId HeaIIh AssembIy has repeaIedIy requesIed Member SIaIes Io gIve workers' heaIIh a hIgh prIorIIy In Ihe overaII programme oI work and Io IncorporaIe II as an essenIIaI componenI oI PHC. There are dIIIerenI IeveIs oI PHC workers: docIors In charge oI occupaIIonaI heaIIh, dedIcaIed heaIIh care personneI wIIh backgrounds In generaI educaIIon, heaIIh assIsIanIs, such as nurses and heaIIh IechnIcIans especIaIIy IraIned In occupaIIonaI heaIIh, and quaIIIIed workers wIIh vocaIIonaI IraInIng backgrounds. There are many sIraIegIes In common beIween PHC and occupaIIonaI heaIIh. In IacI, an adequaIe InpIanI occupaIIonaI heaIIh servIce meeIs aImosI aII Ihe prIncIpIes oI PHC as IoIIows. HealIh educaIion and communiIy parIicipaIion These are IundamenIaI aspecIs oI PHC and equaIIy basIc In occupaIIonaI heaIIh, I.e. Io educaIe workers In saIeIy and heaIIh, seIIcare and heaIIhy IIIesIyIe Ior prevenIIon oI dIsease and promoIIon oI heaIIh and Io promoIe workers' parIIcIpaIIon In prevenIIve programmes In Ihe workpIace whIch Is a counIerparI oI "communIIy parIIcIpaIIon". PrevenIion ol healIh hazards aI Ihe source A prImary prIncIpIe In PHC and occupaIIonaI heaIIh. In occupaIIonaI heaIIh, IdenIIIIcaIIon oI saIeIy and heaIIh hazards Is IundamenIaI. RIsk evaIuaIIon agaInsI hygIenIc sIandards Is a known pracIIce and conIroI aI Ihe source Is Ihe prImary objecIIve. 1U OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers Team work A requIremenI In Ihe PHC approach whIch becomes more specIIIc In occupaIIonaI heaIIh pracIIce where Ihe envIronmenIaI hygIenIsI In Ihe workpIace, Ihe occupaIIonaI physIcIans, nurses, saIeIy supervIsors, Ihe empIoyers and workers' represenIaIIves comprIse Ihe occupaIIonaI heaIIh Ieam. II Is even IegaIIzed In mosI counIrIes Ihrough "occupaIIonaI heaIIh and saIeIy commIIIees" whIch usuaIIy comprIse IhIs Ieam. NaIIonaI occupaIIonaI heaIIh programmes requIre cooperaIIon and Ieam work among Ihe naIIonaI heaIIh servIces: mInIsIrIes oI heaIIh, educaIIon, envIronmenI, IndusIry, Iabour, socIaI securIIy and oIIen Ihe mInIsIry oI agrIcuIIure. EquiIy OccupaIIonaI heaIIh care does noI dIscrImInaIe among workIng peopIe. II caIIs Ior equaI heaIIh care Ior Ihe underserved and IrIes Io remove any dIscrImInaIIon beIween whIIe coIIar and oIher workers as weII as beIween women and men. AccessibiliIy There Is noIhIng more accessIbIe In Ihe heaIIh care sysIem Ihan Ihe InpIanI heaIIh servIce. LIIorIs Io make occupaIIonaI heaIIh care accessIbIe Io remoIe areas as weII as Io underserved workIng peopIe are whaI Is now requIred. AllordabiliIy OccupaIIonaI heaIIh Is aIIordabIe. The esIabIIshmenI oI an occupaIIonaI heaIIh servIce shouId sIarI In Ihe earIy sIages oI deveIopIng IacIorIes and IndusIrIaI pIanIs. II Is possIbIe Io use sImpIe IechnoIogy, e.g. dIrecI readIng equIpmenI, such as a noIse meIer, and Io IoIIow a basIc prevenIIve programme. WIIh earIy deIecIIon mosI dIseases are prevenIabIe resuIIIng In Ihe mInImIzIng oI Ihe cosIs oI Iherapy. However, Ihere are some occupaIIonaI dIseases whIch are noI amenabIe Io IreaImenI, e.g. sIIIcosIs. ConIribuIion Io Ihe naIional economy There Is no heaIIh programme IhaI conIrIbuIes more Io Ihe naIIonaI economy Ihan IhaI aImIng aI a heaIIhy workIng producIIve popuIaIIon. PrevenIIve occupaIIonaI heaIIh maInIaIns workers' producIIvIIy. HeaIIhy workers Increase IndusIrIaI ouIpuI and Iower Ihe cosI oI producIIon and, Ihrough IheIr Incomes, Ihey can conIrIbuIe Io Ihe heaIIh oI IheIr IamIIIes and IheIr communIIIes. Workers consIIIuIe a Iarge secIor oI Ihe popuIaIIon. II Is noI possIbIe Ior a naIIon Io survIve when IIs Iabour Iorce Is weak and III. The goaIs oI IhIs manuaI are: Io creaIe a caIegory oI heaIIh personneI IhaI Is weII orIenIed In occupaIIonaI heaIIh pracIIce In order Io IIII Ihe gap In occupaIIonaI heaIIh personneI and coverage Ior workIng peopIe; and OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 11 by IoIIowIng Ihe PHC approach, Io emphasIze Ihe prevenIIve objecIIve oI occupaIIonaI heaIIh servIces In Ihe workpIace. The manuaI ouIIInes a currIcuIum Ior IraInIng oI PHC workers/communIIy heaIIh workers. The IraInIng programme can be adjusIed as requIred dependIng on Ihe IeveI oI IraInees; Ior exampIe, II can be upgraded Ior generaI pracIIIIoners or sImpIIIIed Ior workers In Ihe workpIace. AcknowledgemenIs The RegIonaI OIIIce Ior Ihe LasIern MedIIerranean Ihanks WHO headquarIers Ior Ihe IInancIaI conIrIbuIIon whIch enabIed Ihe pubIIcaIIon oI IhIs manuaI and graIeIuIIy acknowIedges Ihe proIessIonaI conIrIbuIIons and advIce gIven by Ihe IoIIowIng IndIvIduaIs: Dr IN Ababneh, OccupaIIonaI HeaIIh Programme Manager, MInIsIry oI HeaIIh, Amman, |ordan. Dr S ArnaouI, RegIonaI AdvIser, HeaIIh oI SpecIaI Groups, WHO RegIonaI OIIIce Ior Ihe LasIern MedIIerranean. Dr H Bashor, AssocIaIe ProIessor oI LpIdemIoIogy, DeparImenI oI CommunIIy MedIcIne, IacuIIy oI MedIcIne, Damascus UnIversIIy, SyrIan Arab RepubIIc. Dr G LIjkemans, OccupaIIonaI and LnvIronmenIaI HeaIIh DeparImenI, ProIecIIon oI Ihe Human LnvIronmenI, WHO headquarIers, Geneva. Dr MA LI BaIawI, Iormer ChIeI oI OccupaIIonaI HeaIIh, WHO headquarIers, Geneva. Dr GH LI Samra, ProIessor, DeparImenI oI IndusIrIaI MedIcIne and OccupaIIonaI DIseases, IacuIIy oI MedIcIne, UnIversIIy oI CaIro, LgypI. Dr AM Lmara, ProIessor oI OccupaIIonaI MedIcIne, IacuIIy oI MedIcIne, UnIversIIy oI CaIro, LgypI. Dr ZI IakhrI, OccupaIIonaI HeaIIh DeparImenI, MInIsIry oI HeaIIh, RIyadh, SaudI ArabIa. Dr AA Iarshad, MInIsIry oI HeaIIh and MedIcaI LducaIIon, Teheran, IsIamIc RepubIIc oI Iran. Dr H IrumkIn, AssocIaIe ProIessor oI LnvIronmenIaI and OccupaIIonaI HeaIIh, RoIIIns SchooI oI PubIIc HeaIIh, Lmory UnIversIIy, GeorgIa, USA. Dr G HaIez, SpecIaI AdvIser Io Ihe RegIonaI DIrecIor, Iormer DIrecIor, HeaIIh ProIecIIon and PromoIIon, WHO RegIonaI OIIIce Ior Ihe LasIern MedIIerranean, CaIro, LgypI. Dr R HeImer, DIrecIor, ProIecIIon oI Ihe Human LnvIronmenI (PHL), WHO headquarIers, Geneva. Dr MA KhaIII, Iormer DIrecIor, HeaIIh ProIecIIon and PromoIIon, WHO RegIonaI OIIIce Ior Ihe LasIern MedIIerranean, CaIro, LgypI. 12 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers Dr R MahaInI, RegIonaI CoordInaIor, IamIIy and CommunIIy HeaIIh, WHO RegIonaI OIIIce Ior Ihe LasIern MedIIerranean, CaIro, LgypI. Dr MI MIkheev, Iormer ChIeI oI OccupaIIonaI HeaIIh, WHO headquarIers, Geneva. Dr MH NoweIr, ProIessor, IndusIrIaI LngIneerIng DeparImenI, KIng AbdeI AzIz UnIversIIy, |eddah, SaudI ArabIa. Dr P Rookmaaker, ProIessor, InIernaIIonaI LrgonomIcs AssocIaIIon, The NeIherIands. Mr AS KaIeem, SpecIaIIsI In WorkIng CondIIIons and LnvIronmenI, InIernaIIonaI Labour OrganIsaIIon, NorIh AIrIca MuIIIdIscIpIInary AdvIsory Team (ILO/NAMAT), CaIro, LgypI. lNTRODUCTlON OccupaIional healIh: a deliniIion OccupaIIonaI heaIIh Is a muIIIdIscIpIInary acIIvIIy aImed aI: Ihe proIecIIon and promoIIon oI Ihe heaIIh oI workers by prevenIIng and conIroIIIng occupaIIonaI dIseases and accIdenIs and by eIImInaIIng occupaIIonaI IacIors and condIIIons hazardous Io heaIIh and saIeIy aI work; Ihe deveIopmenI and promoIIon oI heaIIhy and saIe work, work envIronmenIs and work organIzaIIons; Ihe enhancemenI oI Ihe physIcaI, menIaI and socIaI weIIbeIng oI workers and supporI Ior Ihe deveIopmenI and maInIenance oI IheIr workIng capacIIy, as weII as proIessIonaI and socIaI deveIopmenI aI work; enabIIng workers Io conducI socIaIIy and economIcaIIy producIIve IIves and Io conIrIbuIe posIIIveIy Io susIaInabIe deveIopmenI. OccupaIIonaI heaIIh has graduaIIy deveIoped Irom a monodIscIpIInary, rIsk orIenIed acIIvIIy Io a muIIIdIscIpIInary and comprehensIve approach IhaI consIders an IndIvIduaI's physIcaI, menIaI and socIaI weIIbeIng, generaI heaIIh and personaI deveIopmenI. lnIeracIion beIween work and healIh The socIaI and economIc ImporIance oI work receIves consIderabIe aIIenIIon because a prImary IuncIIon oI work In any socIeIy Is Io produce and dIsIrIbuIe goods and servIces. Iar Iess aIIenIIon Is paId Io Ihe ImporIance oI work Io Ihe IndIvIduaI, yeI II Is cIear Irom recenI research IhaI work pIays a crucIaI and perhaps unparaIIeIed psychoIogIcaI roIe In Ihe IormaIIon oI seIIesIeem and a sense oI order. Work Is a powerIuI Iorce In shapIng a person's sense oI IdenIIIy. II can Iend vIIaIIIy Io exIsIence and esIabIIshes Ihe cycIIcaI paIIerns oI day, week, monIh and year. II Is beIIeved IhaI work Ior whIch Ihere Is no economIc gaIn, such as chIId care, care Ior Ihe aged and voIunIary work, aIso has IIs rewards and conIrIbuIes Io personaI graIIIIcaIIon. PosiIive healIh ellecIs ol work T\o-\n) ntcncton There Is a conIInuous Iwoway InIeracIIon beIween a person and Ihe physIcaI and psychoIogIcaI workIng envIronmenI: Ihe work envIronmenI may InIIuence Ihe person's heaIIh eIIher posIIIveIy or negaIIveIy and producIIvIIy Is, In Iurn, InIIuenced by Ihe worker's sIaIe oI physIcaI and menIaI weIIbeIng. Work, when II Is weII adjusIed and producIIve, can be an ImporIanI IacIor In heaIIh promoIIon, e.g. parIIaIIy dIsabIed workers may be rehabIIIIaIed by underIakIng Iasks suIIed Io IheIr physIcaI and menIaI IImIIaIIons and, In IhIs way, may subsIanIIaIIy Increase IheIr workIng capacIIy. However, Ihe IacI IhaI work can have a posIIIve InIIuence on heaIIh has noI yeI been IuIIy expIoIIed; knowIedge oI work physIoIogy and ergonomIcs needs Io be IurIher deveIoped and appIIed Io beneIII worker's heaIIh. 14 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers HcntI Inznd: When work Is assocIaIed wIIh heaIIh hazards, II may cause occupaIIonaI dIsease, be one oI Ihe muIIIpIe causes oI oIher dIsease or may aggravaIe exIsIIng IIIheaIIh oI nonoccupaIIonaI orIgIn. In deveIopIng counIrIes, where work Is becomIng IncreasIngIy mechanIzed, a number oI work processes have been deveIoped IhaI IreaI workers as IooIs In producIIon, puIIIng IheIr heaIIh and IIves aI rIsk. The occupaIIonaI heaIIh Iessons Iearned durIng Ihe IndusIrIaI RevoIuIIon shouId be borne In mInd In pIannIng Ior heaIIh In deveIopIng counIrIes II such probIems are Io be avoIded. Uncno)ncnt |ob Ioss may adverseIy aIIecI a worker's physIoIogIcaI and menIaI heaIIh. II unempIoymenI persIsIs, Ihe person's heaIIh conIInues Io decIIne and chronIc dIsorders can appear. The menIaI and IInancIaI dIsIress caused by Ihe job Ioss can spread Io oIher IamIIy members. In a deveIopIng counIry, job Ioss can have proIound eIIecIs IhaI spread beyond Ihe worker's own IamIIy sInce, where Ihere Is IImIIed paId empIoymenI, a person In a weIIpaId job exerIs an ImporIanI InIIuence In Ihe communIIy. In addIIIon Io havIng an obvIous economIc InIIuence and hIgh socIaI sIandIng, such a worker may serve as a good source oI heaIIh InIormaIIon and seI an exampIe wIIh a heaIIhy IIIesIyIe. Loss oI empIoymenI Ior such a person can aIso aIIecI Ihe ImmedIaIe communIIy as weII as Ihe person's IamIIy. A worker's heaIIh may aIso suIIer weII beIore Ihe acIuaI job Ioss. BoIh IeeIIngs oI job InsecurIIy and knowIedge oI ImpendIng job Ioss have been assocIaIed wIIh menIaI and physIcaI heaIIh compIaInIs. SImIIarIy, Ihose who have never had Ihe opporIunIIy Io be empIoyed, e.g. because oI unavaIIabIIIIy oI jobs, have no chance Io deveIop an IdenIIIy or sense oI beIongIng Ihrough work whIch Is ImporIanI Ior psychoIogIcaI and socIaI weIIbeIng. Such peopIe are noI accessIbIe Io heaIIh messages In Ihe workpIace and may be unaware oI Ihe posIIIve reIaIIonshIp beIween work and heaIIh. In addIIIon, because Ihey have a IoI oI Iree IIme, someIImes assocIaIed wIIh anxIeIy and depressIon, Ihe never empIoyed are more IIkeIy Ihan Ihose In empIoymenI Io consume aIcohoI, cIgareIIes and drugs. HealIh, workplace, economy and susIainable developmenI The mosI successIuI economIes have demonsIraIed IhaI workpIaces desIgned accordIng Io good prIncIpIes oI occupaIIonaI heaIIh, saIeIy and ergonomIcs are aIso Ihe mosI susIaInabIe and producIIve. In addIIIon, a heaIIhy economy, hIgh quaIIIy oI producIs or servIces and IongIerm producIIvIIy are dIIIIcuII Io achIeve In poor workIng condIIIons where workers are exposed Io heaIIh and saIeIy hazards. PrIncIpIe 1 oI Ihe RIo DecIaraIIon on LnvIronmenI and DeveIopmenI (UnIIed NaIIons ConIerence on LnvIronmenI and DeveIopmenI, RIo de |aneIro, 1992) sIaIes: "Human beIngs are aI Ihe cenIre oI concern Ior susIaInabIe deveIopmenI. They are enIIIIed Io a heaIIhy and producIIve IIIe In harmony wIIh naIure". SusIaInabIe deveIopmenI Is deIIned as a sIraIegy Io "meeI Ihe needs oI Ihe presenI worId popuIaIIon wIIhouI causIng adverse eIIecI on heaIIh and on Ihe envIronmenI, and wIIhouI depIeIIng or OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 15 endangerIng Ihe gIobaI resource base, hence wIIhouI compromIsIng Ihe abIIIIy oI IuIure generaIIons Io meeI IheIr needs". In Ierms oI occupaIIonaI heaIIh, Ihe above prIncIpIes mean Ihe saIIsIacIIon oI maIerIaI needs Ihrough work and oIher producIIon processes wIIhouI causIng danger Io human heaIIh, Ihe ecosysIem, Ihe resource base or Ihe heaIIh oI Ihe communIIy, eIIher In Ihe shorI Ierm or Ihe Iong Ierm. OccupaIIonaI heaIIh Is a basIc eIemenI and consIIIuIes a socIaI and heaIIh dImensIon oI Ihe prIncIpIe oI susIaInabIe deveIopmenI. OccupaIIonaI heaIIh Is aI Ihe cenIre oI susIaInabIe deveIopmenI In Ihe IoIIowIng ways. The prevenIIon oI occupaIIonaI accIdenIs, InjurIes and dIseases and Ihe proIecIIon oI workers agaInsI physIcaI and psychoIogIcaI overIoad ImpIy approprIaIe use oI resources, mInImIzIng Ihe unnecessary Ioss oI human and maIerIaI resources. The objecIIve oI heaIIhy and saIe work envIronmenIs caIIs Ior Ihe use oI saIe, Iowenergy, IowIoxIcemIssIon, IowwasIe (green) IechnoIogy, and In many counIrIes occupaIIonaI heaIIh IegIsIaIIon requIres Ihe use oI Ihe besI avaIIabIe producIIon IechnoIogy. The occupaIIonaI heaIIh approach may IacIIIIaIe undIsIurbed producIIon IhaI Increases Ihe quaIIIy oI producIs, producIIvIIy and process managemenI and heIps Io avoId unnecessary Ioss oI energy and maIerIaIs and Io prevenI an unwanIed ImpacI on Ihe envIronmenI. Many envIronmenIaI hazards and burdens are derIved Irom occupaIIonaI seIIIngs, e.g. IndusIry, agrIcuIIuraI pracIIces, IransporIaIIon and servIces. Those responsIbIe Ior occupaIIonaI heaIIh and saIeIy are weII InIormed oI processes and agenIs IhaI may be hazardous Io Ihe envIronmenI. OIIen IhIs InIormaIIon Is avaIIabIe Io Ihem Irom Ihe earIIesI sIage oI a probIem enabIIng prImary prevenIIon whIch Is no Ionger possIbIe once Ihe hazardous eIemenIs are reIeased InIo Ihe generaI envIronmenI. The ImpacI oI occupaIIonaI heaIIh on envIronmenIaI proIecIIon Irom IndusIry Is IIkeIy Io be boIh eIIecIIve and cosIeIIecIIve. In many IndusIrIaIIzed counIrIes Ihere are moves Io make cIoser IInks beIween occupaIIonaI heaIIh and envIronmenIaI heaIIh approaches. OccupaIIonaI heaIIh servIces aIm Io ensure workers' heaIIh, saIeIy, workIng capacIIy and weIIbeIng. A heaIIhy, producIIve and weII moIIvaIed workIorce Is Ihe key agenI Ior overaII socIoeconomIc deveIopmenI. In addIIIon, hIghquaIIIy and producIIve work ensures heaIIhy producIIon oI maIerIaIs, goods and servIces and Ihe consIderaIIon and pracIIcaI ImpIemenIaIIon oI Ihe prIncIpIes oI susIaInabIe deveIopmenI. MosI envIronmenIaI heaIIh hazards IhaI have IaIer been Iound Io aIIecI Ihe heaIIh oI Ihe generaI popuIaIIon were IIrsI deIecIed In Ihe work envIronmenI. The occupaIIonaI envIronmenI provIdes an earIy warnIng sysIem Ior cerIaIn 1b OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 1 In) dctccton o IcntI nnncnt n occuntonn cxo:uc to IcntI Inznd:. Kcot o n WHO 5tud) Cou. Geneva, WorId HeaIIh OrganIzaIIon, 197S (WHO TechnIcaI ReporI SerIes No. S71). envIronmenIaI heaIIh hazards jusI as II aIso provIdes eIIecIIve modeIs Ior prevenIIve acIIon. Ior many aduIIs Ihe work envIronmenI Is Ihe mosI demandIng envIronmenI In Ierms oI physIcaI, chemIcaI, ergonomIc or psychoIogIcaI sIresses and physIcaI workIoad. The prIncIpIe oI Ihe RIo DecIaraIIon wIIh regard Io a heaIIhy and producIIve IIIe Is parIIcuIarIy reIevanI Io Ihe work envIronmenI and caIIs Ior occupaIIonaI heaIIh acIIon. The sIaIe oI Ihe generaI envIronmenI and Ihe ecosysIem has an ImpacI on Ihe heaIIh oI workers eIIher dIrecIIy or IndIrecIIy In severaI occupaIIons, e.g. agrIcuIIure, mInIng, IIshery and manuIacIurIng. There Is a Iwoway reIaIIonshIp beIween occupaIIonaI heaIIh and saIeIy on Ihe one hand, and occupaIIonaI heaIIh and sound envIronmenIaI deveIopmenI on Ihe oIher. LquaIIy ImporIanI Ior personaI weIIbeIng and Ior socIoeconomIc deveIopmenI oI communIIIes and counIrIes Is an empIoymenI poIIcy IhaI ensures access Io work Ior everyone and enabIes IndIvIduaIs Io susIaIn IhemseIves and IheIr IamIIIes. HIghesI possIbIe empIoymenI Is aIso a key IacIor In Ihe saIe, sIabIe and susIaInabIe socIaI deveIopmenI oI counIrIes, whIIe hIgh unempIoymenI raIes and oIher assocIaIed probIems endanger such deveIopmenI. In deveIopIng counIrIes, Ihe heaIIh and weIIbeIng oI Ihe IamIIy Is crIIIcaIIy dependenI on Ihe heaIIh and producIIvIIy oI IIs workIng member, Ihus makIng severaI members oI Ihe communIIy dependenI on Ihe heaIIh oI Ihe worker. In a sIIuaIIon where organIzed socIaI proIecIIon Is IackIng, Ihe Ioss oI heaIIh, IIIe or workIng capacIIy oI such a key member oI Ihe IamIIy oIIen means severe crIsIs Ior Ihe resI oI Ihe IamIIy, aIIecIIng IndIrecIIy Ihe weIIbeIng, heaIIh and economy oI communIIIes aI Iarge and oI IuIure generaIIons. OccupaIIonaI heaIIh Is a basIc eIemenI and consIIIuIes a socIaI and heaIIh dImensIon oI Ihe prIncIpIe oI overaII deveIopmenI. OccupaIIonaI heaIIh pracIIces consIIIuIe a seI oI key acIIvIIIes Ior such deveIopmenI. Work as a lacIor in healIh promoIion WHO deIInes heaIIh as a sIaIe oI compIeIe physIcaI, menIaI and socIaI weIIbeIng and noI mereIy Ihe absence oI dIsease or InIIrmIIy. AccordIng Io Ihe WHO SIudy Group on LarIy DeIecIIon oI HeaIIh ImpaIrmenI In OccupaIIonaI Lxposure Io HeaIIh Hazards: HeaIIh ... connoIes raIher a way oI IuncIIonIng wIIhIn one's envIronmenI (work, recreaIIon, IIvIng). II noI onIy means Ireedom Irom paIn or dIsease, buI aIso Ireedom Io deveIop and maInIaIn one's IuncIIonaI capacIIIes. HeaIIh deveIops and Is maInIaIned Ihrough InIeracIIon beIween Ihe genoIype and Ihe IoIaI envIronmenI. The work envIronmenI consIIIuIes an ImporIanI parI oI man's IoIaI envIronmenI, so heaIIh Is Io a Iarge exIenI aIIecIed by work condIIIons. 1 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 17
HeaIIh promoIIon was deIIned by Ihe OIIawa CharIer Ior HeaIIh PromoIIon, 1986, as: ... Ihe process oI enabIIng peopIe Io Increase conIroI over, and Io Improve, IheIr heaIIh. To reach a sIage oI compIeIe physIcaI, menIaI and socIaI weIIbeIng, an IndIvIduaI or group musI be abIe Io IdenIIIy and Io reaIIze aspIraIIons, Io saIIsIy needs, and Io change or cope wIIh Ihe envIronmenI. ThereIore, heaIIh promoIIon Is noI jusI Ihe responsIbIIIIy oI Ihe heaIIh secIor, buI goes beyond heaIIhy IIIesIyIes Io weIIbeIng. 2 HeaIIh promoIIon Is a conIInuum rangIng Irom Ihe IreaImenI oI dIsease Io Ihe prevenIIon oI dIsease IncIudIng proIecIIon agaInsI specIIIc rIsks, Io Ihe promoIIon oI opIImaI heaIIh. AchIevIng opIImaI heaIIh IncIudes: ImprovIng physIcaI abIIIIIes In reIaIIon Io sex and age; ImprovIng menIaI abIIIIy; deveIopIng reserve capacIIIes; adapIabIIIIy Io changIng cIrcumsIances oI work and IIIe and reachIng new IeveIs oI IndIvIduaI achIevemenI In creaIIve and oIher work. In a work seIIIng Ihese heaIIh IndIcaIors may be evaIuaIed quanIIIaIIveIy by IndIces oI absenIeeIsm, job saIIsIacIIon and work sIabIIIIy. HealIh proIecIion and promoIion acIiviIies in Ihe workplace Nntonn go\cnncnt: NaIIonaI governmenIs have an InIeresI In workers' heaIIh parIIy because II has a dIrecI InIIuence on naIIonaI producIIvIIy. GovernmenIs are responsIbIe Ior esIabIIshIng and maInIaInIng saIe workIng condIIIons and ensurIng, Ihrough IegIsIaIIon, IhaI occupaIIonaI heaIIh servIces are provIded Ior aII workers In aII branches oI economIc acIIvIIy, IncIudIng Ihose In Ihe pubIIc secIor. HeaIIh promoIIon programmes are noI usuaIIy a sIaIuIory requIremenI buI occupaIIonaI heaIIh servIces can provIde a Iocus Ior IheIr ImpIemenIaIIon. Mnnngcncnt Those responsIbIe Ior Ihe managemenI oI a workpIace have an InIeresI In workers' heaIIh promoIIon Ior Ihe same reason as naIIonaI governmenIs: heaIIhy workers are essenIIaI Ior opIImaI producIIvIIy. In addIIIon Io Ihe humanIIarIan vaIue oI ImprovIng workers' heaIIh, Ihe economIc vaIue Is IhereIore parIIcuIarIy ImporIanI Io empIoyers. ThIs Is aIso Irue Ior seIIempIoyed workers as IheIr producIIvIIy Is oIIen compIeIeIy dependenI on IheIr own heaIIh. The prIme responsIbIIIIy Ior heaIIh and saIeIy In a workpIace resIs wIIh Ihe managemenI, whIch IhereIore pIays an essenIIaI roIe In Ihe success oI any heaIIh promoIIon programme. To ensure Ihe success oI a programme, managemenI musI aIIow Ihe necessary resources and IIme Io be dedIcaIed Io II, demonsIraIe IIs desIre Ior empIoyees Io parIIcIpaIe and be wIIIIng Io accepI suggesIIons Irom empIoyees on whaI shouId be done. ManagemenI musI aIso have suIIIcIenI apprecIaIIon oI Ihe need Ior heaIIh promoIIon and dIsease prevenIIon Io be abIe Io assess Ihe reIaIIve merIIs oI varIous programmes, deIermIne prIorIIIes and deIegaIe responsIbIIIIy Ior achIevIng programme success. 2 OIIawa CharIer Ior HeaIIh PromoIIon. IIrsI InIernaIIonaI ConIerence on heaIIh PromoIIon, OIIawa, Canada, 17-21 November 1986. 1 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers Woc: The worker sIands Io beneIII Irom heaIIh promoIIon programmes by havIng a saIe and heaIIhy work envIronmenI, a convenIenI IocaIIon Io Iearn abouI and puI InIo pracIIce a heaIIhy IIIesIyIe, readIIy avaIIabIe opporIunIIIes Ior screenIng and heaIIh care and an opporIunIIy uIIImaIeIy Io achIeve opIImaI heaIIh. HeaIIh has an aII encompassIng ImpacI on Ihe worker's IIIe, by aIIecIIng hIs or her abIIIIy Io InIeracI wIIh oIhers, Io work and Io be seIIreIIanI. The worker's conIrIbuIIon Io workpIace heaIIh promoIIon Is essenIIaI Io any programme's success. Workers shouId be InvoIved In Ihe programme's desIgn and encourage IheIr coworkers Io parIIcIpaIe. Woc:' cc:cntnt\c: nnd unon: The roIe oI workers' represenIaIIves, organIzaIIons and unIons Is Io negoIIaIe wIIh Ihe managemenI Io ensure IhaI approprIaIe heaIIh programmes are ImpIemenIed and IhaI an approprIaIe baIance Is achIeved beIween Ihe varIous heaIIh programmes. The workers' organIzaIIons shouId aIso ensure IhaI cerIaIn prIncIpIes be IoIIowed, e.g. conIIdenIIaIIIy and nondIscrImInaIIon. Connuntc: HeaIIh Is InIIuenced by many IacIors ouIsIde Ihe workpIace. ConsequenIIy, heaIIh promoIIon Ior Ihe workIorce cannoI be regarded soIeIy as Ihe responsIbIIIIy oI occupaIIonaI heaIIh proIessIonaIs. The communIIy, Ihrough IIs prImary heaIIh workers and pubIIc heaIIh proIessIonaIs, has cIearcuI responsIbIIIIIes Ior IndIvIduaI and group heaIIh educaIIon as a means oI heaIIh promoIIon. Wherever possIbIe, heaIIh educaIIon programmes shouId be a joInI acIIvIIy oI occupaIIonaI and communIIy heaIIh proIessIonaIs. Mass medIa can aIso pIay an ImporIanI roIe In heaIIh educaIIon. In deveIopIng counIrIes, parIIcuIarIy In ruraI areas and smaII workpIaces, Ihe prImary heaIIh worker may be Ihe soIe provIder oI heaIIh proIecIIon and promoIIon servIces Ior boIh workers and Ihe resI oI Ihe communIIy. Occuntonn IcntI oc::onn: HeaIIh promoIIon Is an essenIIaI parI oI Ihe occupaIIonaI heaIIh proIessIonaI's mandaIe. PhysIcIans, nurses, saIeIy oIIIcers, heaIIh educaIors and PHC workers wIII pIay dIIIerenI roIes In work pIace heaIIh promoIIon and shouId be IraIned accordIngIy e.g. Ihe roIe oI Ihe occupaIIonaI heaIIh nurse Is Io educaIe, screen and counseI workers, whereas IhaI oI an occupaIIonaI hygIenIsI Is Io assess Ihe conIroI oI heaIIh hazards whIIe keepIng In Iouch wIIh Ihe deveIopmenI and progress oI heaIIh promoIIon programmes. TogeIher wIIh oIhers, such as ergonomIsIs, nuIrIIIon specIaIIsIs and psychoIogIsIs, occupaIIonaI heaIIh proIessIonaIs can: proIecI workers' heaIIh by conIroIIIng hazards In Ihe workpIace and by InIroducIng ergonomIcs advIse workers and managers on heaIIh promoIIon acIIvIIIes and on how Io Improve workIng condIIIons OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 19 monIIor Ihe work envIronmenI and workers' heaIIh wIIh a vIew Io earIy IdenIIIIcaIIon oI heaIIh rIsks and evaIuaIIon oI Ihe eIIecIIveness oI heaIIh proIecIIon and promoIIon programmes. In many cIrcumsIances, In deveIopIng as weII as deveIoped counIrIes, occupaIIonaI heaIIh proIessIonaIs can cover onIy a smaII proporIIon oI workpIaces and workers. In such cases, oIhers responsIbIe Ior provIdIng heaIIh care Ior workers shouId recognIze heaIIh promoIIon as one oI IheIr major Iasks and shouId receIve some IraInIng In occupaIIonaI heaIIh. MODULE 1 Work environment 1. OB|ECTlVES DeIecI work hazards as reIaIed Io occupaIIon, work and work envIronmenI InspecI workpIaces Ior Ihe dIscovery oI acIuaI hazards and unsaIe workers' behavIour Use sImpIe meIhods and IechnIques Ior evaIuaIIon oI work hazards and Ior IesIIng conIroI measures ReporI work and envIronmenIaI hazards Io concerned bodIes Know prIncIpIes oI Ihe conIroI oI work hazards and work envIronmenI and parIIcIpaIe In seIecIIng approprIaIe conIroI measures and opIImaI use oI avaIIabIe resources ParIIcIpaIe In Ihe managemenI oI work emergency pIans and In IIrsI aId LducaIe workers on Ihe prIncIpIes oI saIe conducI aI work ParIIcIpaIe In InvesIIgaIIng work compIaInIs, compensaIIon cases, rehabIIIIaIIon, socIaI weIIare, eIc. CoordInaIe wIIh oIher proIessIonaIs In Ihe occupaIIonaI muIIIdIscIpIInary Ieam: saIeIy oIIIcer and commIIIee, occupaIIonaI hygIenIsI, physIcIan and nurse, sanIIarIan, IIrsI aId aIIendanI, pIanI engIneer and Ioreman. 2. lNTRODUCTlON AND BASlC CONCEPTS 2.1 OccupaIional hygiene ThIs Is Ihe pracIIce oI assessmenI and conIroI oI envIronmenIaI IacIors and sIresses arIsIng In or Irom Ihe workpIace, whIch may cause Injury, sIckness, ImpaIred heaIIh and weIIbeIng or sIgnIIIcanI dIscomIorI and IneIIIcIency among workers or among Ihe cIIIzens oI Ihe communIIy. II encompasses Ihe sIudy oI: IoxIcoIogy IndusIrIaI processes Ihe chemIcaI and physIcaI behavIour oI aIr conIamInanIs envIronmenIaI sampIIng IechnIques and sIaIIsIIcs Ihe desIgn and evaIuaIIon oI venIIIaIIon sysIems 22 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers noIse conIroI radIaIIon proIecIIon Ihe heaIIh eIIecIs oI occupaIIonaI hazards. OccupaIIonaI/IndusIrIaI hygIenIsIs use envIronmenIaI monIIorIng and anaIyIIcaI meIhods Io deIecI Ihe exIenI oI worker exposure and empIoy engIneerIng, work pracIIce conIroIs and oIher meIhods Io conIroI poIenIIaI heaIIh hazards. OccupaIIonaI/IndusIrIaI hygIenIsIs musI work wIIh physIcIans Io deveIop comprehensIve occupaIIonaI heaIIh programmes and wIIh epIdemIoIogIsIs Io perIorm research on heaIIh eIIecIs. 2.2 Work-siIe analysis ThIs Is an essenIIaI procedure IhaI heIps In deIermInIng whaI jobs and worksIaIIons are Ihe sources oI poIenIIaI probIems. DurIng Ihe worksIIe anaIysIs: exposures, probIem Iasks and rIsks are IdenIIIIed and measured. The mosIeIIecIIve worksIIe anaIyses IncIude aII jobs, operaIIons and work acIIvIIIes. The occupaIIonaI/IndusIrIaI hygIenIsI InspecIs, researches or anaIyses how Ihe parIIcuIar chemIcaIs or physIcaI hazards aI Ihe worksIIe aIIecI worker heaIIh. II a sIIuaIIon hazardous Io heaIIh Is dIscovered, he or she recommends Ihe approprIaIe correcIIve acIIon. Ixnnc An occupaIIonaI/IndusIrIaI hygIenIsI mIghI be asked Io deIermIne Ihe composIIIon and concenIraIIons oI aIr conIamInanIs In a workpIace where Ihere have been compIaInIs oI eye, nose and IhroaI IrrIIaIIon. The hygIenIsI In IhIs sIIuaIIon wouId aIso deIermIne II Ihe conIamInanI exposures exceeded Ihe permIssIbIe exposure IImIIs requIred by Ihe naIIonaI reguIaIIons and sIandards. II Ihe probIem was Ihe resuII oI aIrborne maIerIaIs (a concIusIon IhaI mIghI be reached In consuIIaIIon wIIh a physIcIan or epIdemIoIogIsI), Ihen Ihe hygIenIsI wouId be responsIbIe Ior seIecIIng Ihe IechnIques used Io reduce or eIImInaIe Ihe exposure e.g. InsIaIIIng exhausI venIIIaIIon around Ihe source oI Ihe aIr conIamInanIs and IsoIaIIng II Irom Ihe generaI work area. IoIIowup sampIIng Io verIIy IhaI Ihe conIroIs had been eIIecIIve wouId aIso be Ihe hygIenIsI's responsIbIIIIy. 3. RECOGNlTlON Ol HEALTH HAZARDS 3.1 lnspecIion ThIs Is Ihe IIrsI sIep In Ihe process IeadIng Io evaIuaIIon and conIroI and enIaIIs Ihe IdenIIIIcaIIon oI maIerIaIs and processes IhaI have Ihe poIenIIaI Io cause harm Io workers. InspecIIon oI Ihe workpIace Is Ihe besI source oI dIrecIIy reIevanI daIa abouI heaIIh hazards. There Is no subsIIIuIe Ior observaIIon oI work pracIIces, use oI chemIcaI and physIcaI agenIs, and Ihe apparenI eIIecIIveness oI conIroI measures. The PHC worker shouId be abIe Io recognIze major and obvIous heaIIh hazards and dIsIInguIsh Ihose IhaI requIre IormaI evaIuaIIon by Ihe IndusIrIaI hygIenIsI. Work envronnent: ModuIe 1 23 3.2 PoIenIial healIh hazards A contnnnnnt: These are commonIy cIassIIIed as eIIher parIIcuIaIe or gas and vapour conIamInanIs (a) ParIIcuIaIe conIamInanIs DusIs: soIId parIIcIes generaIed by handIIng, crushIng, grIndIng, coIIIdIng, expIodIng, and heaIIng organIc or InorganIc maIerIaIs such as rock, ore, meIaI, coaI, wood and graIn. Any process IhaI produces dusI IIne enough Io remaIn In Ihe aIr Iong enough Io be InhaIed or IngesIed shouId be regarded as hazardous unIII proven oIherwIse. Iumes: Iormed when maIerIaI Irom a voIaIIIIzed soIId condenses In cooI aIr. In mosI cases, Ihe soIId parIIcIes resuIIIng Irom Ihe condensaIIon reacI wIIh aIr Io Iorm an oxIde. MIsIs: IIquId suspended In Ihe aImosphere. MIsIs are generaIed by IIquIds condensIng Irom a vapour back Io a IIquId or by a IIquId beIng dIspersed by spIashIng or aIomIzIng. AerosoIs: a Iorm oI a mIsI characIerIzed by hIghIy respIrabIe, mInuIe IIquId parIIcIes. IIbres: soIId parIIcIes whose IengIh Is severaI IImes greaIer Ihan IheIr dIameIer, e.g. asbesIos. (b) Gas and vapour conIamInanIs Gases: IormIess IIuIds IhaI expand Io occupy Ihe space or encIosure In whIch Ihey are conIIned. They are aIomIc, dIaIomIc or moIecuIar In naIure as opposed Io dropIeIs or parIIcIes, whIch are made up oI mIIIIons oI aIoms or moIecuIes. Through evaporaIIon, IIquIds change InIo vapours and mIx wIIh surroundIng aImosphere. Vapours: Ihe voIaIIIe Iorm oI subsIances IhaI are normaIIy In a soIId or IIquId sIaIe aI room IemperaIure and pressure. CIcncn Inznd: HarmIuI chemIcaI compounds In Ihe Iorm oI soIIds, IIquIds, gases, mIsIs, dusIs, Iumes and vapours exerI IoxIc eIIecIs by InhaIaIIon (breaIhIng), absorpIIon (Ihrough dIrecI conIacI wIIh Ihe skIn) or IngesIIon (eaIIng or drInkIng). AIrborne chemIcaI hazards exIsI as concenIraIIons oI mIsIs, vapours, gases, Iumes or soIIds. Some are IoxIc Ihrough InhaIaIIon and some oI Ihem IrrIIaIe Ihe skIn on conIacI; some can be IoxIc by absorpIIon Ihrough Ihe skIn or Ihrough IngesIIon and some are corrosIve Io IIvIng IIssue. The degree oI worker rIsk Irom exposure Io any gIven subsIance depends on Ihe naIure and poIency oI Ihe IoxIc eIIecIs and Ihe magnIIude and duraIIon oI exposure. 24 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers oogcn Inznd: These exIsI In exposures Io bacIerIa, vIruses, IungI and oIher IIvIng organIsms IhaI can cause acuIe and chronIc InIecIIons by enIerIng Ihe body eIIher dIrecIIy or Ihrough breaks In Ihe skIn. OccupaIIons IhaI deaI wIIh pIanIs or anImaIs or IheIr producIs, or wIIh Iood and Iood processIng may expose workers Io bIoIogIcaI hazards. LaboraIory and medIcaI personneI aIso can be exposed Io bIoIogIcaI hazards. Any occupaIIons IhaI resuII In conIacI wIIh bodIIy IIuIds expose workers Io bIoIogIcaI hazards. In occupaIIons where anImaIs are InvoIved, bIoIogIcaI hazards are deaII wIIh by prevenIIng and conIroIIIng dIseases In Ihe anImaI popuIaIIon as weII as properIy carIng Ior and handIIng InIecIed anImaIs. AIso, eIIecIIve personaI hygIene, parIIcuIarIy proper aIIenIIon Io mInor cuIs and scraIches especIaIIy on Ihe hands and Iorearms, heIps keep worker rIsks Io a mInImum. In occupaIIons where Ihere Is poIenIIaI exposure Io bIoIogIcaI hazards, workers shouId pracIIce proper personaI hygIene, parIIcuIarIy hand washIng. HospIIaIs shouId provIde proper venIIIaIIon, proper personaI proIecIIve equIpmenI such as gIoves and respIraIors, adequaIe InIecIIous wasIe dIsposaI sysIems and approprIaIe conIroIs IncIudIng IsoIaIIon In InsIances oI parIIcuIarIy conIagIous dIseases, e.g. IubercuIosIs. II):cn Inznd: These IncIude excessIve IeveIs oI noIse, vIbraIIon, IIIumInaIIon and IemperaIure, and IonIzIng and nonIonIzIng eIecIromagneIIc radIaIIon. Noise, Ior exampIe, Is a sIgnIIIcanI physIcaI hazard, whIch can be conIroIIed by: InsIaIIIng equIpmenI and sysIems IhaI have been engIneered, desIgned and buIII Io operaIe quIeIIy encIosIng or shIeIdIng noIsy equIpmenI makIng cerIaIn IhaI equIpmenI Is In good repaIr and Is properIy maInIaIned wIIh aII worn or unbaIanced parIs repIaced mounIIng noIsy equIpmenI on specIaI mounIs Io reduce vIbraIIon InsIaIIIng sIIencers, muIIIers or baIIIes subsIIIuIIng quIeI work meIhods Ior noIsy ones, e.g. weIdIng parIs raIher Ihan rIveIIng Ihem IreaIIng IIoors, ceIIIngs and waIIs wIIh acousIIc maIerIaI Io reduce reIIecIed or reverberanI noIse erecIIng sound barrIers aI adjacenI worksIaIIons around noIsy operaIIons Io reduce worker exposure Io noIse generaIed aI adjacenI worksIaIIons IncreasIng Ihe dIsIance beIween Ihe source and Ihe receIver, e.g. by IsoIaIIng workers In acousIIc booIhs, IImIIIng workers' exposure IIme Io noIse and provIdIng hearIng proIecIIon. Work envronnent: ModuIe 1 25 OccupaIIonaI hygIene reguIaIIons requIre IhaI workers In noIsy surroundIngs be perIodIcaIIy IesIed as a precauIIon agaInsI hearIng Ioss. lonizing radiaIion can be conIroIIed by: ReducIng exposure IIme: danger Irom radIaIIon Increases wIIh Ihe amounI oI IIme one Is exposed Io II. The shorIer Ihe IIme oI exposure Ihe smaIIer Ihe radIaIIon danger. IncreasIng dIsIance: a vaIuabIe IooI In conIroIIIng exposure Io boIh IonIzIng and nonIonIzIng radIaIIon. RadIaIIon IeveIs Irom some sources can be esIImaIed by comparIng Ihe squares oI Ihe dIsIances beIween Ihe worker and Ihe source. ShIeIdIng: Ihe greaIer Ihe proIecIIve mass beIween a radIoacIIve source and Ihe worker, Ihe Iower Ihe radIaIIon exposure. SImIIarIy, shIeIdIng workers Irom nonIonIzIng radIaIIon can aIso be an eIIecIIve conIroI meIhod. In some InsIances, however, IImIIIng exposure Io or IncreasIng dIsIance Irom cerIaIn Iorms oI non-ionizing radiaIion, e.g. Iasers, Is noI eIIecIIve. An exposure Io Iaser radIaIIon IhaI Is IasIer Ihan Ihe bIInkIng oI an eye can be hazardous and wouId requIre workers Io be mIIes Irom Ihe Iaser source beIore beIng adequaIeIy proIecIed. RadianI heaI exposure can be conIroIIed by: InsIaIIIng reIIecIIve shIeIds and by provIdIng proIecIIve cIoIhIng In IacIorIes such as sIeeI mIIIs. Igononc Inznd: The scIence oI ergonomIcs sIudIes and evaIuaIes a IuII range oI Iasks IncIudIng, buI noI IImIIed Io, IIIIIng, hoIdIng, pushIng, waIkIng and reachIng. Many ergonomIc probIems resuII Irom IechnoIogIcaI changes: Increased assembIy IIne speeds addIng specIaIIzed Iasks Increased repeIIIIon. Some probIems arIse Irom poorIy desIgned job Iasks. Any oI Ihose condIIIons can cause ergonomIc hazards: excessIve vIbraIIon noIse eye sIraIn repeIIIIve moIIon heavy IIIIIng probIems poorIy desIgned IooIs or work areas. RepeIIIIve moIIons or repeaIed shocks over proIonged perIods oI IIme as In jobs InvoIvIng sorIIng, assembIIng and daIa enIry can oIIen cause IrrIIaIIon and 2b OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers InIIammaIIon oI Ihe Iendon sheaIh oI Ihe hands and arms, a condIIIon known as carpaI IunneI syndrome. LrgonomIc hazards are avoIded prImarIIy by Ihe eIIecIIve desIgn oI a job or jobsIIe and by beIIer desIgned IooIs or equIpmenI IhaI meeI workers' needs In Ierms oI physIcaI envIronmenI and job Iasks. Through Ihorough worksIIe anaIyses, empIoyers can seI up procedures Io correcI or conIroI ergonomIc hazards by: usIng Ihe approprIaIe engIneerIng conIroIs, e.g. desIgnIng or redesIgnIng work sIaIIons, IIghIIng, IooIs and equIpmenI IeachIng correcI work pracIIces, e.g. shIIIIng workers among severaI dIIIerenI Iasks, reducIng producIIon demand and IncreasIng resI breaks provIdIng and mandaIIng personaI proIecIIve equIpmenI where necessary. LvaIuaIIng workIng condIIIons Irom an ergonomIc sIandpoInI InvoIves IookIng aI Ihe IoIaI physIoIogIcaI and psychoIogIcaI demands oI Ihe job on Ihe worker. OveraII, Ihe beneIIIs oI a weIIdesIgned, ergonomIc work envIronmenI can IncIude Increased eIIIcIency, Iewer accIdenIs, Iower operaIIng cosIs and more eIIecIIve use oI personneI. I:)cIo:ocn ncto: These may IncIude borIng, repeIIIIve Iasks, producIIon pressure, sIress, Iow pay and Iack oI recognIIIon. Accdcnt ncto: The maIn causes oI accIdenIs IncIude: unsaIe mechanIcaI and physIcaI condIIIons unsaIe acIs unsaIe personaI IacIors. 3.3 Techniques used in recognizing healIh hazards Mntcn n\cnto) A maIerIaI InvenIory Is used Ior keepIng an accounI oI raw maIerIaIs, InIermedIaIe and end producIs, wasIe producIs and byproducIs. II Is IaIIored Io meeI Ihe specIIIc requIremenIs oI IocaI cIrcumsIances IakIng InIo consIderaIIon Ihe IoIIowIng. (a) Who wIII use Ihe InvenIory saIeIy advIsers and represenIaIIves occupaIIonaI hygIenIsIs docIors nurses emergency servIce personneI purchasIng sIaII. Work envronnent: ModuIe 1 27 (b) WhaI InIormaIIon Is requIred Ihe naIure oI Ihe maIerIaI, I.e. composIIIon, physIcaI daIa, IIre and expIosIon daIa, basIc IoxIcoIogIcaI and saIeIy daIa, eIc. Ihe use oI Ihe maIerIaI, IncIudIng sIorage, handIIng and conIroI procedures, IIrsI aId, eIc. admInIsIraIIve deIaIIs, I.e. Irade and chemIcaI names, company reIerence numbers, address oI manuIacIures/suppIIers, IabeIIIng and packIng requIremenIs, wasIe dIsposaI, eIc. (c) How Ihe InvenIory wIII be updaIed any new subsIances shouId be consIdered Irom a heaIIh and saIeIy vIewpoInI beIore purchasIng, use and IncIusIon In Ihe InvenIory Ior exIsIIng maIerIaIs, heaIIh and saIeIy sIaII shouId have a sysIem Ior ensurIng, Ihrough IheIr InIormaIIon sources, IhaI Ihe hazard daIa conIaIned In Ihe daIa sheeI Is Ihe besI InIormaIIon currenIIy avaIIabIe Ihe avaIIabIIIIy oI compuIerIzed daIahandIIng sysIems augmenIs Ihe use oI a maIerIaIs InvenIory. Iocc:: n\cnto) The aIm Is Io documenI hazards assocIaIed wIIh each process and Io record how each Is beIng managed and conIroIIed. The process InvenIory shouId IncIude deIaIIs oI: Ihe process Ihe maIerIaIs InvoIved (IncIudIng InIermedIaIe and wasIes) poInIs oI maIerIaI enIry and exII normaI operaIIng procedures poIenIIaI hazards Ihe poIenIIaI Ior emIssIons InIo Ihe aImosphere Ihe poIenIIaI Ior exposure arrangemenIs Ior engIneerIng conIroIs oIher precauIIons IncIudIng proIecIIve equIpmenI. The process InvenIory aIso provIdes Ihe opporIunIIy Io documenI hazards oIher Ihan Ihose assocIaIed wIIh chemIcaIs, e.g. heaI, noIse and radIaIIon, and Io IncIude dIsposaI procedures Ior hazardous wasIe producIs. The InvenIory couId be based on: IIow oI a parIIcuIar producI or maIerIaI deparImenIaI or equIpmenI IIow geographIc IocaIIon. 2 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers Wn-tIougI occuntonn I)gcnc :u\c) A waIkIhrough survey oI Ihe premIses permIIs observaIIon oI aII pIanI operaIIons and Is carrIed ouI Io make a preIImInary assessmenI oI poIenIIaI hazards. PossIbIe sources and poIenIIaI conIamInanIs Irom specIIIc Iypes oI processes can be IdenIIIIed (see appendIx 1.1). The waIkIhrough survey provIdes an ImporIanI opporIunIIy Io meeI pIanI personneI and Io InIeracI wIIh engIneers, Ioremen and oIher workers who know Ihe process probIems and are aware oI compIaInIs or sympIoms among workers. (a) GeneraI prIncIpIes addressed by Ihe waIkIhrough survey hazards presenI In Ihe work pIace esIImaIed/IIkeIy scaIe oI Ihe IdenIIIIed hazards Ihe conIroI measures currenIIy In Iorce Ior each hazard procedures ImpIemenIed Io maInIaIn Ihe conIroI measures Ihe monIIorIng requIred. (b) Survey meIhods Surveys are usuaIIy carrIed ouI wIIhouI Ihe use oI measurIng InsIrumenIs. Much oI Ihe InIormaIIon requIred can be assembIed In advance oI Ihe survey (see an occupaIIonaI/IndusIrIaI survey check IIsI In appendIx 1.2). The IoIIowIng aIds are requIred Io carry ouI Ihe work: survey reporI Iorms noIepad or dIcIaIIon machIne pIan oI premIses camera smoke Iubes. The occupaIIonaI hygIenIsI (or whoever Is nomInaIed Io underIake Ihe Iask by Ihe PHC workers) proceeds Ihrough each oI Ihe work areas, preIerabIy In accordance wIIh Ihe workIng IuncIIons, oIIen commencIng wIIh producIIon Irom goods Inward Io dIspaIch, and preIerabIy accompanIed In each area oI Ihe premIses by eIIher a IocaI supervIsor or engIneer wIIh generaI responsIbIIIIIes. Sources oI InIormaIIon used durIng Ihe survey are: workers InvoIved In IheIr daIIy Iasks senses oI smeII, hearIng and Iouch Ior deIecIIon oI odours, heaI and noIse phoIography Ior documenIIng Ihe generaI vIsuaI appearance oI each envIronmenI and any acIIvIIy deservIng IurIher aIIenIIon smoke Iube IesI Ior IocaI exhausI venIIIaIIon observaIIon, Ihe key Io an eIIecIIve survey, noIIng any ergonomIcs probIems, e.g. poorIy desIgned IIghIIng, unsaIe workIng pracIIces, unguarded equIpmenI, eIc. Work envronnent: ModuIe 1 29 (c) ReporIs The reporI shouId be wrIIIen cIearIy and concIseIy and shouId be sIrucIured as IoIIows: InIroducIIon summary oI ImmedIaIe hazards and acIIon Iaken or recommended Io resoIve Ihe probIem permanenIIy and/or IemporarIIy pendIng IurIher evaIuaIIon summary oI hazards requIrIng IurIher monIIorIng/evaIuaIIon waIkIhrough survey reporI Iorms as compIeIed durIng survey dIscussIons oI meIhods arIsIng Irom survey proposed occupaIIonaI hygIene work pIan. (d) Summary oI a survey a survey Is a preIImInary assessmenI desIgned Io IdenIIIy hazards and conIroI measures, carrIed ouI by compeIenI sIaII wIIh Ihe heIp oI IocaI supervIsIng sIaII II shouId be comprehensIve by IocaIIon and by IIme Ior cycIIcaI/occasIonaI processes II Is a necessary preIude Io deIaIIed InvesIIgaIIons oI specIIIc hazards II Is necessary Io gaIher a range oI daIa perIaInIng Io Ihe subjecI In order Io IuIIy prepare Ior Ihe survey Ihe Iwo maIn eIemenIs oI Ihe survey daIa source are Ihe workIorce and observaIIon phoIography Is very ImporIanI reporIs shouId be sIrucIured careIuIIy and be concIse. A-:nnng ognnnc: An aIrsampIIng programme musI be desIgned Io answer specIIIc quesIIons oIherwIse II may noI IuIIII Ihe need Ior whIch II was InIIIaIed, e.g. a prospecIIve epIdemIoIogIcaI programme requIres random sampIIng In order Ior sIaIIsIIcaI predIcIIons Io be vaIId. SampIIng Ior worker proIecIIon, on Ihe oIher hand, wIII requIre seIecIIon oI persons aI maxImum rIsk. Reasons Ior sampIIng are varIed and may IncIude Ihe IoIIowIng: heaIIh rIsk evaIuaIIon: Io measure worker exposure In order Io esIImaIe Ihe rIsk oI undesIrabIe heaIIh eIIecIs and Ihe need Ior conIroI measures envIronmenIaI proIecIIon: Io deIermIne Ihe amounI oI any IoxIc or hazardous maIerIaIs reIeased Io Ihe envIronmenI compIIance: Io ensure IhaI exposure IeveIs Ior workers or envIronmenIaI reIeases are wIIhIn reguIaIory IImIIs and Io saIIsIy IegIsIaIIve monIIorIng requIremenIs 3U OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers process conIroI: Io evaIuaIe Ihe perIormance oI engIneerIng or oIher process conIroIs and Io ensure IhaI conIamInanI conIroI remaIns adequaIe source IdenIIIIcaIIon: Io IInd and conIroI conIamInanI sources documenIaIIon oI exposure: Io maInIaIn records oI exposure Ior prospecIIve sIudIes or Ior InsIIIuIIonaI proIecIIon agaInsI IuIure IegaI acIIon. The sampIIng sIraIegy Ior each oI Ihe sIaIed purposes wIII requIre dIIIerenI proIocoIs and sampIIng sysIems. The Iypes oI sampIes reIer Io wheIher a personaI exposure sampIe shouId be coIIecIed In Ihe breaIhIng zone oI a worker, or wheIher an area, sIack or oIher envIronmenIaI sampIe Is preIerabIe. SampIIng Irom exhausI sIacks Is commonIy done Ior process and emIssIon conIroI. HeaIIh proIecIIon requIres personaI exposure monIIorIng. Occupational hygiene sampling protocols Furpose Type o] snmpIe HeaIth rIsk evaIuatIon PersonaI EnvIronmentaI protectIon Area, envIronmentaI CompIIance PersonaI, envIronmentaI, stack Process controI Area, personaI, stack Source IdentIIIcatIon Area, stack DocumentatIon oI exposure PersonaI 4. EVALUATlON Ol HEALTH HAZARDS LvaIuaIIon oI heaIIh hazards wIIhIn a pIanI IncIudes measuremenI oI exposures (and poIenIIaI exposures), comparIson oI Ihose exposures Io exIsIIng sIandards and recommendaIIon oI conIroIs II needed. 4.1 Exposure measuremenI Iechniques These IechnIques are based on Ihe naIure oI hazards and Ihe rouIes oI envIronmenIaI conIacI wIIh Ihe worker, e.g. aIr sampIIng can show Ihe concenIraIIon oI IoxIc parIIcuIaIes, gases and vapours IhaI workers may InhaIe skIn wIpes can be used Io measure Ihe degree oI skIn conIacI wIIh IoxIc maIerIaIs IhaI may peneIraIe Ihe skIn noIse dosImeIers record and eIecIronIcaIIy InIegraIe workpIace noIse IeveIs Io deIermIne IoIaI daIIy exposure. 5cccton nnd cnnton o n:tuncnt: InsIrumenIs are generaIIy cIassIIIed as IoIIows: dIrecI readIng InsIrumenIs sampIIng InsIrumenIs whIch remove Ihe conIamInanI (Ior subsequenI IaboraIory anaIysIs) Irom a measured quanIIIy oI aIr Work envronnent: ModuIe 1 31 sampIIng InsIrumenIs whIch coIIecI a known voIume oI aIr Ior subsequenI IaboraIory anaIysIs. AII Ihese Iypes oI equIpmenI musI be caIIbraIed agaInsI a sIandard aIr IIow measurIng devIce beIore and aIIer use In Ihe IIeId. IurIhermore, dIrecI readIng InsIrumenIs musI be caIIbraIed agaInsI a known concenIraIIon oI Ihe subsIance Ior whIch Ihey are used. I:tn:Ing oc nnn)tcn nctIod: The use oI accuraIe, sensIIIve, specIIIc and reproducIbIe anaIyIIcaI meIhods Is as ImporIanI as Ihe proper caIIbraIIon oI Ihe sampIIng equIpmenI. Among dIIIIcuIIIes IhaI shouId be overcome In Ihe measuremenIs (sampIIng/anaIysIs) are: InIerIerence and reacIIons when deaIIng wIIh mIxIures oI chemIcaIs, whIch Is oIIen Ihe case IIucIuaIIons In concenIraIIon. OIher IacIors aIIecIIng a worker's upIake oI Ihe conIamInanIs IncIude: rouIes oI enIry oI maIerIaI oIher Ihan respIraIIon, e.g. skIn absorpIIon physIcaI acIIvIIy oI workers, whIch aIIecIs Ihe respIraIIon raIe wheIher or noI respIraIors are used In Ihe workpIace. When avaIIabIe, sIandard meIhods oI anaIysIs shouId be used such as Ihose recommended by: WHO InIernaIIonaI OrganIzaIIon Ior SIandardIzaIIon Luropean CommunIIy AmerIcan IndusIrIaI HygIene AssocIaIIon (AHIA) AnaIyIIcaI CommIIIee U.S. NaIIonaI InsIIIuIe Ior OccupaIIonaI SaIeIy and HeaIIh (NIOSH) U.S. OccupaIIonaI SaIeIy and HeaIIh AdmInIsIraIIon (OSHA) AmerIcan ConIerence oI GovernmenIaI IndusIrIaI HygIenIsIs (ACGIH) The AmerIcan PubIIc HeaIIh AssocIaIIon (APHA) The AmerIcan NaIIonaI SIandards InsIIIuIe (ANSI). 5tntcg) o :nnng nnd ncn:ucncnt Lvery eIIorI musI be made Io geI measuremenIs (or sampIes) IhaI represenI Ihe workers' exposures. ThIs Is achIeved by answerIng Ihe IoIIowIng: Where Io sampIe7 Whom Io sampIe7 How Iong Io sampIe7 32 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers How many sampIes Io Iake7 When Io sampIe7 A suIIIcIenI number oI sampIes musI be coIIecIed or readIngs made wIIh dIrecI readIng InsIrumenIs, Ior Ihe proper duraIIon, Io permII Ihe assessmenI oI daIIy, IImeweIghIed average (TWA) exposures and Io evaIuaIe peak exposure concenIraIIons when needed. 4.2 lnIerpreIaIion ol lindings A greaI deaI oI judgemenI musI be used In InIerpreIaIIon and reporIIng Ihe resuIIs. The InvesIIgaIor musI have Ihe IoIIowIng IacIs: naIure oI subsIance or physIcaI agenIs InIensIIy (concenIraIIon) oI exposure duraIIon oI exposure. The hygIenIsI's decIsIon on wheIher a hazard Is presenI Is based on Ihree sources oI InIormaIIon: scIenIIIIc IIIeraIure and varIous exposure IImII guIdes Ihe IegaI requIremenIs oI Ihe naIIonaI occupaIIonaI heaIIh and saIeIy reguIaIIons InIeracIIons wIIh oIher heaIIh proIessIonaIs who have examIned Ihe exposed workers and evaIuaIed IheIr heaIIh sIaIus. OccupaIIonaI exposure IImIIs reIer Io aIrborne concenIraIIons oI subsIances condIIIons under whIch II Is beIIeved IhaI nearIy aII workers may be repeaIedIy exposed day aIIer day wIIhouI adverse heaIIh eIIecI. They are based on avaIIabIe InIormaIIon Irom IndusIrIaI experIence, Irom experImenIaI human and anImaI sIudIes; and, when possIbIe, Irom a combInaIIon oI Ihe Ihree 4.3 Recommended exposure limiIs Many sIandards have been recommended by dIIIerenI naIIonaI and InIernaIIonaI agencIes. The mosI popuIar and comprehensIve however are Ihe IIsI oI IhreshoId IImII vaIues (TLVs) Ior chemIcaI subsIances and physIcaI agenIs and Ihe bIoIogIcaI exposure IndIces (BLIs) Issued by Ihe AmerIcan ConIerence oI GovernmenIaI IndusIrIaI HygIenIsIs (ACGIH). There are Ihree caIegorIes oI TLV: TImeweIghIed average (TWA8): Ihe empIoyee's average aIrborne exposure In any 8-hour work shIII oI a 40-hour work week, whIch shaII noI be exceeded. ShorIIerm exposure IImII (STLL): Ihe empIoyee's 1S-mInuIe TWA exposure, whIch shaII noI be exceeded aI any IIme durIng a work day unIess anoIher IIme IImII Is specIIIed In a parenIheIIcaI noIaIIon beIow Ihe IImII. II anoIher IIme perIod Is specIIIed, Ihe TWA exposure over IhaI IIme IImII shaII noI be exceeded aI any IIme over a work day. Work envronnent: ModuIe 1 33 CeIIIngC: Ihe empIoyee's exposure, whIch shaII noI be exceeded durIng any parI oI Ihe work day. II InsIanIaneous monIIorIng Is noI IeasIbIe, Ihe ceIIIng shaII be assessed as a 1S-mInuIe TWA exposure, whIch shaII noI be exceeded aI any IIme over a work day. ConsIderaIIons are IncIuded Ior: skIn noIaIIon (Ior probabIe skIn absorpIIon) mIxIures (Ior exposure Io mIxIures oI conIamInanIs) IoIaI, InhaIabIe, IhoracIc and respIrabIe parIIcuIaIe maIIer ParIIcuIaIe noI oIherwIse cIassIIIed (PNOC) sImpIe asphyxIaIes: InerI gases or vapours BIoIogIcaI exposure IndIces (BLI) physIcaI IacIors unusuaI work scheduIes. 5. CONTROLLlNG HAZARDS OccupaIIonaI/IndusIrIaI hygIenIsIs recognIze IhaI engIneerIng, work pracIIce and admInIsIraIIve conIroIs are Ihe prImary means oI reducIng empIoyee exposure Io occupaIIonaI hazards. 5.1 Engineering conIrols These mInImIze empIoyee exposure by eIIher reducIng or removIng Ihe hazard aI Ihe source or IsoIaIIng Ihe worker Irom Ihe hazard. They IncIude: eIImInaIIng IoxIc chemIcaIs and subsIIIuIIng nonIoxIc chemIcaIs encIosIng work processes or conIInIng work operaIIons InsIaIIIng generaI and IocaI venIIIaIIon sysIems. 5.2 Work pracIice conIrols These aIIer Ihe manner In whIch a Iask Is perIormed. Some IundamenIaI and easIIy ImpIemenIed work pracIIce conIroIs IncIude: changIng exIsIIng work pracIIces Io IoIIow proper procedures IhaI mInImIze exposures whIIe operaIIng producIIon and conIroI equIpmenI InspecIIng and maInIaInIng process and conIroI equIpmenI on a reguIar basIs ImpIemenIIng good housekeepIng procedures provIdIng good supervIsIon prohIbIIIng eaIIng, drInkIng, smokIng, chewIng Iobacco or gum and appIyIng cosmeIIcs In reguIaIed areas. 34 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 5.3 AdminisIraIive conIrols These IncIude: ConIroIIIng empIoyees' exposure by scheduIIng producIIon and Iasks, or boIh, In ways IhaI mInImIze exposure IeveIs; e.g. Ihe empIoyer mIghI scheduIe operaIIons wIIh hIghesI exposure poIenIIaI durIng perIods when Ihe IewesI empIoyees are presenI. When eIIecIIve work pracIIces or engIneerIng conIroIs are noI IeasIbIe or whIIe such conIroIs are beIng InsIIIuIed, approprIaIe personaI proIecIIve equIpmenI musI be used, e.g. gIoves, saIeIy goggIes, heImeIs, saIeIy shoes, proIecIIve cIoIhIng and respIraIors. To be eIIecIIve, personaI proIecIIve equIpmenI musI be IndIvIduaIIy seIecIed, properIy IIIIed and perIodIcaIIy reIIIIed, conscIenIIousIy and properIy worn, reguIarIy maInIaIned and repIaced as necessary. 6. TASKS lOR TRAlNEES AcquaInI yourseII wIIh IocaI IndusIrIes, occupaIIons, workers' popuIaIIon and avaIIabIe occupaIIonaI heaIIh and saIeIy servIces, eIc. Survey workpIaces (usIng Ihe waIkIhrough meIhod) In IormaI and InIormaI secIors, agrIcuIIure, smaIIscaIe IndusIrIes and oIher Irades; IamIIIarIze yourseII and coIIecI daIa on IechnIcaI operaIIons, maIerIaIs processed and handIed, Iabour; and Iry Io dIscover and deIIne hazards. ReporI and reIer hazards Io concerned bodIes and IoIIowup on IheIr acIIons. Assess envIronmenIaI hazards usIng sImpIe, convenIIonaI meIhods and dIrecI readIng InsIrumenIs; InspecI avaIIabIe conIroI measures and equIpmenI and IesI IheIr eIIIcIency (e.g. usIng smoke Iubes); and seek advIce Ior InIerpreIaIIon oI resuIIs and makIng suggesIIons Ior conIroIs. ParIIcIpaIe In daIa coIIecIIon and anaIysIs on workers' heaIIh. Be ready Io heIp In an emergency and be abIe Io admInIsIer IIrsI aId. CoordInaIe wIIh oIher proIessIonaIs In areas such as: workers' educaIIon InvesIIgaIIng compIaInIs vocaIIonaI rehabIIIIaIIon workers' socIaI weIIare oIher maIIers reIevanI Io opIImaI work pIace and work envIronmenI and Io workers' heaIIh. Work envronnent: ModuIe 1 35 APPENDlX 1.1 POTENTlALLY HAZARDOUS OPERATlONS AND ASSOClATED AlR CONTAMlNANTS 1 Frocess types Contnmnnnt type Contnmnnnt exnmpIes Hot operntons WeIdIng Cases (g) Chromates (p) ChemIcaI reactIons PartIcuIates (p) ZInc and compounds (p) SoIderIng (Dust, Iumes, mIsts) Manganese and compounds (p) MeItIng MouIdIng urnIng Lqud operntons PaIntIng Vapours (v) enzene (v) DegreasIng Cases (g) TrIchIorethyIene (v) DIppIng MIsts (m) MethyIene chIorIde (v) SprayIng T,T,TTrIchIoroethyIene (v) rushIng HydrochIorIc acId (m) CoatIng SuIIurIc acId (m) EtchIng Hydrogen chIorIde (g) CIeanIng CyanIde saIts (m) Dry cIeanIng ChromIc acId (m) PIckIIng Hydrogen cyanIde (g) PIatIng mIxIng TD, MD (v) CaIvanIzIng Hydrogen suIIIde (g) ChemIcaI reactIons SuIIur dIoxIde (g) Carbon tetrachIorIde (v) 5oId operntons PourIng Dusts Cement MIxIng Quartz (Iree sIIIca) SeparatIon FIbrous gIass ExtractIon CrushIng ConveyIng LoadIng aggIng Fressurzed sprnyng CIeanIng parts Vapours (v) OrganIc soIvents (v) AppIyIng pestIcIdes Dust (d) ChIordane (m) DegreasIng MIst (m) ParathIon (m) Sand bIastIng TrIchIoroethyIene (v) PaIntIng T,T,TTrIchIoroethane (v) MethyIene chIorIde (v) Quartz (Iree sIIIca, d) 5hnpng operntons CuttIng Dusts Asbestos CrIndIng eryIIIum FIIIng UranIum MIIIIng ZInc MouIdIng Lead SawIng DrIIIIng 1 LeIdeI NA, Busch KA, Lynch |R. Occuntonn cxo:uc :nnng :tntcg) nnnun. CIncInnaII, OhIo, US DeparImenI oI HeaIIh, LducaIIon and WeIIare, 1977:77-17S. 3b OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers APPENDlX 1.2 AN OCCUPATlONAL HYGlENE SURVEY CHECK LlST 1. DeIermIne purpose and scope oI sIudy: ComprehensIve occupaIIonaI hygIene survey7 LvaIuaIIon oI exposures oI IImIIed group oI workers Io specIIIc agenIs7 DeIermInaIIon oI compIIance wIIh specIIIc recognIzed sIandards7 LvaIuaIIon oI compIIance wIIh specIIIc recognIzed sIandards7 Response Io specIIIc compIaInI7 2. DIscuss purpose oI sIudy wIIh approprIaIe represenIaIIves oI managemenI and Iabour. S. IamIIIarIze yourseII wIIh pIanI operaIIons: ObIaIn and sIudy process IIow sheeIs and pIanI IayouI. CompIIe an InvenIory oI raw maIerIaIs, InIermedIaIes byproducIs and producIs. RevIew reIevanI IoxIcoIogIcaI InIormaIIon. ObIaIn a IIsI oI job cIassIIIcaIIons and Ihe envIronmenIaI sIresses Io whIch workers are poIenIIaIIy exposed. Observe Ihe acIIvIIIes assocIaIed wIIh job cIassIIIcaIIon. RevIew reporIs oI prevIous sIudIes. DeIermIne subjecIIveIy Ihe poIenIIaI heaIIh hazards assocIaIed wIIh pIanI operaIIons. RevIew adequacy oI IabeIIIng and warnIng. 4. Prepare Ior IIeId sIudy: DeIermIne whIch chemIcaI and physIcaI agenIs are Io be evaIuaIed. LsIImaIe, II possIbIe, ranges oI conIamInanI concenIraIIons. RevIew, or deveIop II necessary, sampIIng and anaIyIIc meIhods, payIng parIIcuIar aIIenIIon Io Ihe IImIIaIIons oI Ihe meIhods. CaIIbraIe IIeId equIpmenI as necessary. AssembIe aII IIeId equIpmenI. ObIaIn personaI proIecIIve equIpmenI as requIred (hard haI, saIeIy gIasses, hearIng proIecIIon, respIraIory proIecIIon, saIeIy shoes, coveraIIs, gIoves, eIc.). Prepare a IenIaIIve sampIIng scheduIe. Work envronnent: ModuIe 1 37 RevIew occupaIIonaI heaIIh and saIeIy reguIaIIons beIng appIIed by Ihe heaIIh auIhorIIIes. S. ConducI IIeId sIudy: ConIIrm process operaIIng scheduIe wIIh supervIsory personneI. AdvIse represenIaIIves oI managemenI and Iabour oI your presence In Ihe area. DepIoy personaI monIIorIng or generaI area sampIIng unIIs. Ior each sampIe, record Ihe IoIIowIng daIa: sampIe IdenIIIIcaIIon number descrIpIIon oI sampIe (as deIaIIed as possIbIe) IIme sampIIng began IIow raIe oI sampIed aIr (check IrequenIIy) IIme sampIIng ended any oIher InIormaIIon or observaIIon IhaI mIghI be sIgnIIIcanI (e.g., process upseIs, venIIIaIIon sysIem noI operaIIng, use oI personaI proIecIIon) DIsmanIIe sampIIng unIIs. SeaI and IabeI adequaIeIy aII sampIes (IIIIers, IIquId soIuIIons, charcoaI or sIIIca geI Iubes, eIc.) IhaI requIre subsequenI IaboraIory anaIyses. 6. InIerpreI resuIIs oI sampIIng programme: ObIaIn resuIIs oI aII anaIyses. DeIermIne IImeweIghIed average exposures oI job cIassIIIcaIIon evaIuaIed. DeIermIne peak exposures oI workers. DeIermIne sIaIIsIIcaI reIIabIIIIy oI daIa, e.g. esIImaIe probabIe error In deIermInaIIon oI average exposures. Compare sampIIng resuIIs wIIh appIIcabIe IndusIrIaI hygIene sIandards and reguIaIIons. 7. DIscuss survey resuIIs wIIh approprIaIe represenIaIIves oI managemenI and Iabour. 8. ImpIemenI correcIIve acIIon comprIsed oI, as approprIaIe: LngIneerIng conIroIs (IsoIaIIon, venIIIaIIon, eIc.). AdmInIsIraIIve conIroIs (job roIaIIon, reduced work IIme, eIc.). PersonaI proIecIIon. BIoIogIc sampIIng programme. MedIcaI surveIIIance. LducaIIon and IraInIng. 3 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 9. DeIermIne wheIher oIher heaIIh and saIeIy consIderaIIons warranI IurIher evaIuaIIon: AIr poIIuIIon7 WaIer poIIuIIon7 SoIId wasIe dIsposaI7 SaIeIy7 HeaIIh physIcs7 10. ScheduIe reIurn vIsII(s) Io evaIuaIe eIIecIIveness oI conIroIs: WaIkIhrough and observaIIon. MeasuremenIs. MODULE 2 Occupational and other workrelated diseases 1. OB|ECTlVES UndersIand Ihe reIaIIonshIp beIween work and heaIIh UndersIand Ihe InIeracIIon oI man, envIronmenI and work Know Ihe varIous Iypes oI sIresses or hazards IhaI may be presenI In dIIIerenI Iypes oI occupaIIons IncIudIng IndusIry, agrIcuIIure eIc. Know Ihe concepI oI occupaIIonaI and workreIaIed dIseases and Ihe concepI oI aggravaIIon RecognIze generaI heaIIh probIems oI workers and wheIher or noI Ihey are workreIaIed Survey Ihe workpIace, recognIze sIgns and sympIoms oI earIy ImpaIrmenI oI heaIIh and carry ouI sImpIe IesIs Io supporI Ihe dIagnosIs oI an occupaIIonaI and/or workreIaIed dIsease GIve advIce Io managemenI regardIng Ihe conIroI and prevenIIon oI Ihe IdenIIIIed hazards GIve advIce Io workers and educaIe Ihem regardIng Ihe naIure oI hazards Ihey are exposed Io, conIroI measures, personaI hygIene, earIy sympIoms and IIrsI aId ReIer paIIenIs and aIIecIed workers Ior IurIher InvesIIgaIIon and IreaImenI ConsuII wIIh Ihe reIaIed auIhorIIy on envIronmenIaI monIIorIng oI Ihe workpIace and on ImpIemenIaIIon and maInIenance oI conIroI measures (especIaIIy engIneerIng) Know Ihe Iaws, ruIes and reguIaIIons governIng occupaIIonaI saIeIy and heaIIh IncIudIng hazard conIroI aI Ihe workpIace, recommended sIandards and IhreshoId IImII vaIues, prepIacemenI and perIodIc medIcaI examInaIIons, scheduIe oI occupaIIonaI dIseases (as appIIcabIe), Insurance and compensaIIons Ior occupaIIonaI dIsease and accIdenIs Keep medIcaI records IncIudIng personaI medIcaI IIIes, records oI accIdenIs and occupaIIonaI dIseases, records oI prepIacemenI and perIodIc examInaIIons Keep records oI envIronmenIaI monIIorIng, saIeIy acIIvIIIes, workpIace surveys and reporI on heaIIh and saIeIy Irends aI Ihe workpIace. 4U OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 2. lNTRODUCTlON AND BASlC CONCEPTS 2.1 OccupaIional and work-relaIed disease "OccupaIIonaI dIseases . sIand aI one end oI Ihe specIrum oI workreIaIedness where Ihe reIaIIonshIp Io specIIIc causaIIve IacIors aI work has been IuIIy esIabIIshed and Ihe IacIors concerned can be IdenIIIIed, measured, and evenIuaIIy conIroIIed. AI Ihe oIher end |are] dIseases |IhaI] may have a weak, InconsIsIenI, uncIear reIaIIonshIp Io workIng condIIIons; In Ihe mIddIe oI Ihe specIrum Ihere Is a possIbIe causaI reIaIIonshIp buI Ihe sIrengIh and magnIIude oI II may vary." 1 2.2 Degree ol work-relaIedness The degree oI workreIaIedness oI a workconnecIed dIsease condIIIon varIes In dIIIerenI sIIuaIIons and deIermInes wheIher a dIsease Is consIdered an occupaIIonaI dIsease, a workreIaIed dIsease or aggravaIIon oI a concurrenI dIsease, e.g. A specIIIc agenI IIke Iead or sIIIca, whIch Is presenI essenIIaIIy In Ihe workpIace, causes a dIsease condIIIon whIch cannoI occur due Io oIher causes; IhIs Is an occupaIIonaI dIsease. Where InIecIIon can occur aI Ihe workpIace, an occupaIIonaI dIsease can aIso be caused by a specIIIc agenI, such as IubercuIosIs among heaIIh care workers In a IubercuIosIs IreaImenI cenIre. OI course InIecIIon can aIso occur In Ihe generaI popuIaIIon under nonoccupaIIonaI condIIIons. WorkreIaIed dIseases occur much more IrequenIIy Ihan occupaIIonaI dIseases. They are caused by Ihe InIeracIIon oI severaI exIrInsIc rIsk IacIors and a number oI InIrInsIc IacIors each oI whIch may or may noI operaIe In any IndIvIduaI case. OccupaIIonaI hazards are among Ihe rIsk IacIors whIch can conIrIbuIe Io Ihe occurrence oI workreIaIed dIseases. LxampIes are many and IncIude: - behavIouraI responses - psychosomaIIc IIIness - hyperIensIon - coronary hearI dIsease - chronIc nonspecIIIc respIraIory dIsease - IocomoIor dIsorders. Work condIIIons can aggravaIe preexIsIIng dIsease: hepaIIc dysIuncIIon can be aggravaIed by exposure Io cerIaIn chIorInaIed hydrocarbons; bronchIaI asIhma can be aggravaIed by dusI exposure and renaI dIsease can be aggravaIed by InorganIc mercury, cadmIum and cerIaIn soIvenIs. 1 Idcntcnton nnd conto o \o-cntcd d:cn:c:. ReporI oI a WHO LxperI CommIIIee (WHO TechnIcaI ReporI SerIes No. 714), Geneva, WorId HeaIIh OrganIzaIIon, 198S. OccuntonnI nnd other work-reInted dsenses: ModuIe 2 41 Lxposure Io combInaIIons oI occupaIIonaI hazards may resuII In synergIsIIc eIIecIs whIch are much more pronounced Ihan eIIecIs oI IndIvIduaI exposures sImpIy added IogeIher. IndIvIduaI suscepIIbIIIIy Io Ihe eIIecIs oI some occupaIIonaI exposures varIes. GeneIIc IacIors are ImporIanI deIermInanIs oI IndIvIduaI suscepIIbIIIIy. 3. OCCUPATlONAL DlSEASES 3.1 DeliniIion OccupaIIonaI dIseases are adverse heaIIh condIIIons In Ihe human beIng, Ihe occurrence or severIIy oI whIch Is reIaIed Io exposure Io IacIors on Ihe job or In Ihe work envIronmenI. Such IacIors can be: PhysIcaI: e.g. heaI, noIse, radIaIIon ChemIcaI: e.g. soIvenIs, pesIIcIdes, heavy meIaIs, dusI BIoIogIcaI: e.g. IubercuIosIs, hepaIIIIs B vIrus, HIV LrgonomIc: e.g. ImproperIy desIgned IooIs or work areas, repeIIIIve moIIons PsychosocIaI sIressors: e.g. Iack oI conIroI over work, InadequaIe personaI supporI MechanIcaI: Ihese maInIy cause work accIdenIs and InjurIes raIher Ihan occupaIIonaI dIseases. 3.2 CharacIerisIics ol occupaIional diseases The occupaIIonaI cause oI occupaIIonaI dIsease Is oIIen overIooked by heaIIh care provIders. ThIs Is due Io severaI specIaI characIerIsIIcs oI occupaIIonaI dIsease IhaI may obscure IIs occupaIIonaI orIgIn. The cIInIcaI and paIhoIogIcaI presenIaIIon oI mosI occupaIIonaI dIseases Is IdenIIcaI Io IhaI oI nonoccupaIIonaI dIseases; e.g. asIhma (excessIve aIrway narrowIng In Ihe Iungs) due Io aIrborne exposure Io IoIuene dIIsocyanaIe Is cIInIcaIIy IndIsIInguIshabIe Irom asIhma due Io oIher causes. OccupaIIonaI dIsease may occur aIIer Ihe IermInaIIon oI exposure. An exIreme exampIe wouId be asbesIosreIaIed mesoIheIIoma (a cancer aIIecIIng Ihe Iung and abdomen) whIch can occur S0 or 40 years aIIer Ihe exposure. The cIInIcaI manIIesIaIIons oI occupaIIonaI dIsease are reIaIed Io Ihe dose and IImIng oI exposure; e.g. aI very hIgh aIrborne concenIraIIons, eIemenIaI mercury Is acuIeIy IoxIc Io Ihe Iungs and can cause puImonary IaIIure, whIIe aI Iower IeveIs oI exposure, eIemenIaI mercury has no paIhoIogIc eIIecI on Ihe Iungs buI can have chronIc adverse eIIecIs on Ihe cenIraI and perIpheraI nervous sysIems. OccupaIIonaI IacIors can acI In combInaIIon wIIh nonoccupaIIonaI IacIors Io produce dIsease; e.g. exposure Io asbesIos aIone Increases Ihe rIsk oI Iung 42 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers cancer IIveIoId; and Ihe IongIerm smokIng oI cIgareIIes Increases Ihe rIsk oI Iung cancer beIween S0 and 70 IoId. 3.3 PrevenIion ol occupaIional diseases Inn) c\cnton PrImary prevenIIon Is accompIIshed by reducIng Ihe rIsk oI dIsease. In Ihe occupaIIonaI seIIIng, IhIs Is mosI commonIy done by reducIng Ihe magnIIude oI exposure Io hazardous subsIances. As Ihe dose Is reduced so Is Ihe rIsk oI adverse heaIIh consequences. Such reducIIons are IypIcaIIy managed by IndusIrIaI hygIene personneI and are besI accompIIshed by changes In producIIon process or assocIaIed InIrasIrucIure, e.g. Ihe subsIIIuIIon oI a hazardous subsIance wIIh a saIer one, or encIosure or specIaI venIIIaIIon oI equIpmenI or processes IhaI IIberaIe aIrborne hazards. These are known as engIneerIng conIroIs. OIher meIhods oI exposure reducIIon IncIude use oI personaI proIecIIve equIpmenI and roIaIIon oI workers Ihrough areas In whIch hazards are presenI Io reduce Ihe dose Io each worker (NB: IhIs meIhod does, however, Increase Ihe number oI workers exposed Io Ihe hazard). 5ccondn) c\cnton ThIs Is accompIIshed by IdenIIIyIng heaIIh probIems beIore Ihey become cIInIcaIIy apparenI (I.e. beIore workers reporI IeeIIng III) and InIervenIng Io IImII Ihe adverse eIIecIs oI Ihe probIem. ThIs Is aIso known as occupaIIonaI dIsease surveIIIance. The underIyIng assumpIIon Is IhaI such earIy IdenIIIIcaIIon wIII resuII In a more IavourabIe ouIcome. An exampIe oI secondary prevenIIon Is Ihe measuremenI oI bIood Iead IeveIs In workers exposed Io Iead. An eIevaIed bIood Iead IeveI IndIcaIes a IaIIure oI prImary prevenIIon buI can aIIow Ior correcIIve acIIon beIore cIInIcaIIy apparenI Iead poIsonIng occurs. CorrecIIve acIIon wouId be Io Improve Ihe prImary prevenIIon acIIvIIIes IIsIed above. Tctn) c\cnton ThIs Is accompIIshed by mInImIzIng Ihe adverse cIInIcaI eIIecIs on heaIIh oI a dIsease or exposure. TypIcaIIy IhIs Is IhoughI oI as cIInIcaI occupaIIonaI medIcIne. An exampIe oI IerIIary prevenIIon Is Ihe IreaImenI oI Iead poIsonIng (headache, muscIe and joInI paIn, abdomInaI paIn, anaemIa, kIdney dysIuncIIon) by admInIsIraIIon oI cheIaIIng medIcaIIon. The goaI Is Io IImII sympIoms or dIscomIorI, mInImIze Injury Io Ihe body and maxImIze IuncIIonaI capacIIy. OccuntonnI nnd other work-reInted dsenses: ModuIe 2 43 3.4 Physical hazards aI Ihe workplace TIcnn :tc:: (a) ThermaI envIronmenI The IemperaIure oI Ihe human body when heaIIhy Is aI a consIanI oI around S7 C Ihrough a dynamIc baIance beIween heaI producIIon and heaI Ioss. The heaI reguIaIIng cenIre In Ihe hypoIhaIamus conIroIs IhIs baIance. HeaI Is produced by Ihe meIaboIIc processes, by muscuIar acIIvIIy and by Iood consumpIIon. HeaI Is exchanged wIIh Ihe surroundIng envIronmenI by conducIIon, convecIIon, radIaIIon and evaporaIIon oI sweaI. HeaI exchange Is InIIuenced by aIr IemperaIure, aIr veIocIIy, reIaIIve humIdIIy and radIaIIon. VarIous combInaIIons oI Ihese IacIors can cause dIIIerenI degrees oI comIorI and dIscomIorI and severaI IndIces have been descrIbed Io express Ihe degree oI IhermaI sIress resuIIIng Irom combInaIIons oI Ihese IacIors, e.g. Ihe eIIecIIve IemperaIure, Ihe correcIed eIIecIIve IemperaIure and weIbuIbgIobe IemperaIure IndIces. (b) Types oI IhermaI sIress CoId sIress: ThIs exIsIs when Ihe surroundIng IemperaIure IaIIs, as occurs when enIerIng coId sIorage rooms. A human IrIes Io reduce Ihe exposed skIn surIace (by bendIng Ihe joInIs II possIbIe or by wearIng IhIck wooIIen cIoIhes). PerIpheraI vasoconsIrIcIIon oI skIn vesseIs occurs resuIIIng In vascuIar Injury, chIIbIaIns, IrosI bIIe (dry gangrene) or Irench IooI (weI gangrene). HeaI producIIon Increases Ihrough Increased muscIe Ione and shIverIng. LxIreme cases resuII In hypoIhermIa, IowerIng oI Ihe IemperaIure oI core organs and deaIh. HeaI sIress: Ihe sIages VasomoIor conIroI: As Ihe heaI sIress Increases, more bIood Is pumped Io Ihe skIn and Iess Io Ihe vIsceraI organs and braIn. There Is cardIovascuIar sIress and IachycardIa. MuscuIar work Is reduced sInce II produces more heaI. HeaI exhausIIon Is manIIesIed by headaches, dIzzIness, sIeepIness, Iack oI concenIraIIon and anorexIa. LvaporaIIve cooIIng: The body sIarIs Io sweaI wIIh Ihe amounI reIaIed Io Ihe degree oI sIress and accIImaIIzaIIon. Loss oI sodIum chIorIde Ihrough sweaIIng causes heaI cramps (paInIuI cramps sIarIIng In Ihe workIng muscIes and spreadIng Io oIher muscIes) and dehydraIIon whIch aggravaIes cardIovascuIar probIems. The voIume oI urIne Is reduced. HIgh aIr veIocIIy and Iow reIaIIve humIdIIy heIp cooIIng Ihrough Ihe evaporaIIon oI sweaI. Dry heaI exposure Is encounIered In IoundrIes, sIeeI mIIIs and In Ihe gIass IndusIry and moIsI heaI exposure In IexIIIe mIIIs, mInes, Ihe Iood cannIng IndusIry and IaundrIes. HeaI sIroke: II sweaIIng Is noI suIIIcIenI Io keep Ihe body IemperaIure wIIhIn Ihe physIoIogIcaI range, Ihe heaI reguIaIIng cenIre IaIIs, sweaIIng sIops, Ihe skIn Is IIushed and Ihe paIIenI Is saId Io suIIer Irom heaI sIroke. UnconscIousness and deaIh may IoIIow. HeaI sIroke occurs In workers In hoI humId envIronmenIs especIaIIy when exposed Io dIrecI sunIIghI. II Is an emergency sIIuaIIon where rapId cooIIng, rehydraIIon and repIacemenI oI eIecIroIyIes are IndIcaIed. 44 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers (c) PrevenIIon oI heaI sIress A graduaI exposure Io a hoI envIronmenI resuIIs In accIImaIIzaIIon and beIIer IoIerance. HeaI sIress Is especIaIIy dangerous Ior chIIdren, Ihe eIderIy and paIIenIs wIIh cardIovascuIar, renaI and skIn dIseases. LngIneerIng conIroI measures shouId be used Io prevenI heaI exposure IncIudIng shIeIdIng, InsuIaIIon and venIIIaIIon. PrepIacemenI and perIodIc medIcaI examInaIIons are ImporIanI; IosI IIuIds and sodIum chIorIde shouId be repIaced; personaI proIecIIve cIoIhes can heIp In some sIIuaIIons and workers shouId be gIven adequaIe resI perIods Io be spenI In a more comIorIabIe envIronmenI. No:c NoIse Is unwanIed sound. Workers are exposed Io noIse In: IexIIIe and gIass IndusIrIes shIp buIIdIng aeropIane manuIacIure engIneerIng IndusIrIes manuIacIure oI boIIers and pressure vesseIs power pIanIs. Sound Is propagaIed In Ihe Iorm oI waves, each oI whIch can be descrIbed In Ierms oI Irequency or number oI cycIes per second measured In herIz (Hz) and InIensIIy as expressed In decIbeIs (dB). The human ear can hear sounds rangIng In Irequency Irom 20 Hz Io 20 000 Hz. The InIensIIy oI very IaInI sounds Is around 0 dB and a jeI engIne can produce sounds oI 1S0 dB, whIch Is paInIuI Io Ihe ear. The sounds we normaIIy hear are compIex sounds Iormed Irom many waves oI varyIng IrequencIes and InIensIIIes. OrdInary speech Is heard aI IrequencIes oI S00 Hz Io 2000 Hz. In addIIIon Io InIerIerence wIIh Ihe hearIng oI normaI speech, noIse can cause annoyance and sIress and can Iead Io Increased accIdenI raIes and Iower producIIvIIy. LxIraaudIIory eIIecIs are observed In dIIIerenI sysIems, IncIudIng endocrIne, gasIroInIesIInaI and cardIovascuIar sysIems, and InIerIere wIIh sIeep. The mosI ImporIanI eIIecI oI exposure Io noIse Is noIseInduced hearIng Ioss (NIHL). HearIng ImpaIrmenI Is aI IIrsI Iemporary; as exposure Io noIse (abouI 8S dB) conIInues, hearIng ImpaIrmenI becomes permanenI. NIHL usuaIIy Iakes many years (7-10 years) Io deveIop. The mosI hazardous Is hIgh InIensIIy, hIgh Irequency, conIInuous noIse. PersonaI suscepIIbIIIIy has a deIInIIe eIIecI. AudIomeIry reveaIs earIy hearIng ImpaIrmenI aI IrequencIes oI S000-6000 Hz beIore hearIng oI normaI speech Is aIIecIed. Hence, Ihe ImporIance oI measuremenI oI hearIng on prepIacemenI and perIodIc hearIng examInaIIons. Measures Io conIroI noIse In Ihe workpIace IncIude: desIgn and maInIenance oI machInery segregaIIon and dIspersIon oI noIse sources OccuntonnI nnd other work-reInted dsenses: ModuIe 2 45 prevenIIon oI propagaIIon and reIIecIIon oI noIse by Ihe use oI sound prooIIng maIerIaIs Ior IIoors, waIIs and ceIIIngs roIaIIon oI workers reducIIon oI work exposure hours use oI personaI proIecIIve devIces, e.g. ear pIugs, ear muIIs and heImeIs. Vnton Workers exposed Io whoIe vIbraIIons IncIude IracIor drIvers, IransporI workers, workers InvoIved In drIIIIng Ior peIroIeum and Ihose In Ihe IexIIIe IndusIry. WhoIe body vIbraIIons cause varIous aIImenIs reIaIed Io congesIIon oI peIvIc and abdomInaI organs. SegmenIaI vIbraIIons aIIecI workers usIng pneumaIIc or eIecIrIcaI vIbraIIng IooIs In mInIng, road consIrucIIon, shoe manuIacIure and sawIng. VascuIar changes In Ihe upper IImbs Iead Io "dead hands" and "whIIe IIngers" and proIonged exposure Ieads Io rareIacIIon In Ihe smaII bones and wrIsI. Ioo o dccct\c unnnton LIghIIng sIandards depend on Ihe Iype oI work perIormed and degree oI precIsIon requIred. AdequaIe IIghIIng shouId be provIded eIIher by naIuraI or arIIIIcIaI means, avoIdIng shadows and gIare and observIng approprIaIe coIours and conIrasI. DeIecIIve IIIumInaIIon Ieads Io eye sIraIn, IaIIgue and Increased accIdenI raIes. DeIecIIve IIIumInaIIon In mIners Ieads Io mIner's nysIagmus (rapId, InvoIunIary movemenI oI Ihe eyes). Kndnton (a) NonIonIzIng radIaIIon UIIravIoIeI radIaIIon Lxposure occurs In weIdIng, meIaI cuIIIng and exposure Io carbon arc and causes skIn eryIhema, burns and hyperpIgmenIaIIon. Lxposure oI Ihe eyes causes "arc eye" wIIh conjuncIIvIIIs and severe paIn and may Iead Io corneaI uIceraIIon. Lye proIecIIon usIng specIaI Iace shIeIds Is necessary. ProIonged exposure causes aIrophy oI Ihe skIn and epIIheIIomas. InIrared radIaIIon Lxposure occurs In IronI oI Iurnaces, In sIeeI mIIIs, In Ihe gIass IndusIry, In bIacksmIIhs and In chaIn manuIacIure. Lxposure oI Ihe eyes can cause caIaracIs or corneaI aIIecIIon. SkIn burns can aIso occur. CompIeIe proIecIIon oI Ihe eyes can be achIeved by wearIng specIaI goggIes. (b) IonIzIng radIaIIon Sources oI radIaIIon IncIude radIoacIIve IsoIopes and Xray machInes. IonIzIng radIaIIon Is used In medIcIne, IndusIry, agrIcuIIure, research and aIomIc warIare. RadIaIIons are eIIher eIecIromagneIIc waves, IIke Xrays and gammarays, or mInuIe 4b OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers parIIcIes, IIke aIpha, beIa and neuIrons. BoIh Iypes cause IonIzaIIon or excIIaIIon oI aIoms whIch Ieads Io IIssue desIrucIIon. The eIIecI oI IonIzIng IrradIaIIon depends on Ihe dose, Iype oI radIaIIon, wheIher exposure was conIInuous or InIerrupIed and wheIher II was IoIaI body or IocaIIzed, as weII as Ihe Iype oI IIssue IrradIaIed. The power oI peneIraIIon oI dIIIerenI Iypes oI radIaIIon varIes Irom very hIgh, such as Xray and gammaray radIaIIon, Io very Iow, such as aIpha radIaIIon. DIIIerenI IIssues vary In IheIr sensIIIvIIy Io radIaIIon, wIIh Ihe IIssues oI Ihe haemopoIeIIc sysIem and Ihe gasIroInIesIInaI mucosa beIng Ihe mosI sensIIIve and Ihose oI Ihe bones and muscIes beIng Ihe IeasI sensIIIve. LIIecIs may vary: DeaIh occurs wIIhIn hours II Ihe whoIe body Is exposed Io a hIgh dose. AcuIe radIaIIon syndrome occurs II Ihe dose Is Iess. SIgns and sympIoms appear wIIhIn 24-48 hours and are due Io aIIecIIon oI Ihe gasIroInIesIInaI mucosa causIng severe bIoody dIarrhoea and shock oI Ihe haemopoIeIIc sysIem and oI Ihe skIn. II deaIh occurs II Is due Io haemorrhage (due Io IhrombocyIopenIa) or InIecIIon (due Io damage oI InIesIInaI mucosa and IeukopenIa). BeIaradIaIIon aIIecIs Ihe skIn onIy, causIng skIn burns and aIopecIa. ChronIc radIaIIon eIIecIs may IoIIow Iong aIIer an acuIe exposure or IoIIow repeaIed exposure Io doses noI enough Io cause acuIe eIIecIs. ChronIc eIIecIs IncIude skIn aIrophy, Ioss oI IInger prInIs, aIopecIa, naII changes, IeIanIecIasIa, pIgmenIaIIon, keraIoses and epIIheIIomas. OIher eIIecIs IncIude sIerIIIIy, aborIIon, muIagenIc eIIecIs and bIrIh deIecIs. ConIroI oI exposure Io exIernaI radIaIIon sources resIs on Ihree generaI prIncIpIes: 1. KeepIng suIIIcIenI dIsIance beIween source and worker. 2. ReducIng IIme oI exposure. S. ConIaInmenI and shIeIdIng. ConIroI oI exposure Io InIernaI IrradIaIIon (upIake oI radIoacIIve maIerIaIs) IoIIows more sIrIngenI reguIaIIons. LaboraIorIes or esIabIIshmenIs In whIch radIoacIIve maIerIaIs are handIed shouId be consIrucIed In such a way as Io oIIer maxImum conIaInmenI, encIosure and shIeIdIng oI radIoacIIve maIerIaI, and Io ensure easy and compIeIe cIeanIng In case oI spIIIs. HandIIng by remoIe conIroI Is very useIuI. VenIIIaIIon and wasIe dIsposaI sysIems shouId be separaIe Irom Ihose oI oIher areas and radIoacIIve wasIe shouId noI reach pubIIc wasIe sysIems. RadIoacIIve wasIe shouId be dIsposed oI In such a way IhaI envIronmenIaI conIamInaIIon Is noI IIkeIy. LnvIronmenIaI monIIorIng shouId be pracIIsed and aIarm sysIems shouId be provIded. OccuntonnI nnd other work-reInted dsenses: ModuIe 2 47 OIher measures IncIude: prepIacemenI and perIodIc medIcaI examInaIIons wIIh specIaI emphasIs on eyes, skIn and bIood personaI proIecIIve cIoIhIng personaI monIIorIng badges pockeI dosImeIers whoIe body counIers monIIorIng oI radIoacIIvIIy In bIoIogIcaI IIuIds. CInngc: n nonctc c::uc (a) Increased baromeIrIc pressure Workers exposed Io Increased baromeIrIc pressure are dIvers, Irogmen, submarIne crew and workers engaged In underwaIer consIrucIIon oI pIers, brIdges eIc. BaromeIrIc pressure Increases by 1 aImosphere Ior every 10 meIres descended underwaIer. DurIng descenI: II Ihe openIngs IeadIng Io Ihe paranasaI sInuses or Ihe mIddIe ear are bIocked (e.g. due Io caIarrh and oedema oI a mucous membranes), Ihe pressure In Ihe cavIIIes cannoI be equaIIzed wIIh Ihe ouIsIde pressure and IhIs resuIIs In severe paIn, oedema oI Ihe IInIng mucous membrane, haemorrhage and maybe rupIure oI Ihe ear drum. DurIng Ihe sIay under waIer, because oI Ihe dIssoIuIIon oI excess amounIs oI gases In Ihe bIood and IIssues, oxygen poIsonIng and nIIrogen narcosIs may occur wIIh serIous consequences. DIvers may aIso suIIer asphyxIa and even drownIng. II rapId ascenI occurs wIIh Ihe gIoIIIs cIosed (e.g. II Ihe worker panIcs) Ihe Iung may rupIure due Io expansIon oI gases, especIaIIy In Ihe presence oI a weak spoI. RapId ascenI, noI IoIIowIng Ihe recommendaIIons oI sIandard surIacIng IabIes, resuIIs In Ihe IormaIIon oI gas bubbIes In Ihe bIood and IIssues due Io IIberaIIon Irom soIuIIon oI Ihe excess gases IhaI were dIssoIved under pressure. In Ihe bIood sIream, gas (especIaIIy N 2 ) causes aIr emboIIsm and paraIysIs and In Iense IIssues (IIgamenIs around joInIs) causes severe paIn known as "Ihe bends", aIso reIerred Io as "CaIsson dIsease" or decompressIon sIckness. Workers who work under Increased pressure under waIer Ior many years may suIIer Irom asepIIc bone necrosIs, especIaIIy In Ihe head oI Ihe Iemur. CaIsson dIsease may manIIesI wIIhIn 24 hours oI ascenI and caIIs Ior urgenI compressIon In a compressIon chamber unIII sympIoms dIsappear. Pressure Is Ihen reIeased accordIng Io recommended sIeps. A worker wIIh an upper respIraIory InIecIIon shouId noI be aIIowed Io dIve Io avoId compIIcaIIons durIng descenI. 4 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers (b) Reduced baromeIrIc pressure Passenger pIanes are normaIIy pressurIzed buI mIIIIary pIIoIs may be exposed Io reduced aImospherIc pressure. In IhIs case expansIon oI InIesIInaI gases may cause respIraIory embarrassmenI buI beIore decompressIon sIckness occurs Ihey wIII have Ianded. Workers aI hIgh aIIIIude suIIer Irom eIIecIs oI reduced parIIaI pressure oI oxygen. The body compensaIes by IncreasIng Ihe puIse raIe, IncreasIng Ihe breaIhIng raIe and poIycyIhemIa. 3.5 Chemical hazards (occupaIional poisoning) Workers In dIIIerenI occupaIIons are exposed Io Ihousands oI chemIcaIs, some oI whIch can cause occupaIIonaI dIseases. Ior Ihe sake oI dIscussIon, Ihese chemIcaIs are cIassIIIed accordIng Io IheIr physIcaI sIaIe, chemIcaI composIIIon or physIoIogIcaI acIIon. Cn:c: nnd \nou: These can be cIassIIIed accordIng Io IheIr physIoIogIcaI acIIon InIo: asphyxIanIs, IrrIIanI gases, organomeIaIIIc compounds and anaesIheIIc vapours. (a) AsphyxIanIs Can cause asphyxIa eIIher by repIacIng oxygen or by some oIher mechanIsm. They are cIassIIIed InIo: :nc n:I)xnnt: and cIcncn n:I)xnnt:. 5nc n:I)xnnt:: repIace oxygen, e.g. nIIrogen, meIhane, hydrogen and carbon dIoxIde. NiIrogen: a sImpIe asphyxIanI used In Ihe IerIIIIzer IndusIry and presenI In mInes when O 2 Is consumed. In mInes II can be deIecIed by Ihe saIeIy Iamp whIch Is exIInguIshed aI O 2 concenIraIIon oI 17. AI 12 O 2 Ihere Is dyspnea, cyanosIs, unconscIousness, Ioss oI moIor power, convuIsIons and deaIh. MeIhane (marsh gas): resuIIs Irom decomposIIIon oI organIc maIIer and Is presenI In marshes, sewers and mInes. II Is a sImpIe asphyxIanI, InIIammabIe and IIghIer Ihan aIr. Carbon dioxide (CO 2 ): resuIIs Irom combusIIon oI IueIs; II Is a coIourIess gas, heavIer Ihan aIr. II can be Iound In mInes, weIIs, caves and cIose Io Iurnaces and brIck kIIns. II Is aIso presenI In Ihe manuIacIure oI soII drInks, beer, In Ihe sugar IndusIry and Is used as dry Ice. In addIIIon II can be used Io exIInguIsh IIres. CO 2 Is a sImpIe asphyxIanI buI In Iow concenIraIIons sIImuIaIes rapId respIraIIon. ResuscIIaIIon caIIs Ior O 2 InhaIaIIon, warmIh, cardIorespIraIory sIImuIanIs and II respIraIIon sIops, arIIIIcIaI respIraIIon. CIcncn n:I)xnnt:: InIerIere Ihrough some chemIcaI acIIon wIIh Ihe respIraIory IuncIIon oI Ihe bIood, IIssue ceIIs or respIraIory cenIre, e.g. carbon monoxIde (CO), hydrogen suIIIde and hydrocyanIc acId. OccuntonnI nnd other work-reInted dsenses: ModuIe 2 49 Carbon monoxide (CO): a coIourIess, odourIess gas whIch resuIIs Irom IncompIeIe combusIIon oI IueI. II Is a producI oI coaI dIsIIIIaIIon pIanIs, sIeeI Iurnaces, IueI boIIers and Iurnaces and home heaIIng appIIances. II Is aIso presenI In vehIcIe exhausI Iumes. CO has a greaI aIIInIIy Io haemogIobIn (HbCO) (210 IImes IhaI oI O 2 ) and Ihus InIerIeres wIIh O 2 IransporI. Lxposure causes headaches, dIzzIness, chesI oppressIon, Ioss oI moIor power, unconscIousness, convuIsIons, cardIovascuIar eIIecIs, coma and deaIh (dependIng on Ihe percenIage oI HbCO In Ihe bIood). PrevenIIon oI CO poIsonIng depends on proper desIgn, maInIenance and reguIar InspecIIon oI home appIIances and IndusIrIaI sources and aIso on conIroI measures In garages. In a case oI poIsonIng, O 2 InhaIaIIon Is IndIcaIed (wIIh S CO 2 ), wIIh warmIh, sIImuIanIs and arIIIIcIaI respIraIIon provIded II needed; Ihe worker shouId be removed Irom exposure IIrsI. Hydrogen sullide (H 2 S): a coIourIess gas, heavIer Ihan aIr; II has Ihe odour oI roIIen eggs. Lxposure occurs In oII IIeIds and reIInerIes, IannerIes, sewers and In Ihe manuIacIure oI rayon and arIIIIcIaI rubber. II can be deIecIed by IIs smeII and causes paraIysIs oI Ihe oIIacIory nerve aIIer a shorI whIIe. In addIIIon Io beIng a chemIcaI asphyxIanI, II has an IrrIIanI eIIecI on Ihe eyes and upper respIraIory cenIre; II aIso causes asphyxIa by combInIng wIIh cyIochrome oxIdase enzyme and prevenIIng IIssue respIraIIon. II respIraIory paraIysIs occurs arIIIIcIaI respIraIIon Is IndIcaIed. NIIrIIes (subIInguaI and InIravenous) serve Io break Ihe combInaIIon beIween Ihe gas and cyIochrome oxIdase enzyme by IormIng meIhaemogIobIn. Hydrocyanic acid (HCN): a coIourIess gas IhaI has Ihe odour oI bIIIer aImonds. HCN Is used In IumIgaIIon oI shIps as a pesIIcIde and IIs saIIs are used In phoIography, meIaI hardenIng, eIecIropIaIIng and In exIracIIon oI goId Irom ore. The gas can be absorbed Ihrough Ihe skIn and IIs InorganIc saIIs are among Ihe mosI poIenI poIsons. They produce IheIr eIIecIs Ihrough InhIbIIIng cyIochrome oxIdase enzyme Ihus InIerIerIng wIIh IIssue respIraIIon. SIgns and sympIoms appear wIIhIn mInuIes In Ihe Iorm oI dIzzIness, oppressIon oI Ihe chesI, cardIorespIraIory manIIesIaIIons, unconscIousness and deaIh whIch, In severe cases, occurs wIIhIn mInuIes. OrganIc saIIs are noI as IoxIc. IIrsI aId IncIudes Ihe InhaIaIIon oI amyI nIIrIIe and InIravenous InjecIIon oI sodIum nIIrIIe IoIIowed by sodIum IhIosuIIaIe. CobaII LDTA and hydroxocobaIamIn are aIso used In Ihe IreaImenI oI cyanIde poIsonIng. CardIorespIraIory sIImuIanIs, warmIh and arIIIIcIaI respIraIIon may aIso be IndIcaIed. SInce HCN Is a very rapId poIson, Ihe IIrsI aId equIpmenI shouId be very cIose Io Ihe work sIIe and a weIIIraIned IIrsI aId aIIendanI avaIIabIe aI aII work shIIIs. (b) IrrIIanI gases These can cause IrrIIaIIon or InIIammaIIon oI Ihe mucous membranes wIIh whIch Ihey come InIo conIacI. ThIs properIy depends on IheIr degree oI soIubIIIIy In waIer. 5U OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers HIghIy soIubIe gases, IIke ammonIa, aIIecI Ihe upper respIraIory passages. Less soIubIe gases IIke chIorIne and suIIur dIoxIde aIIecI boIh Ihe upper respIraIory passages and Ihe Iung IIssues. Gases whIch are even Iess soIubIe, IIke nIIrogen oxIdes and phosgene, acI essenIIaIIy on Ihe Iungs and In IhIs case Ihe IrrIIanI aIIecI may be deIayed Ior hours. Sullur dioxide (SO 2 ): one oI Ihe mosI common aIr poIIuIanIs. II resuIIs Irom Ihe combusIIon oI IueIs conIaInIng suIIur and Is presenI In vehIcIe exhausI Iumes, In IronI oI Iurnaces and Is aIso produced In Ihe exIracIIon oI meIaIs Irom suIphIde ores. II Is used In Ihe producIIon oI suIIurIc acId, In Ihe preservaIIon oI IruIIs, In sugar IndusIry and In Ihe bIeachIng oI wooI. II Is coIourIess, has a pungenI odour and Is oxIdIzed In aIr InIo suIIur IrIoxIde. Lxposure causes IrrIIaIIon oI Ihe eyes and upper respIraIory passages. HIgh concenIraIIons may cause oedema oI Ihe Iarynx, puImonary oedema, pneumonIa and even deaIh. Ammonia (NH S ): a common upper aIrway IracI IrrIIanI. II Is a hIghIy soIubIe aIkaIIne gas IhaI Is wIdeIy used In IndusIry as a reIrIgeranI and In Ihe manuIacIure oI IerIIIIzers, expIosIves and pIasIIcs. II aIIacks Ihe skIn, Ihe conjuncIIva and Ihe mucous membranes oI Ihe upper respIraIory IracI. Oedema oI Ihe Iarynx and puImonary oedema can occur wIIh exposure Io hIgh concenIraIIons and can cause deaIh. ManagemenI consIsIs oI removIng Ihe paIIenI Irom exposure IoIIowed by supporIIve care wIIh oxygen and aIIenIIon Io IIuId and eIecIroIyIe homeosIasIs. MosI paIIenIs graduaIIy Improve over IIme and make a IuII recovery wIIhouI parenchymaI Iung damage excepI Ior bronchIecIasIs. lormaldehyde (HCHO): a poIenI upper respIraIory IracI IrrIIanI IhaI Is used as a dIsInIecIanI and IndusIrIaI cIeaner and may reIease gas Irom parIIcIe board. II Is an anImaI carcInogen and may cause acuIe bronchIaI IrrIIaIIon In humans. Hydrogen lluoride (HI): a poIenI upper respIraIory IracI acId IrrIIanI IhaI causes puImonary oedema. II Is used In Ihe mIcroeIecIronIcs IndusIry Ior eIchIng sIIIcon chIps and Is aIso used Io eIch gIass. Ozone (O S ): an ImporIanI IrrIIanI produced by phoIochemIcaI oxIdaIIon oI vehIcIe exhausI Iumes and whIch Is generaIed In arc weIdIng. Ozone causes nose and eye IrrIIaIIon and Is aIso a poIenI respIraIory IracI IrrIIanI causIng coughIng, IIghIness In Ihe chesI and shorIness oI breaIh. Chlorine (CI 2 ): a greenIsh yeIIow gas wIIh a pungenI IrrIIaIIng odour. II aIIecIs Ihe upper and Iower respIraIory IracI. Lxposure occurs In Ihe producIIon oI sodIum hydroxIde. The gas Is used In bIeachIng and waIer dIsInIecIIon and exposure can occur durIng Ihe IransporI oI IIquId chIorIne. Lxposure causes IrrIIaIIon oI Ihe eyes and upper respIraIory IracI and Iarger concenIraIIons may resuII In puImonary oedema and deaIh. Phosgene (COCI 2 ): resuIIs Irom decomposIIIon oI chIorInaIed hydrocarbons when Ihey come InIo conIacI wIIh a hoI surIace (CCI 4 Is used In IIre IIghIIng). Phosgene Is sparIngIy soIubIe In waIer, IhereIore upper respIraIory IrrIIaIIon Is sIIghI. However, OccuntonnI nnd other work-reInted dsenses: ModuIe 2 51 deIayed puImonary oedema can occur and IhereIore Ihe paIIenI shouId be observed Ior 48 hours and gIven resI, warmIh sIImuIanIs and O 2 . NiIrogen oxides (NO x ): nIIrous oxIde (N 2 O) Is an anaesIheIIc and In Ihe absence oI O 2 Is a sImpIe asphyxIanI. NIIrogen oxIdes are a mIxIure oI NO 2 and N 2 O 4 and are brown In coIour. Lxposure occurs In chemIcaI IaboraIorIes, In Ihe expIosIve IndusIry, In Ihe manuIacIure oI nIIrIc or suIIurIc acIds, IerIIIIzer IndusIry and on sIow combusIIon oI nIIrogenconIaInIng maIerIaIs. II Is presenI In weIdIng operaIIons and In soIIs. Due Io IheIr poor waIer soIubIIIIy, nIIrogen oxIdes can be InhaIed In hIgh concenIraIIon wIIhouI suIIIcIenI warnIng IrrIIaIIon buI II has a severe IrrIIanI eIIecI on Ihe Iung IIssue. SympIoms may be deIayed 2-20 hours, aIIer whIch IaIaI puImonary oedema may occur. ThereIore, regardIess oI Ihe condIIIon oI Ihe paIIenI when IIrsI seen, he/she shouId be puI under cIose observaIIon, preIerabIy In hospIIaI, Ior aI IeasI 24 hours. (c) OrganomeIaIIIc compounds Arsine (ASH S ): produced durIng chemIcaI IreaImenI oI meIaIs when arsenIc Is presenI as an ImpurIIy and nascenI hydrogen Is evoIved. II Is coIourIess and has a garIIc odour. Lxposure resuIIs In haemoIysIs, anaemIa, jaundIce and anurIa In severe cases. Nickel carbonyl |NI(CO) 4 ]: a voIaIIIe IIquId produced durIng Ihe exIracIIon oI nIckeI. InhaIaIIon causes severe puImonary IrrIIaIIon. (d) AnaesIheIIc vapours Many oI Ihese have some oIher sysIemIc eIIecI as weII and Iend Io accumuIaIe In Iow, cIosed, poorIy venIIIaIed pIaces. The IoIIowIng precauIIons shouId be observed when Ihere Is poIenIIaI exposure Io noxIous gases. WorkpIaces shouId be venIIIaIed or sIeamed repeaIedIy. II Ihere Is IIkeIIhood oI Ihe presence oI noxIous gases or InsuIIIcIenI oxygen, gas masks shouId be provIded. Workers shouId be properIy IraIned and shouId aIways work In Ieams wIIh one Ieam member nomInaIed Io observe Irom a dIsIance, away Irom possIbIe conIamInaIIon. IIrsI aId equIpmenI, IncIudIng oxygen, shouId be readIIy avaIIabIe wIIh a IraIned Ieam oI rescuers. An aIIecIed worker shouId be removed Irom Ihe exposure and kepI warm and resIed. II breaIhIng sIops, arIIIIcIaI respIraIIon shouId be conIInued unIII recovery or deaIh Is ascerIaIned. 52 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers Mctn: In IndusIry, poIsonIng wIIh meIaIs usuaIIy Iakes Ihe chronIc Iorm and resuIIs Irom Ihe absorpIIon oI smaII amounIs over Iong perIods oI IIme. AcuIe poIsonIng may resuII Irom accIdenIaI (or suIcIdaI) InIake oI Iarge doses oI some oI Ihe more IoxIc compounds (IIke arsenIcaIs). MeIaIs and IheIr compounds gaIn access InIo Ihe body by InhaIaIIon, IngesIIon and, In a Iew cases, Ihrough Ihe skIn. A Iarge number oI meIaIIIc compounds are used In IndusIry wIIh Ihe IoIIowIng beIng some oI Ihe more ImporIanI. (a) Lead lnorganic lead: Lxposure Io InorganIc Iead compounds occurs In mInIng, exIracIIon, smeIIIng, meIaI cuIIIng, manuIacIure oI Iead pIpes, Iead paInIs, manuIacIure oI Iead baIIerIes, crysIaI gIass and hoI meIaI IypeseIIIng. II Is absorbed as dusI vIa Ihe respIraIory IracI, and vIa Ihe gasIroInIesIInaI IracI wIIh Iood and drInks. InorganIc Iead Is noI absorbed Ihrough Ihe skIn. The sIgns and sympIoms oI exposure IncIude a bIue IIne on Ihe gums, InIesIInaI coIIc and consIIpaIIon, anaemIa, generaI weakness and, In severe cases, IooI drop and wrIsI drop. LncephaIopaIhy due Io Iead Is now very rare. LngIneerIng conIroI meIhods Io prevenI exposure are venIIIaIIon, mechanIzaIIon and housekeepIng. PersonaI cIeanIIness, change oI cIoIhes, washIng IacIIIIIes and provIsIon oI cIean areas Ior eaIIng and sIorIng Iood wIII reduce upIake oI Iead by mouIh. PerIodIc medIcaI examInaIIon heIps deIecI earIy aIIecIIon. Organic lead (IeIraeIhyl lead): OrganIc Iead Is sIIII used as a IueI addIIIve In gasoIIne. II Is a voIaIIIe IIquId and can be absorbed by InhaIaIIon and Ihrough Ihe skIn. Lxposure causes excIIaIIon oI Ihe cenIraI nervous sysIem Ihen depressIon and may end In deaIh. (b) Mercury Mercury Is a voIaIIIe IIquId meIaI. Lxposure occurs In mInIng, exIracIIon, chemIcaI IaboraIorIes, Ihe chemIcaI IndusIry In generaI, Ihe pharmaceuIIcaI IndusIry, Ihe manuIacIure oI IhermomeIers and baromeIers, Ihe expIosIve IndusIry, Ihe manuIacIure oI mercury vapour Iamps, Ihe manuIacIure oI pesIIcIdes, mIrrors and In denIIsIry. lnorganic mercury compounds: cause sIomaIIIIs, a brown IIne on Ihe gums, Ioose IeeIh, meIaIIIc IasIe, Iremors and personaIIIy changes. There Is kIdney aIIecIIon and gasIroInIesIInaI dIsIurbances. Organic mercury (pesIicides): exerI IheIr eIIecI on Ihe cenIraI nervous sysIem. Mercury IuImInaIe (an expIosIve) causes skIn uIcers and perIoraIIon oI Ihe nasaI sepIum. (c) Manganese Lxposure occurs In mInIng, exIracIIon, Ihe sIeeI IndusIry, Ihe dry baIIery IndusIry, Ihe gIass and ceramIcs IndusIry, Ihe manuIacIure oI weIdIng rods and In Ihe chemIcaI IndusIry. Manganese exposure can cause pneumonIa and can aIIecI Ihe OccuntonnI nnd other work-reInted dsenses: ModuIe 2 53 cenIraI nervous sysIem causIng ParkInson dIsease, Iremors, mask Iace, rIgIdIIy and personaIIIy change. (d) ArsenIc Lxposure occurs In mInIng and exIracIIon. ArsenIc compounds are used In pesIIcIdes, wood preservaIIves, medIcInes, paInIs and Ihe chemIcaI IndusIry. AcuIe exposure causes severe gasIroenIerIIIs, shock and even deaIh. ChronIc exposure Io arsenIc causes aIIecIIon oI Ihe perIpheraI nerves, skIn IesIons, skIn cancer, anaemIa, perIoraIIon oI Ihe nasaI sepIum and Iung cancer. Ognnc :o\cnt: OrganIc soIvenIs are organIc IIquIds In whIch oIher subsIances can be dIssoIved wIIhouI changIng IheIr chemIcaI composIIIon. They are used In Ihe exIracIIon oI oIIs and IaIs In Ihe Iood IndusIry, Ihe chemIcaI IndusIry, paInI, varnIshes, enameI, Ihe degreasIng process, dry cIeanIng, prInIIng and dyIng In Ihe IexIIIe and rayon IndusIrIes. OrganIc soIvenIs are voIaIIIe: many oI Ihem are InIIammabIe and Ihey are consIdered IIre hazards. ChemIcaI groups IncIude: hydrocarbon soIvenIs aIcohoIs and eIhers keIones esIers gIycoIs and IheIr compounds. SoIvenIs are absorbed maInIy Ihrough Ihe Iungs, vIa Ihe gasIroInIesIInaI IracI II Iaken by mouIh, and many oI Ihem can be absorbed vIa InIacI skIn. As a group, soIvenIs aIIecI severaI oI Ihe body's sysIems and can cause Ihe IoIIowIng eIIecIs: nervous sysIem: dIzzIness, unconscIousness and deaIh, perIpheraI neurIIIs, aIIecIIon oI vIsIon, InsomnIa, headache and easy IaIIgue gasIroInIesIInaI sysIem: dyspepsIa, anorexIa and nausea and may be secondary Io IIver aIIecIIon respIraIory IracI: may show upper respIraIory IrrIIaIIon In some cases kIdney: aIIecIIon may cause nephrIIIs or renaI IaIIure bIood IormIng organs: may be aIIecIed causIng anaemIa or even IeukaemIa skIn: may show conIacI dermaIIIIs or acne. SpecIIIc exampIes oI poIsonIng by organIc soIvenIs: PeIroIeum producIs: may cause unconscIousness and when swaIIowed by accIdenI cause gasIrIIIs or pneumonIa due Io aspIraIIon InIo Iungs. BenzoI (benzene, C 6 H 6 ): Is a producI oI coaI dIsIIIIaIIon and Is used In Ihe paInI IndusIry, arIIIIcIaI rubber manuIacIurIng, Ihe pharmaceuIIcaI and chemIcaI 54 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers IndusIrIes, rubber producIs manuIacIurIng and degreasIng. The cenIraI nervous sysIem IoxIcIIy Is Ihe mosI ImporIanI aspecI oI acuIe hIgh dose exposure Io benzoI. ApIasIIc anaemIa Is Ihe cIassIc cause oI deaIh In chronIc benzoI poIsonIng. BenzoIInduced IeukaemIa may deveIop In some cases In persons who prevIousIy have had apIasIIc anaemIa. The IoxIc eIIecIs oI benzoI are besI prevenIed by repIacIng II wIIh Iess IoxIc compounds. There are many soIvenIs saIer Ihan benzoI. ChIorInaIed hydrocarbons: Ihe addIIIon oI chIorIne Io carbon and hydrogen Increases Ihe sIabIIIIy and decreases Ihe IIammabIIIIy oI Ihe resuIIIng compounds. They have sIIghIIy pungenI odours. SIx chIorInaIed aIIphaIIc hydrocarbons are commonIy used as soIvenIs: IrIchIoreIhyIene perchIoroeIhyIene (IeIrachIoroeIhyIene) 111IrIchIoroeIhane (meIhyI chIoroIorm) meIhyIene chIorIde (dIchIoromeIhane) carbon IeIrachIorIde chIoroIorm. AcuIe eIIecIs IncIude: anaesIhesIa: dIzzIness, headache, nausea, vomIIIng, IaIIgue, "drunkenness", sIurred speech, dIsequIIIbrIum, dIsorIenIaIIon, depressIon, Ioss oI conscIousness respIraIory IracI IrrIIaIIon: sore nose, sore IhroaI, cough. ChronIc eIIecIs IncIude: dermaIIIIs, neurobehavIouraI dysIuncIIon, hepaIoceIIuIar Injury and renaI IubuIar dysIuncIIon. Iunonn) du:t d:cn:c: II Ihe work aImosphere Is dusIy, dusI wIII InevIIabIy be InhaIed. DusI parIIcIes beIow IIve mIcrons In dIameIer are caIIed respIrabIe sInce Ihey have Ihe chance Io peneIraIe Io Ihe aIveoII. The respIraIory IracI has cerIaIn deIence mechanIsms agaInsI dusI buI when Ihe envIronmenI Is very dusIy a sIgnIIIcanI amounI oI dusI can be reIaIned In Ihe Iungs. DIIIerenI kInds oI dusI have dIIIerenI eIIecIs: SoIubIe parIIcIes oI IoxIc compounds reach Ihe bIood and cause poIsonIng, e.g. Iead. IrrIIanI dusIs cause IrrIIaIIon oI Ihe upper respIraIory IracI and Ihe Iungs and cerIaIn meIaI Iumes cause chemIcaI pneumonIa, e.g. cadmIum, beryIIIum and manganese. Some oIhers cause sensIIIzaIIon resuIIIng In asIhma or exIrInsIc aIIergIc aIveoIIIIs, e.g. some organIc dusIs. MeIaI Iume Iever Is caused by InhaIaIIon oI Iumes oI zInc and copper causIng Iever, body aches and chIIIs Ior 1-2 days. OccuntonnI nnd other work-reInted dsenses: ModuIe 2 55 PneumonIc anIhrax Is caused by InhaIaIIon oI wooI dusI conIaInIng Ihe spores. BenIgn pneumoconIosIs whIch causes Xray opacIIIes (noduIaIIon) wIIhouI sympIoms or dIsabIIIIy Is caused by InhaIaIIon oI Iron, barIum and IIn dusI. ByssInosIs Is caused by proIonged exposure (7-10 years) Io coIIon dusI In Ihe IexIIIe IndusIry especIaIIy In Ihe gInnIng, baIe openIng and cardIng. II Is manIIesIed by chesI IIghIness on Ihe IIrsI day IoIIowIng a weekend. InIIIaIIy, Ihe paIIenI Is Iree oI sympIoms Ior Ihe resI oI Ihe week. ChronIc bronchIIIs, emphysema and dIsabIIIIy are common compIIcaIIons. PneumoconIosIs Is dIsabIIng puImonary IIbrosIs IhaI resuIIs Irom Ihe InhaIaIIon oI varIous Iypes oI InorganIc dusI, such as sIIIca, asbesIos, coaI, IaIc and chIna cIay, e.g. sIIIcosIs and asbesIosIs: Silicosis: sIIIcosIs resuIIs Irom Ihe InhaIaIIon oI respIrabIe parIIcIes oI Iree crysIaIIIne sIIIca (SIO 2 ). Lxposure occurs In mInIng and quarryIng operaIIons, sIone cuIIIng and shapIng, Ioundry operaIIons, gIass and ceramIcs manuIacIure, sandbIasIIng and manuIacIure oI abrasIve soaps. II Iakes many years Io deveIop Ihe dIsease (7-10 years, someIImes Iess) and IhIs depends on Ihe concenIraIIon oI Ihe dusI aI Ihe workpIace, IIs sIIIca conIenI, Ihe parIIcIe sIze and on IndIvIduaI suscepIIbIIIIy. The dusI parIIcIes seIIIe In Ihe Iungs and cause smaII noduIes oI IIbrosIs IhaI progressIveIy become more numerous, enIarge and coaIesce causIng IIbrosIs and progressIve Ioss oI Iung IuncIIon and dIsabIIIIy. There may be coughIng and expecIoraIIon. In Ihe earIy sIages Ihere may be sIgns deIecIabIe by Xray buI IaIer on Ihe worker compIaIns oI IncreasIng dyspnoea on exerIIon. CompIIcaIIons IncIude puImonary IubercuIosIs and cardIac or respIraIory IaIIure. The dIsease can be deIecIed even beIore Ihe sympIoms appear by Xray examInaIIon whIch shows numerous bIIaIeraI noduIar shadows oI dIIIerenI sIzes or Iarge masses oI IIbrosIs. AsbesIosis: asbesIosIs Is caused by InhaIaIIon oI asbesIos IIbres. II Is a hydraIed magnesIum sIIIcaIe whIch Is resIsIanI Io heaI and many chemIcaIs. In addIIIon Io mInIng and exIracIIon, exposure Io asbesIos occurs In IIs use Ior InsuIaIIon, In Ihe makIng oI asbesIos cIoIh, In Ihe manuIacIure oI asbesIos cemenI pIpes and oIher producIs, vInyI IIoor IIIes and In brake and cIoIh IInIng. AsbesIos IIbres, when InhaIed, wIII cause dIIIuse InIersIIIIaI IIbrosIs oI Ihe Iungs, pIeuraI IhIckenIng and caIcIIIcaIIon. BronchogenIc carcInoma or pIeuraI and perIIoneaI mesoIheIIoma are known eIIecIs. The earIy sympIoms IncIude progressIve dyspnoea on exerIIon, cough, expecIoraIIon, chesI paIn, cyanosIs and cIubbIng oI Ihe IIngers. The dIsease Iakes abouI seven years Io deveIop and depends upon Ihe dusI concenIraIIon aI Ihe workpIace. LarIy deIecIIon depends on sympIoms and sIgns and Ihe Xray pIcIure. SmokIng Increases Ihe rIsk oI deveIopIng Iung cancer severaI IoId. DusI conIroI measures IncIude: subsIIIuIIon oI harmIuI dusI wIIh a harmIess one auIomaIIon and mechanIzaIIon oI dusIy processes segregaIIon oI dusIy jobs encIosure oI dusIy operaIIons 5b OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers venIIIaIIon oI generaI and IocaI exhausI Iumes housekeepIng and generaI cIeanIIness Ihe use oI waIer In dusI suppressIon Ior IoxIc dusI: personaI cIeanIIness, washIng IacIIIIIes, changIng work cIoIhes beIore goIng home, washIng oI work cIoIhes, provIsIon oI separaIe areas Ior eaIIng, drInkIng and smokIng heaIIh educaIIon prepIacemenI medIcaI examInaIIon personaI proIecIIve equIpmenI. Ic:tcdc: PesIIcIdes are a group oI chemIcaIs used Io desIroy varIous kInds oI pesIs IncIudIng InsecIs, rodenIs, weeds, snaIIs, IungI, eIc. The degree oI IoxIcIIy oI dIIIerenI pesIIcIdes varIes greaIIy Irom deadIy poIsons Io sIIghIIy harmIuI pesIIcIdes. Lxposure Io pesIIcIdes occurs In IndusIrIes where Ihe pesIIcIdes are manuIacIured and IormuIaIed, and durIng IheIr appIIcaIIon In agrIcuIIure or In pubIIc heaIIh. PesIIcIdes are aIso used aI home. They are cIassIIIed InIo severaI groups, accordIng Io IheIr chemIcaI composIIIon. The mosI IrequenIIy used nowadays are organophosphaIes, carbamaIes and IhIocarbamaIes, pyreIhroIds and organochIorIne pesIIcIdes. OIher groups IncIude Iead arsenaIe, organIc mercury, IhaIIIum compounds, coumarIn, bromomeIhane, cresoIs, phenoIs, nIcoIIne, zInc phosphIde, eIc. PesIIcIdes are absorbed Ihrough Ihe Iungs, Ihe gasIroInIesIInaI IracI and someIImes Ihrough Ihe InIacI skIn and eyes (organophosphaIes). (a) OrganochIorIne LxampIes are DDT, aIdrIn, dIeIdrIn, IoxaIene and gammaxane. They are sIIghIIy Io moderaIeIy IoxIc, and are noI bIodegradabIe In Ihe envIronmenI or In Ihe human body. They accumuIaIe In Ihe envIronmenI and Ior IhIs reason have been banned In many counIrIes. AcuIe exposure causes IrrIIabIIIIy oI Ihe cenIraI nervous sysIem. SympIoms appear aIIer S0 mInuIes Io severaI hours (usuaIIy noI more Ihan 12 hours). They IncIude headache, dIzzIness, nausea, abdomInaI paIn, IrrIIabIIIIy, convuIsIons, coma, pyrexIa, IachycardIa, shaIIow respIraIIon and deaIh. II Ihe paIIenI survIves, convuIsIons sIop wIIhIn 24 hours buI weakness, headaches and anorexIa may conIInue Ior Iwo weeks or more. ChronIc exposure may cause gasIroInIesIInaI, IIver, kIdney or nervous aIIecIIon. IIrsI aId IreaImenI: Remove conIamInaIed cIoIhIng. Wash skIn wIIh soap and waIer buI do noI rub Ihe skIn. OccuntonnI nnd other work-reInted dsenses: ModuIe 2 57 Induce vomIIIng, sIomach wash and saIIne caIharIIc. AdmInIsIer sedaIIve Ior convuIsIons. AdmInIsIer cardIorespIraIory sIImuIanIs. (b) OrganophosphaIes These IncIude paraIhIon, meIhyI paraIhIon, maIaIhIon and IeIraeIhyI pyrophosphaIe. OrganophosphaIes IncIude some exIremeIy IoxIc and some sIIghIIy IoxIc compounds. They do noI accumuIaIe In Ihe envIronmenI or In Ihe human body. They are bIodegradabIe wIIhIn a Iew weeks. OrganophosphaIes cause Ihe InhIbIIIon oI Ihe choIIneesIerase enzyme resuIIIng In accumuIaIIon oI aceIyI choIIne In Ihe body. SympIoms and sIgns IncIude dyspnoea, sweaIIng, nausea, abdomInaI coIIc, dIarrhoea, consIrIcIIon oI Ihe pupIIs, muscIe IwIIches, IrrIIabIIIIy, anxIeIy, headaches, aIaxIa, convuIsIons, respIraIory and cIrcuIaIory IaIIure, coma and deaIh. In severe cases sympIoms appear wIIhIn mInuIes and In sIIghI cases aIIer hours buI never exceedIng 24 hours. DeaIh may occur wIIhIn hours In severe cases. II recovery occurs II Iakes a Iew weeks Ior Ihe paIIenI Io reIurn Io normaI. BIood examInaIIon reveaIs reducIIon oI choIIneesIerase acIIvIIy; Ihe IesI Is used In perIodIc medIcaI examInaIIons. IIrsI aId IreaImenI: Take paIIenI Io hospIIaI. Remove conIamInaIed cIoIhIng. Wash skIn wIIh waIer wIIhouI rubbIng (II avaIIabIe, a soIuIIon oI S ammonIa or 2 chIoramIne Is more eIIecIIve Ihan waIer). However, II eyes are conIamInaIed Ihey musI be washed wIIh waIer. II Ihe pesIIcIde has been swaIIowed, IIrsI gIve Ihe paIIenI waIer Io drInk and Ihen Induce vomIIIng by puIIIng your IInger down Ihe paIIenI's IhroaI. AdmInIsIer aIropIne (Ihe anIIdoIe) InIravenousIy. AdmInIsIer arIIIIcIaI respIraIIon II requIred. AdmInIsIer cardIorespIraIory sIImuIanIs. LaIer, IreaI Ihe paIIenI wIIh oxImes. (c) CarbamaIes and IhIocarbamaIes These are moderaIeIy IoxIc (carbaryI) and cause IoxIcIIy Ihrough Ihe same mechanIsm as organophosphaIes excepI IhaI InhIbIIIon oI choIIneesIerase enzyme Is Iemporary and recovers sponIaneousIy wIIhIn 48 hours II deaIh does noI occur. (d) PyreIhroIds These are synIheIIc pesIIcIdes oI Iow IoxIcIIy used In homes. ToxIc sympIoms Iake Ihe Iorm oI sensIIIvIIy reacIIons. 5 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 5nc Inndng o c:tcdc: PesIIcIdes are IIcensed Ior use by Ihe governmenI IoIIowIng careIuI consIderaIIon oI IheIr IoxIcIIy Io humans. LxIremeIy IoxIc subsIances shouId noI be handIed IreeIy by Ihe pubIIc. LxIra care shouId be Iaken durIng IransporIaIIon oI chemIcaIs Io ensure IhaI conIaIners are noI crushed nor IheIr conIenIs spIII. II any spIIIage occurs, II shouId be reporIed and deconIamInaIIon procedures carrIed ouI. AII pesIIcIde conIaIners shouId be properIy IabeIIed In Ihe IocaI Ianguage. SIorage sIIes shouId be properIy cIeaned and venIIIaIed and shouId noI be used by unauIhorIzed personneI. BeIore usIng such chemIcaIs appIIcaIIon, workers shouId be weII IraIned and have receIved heaIIh educaIIon. PubIIc heaIIh measures shouId be Iaken Io avoId conIamInaIIon oI waIer bodIes and resIdenIIaI areas by chemIcaIs. Crops shouId noI be harvesIed beIore Ihe IIme necessary Ior pesIIcIdes Io bIodegrade. LmpIy conIaIners and pesIIcIde wasIe shouId be properIy dIsposed oI. Workers shouId pracIIse good personaI hygIene. IIrsI aId IreaImenI and anIIdoIes shouId be avaIIabIe. PrepIacemenI and perIodIc medIcaI examInaIIons shouId be underIaken. AII concerned, IncIudIng Ihe pubIIc, shouId receIve heaIIh educaIIon regardIng pesIIcIdes. PersonaI proIecIIve equIpmenI shouId be suppIIed Io workers. LngIneerIng conIroI measures shouId be In pIace wIIhIn Ihe chemIcaI IndusIry. 3.6 Biological hazards Occuntonn nccton: Human dIseases caused by workassocIaIed exposure Io mIcrobIaI agenIs, e.g. bacIerIa, vIruses, rIckeIIsIa, IungI and parasIIes (heImInIhs, proIozoa), are caIIed occupaIIonaI InIecIIons. An InIecIIon Is descrIbed as occupaIIonaI when some aspecI oI Ihe work InvoIves conIacI wIIh a bIoIogIcaIIy acIIve organIsm. Lxposure occurs among heaIIh care workers In Iever hospIIaIs, IaboraIorIes and generaI hospIIaIs; among veIerInarIans and agrIcuIIuraI workers In anImaI husbandry and daIry Iarms and peI shops; and among sewerage workers, wooI sorIers and workers In Ihe IeaIher IndusIry. OccuntonnI nnd other work-reInted dsenses: ModuIe 2 59 /Occuntonn) unonn) tuccuo:: HeaIIh care workers In IubercuIosIs IreaImenI cenIres, In IaboraIorIes and In veIerInary cIInIcs are parIIcuIarIy aIIecIed. The dIsease Is caused by M)conctcun tuccuo:: (Koch's bacIIIus) and Is IransmIIIed occupaIIonaIIy by dropIeI InIecIIon, conIacI wIIh InIecIed maIerIaI Irom humans (spuIum) or anImaIs. The organIsm can survIve In dusI and away Irom dIrecI sunIIghI Ior many days and enIers Ihe body Ihrough Ihe respIraIory IracI or abraded skIn where II causes a skIn uIcer. The dIsease usuaIIy aIIecIs Ihe Iungs buI can aIso aIIecI Ihe gasIroInIesIInaI IracI, bones, kIdneys, menInges, pIeura and perIIoneum. PuImonary IubercuIosIs Is manIIesIed by coughIng, expecIoraIIon, haemopIysIs, Ioss oI weIghI, Ioss oI appeIIIe, nIghI sweaIs and nIghI Iever. II can be dIagnosed by chesI Xray and bacIerIoIogIcaI examInaIIon oI Ihe spuIum. Workers shouId undergo a prepIacemenI examInaIIon and be IesIed wIIh IubercuIIn and vaccInaIed wIIh BCG II Ihe IubercuIIn IesI Is negaIIve. PrepIacemenI and perIodIc Xrays shouId be Iaken. HeaIIh educaIIon Is ImporIanI and proper dIsposaI oI InIecIed maIerIaI shouId be observed. ucco:: BruceIIosIs Is caused by an organIsm whIch can InIecI caIIIe, sheep and pIgs. The dIsease causes recurrenI aborIIon In anImaIs and Is presenI In Ihe pIacenIa, In anImaI secreIIons, In mIIk and In urIne. Lxposed workers are veIerInarIans, workers In agrIcuIIure and anImaI husbandry, shepherds and IaboraIory and sIaughIerhouse workers. MosI occupaIIonaI cases occur Ihrough conIacI wIIh InIecIed anImaIs or IheIr secreIIons and producIs. The IncubaIIon perIod Is 2-4 weeks. The acuIe sIage (unduIanI Iever) exIends Ior 2-4 weeks wIIh Iever, enIarged spIeen and Iymph nodes. In Ihe subacuIe phase Ihe organIsm IocaIIzes In joInIs, InIesIInes, reproducIIve organs, pIeura or menInges. In Ihe chronIc phase Ihe IocaIIzed dIsease conIInues wIIh occasIonaI Iever or Ihe onIy sympIom may be generaI weakness. DurIng IhIs sIage Ihe dIsease Is dIIIIcuII Io dIagnose. ThereIore, perIodIc medIcaI examInaIIon oI aII exposed workers shouId be carrIed ouI usIng seroIogIcaI IesIs. ConIroI oI Ihe dIsease In humans depends on conIroI In anImaIs. Workers shouId wear proIecIIve cIoIhIng and observe proper cookIng oI anImaI producIs and boIIIng oI mIIk sInce Ihe dIsease can aIso be IransmIIIed Ihrough Iood. AntInx AnIhrax Is essenIIaIIy an anImaI dIsease. Lxposed workers are Ihose In agrIcuIIure and anImaI husbandry, sIaughIer houses, IannerIes and Ihose workIng In Ihe manuIacIure oI goods Irom wooI, haIr, bones and IeaIher. The dIsease aIIecIs caIIIe, sheep, horses and pIgs and when Ihe anImaI dIes Ihe anIhrax bacIIIus Iorms spores whIch are exIremeIy resIsIanI and can survIve Ior years. InIecIIon can occur Ihrough Ihe skIn, Ihe Iungs or Ihe InIesIIne. InIecIIon Ihrough Ihe skIn causes a "maIIgnanI pusIuIe". II sIarIs wIIh eryIhema 1-8 days aIIer InIecIIon whIch Ieads Io a papuIe Ihen pusIuIe wIIh surroundIng sweIIIng and IocaI Iymph node enIargemenI. InIecIIon Ihrough Ihe Iung occurs In wooI sIores causIng bU OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers severe IaIaI pneumonIa. InIecIIon Ihrough Ihe InIesIInes causes sepIIcaemIa. AnImaI producIs InIended Ior use In IndusIry shouId be careIuIIy examIned and dIsInIecIed. Vn Icntt: nnd C HeaIIh care workers who are IIkeIy Io come InIo conIacI wIIh Ihe bIood and body IIuIds oI InIecIed persons are aI greaI rIsk oI InIecIIon. An acuIe onseI oI hepaIIIIs Is Ihe excepIIon; more oIIen Ihere are vague generaI sympIoms or none aI aII and Ihe InIecIIon Is dIscovered on rouIIne seroIogIcaI examInaIIon. The dIsease may pass InIo chronIc acIIve hepaIIIIs: IIver cIrrhosIs, hepaIIc IaIIure and IIver carcInoma. Because oI Ihe exposure Io paIIenIs' body IIuIds vIa conIamInaIed gIassware and oIher conIamInaIed equIpmenI, such as needIes, whIch may provIde an opporIunIIy Ior conIacI wIIh mucous membranes or parenIeraI InnocuIaIIon, sIrIcI "InIecIIon conIroI" procedures shouId be deveIoped Ior sIIuaIIons where Ihere Is poIenIIaI rIsk, such as phIeboIomy, denIIsIry and haemodIaIysIs. Workers aI Increased rIsk oI hepaIIIIs B InIecIIon shouId receIve hepaIIIIs B ImmunIzaIIon. Acqucd nnunodcccnc) :)ndonc /AII5) TransmIssIon oI Ihe acquIred ImmunodeIIcIency syndrome (AIDS) agenI, Ihe human ImmunodeIIcIency vIrus (HIV), occurs onIy Ihrough sexuaI conIacI, perInaIaIIy Irom an InIecIed moIher and Ihrough conIamInaIed bIood or bIood producIs. SeroconversIon aIIer a needIesIIck Injury Is esIImaIed Io be Iess Ihan 1, whIch Is much Iower Ihan Ihe rIsk (6-S0) oI acquIrIng hepaIIIIs B aIIer a needIesIIck Injury. The vIrus Is noI IransmIIIed Ihrough casuaI, nonInIImaIe workpIace conIacI or socIaI encounIers, such as eaIIng In resIauranIs or usIng pubIIc IransporIaIIon or baIhroom IacIIIIIes. The IoIIowIng groups are aI poIenIIaI rIsk oI conIacI wIIh HIVInIecIed body IIuIds: bIood bank IechnoIogIsIs dIaIysIs IechnIcIans emergency room personneI morIIcIans denIIsIs medIcaI IechnIcIans surgeons IaboraIory workers prosIIIuIes. OccuntonnI nnd other work-reInted dsenses: ModuIe 2 b1 Ior occupaIIonaI heaIIh proIessIonaIs, empIoyees IraIned In IIrsI aId and pubIIc saIeIy personneI who may provIde medIcaI servIces Io HIVInIecIed IndIvIduaIs, reasonabIe sIeps shouId be Iaken Io avoId skIn, parenIeraI or mucous membrane conIacI wIIh poIenIIaIIy InIecIed bIood, pIasma or secreIIons. Hands or skIn shouId be washed ImmedIaIeIy and careIuIIy II bIood conIacI occurs. Mucous membranes (IncIudIng Ihe eyes and mouIh) shouId be proIecIed by eye gIasses or masks durIng procedures IhaI couId generaIe spIashes or aerosoIs oI InIecIed bIood or secreIIons (sucIIonIng, endoscopy). ConIamInaIed surIaces shouId be dIsInIecIed usIng S sodIum hypochIorIIe. Workers In Ihe personaI servIce secIor, who work wIIh needIes or oIher InsIrumenIs IhaI can peneIraIe InIacI skIn, such as IaIIooIsIs and haIrdressers, shouId IoIIow precauIIons IndIcaIed Ior heaIIh care workers and pracIIse asepIIc IechnIques and sIerIIIzaIIon oI InsIrumenIs. AII personaI servIce workers shouId be educaIed concernIng IransmIssIon oI bIoodborne InIecIIons, IncIudIng AIDS and hepaIIIIs B. 3.7 OIher exposures and Iheir healIh ellecIs Occuntonn dcnnto:c: OccupaIIonaI dermaIoses are Ihe mosI common occupaIIonaI dIseases and are aImosI aIways prevenIabIe by a combInaIIon oI envIronmenIaI, personaI and medIcaI measures. The skIn can be aIIecIed by many IacIors: repeaIed mechanIcaI IrrIIaIIon may cause caIIosIIIes and IhIckenIng oI Ihe skIn varIous kInds oI radIaIIon (see ModuIe 1, S.2, PoIenIIaI heaIIh hazards) IubercuIosIs and anIhrax chemIcaIs can cause IrrIIaIIon or sensIIIzaIIon. Types oI occupaIIonaI dermaIosIs: acuIe conIacI eczema due Io IrrIIaIIon or sensIIIzaIIon chronIc conIacI eczema due Io IrrIIaIIon or sensIIIzaIIon chIoracne (IubrIcaIIng and cuIIIng oIIs, Iar and chIorInaIed naphIhaIenes) phoIosensIIIzaIIon (chemIcaIs, drugs and pIanIs) hypopIgmenIaIIon and hyperpIgmenIaIIon (dyes, heavy meIaIs and chIorInaIed hydrocarbons) keraIoses (IonIzIng radIaIIon, uIIravIoIeI radIaIIon) benIgn Iumours and epIIheIIomas (UV, IonIzIng radIaIIon, Iar, sooI, arsenIc) uIcers (Irauma, burns). b2 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers Occuntonn cnncc The cause oI cancer Is sIIII noI compIeIeIy undersIood. II has been observed however, Ihrough epIdemIoIogIcaI sIudIes and sIaIIsIIcaI daIa IhaI cancer oI cerIaIn organs has been assocIaIed wIIh cerIaIn exposures. OccupaIIonaI cancer Is no dIIIerenI Irom ordInary cancer as Iar as sIgns and sympIoms or hIsIopaIhoIogy are concerned. A posIIIve hIsIory oI exposure Io a carcInogenIc agenI can be obIaIned In occupaIIonaI cancer. LxampIes oI some carcInogenIc agenIs and Ihe organs aIIecIed are gIven beIow. Cnrcnogenc ngent Orgnn n]]ected ArsenIc SkIn and Iung ChromIum compounds, hexavaIents Lung NIckeI Lung and nasaI sInus PoIycycIIc aromatIc hydrocarbons SkIn CoaI tars SkIn, scrotum, Iung, bIadder enzoI Iood (IeukaemIa) naphthaIamIne Iadder onIzIng radIatIon SkIn, bone, Iung, bIood (IeukaemIa) Asbestos Lung, pIeura, perItoneum Kcoduct\c ccct: OccupaIIonaI exposure Io cerIaIn chemIcaIs or physIcaI IacIors (IIke IonIzIng radIaIIon) has been Iound Io have cerIaIn eIIecIs on reproducIIve IuncIIons: dysIuncIIon In maIes (sIerIIIIy or deIecIIve spermaIozoa) and IemaIes (anovuIaIIon, ImpIanIaIIon deIecIs In Ihe uIerus) Increased IncIdence oI mIscarrIage, sIIIIbIrIh and neonaIaI deaIh InducIIon oI sIrucIuraI and IuncIIonaI deIecIs In newborn babIes InducIIon oI deIecIs durIng Ihe earIy posInaIaI deveIopmenI sIage. Lxposure oI eIIher parenI may Iead Io reproducIIve deIecIs. ChemIcaIs whIch have been suspecIed oI reproducIIve eIIecIs IncIude: aIcohoIs anaesIheIIc gases cadmIum carbon dIsuIIIde Iead manganese poIyvInyI chIorIde. Occuntonn n:tInn AsIhmaIIc paIIenIs suIIer Irom aIIacks oI shorIness oI breaIh. AIIhough bronchIaI asIhma can be caused by a Iarge number oI subsIances or combInaIIons oI subsIances ouIsIde Ihe workpIace, many occupaIIonaI exposures can be assocIaIed OccuntonnI nnd other work-reInted dsenses: ModuIe 2 b3 wIIh Ihe occurrence oI asIhma. AIIhough In many cases II Is dIIIIcuII Io evaIuaIe how much oI Ihe probIem Is caused by workpIace exposure, In cerIaIn InsIances II Is obvIous IhaI asIhmaIIc aIIacks are caused by work exposure onIy and noI by IacIors ouIsIde work. LxampIes oI subsIances IhaI may cause occupaIIonaI asIhma: PIanI orIgIn: wood dusI IIour and graIn dusI IungaI spores IormaIdehyde gum arabIc AnImaI orIgIn: wooI haIr IeaIhers OIher subsIances: anIIbIoIIcs (penIcIIIIn) IoIuene dIIsocyanaIe pIaIInum saIIs. 4. WORK-RELATED DlSEASES 4.1 CharacIerisIics ol work-relaIed diseases ThIs caIegory has cerIaIn characIerIsIIcs whIch were IdenIIIIed and sIaIed by a WHO LxperI CommIIIee as IoIIows: "MuIIIIacIorIaI dIseases", whIch may IrequenIIy be workreIaIed, aIso occur among Ihe generaI popuIaIIon, and workIng condIIIons and exposures need noI be rIsk IacIors In each case oI any one dIsease. However, when such dIseases aIIecI Ihe worker, Ihey may be workreIaIed In a number oI ways: Ihey may be parIIaIIy caused by adverse workIng condIIIons; Ihey may be aggravaIed, acceIeraIed or exacerbaIed by workpIace exposures; and Ihey may ImpaIr workIng capacIIy. II Is ImporIanI Io remember IhaI personaI characIerIsIIcs, oIher envIronmenIaI and socIocuIIuraI IacIors usuaIIy pIay a roIe as rIsk IacIors Ior Ihese dIseases.... MuIIIIacIorIaI "workreIaIed" dIseases are oIIen more common Ihan occupaIIonaI dIseases and IhereIore deserve adequaIe aIIenIIon by Ihe heaIIh servIce InIrasIrucIure, whIch IncorporaIes Ihe occupaIIonaI heaIIh servIces. 2 The workreIaIed dIseases whIch deserve parIIcuIar aIIenIIon are: behavIouraI and psychosomaIIc dIsorders 2 Idcntcnton nnd conto o \o-cntcd d:cn:c:. ReporI oI a WHO LxperI CommIIIee (WHO TechnIcaI ReporI SerIes No. 714), Geneva, WorId HeaIIh OrganIzaIIon, 198S. b4 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers hyperIensIon coronary hearI dIsease pepIIc uIcers chronIc nonspecIIIc respIraIory dIsease IocomoIor dIsorders. 4.2 Behavioural and psychosomaIic disorders BoIh home and work envIronmenIs can be a major source oI adverse psychosocIaI IacIors. IndIvIduaIs dIIIer wIdeIy In IheIr responses. K: ncto: o cIn\oun nnd :)cIo:onntc d:odc: (a) LnvIronmenIaI psychosocIaI rIsk IacIors work overIoad and underIoad boredom and Iack oI conIroI over work sIIuaIIon shIII work mIgraIIon (mIgranI workers) organIzaIIonaI sIrucIure aI Ihe work esIabIIshmenI and Ihe roIe oI Ihe IndIvIduaI In Ihe organIzaIIon; roIe ambIguIIy and roIe conIIIcI opporIunIIy Ior career deveIopmenI and promoIIon physIcaI InsecurIIy (IIres, expIosIons) and responsIbIIIIy Ior oIher peopIe's saIeIy job desIgn and degree oI InIeresI Iow wages job Iurnover earIy or InvoIunIary reIIremenI unempIoymenI. (b) PhysIcaI sIressors IhermaI envIronmenI noIse vIbraIIon radIaIIon poor IIghIIng. OccuntonnI nnd other work-reInted dsenses: ModuIe 2 b5 (c) LnvIronmenIaI chemIcaI sIressors These can Increase Ihe rIsk oI psychosomaIIc IIIness. Some chemIcaI hazards however, have specIIIc eIIecIs on Ihe cenIraI nervous sysIem, e.g. carbon monoxIde, carbon dIsuIIIde, aIcohoIs and some oIher soIvenIs. (d) SocIaI supporI sysIem ThIs Improves Ihe abIIIIy oI an IndIvIduaI Io adapI Io envIronmenIaI psychosocIaI sIress. SupporI can be Irom Ihe IamIIy, Ihe work communIIy or Ihe communIIy ouIsIde oI work. (e) IndIvIduaI psychosocIaI IacIors InIerIndIvIduaI reIaIIonshIp aI work personaIIIy Iype IndIvIduaI suscepIIbIIIIy age sex. cIn\oun nnd :)cIo:ocn cncton: to :tc:: overeaIIng IeadIng Io obesIIy smokIng aIcohoI and drug abuse and drug addIcIIon, any oI whIch can be a rIsk IacIor Ior psychosomaIIc IIIness IaIIgue anxIeIy depressIon hosIIIIIy and aggressIon neurosIs causIng a range oI menIaI and emoIIonaI dIsorders menIaI dIsorders and psychIaIrIc dIsorders mass psychogenIc IIIness (mass hysIerIa) psychosomaIIc dIsease: headache, backache, muscIe cramps, dIsIurbed sIeep, pepIIc uIcer, dIabeIes meIIIIus, cardIovascuIar dIsorders eIc. 4.3 HyperIension In over 90 oI paIIenIs wIIh hyperIensIon, Ihe dIsease Is caIIed "essenIIaI hyperIensIon" and no cause can be IdenIIIIed. GeneIIc predIsposIIIon Is an ImporIanI rIsk IacIor. Lxposure Io Iead, cadmIum and noIse Is a rIsk IacIor In deveIopIng hyperIensIon and II has aIso been suggesIed IhaI psychosocIaI sIress Is a IacIor In Ihe deveIopmenI oI hyperIensIon. OIher rIsk IacIors In Ihe deveIopmenI oI hyperIensIon IncIude dIeIary habIIs (excess saII and IaIs), obesIIy and physIcaI InacIIvIIy. bb OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 4.4 Coronary hearI disease (CHD) NarrowIng oI Ihe coronary arIerIes causes InadequaIe bIood suppIy Io Ihe hearI muscIe causIng "angIna pecIorIs" or recurrenI brIeI aIIacks oI chesI paIn oIIen assocIaIed wIIh exercIse. OccIusIon oI any arIery causes myocardIaI InIarcIIon or necrosIs oI parI oI Ihe hearI muscIe whIch may cause deaIh wIIhIn a shorI IIme or IaIer on due Io compIIcaIIons. The IncIdence oI Ihe dIsease Is IncreasIng and more and more younger peopIe are beIng aIIecIed. II Is more common In men Ihan women beIow 4S years oI age, buI In oIder age Ihe Iwo sexes may be equaI. The rIsk oI coronary hearI dIsease Is assocIaIed wIIh hyperIensIon, hIgh dIeIary IaI InIake, hIgh serum choIesIeroI and beIng overweIghI. In addIIIon Ihere Is a sIgnIIIcanI IamIIIaI Iendency. A coronaryprone personaIIIy has been descrIbed as Ihe aggressIve, compeIIIIve person who Iakes on Ioo many jobs, IIghIs deadIInes and Is obsessed by Iack oI adequaIe IIme Io IInIsh hIs work. OverIoad aI work has aIso been assocIaIed wIIh coronary hearI dIsease. PsychosocIaI sIress Increases serum choIesIeroI, causes hyperIensIon and enhances cIoI IormaIIon. CIgareIIe smokIng Is anoIher rIsk IacIor Ior CHD. OIher occupaIIonaI IacIors reIaIed Io CHD are sedenIary work, exposure Io carbon dIsuIIIde, carbon monoxIde and nIIraIes and chronIc exposure Io noIse, heaI and coId. SoIvenIs such as benzene, IrIchIoreIhyIene, chIoroIorm, eIhyI chIorIde and IIuorocarbon compounds dIrecIIy aIIecI Ihe myocardIaI IIssue. Lead and mercury cause CHD, secondary Io hyperIensIon, and cobaII, arsenIc and anIImony produce myocardIaI damage. 4.5 PepIic ulcer SeveraI rIsk IacIors have been assocIaIed wIIh Ihe deveIopmenI oI gasIrIc and duodenaI uIcers. These IncIude heredIIy, cerIaIn medIcInes (anaIgesIcs and non sIeroIdaI anIIInIIammaIory drugs), cIgareIIe smokIng, medIcaI IIIness, surgIcaI procedures, Iype oI personaIIIy, IocaI InIecIIon (Hcconctc )o) and occupaIIon. OccupaIIonaI IacIors assocIaIed wIIh Ihe rIsk oI deveIopIng pepIIc uIcers IncIude jobs wIIh a hIgh degree oI responsIbIIIIy and IrreguIar shIII work; Ihe hIgher Ihe work sIress Ihe hIgher Ihe uIcer raIe. AIso pepIIc uIcers are reIaIed Io InhaIed IrrIIanI gases whIch dIssoIve In spuIum and are IngesIed. 4.6 Chronic nonspecilic respiraIory diseases (CNRD) CNRD Is a generaI Ierm used Io descrIbe a group oI dIseases In whIch Ihere Is chronIc cough and spuIum producIIon and/or shorIness oI breaIh aI resI and/or durIng exercIse. These condIIIons IncIude chronIc bronchIIIs, emphysema, bronchIaI asIhma and asIhmaIIc bronchIIIs. AII Ihese dIseases may be acuIeIy or chronIcaIIy exacerbaIed by InIecIIon. CNRD are dIseases oI muIIIpIe eIIoIogy and represenI a cIassIc exampIe oI dIsorders IhaI may be occupaIIonaI In orIgIn, workreIaIed or reIaIed Io Ihe socIaI phenomena oI urbanIzaIIon and IndusIrIaIIzaIIon. When Ihe rIsk oI Ihese dIsorders Is sIrongIy reIaIed Io specIIIc occupaIIonaI exposure such as nonIIbrogenIc dusIs (e.g. coIIon, rIce and IIax) or IrrIIanIs, Ihey OccuntonnI nnd other work-reInted dsenses: ModuIe 2 b7 may easIIy be IhoughI oI as occupaIIonaI dIseases. II Is weII known, however, IhaI oIher IacIors, such as smokIng, cIImaIIc condIIIons, communIIy aIr poIIuIIon, aIopy, IamIIIaI geneIIc IacIors, IndIvIduaI suscepIIbIIIIy, bronchIaI hyperreacIIvIIy, chIIdhood respIraIory InIecIIons, repeaIed respIraIory InIecIIons In aduII IIIe and socIoeconomIc sIaIus, can pIay a major roIe. In any IndIvIduaI case, II Is dIIIIcuII Io ascerIaIn how much synergIsm has occurred beIween any combInaIIon oI Iwo or more. II Is generaIIy beIIeved however, IhaI In smokers who are exposed Io communIIy or workpIace aIr poIIuIIon, smokIng pIays a more ImporIanI roIe In Ihe causaIIon oI CNRD Ihan does aIr poIIuIIon. In dusIy occupaIIons where dusI Is known Io cause specIIIc puImonary dIseases (sIIIcosIs, asbesIosIs, coaI workers' pneumoconIosIs, byssInosIs, eIc.), dusI concenIraIIons Iower and duraIIons shorIer Ihan Ihose whIch cause Ihe specIIIc dIsease may be suIIIcIenI Io conIrIbuIe Io Ihe causaIIon oI CNRD. LxampIes oI occupaIIons where workreIaIed CNRD may occur are Ihose where dusI (organIc or InorganIc), IrrIIanI gases or aerosoIs are presenI. These poIIuIanIs may conIrIbuIe Io Ihe causaIIon oI CNRD by causIng IrrIIaIIon oI Ihe respIraIory mucous membrane or Ihrough aIIergIc mechanIsms. These occupaIIons IncIude Ihe chemIcaI IndusIry, mInIng, IoundrIes, IexIIIe mIIIs, sIIos, cemenI IacIorIes, Ihe gIass IndusIry, Ihe IerIIIIzer IndusIry, sIeeI mIIIs, smeIIers and a muIIIIude oI oIher occupaIIons. 4.7 LocomoIor disorders Two exampIes oI IocomoIor dIsorder wIII be gIven Ior whIch evIdence oI work reIaIedness Is avaIIabIe: Iow back paIn syndrome and shouIderneck paIn syndrome. Io\ nc nn Low back paIn Is a sympIom oI common occurrence In Ihe generaI popuIaIIon, aIIecIs maIes and IemaIes aI aII ages, buI Is more common beIween Ihe ages oI 2S and 64 years. II Is saId Io aIIecI over haII Ihe workIng popuIaIIon aI some IIme durIng IheIr acIIve workIng IIIe and II Is esIImaIed IhaI 2-S oI IndusIrIaI workers experIence Iow back paIn each year. PaIn In Ihe IumbosacraI area can resuII Irom InIIammaIory, degeneraIIve, IraumaIIc, neopIasIIc or oIher dIsorders. In some InsIances II Is cIaImed Io be psychogenIc In orIgIn. The mosI common Iype oI occupaIIonaI Iow back paIn Is nonspecIIIc, oI IndeIermInaIe paIhoIogy and oIIen assocIaIed wIIh posIure, IIIIIng oI heavy objecIs and InjurIous (IwIsIIng) movemenIs oI occupaIIonaI or nonoccupaIIonaI orIgIn. The rIsk IacIors Ior Iow back paIn IncIude congenIIaI back deIecIs, weak muscuIaIure, rheumaIIc aIIecIIon and degeneraIIve condIIIons oI Ihe spIne and InIerverIebraI dIscs. CerIaIn occupaIIons carry a hIgher rIsk oI deveIopIng Iow back paIn. These IncIude heavy manuaI work, mInIng, dockIng, maIerIaI handIIng, jobs requIrIng awkward posIures and posIures IhaI have Io be maInIaIned Ior proIonged perIods or InvoIve IrequenI bendIng, IwIsIIng or whoIe body vIbraIIon, nursIng and poIIcIng. These occupaIIons requIre proper seIecIIon, physIcaI IraInIng, proper pIacemenI and adopIIon oI saIe crIIerIa Ior Ioad IIIIIng. b OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 5Ioudcncc nn A varIeIy oI dIseases may resuII In shouIder and neck paIn: exampIes are InIIammaIory reacIIons In Ihe synovIaI membrane and bursa sysIem and degeneraIIve dIsorders In Ihe carIIIage, IIgamenIs and Iendons. In addIIIon, muscuIar, vascuIar and neuromuscuIar dIsorder may resuII In shouIder paIn and paIn may be reIerred Irom Ihe chesI. DIsorders assocIaIed wIIh generaI muscIe weakness and generaI maIaIse, such as InIecIIons, may aIso resuII In an Increased suscepIIbIIIIy Io shouIder and neck compIaInIs Irom Ioads on Ihe shouIder whIch a worker can normaIIy IoIeraIe. Irom Ihe occupaIIonaI heaIIh sIandpoInI, IndIvIduaI predIsposIng IacIors such as age, dIIIIcuIIIes In organIzIng Ihe work Iask and InIIammaIory rheumaIIc predIsposIIIon pIay a roIe. II has been Iound IhaI workIng wIIh Ihe hands above shouIder heIghI Is more IrequenI In workers wIIh boIh acuIe and chronIc shouIder and neck paIn. However, Increased work Ioads on shouIder and neck muscIes can aIso be produced wIIhouI IIIIIng Ihe arms above Ihe shouIders. IurIher prooI oI Ihe workreIaIedness oI shouIder and neck paIn Is presenIed by Ihe IacI IhaI appIIcaIIon oI ergonomIc prIncIpIes Io Improve meIhods oI work reduces Ihe paIn. 5. TASKS lOR TRAlNEES 1. Carry ouI a workpIace survey and make observaIIons. Look Ior any poIenIIaI and acIuaI hazards (physIcaI, chemIcaI, mechanIcaI, bIoIogIcaI and psychoIogIcaI) ConsIder Ihe avaIIabIIIIy or Ihe need Ior conIroI measures Look Ior any earIy sIgns oI occupaIIonaI dIsease and workreIaIed dIsease In workers. 2. |oIn and work wIIh members oI Ihe occupaIIonaI heaIIh Ieam; reporI your observaIIons and consuII wIIh Ihem regardIng conIroI measures, Ihe need Ior envIronmenIaI and bIoIogIcaI monIIorIng and Ihe managemenI oI cerIaIn occupaIIonaI heaIIh probIems (where appIIcabIe). S. Use your skIIIs In doIng sImpIe IesIs; coIIecI bIoIogIcaI sampIes Ior anaIysIs and advIse on need Ior IurIher InvesIIgaIIons (as appIIcabIe). 4. LducaIe workers on Ihe use and maInIenance oI personaI proIecIIve equIpmenI. S. DIscuss wIIh workers maIIers reIaIIng Io nuIrIIIon and sanIIaIIon and advIse Ihem on heaIIhy eaIIng habIIs, good sanIIary measures and personaI hygIene. 6. AdvIse managemenI regardIng Ihe need Ior conIroI measures and Ihe need Io InvesIIgaIe some occupaIIonaI heaIIh probIems IhaI requIre consuIIaIIon wIIh oIher members oI Ihe occupaIIonaI heaIIh Ieam. OccuntonnI nnd other work-reInted dsenses: ModuIe 2 b9 7. AdvIse managemenI on Ihe ImpIemenIaIIon oI occupaIIonaI heaIIh IegIsIaIIon In Ihe workpIace. 8. AdvIse workers on Ihe need Io observe Ihe conIroI measures InsIIIuIed Ior a heaIIhy and saIe workpIace. 9. Keep and updaIe records oI aII occupaIIonaI heaIIh acIIvIIIes underIaken by you (reporIs on pIanI surveys, reporIs on envIronmenIaI and bIoIogIcaI monIIorIng and reporIs on heaIIh Irends aI Ihe workpIace). MODULE 3 Early detection of occupational diseases 1. OB|ECTlVES UndersIand Ihe ImporIance oI Ihe earIy deIecIIon oI occupaIIonaI dIseases Choose Ihe mosI approprIaIe dIagnosIIc means Ior earIy deIecIIon oI occupaIIonaI dIseases Know how Io parIIcIpaIe eIIecIIveIy In carryIng ouI perIodIc medIcaI examInaIIons Ior workers. 2. lNTRODUCTlON AND BASlC CONCEPTS OccupaIIonaI dIseases are unIque In Ihe sense IhaI Ihe hazards IhaI cause Ihem are known even beIore exposure oI Ihe workers Iakes pIace. ThIs IacI characIerIzes occupaIIonaI dIseases as beIng enIIreIy prevenIabIe; exposure can be conIroIIed or prevenIed. The IdeaI sIIuaIIon oI compIeIe prevenIIon oI occupaIIonaI dIseases by conIroIIIng exposures however, does noI occur In pracIIce, and occupaIIonaI dIseases conIInue Io occur. To mInImIze Ihe damage caused by occupaIIonaI dIseases, Ihe besI aIIernaIIve Is earIy deIecIIon oI paIhoIogIcaI changes aI a sIage when Ihey are reversIbIe. CerIaIn occupaIIonaI exposures cause earIy cIInIcaI, IuncIIonaI, bIochemIcaI, physIoIogIcaI or morphoIogIcaI changes whIch, when deIecIed earIy enough, are reversIbIe. There are many cIInIcaI, IaboraIory or oIher IesIs IhaI have been deveIoped Io deIecI Ihese earIy changes, each exposure havIng IIs specIIIc IesI. UnIorIunaIeIy, Ihere are oIher occupaIIonaI dIseases whIch cannoI be deIecIed aI a reversIbIe sIage. These IncIude acuIe reacIIons Io IrrIIanI gases, e.g. ammonIa, asphyxIanIs, e.g. CO and hydrocyanIc acId, and corrosIve maIerIaIs, e.g. acIds and aIkaIIs; coIIagenous pneumoconIosIs, e.g. sIIIcosIs and asbesIosIs; occupaIIonaI cancer, and many oIher condIIIons. AcuIe condIIIons, caused mosIIy by occupaIIonaI accIdenIs, are amenabIe Io IreaImenI and wIII noI be dIscussed. The progress oI pneumoconIosIs can be sIowed down consIderabIy II exposure Is dIsconIInued. AIso, II Is weII known IhaI deIecIIon oI occupaIIonaI cancer aI an earIy sIage Improves prognosIs. ThereIore, regardIess oI Ihe reversIbIIIIy oI Ihe paIhoIogIcaI changes caused by occupaIIonaI exposure, earIy deIecIIon oI occupaIIonaI dIsease Is desIrabIe. Many IndIces used In earIy deIecIIon oI occupaIIonaI dIseases have very wIde ranges oI normaI varIabIIIIy. ResuIIs oI such IesIs can move beIween Ihe Iwo ends oI Ihe normaI range In a gIven IndIvIduaI wIIhouI beIng recognIzed as abnormaI; an IndIvIduaI wIIh a predIcIed vIIaI capacIIy oI 4 I can deIerIoraIe Irom S I Io S I 72 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers wIIhouI beIng recognIzed as abnormaI unIess Ihe preempIoymenI IeveI Is known. ThereIore, a prepIacemenI record oI varIabIes, as weII as perIodIc examInaIIons, Is necessary Ior Ihe earIy deIecIIon oI dIsease. The Ierms "earIy deIecIIon" and "perIodIc examInaIIon" wIII be used In IhIs IexI Io denoIe examInaIIons carrIed ouI Io deIecI earIy occupaIIonaI dIsease wheIher IhIs earIy dIsease Is reversIbIe (curabIe) or noI. ConsIderIng Ihe very Iarge numbers oI workers IhaI have Io be examIned, perIodIc examInaIIons do noI have Io be comprehensIve checkups. LxamInaIIons usuaIIy sIarI wIIh sImpIe screenIng IesIs and posIIIve cases Ihen undergo comprehensIve examInaIIons Io prove or dIsprove Ihe presence oI occupaIIonaI dIseases. ScreenIng IesIs have Io be sImpIe, sensIIIve, specIIIc, easy, InexpensIve and nonInvasIve. ScreenIng IesIs IncIude IesIs Io deIecI: Ihe presence oI a IoxIc maIerIaI In a cerIaIn bIoIogIcaI sampIe, as an Index oI exposure Io IhaI maIerIaI Ihe presence oI whIch may have been proved by envIronmenIaI monIIorIng, e.g. monIIorIng Iead In bIood Ihe presence oI meIaboIIIes oI a IoxIc subsIance In a bIoIogIcaI sampIe, e.g. monIIorIng organIc suIIaIes In urIne In phenoI exposure. In both cases biological threshold limit values are recommended concentra- tions of the substance or its metabolites in the biological fluids or tissues that should not be exceeded if the disease is to be prevented. Biological threshold limit values are available for many toxic exposures. changes In organ IuncIIons as a resuII oI exposure Io subsIances where Ihe organs are IargeIs Ior Ihe IoxIc acIIon, e.g. kIdney IuncIIons, IIver IuncIIons and puImonary IuncIIons; morphoIogIcaI changes In bIood eIemenIs IhaI may IndIcaIe IoxIc acIIon on Ihe haemopoIeIIc sysIem; IrreversIbIe IIssue changes, e.g. caIaracI due Io exposure Io InIrared radIaIIon, IonIzIng radIaIIon or Xray examInaIIon Io deIecI sIIIcosIs and asbesIosIs; psychomoIor and hIgher cenIraI nervous sysIem IuncIIons, e.g. IesIs have been used Io evaIuaIe exposure Io subsIances known Io aIIecI nervous IuncIIons, e.g. manganese, mercury and carbon dIsuIIIde. As screenIng IesIs IheIr specIIIcIIy Is raIher Iow and Ihey are Ioo eIaboraIe Io be used Ior mass screenIng. The reguIarIIy oI examInaIIons varIes wIIh Ihe Iype oI exposure. DIseases wIIh condIIIons whIch progress rapIdIy, e.g. changes In choIIneesIerase acIIvIIy In Ihose workIng wIIh pesIIcIdes shouId be monIIored aI monIhIy InIervaIs or even more IrequenIIy. AIIecIIon oI Ihe bIood pIcIure due Io IonIzIng radIaIIon can be monIIored aI perIods rangIng Irom 1 Io 6 monIhs dependIng on Ihe exposure dose. Ior dIseases IhaI sIarI Io appear aIIer many years, e.g. noIseInduced hearIng Ioss and sIIIcosIs, perIodIc examInaIIon can sIarI aIIer many years oI exposure (S-S years) and sInce progress Is sIow, examInaIIon can be repeaIed aIIer perIods Irom 1-2 years. Cancer appears aIIer even Ionger perIods. nrIy detecton o] occuntonnI dsenses: ModuIe 3 73 3. EARLY DETECTlON Ol OCCUPATlONAL DlSEASES CAUSED BY PHYSlCAL lACTORS 3.1 HeaI The severIIy oI heaIIh eIIecIs Irom heaI Increases wIIh Ihe IemperaIure, humIdIIy and duraIIon oI exposure. In order oI IncreasIng severIIy Ihe heaIIh eIIecIs are: IassIIude, IrrIIabIIIIy, dIscomIorI Iowered work perIormance and Iack oI concenIraIIon heaI rash heaI exhausIIon heaI sIroke. 3.2 Noise NoIseInduced hearIng Ioss can be deIecIed by audIomeIry. LarIy Ioss aIIecIs hIgh Iones (S000-6000 Hz) Iong beIore hearIng oI every day speech Is aIIecIed. NoIse Induced hearIng Ioss Is permanenI. 3.3 VibraIion VIbraIIons cause vascuIar dIsorders oI Ihe arms and bony changes In Ihe smaII bones oI Ihe wrIsI. VascuIar changes are dIIIIcuII Io deIecI, IesIs are compIIcaIed and non specIIIc, buI bony changes can be deIecIed by Xray examInaIIon oI Ihe wrIsI. The mosI common IIndIng Is rareIacIIon oI Ihe IunaIe bone. 3.4 AImospheric pressure Lxposure Io Increased aImospherIc pressure (under waIer) Ieads Io asepIIc bone necrosIs around Ihe knee, hIp and shouIder whIch can be deIecIed by Xray examInaIIon. 3.5 lnlra-red radiaIion Lxposure Io InIrared radIaIIon causes caIaracI, an opacIIy oI Ihe eye Iens whIch aIIecIs Ihe posIerIor parI oI Ihe Iens. CaIaracI causes progressIve IaIIure oI vIsIon and can be deIecIed by sIII Iamp examInaIIon. The aIIecIed Iens has Io be removed. 3.6 lonizing radiaIion Lxposure Io IonIzIng radIaIIon aIso causes caIaracIs. SInce Ihe bIood IormIng organs are among Ihe mosI sensIIIve Io IonIzIng radIaIIons, Ihe bIood shouId be examIned perIodIcaIIy. The IeucocyIIc counI Is IndIcaIIve oI aIIecIIon and Is more useIuI II Ihe preempIoymenI resuIIs are avaIIabIe. KeraIoses oI Ihe skIn are precancerous condIIIons. 74 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 4. EARLY DETECTlON Ol OCCUPATlONAL DlSEASES CAUSED BY BlOLOGlCAL AGENTS 4.1 Pulmonary Iuberculosis ThIs can be deIecIed by Xray examInaIIon oI Ihe chesI. Mass mInIaIure radIography Is a useIuI IooI. A ManIoux IesI can be sIrongIy posIIIve and GramnegaIIve, acId IasI bacIIII may be deIecIabIe on spuIum cuIIure. 4.2 Chronic brucellosis ChronIc bruceIIosIs Is dIIIIcuII Io dIagnose cIInIcaIIy buI can be deIecIed by seroIogIcaI examInaIIon (Iube aggIuIInaIIon IesI). 4.3 Viral hepaIiIis B and C These can be deIecIed by seroIogIcaI examInaIIon and deIermInaIIon oI hepaIIIIs markers. 5. EARLY DETECTlON Ol OCCUPATlONAL DlSEASES CAUSED BY CHEMlCALS 5.1 MeIals Icnd (a) LssenIIaIs oI dIagnosIs Inognnc-ncutc ccct: abdomInaI paIn (coIIc) encephaIopaIhy haemoIysIs acuIe renaI IaIIure Inognnc-cIonc ccct: IaIIgue and asIhenIa arIhraIgIa and myaIgIas anaemIa perIpheraI neuropaIhy (moIor) neurobehavIouraI dIsIurbances and chronIc encephaIopaIhy gouI and gouIy nephropaIhy chronIc renaI IaIIure nrIy detecton o] occuntonnI dsenses: ModuIe 3 75 A) cnd conound: IaIIgue and IassIIude headaches nausea and vomIIIng neuropsychIaIrIc compIaInIs (memory Ioss, dIIIIcuIIy In concenIraIIng) deIIrIum seIzures coma (b) LarIy deIecIIon oI excessIve exposure Io Iead can be deIermIned by: Ictcnnnton o cnd conccntnton n ood nnd unc An average normaI vaIue oI Iead In bIood oI S0 g/dI Is noI unusuaI In cIIIes wIIh heavy IraIIIc. PaIIenIs wIIh Iead poIsonIng have vaIues oI 80 g/dI or hIgher. Indcc: o ccct deIIaamInoIevuIInaIe dehydraIase In bIood deIIaamInoIevuIInIc acId In urIne coproporphyrIn In urIne zInc proIoporphyrIn In Ihe eryIhrocyIes Mccu) (a) LssenIIaIs oI dIagnosIs Inognnc nccu) acuIe respIraIory dIsIress gIngIvIIIs Iremor eryIhIsm (shyness, emoIIonaI IabIIIIy) proIeInurIa, renaI IaIIure Ognnc nccu) /n) nccu) conound:) menIaI dIsIurbances aIaxIa, spasIIcIIy paraesIhesIas vIsuaI and audIIory dIsIurbances 7b OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers (b) LarIy deIecIIon oI exposure Io mercury (InorganIc and aIkyI organIc mercury) ThIs Is carrIed ouI by Ihe measuremenI oI mercury In urIne. The normaI vaIue In nonexposed IndIvIduaIs Is Iess Ihan 20 g/I. OrganIc aIkyI compounds (meIhyI mercury) can be esIImaIed In pIasma and eryIhrocyIes. Mnngnnc:c (a) LssenIIaIs oI dIagnosIs Acutc ccct: Iever chIIIs dyspnoea (meIaI Iume Iever) CIonc ccct: ParkInsonIIke syndrome behavIouraI syndrome pneumonIa (b) LsIImaIIon The esIImaIIon oI manganese In bIoIogIcaI IIuIds does noI heIp In earIy dIagnosIs. DeIecIIon oI Ihe dIsease In Ihe cIInIcaI sIage depends on Ihe neuropsychIaIrIc manIIesIaIIons. A:cnc (a) LssenIIaIs oI dIagnosIs Acutc ccct: nausea vomIIIng dIarrhoea InIravascuIar haemoIysIs jaundIce oIIgurIa (arsIne) cardIovascuIar coIIapse CIonc ccct: hyperkeraIosIs and hyperpIgmenIaIIon (meIanosIs) perIpheraI neuropaIhy nrIy detecton o] occuntonnI dsenses: ModuIe 3 77 anaemIa cardIac and perIpheraI vascuIar dIsease (b) ChronIc exposure ThIs can be evaIuaIed by measuremenI oI arsenIc In urIne. In nonexposed normaI IndIvIduaIs II does noI exceed S0 g/I. SeaIood raIses Ihe concenIraIIon oI arsenIc In urIne. LsIImaIIon oI arsenIc In haIr and naIIs can gIve a good Index oI chronIc exposure, however exIernaI conIamInaIIon shouId be avoIded. HaIr and naIIs shouId be washed IhoroughIy. 5.2 Organic solvenIs and biological IesIs used lor deIecIion ol exposure Orgnnc soIvent nnd ts henIth e]]ects Methods o] evnIunton o] exposure enzene (benzol) Acute exposure PerIodIc red and whIte ceII counts oI AnaesthesIa: dIzzIness, headache, questIonabIe vaIue but may detect earIy nausea, vomItIng, sIeepIness, haemopoIetIc eIIects IatIgue, sIurred speech, dIsequIIIbrIum, enzene In bIood (specIIIc, sensItIve, dIsorIentatIon, depressIon, Ioss oI the best approach avaIIabIe at present) conscIousness Trans transmuconIc acId In urIne RespIratory tract IrrItatIon: sore nose (reasonabIy specIIIc, sensItIve) and throat, cough PhenyImercapturIc acId In urIne (specIIIc, sensItIve, sophIstIcated methodoIogy) Chronc exposure enzene In urIne (specIIIc, sensItIve, one marrow depressIon wIth a deIayed IImIted experIence) eIIect, many years In some cases PhenoI In urIne (nonspecIIIc, EarIy symptoms and sIgns are vague, InsensItIve) but Iater tIredness and spontaneous enzene In exhaIed breath (specIIIc, bIeedIng may occur as anaemIa, pancytopenIa sensItIve, IImIted practIcabIIIty) andJor thrombocytopenIa become more severe ApIastIc anaemIa, acute myeIobIastIc IeukaemIa and acute erythroIeukaemIa are the most Ieared eIIects oI chronIc exposure Toluene (methyl benzene) ToIuene exposure Is rareIy pure and exposure HIppurIc acId In urIne coIIected at the IrequentIy IncIudes benzene wIth or end oI the work shIIt. (Note: hIppurIc acId wIthout xyIene Is not a metaboIIte specIIIc to toIuene; It can be produced Irom dIetary sources, Acute exposure such as Iood preserved wIth benzoIc NarcotIc acId). ConjunctIvaI IrrItatIon and uIceratIon CardIac arrhythmIa (has caused deaths In "snIIIers") Chronc exposure LIver, kIdney and bone marrow (probabIy due to benzene as contamInant) 7 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers Xylene Acute exposure MethyI hIppurIc acId In urIne Mucous membrane IrrItatIon NarcotIc Chronc exposure ApIastIc anaemIa has been postuIated but may be due to benzene contamInatIon (wIth toIuene) Aminobenzene (aniline) Acute exposure MethaemogIobIn In bIood. MIId skIn IrrItant ParaamInophenoI In urIne Moderate exposure may onIy cause some cyanosIs Severe poIsonIng resuIts In anoxIa and death, whIch may be deIayed Ior a Iew hours aIter exposure Carbon tetrachloride Acute exposure CCI 4 In expIred aIr Nausea, vomItIng, drowsIness, dIzzIness Iood concentratIon Is oI IImIted vaIue Chronc exposure Dry, scaIy dermatItIs CentrIIobuIar necrosIs wIth or wIthout Iatty degeneratIon oI the IIver Acute oIIgurIc renaI IaIIure Polychlorinated biphenyls Acute exposure PCs In bIood SkIn rash (chIoracne) Eye IrrItatIon Nausea, vomItIng Chronc exposure Weakness, weIght Ioss, anorexIa SkIn rash (chIoracne) Numbness and tIngIIng oI extremItIes EIevated serum trIgIycerIdes EIevated IIver enzymes Methylene chloride (dichloromethane) Acute exposure CarboxyhaemogIobIn IeveIs In bIood and SkIn and mucous membrane IrrItant carbon monoxIde In exhaIed aIr Acute IntoxIcatIon wIth stupor, numbness SmokIng aIIects bIoIogIcaI monItorIng and tIngIIng oI IImbs IoIIowIng InhaIatIon resuIts Chronc exposure Dry, scaIy dermatItIs Can precIpItate cardIac InsuIIIcIency due to Increase In carboxyhaemogIobIn Chloroform Acute exposure ChIoroIorm In exhaIed aIr and In bIood SkIn IrrItant, potent anaesthetIc Chronc exposure LIver enIargement and damage potentIated by aIcohoI abuse (causes hepatIc tumours In rodents) OIIgurIc renaI IaIIure ChronIc dry, scaIy dermatItIs nrIy detecton o] occuntonnI dsenses: ModuIe 3 79 Trichloroethane Acute exposure TrIchIoroethane, trIchIoroethanoI and Mucous membrane and skIn IrrItant trIchIoroacetIc acId In expIred aIr, bIood NarcotIc and urIne. CapabIe oI sensItIzIng the myocardIum to adrenaIIne thereby causIng arrhythmIas Chronc exposure Dry, scaIy dermatItIs Trichloroethylene Acute exposure ExpIred aIr Ior trIchIoroethyIene and PowerIuI narcotIc, actIon exacerbated by trIchIoroacetIc acId ethanoI TrIchIoroethanoI and trIchIoroacetIc acId MIId respIratory and skIn IrrItant. In bIood or urIne Chronc exposure PerIphera; neuropathy has been reported AddIctIve Tetrachloroethylene Acute exposure TetrachIoroethyIene, trIchIoroethanoI and PowerIuI narcotIc trIchIoroacetIc acId In bIood, aIveoIar aIr Can cause mucous membrane and skIn and urIne IrrItatIon as weII as IIver damage Chronc exposure CNS depressIon and IIver damage Rodent carcInogen Carbon disulfide (CS 2 ) Acute exposure The IodIne azIde reactIon wIth urIne at Severe skIn and mucous membrane IrrItant the end oI the work day and at the DIzzIness, headaches, psychosIs, drowsIness begInnIng oI the work day wIII detect organIc suIIate metaboIItes oI carbon Chronc exposure dIsuIIIde, but the reactIon Is not Four dIstInct syndromes: specIIIc Ior CS 2 ParkInsonIIke aIIectIon due to the corpus strIatum and gIobus paIIIdus PerIpheraI neuropathy aIIectIng motor and sensory nerves as weII as ocuIar nerves PsychotIc condItIons (rareIy seen nowadays, but Iesser neuropsychIatrIc states are stIII descrIbed) CardIovascuIar dIsease, possIbIy due to Increased bIood choIesteroI and IIpoproteIn IeadIng to IschaemIc heart dIsease and perIpheraI vascuIar damage. (Recent research suggests that part oI thIs cardIovascuIar aIIect may be due to an acute myotoxIc eIIect on cardIac muscIe IeadIng to IataI arrhythmIas 5.3 PesIicides Lxposure Io organophosphaIes can be evaIuaIed by deIermInIng Ihe degree oI InhIbIIIon oI choIIneesIerase acIIvIIy In Ihe bIood. There are IaboraIory meIhods Ior evaIuaIIon oI choIIneesIerase acIIvIIy whIch are accuraIe and saIIsIacIory. There are aIso many sImpIer IIeId survey meIhods and kIIs IhaI are noI as accuraIe buI are quIIe useIuI. SInce Ihere are wIde varIaIIons In Ihe vaIues oI choIIneesIerase acIIvIIy among IndIvIduaIs, II Is ImporIanI Io compare IndIvIduaI IIgures wIIh preexposure IeveIs Ior Ihe same IndIvIduaI, measured by Ihe same meIhod. SympIoms oI poIsonIng wIIh U OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers organophosphaIes appear when choIIneesIerase acIIvIIy have been reduced by S0- 60 oI preexposure IeveIs. Severe cases may show 7S reducIIon. MeasuremenI oI choIIneesIerase acIIvIIy Is aIso Ihe IesI Ior deIecIIon oI poIsonIng or exposure Io carbamaIe and IhIocarbamaIe pesIIcIdes. 5.4 Pulmonary dusI diseases LarIy dIagnosIs oI byssInosIs Is made usIng a specIaI quesIIonnaIre whIch demonsIraIes Ihe presence oI chesI IIghIness on Ihe IIrsI day aIIer Ihe weekend Ieave, In earIy cases. Xray examInaIIon In cases oI byssInosIs yIeIds negaIIve resuIIs and Ihe demonsIraIIon oI aIrway obsIrucIIon by puImonary IuncIIon IesIIng Is noI specIIIc. In Ihe case oI exposure Io IIbrogenIc dusI, aIIer a saIIsIacIory occupaIIonaI hIsIory has been eIIcIIed, a posIIIve Xray Is Ihe maIn IooI Ior earIy dIagnosIs. ThIs Is appIIcabIe In Ihe case oI sIIIcosIs, asbesIosIs, IaIc pneumoconIosIs and chIna cIay pneumoconIosIs. II shouId be noIed, however, IhaI once a posIIIve Xray Is obIaIned, Ihese dIseases are IrreversIbIe. In Ihe case oI exIrInsIc aIIergIc aIveoIIIIs (bagassosIs, Iarmers' Iung), Ihe dIagnosIs oI acuIe, subacuIe and chronIc cases can be conIIrmed by Xray examInaIIon. SeroIogIcaI examInaIIon may heIp. 6. TASKS lOR TRAlNEES 1. IamIIIarIze yourseII wIIh Ihe IechnIques and IechnoIogIes used In earIy deIecIIon oI occupaIIonaI dIseases. 2. Observe how Ihe prepIacemenI/perIodIc medIcaI examInaIIons are carrIed ouI and record your observaIIons oI Ihe communIcaIIon skIIIs requIred In eIIcIIIng InIormaIIon Irom Ihe worker. S. AssocIaIe Ihe resuIIs obIaIned durIng Ihe perIodIc medIcaI examInaIIon wIIh Ihe resuIIs oI envIronmenIaI monIIorIng oI Ihe workpIace. Prepare a reporI on your observaIIons. 4. RevIew Ihe medIcaI records aI Ihe workpIace and make your observaIIons regardIng Ihe hIsIory oI sIgns and sympIoms oI occupaIIonaI dIsease. S. AcquaInI yourseII wIIh Ihe InIernaIIonaI Labour OrganIsaIIon's (ILO) InIernaIIonaI CIassIIIcaIIon oI RadIographs oI PneumoconIoses. 6. RevIew Ihe currenI avaIIabIe daIa on bIoIogIcaI monIIorIng oI occupaIIonaI hazards. 7. AdvIse managemenI on Ihe need Io carry ouI reguIar medIcaI examInaIIons on IheIr workers. 8. AdvIse workers on Ihe need Io pass a medIcaI examInaIIon on a reguIar basIs. 9. AdvIse workers on Ihe need Io recognIze Ihe earIy sIgns and sympIoms oI occupaIIonaI dIseases. MODULE 4 Occupational ergonomics 1. OB|ECTlVES UndersIand Ihe humanmachIne-envIronmenI reIaIIonshIp Be aware oI ergonomIcs as a IooI Ior heaIIhIer and saIer workIng condIIIons Know how Io Iake InIo accounI Ihe workers' dImensIons and Ihe physIcaI/ psychosocIaI capabIIIIIes and IImIIaIIons In order Io avoId harmIuI workIng condIIIons CoIIecI InIormaIIon In Ihe work sIIuaIIon abouI boIh Ihe workers and Ihe naIure oI Ihe work In order Io oIIer correcI and prIorIIIzed advIce CreaIe awareness as Io why and how Io Improve Ihe work sIIuaIIon and Io gIve sImpIe suggesIIons In order Io desIgn ergonomIcaIIy eIIIcIenI new work sIIuaIIons CommunIcaIe wIIh managemenI and workers abouI ImprovemenIs In Ihe work sIIuaIIon In order Io beneIII as much as possIbIe. 2. lNTRODUCTlON AND BASlC CONCEPTS LrgonomIcs Is Ihe sIudy oI Ihe compIex reIaIIonshIps beIween peopIe, physIcaI and psychoIogIcaI aspecIs oI Ihe work envIronmenI (e.g. IacIIIIIes, equIpmenI and IooIs), job demands and work meIhods. II Is a IIeId whIch InIegraIes knowIedge derIved Irom Ihe human scIences (In parIIcuIar anaIomy, physIoIogy and psychoIogy) Io maIch jobs, sysIems, producIs and envIronmenIs Io Ihe physIcaI and menIaI abIIIIIes and IImIIaIIons oI workers. LrgonomIcs sIresses IIIIIng Ihe job Io Ihe worker as compared Io Ihe more usuaI pracIIce oI obIIgIng Ihe worker Io III Ihe job. The aIm oI ergonomIcs Is prImarIIy Io opIImIze, IIrsI and IoremosI, Ihe comIorI, as weII as Ihe heaIIh, saIeIy and eIIIcIency, oI Ihe worker. AppIyIng ergonomIc prIncIpIes however, Is noI onIy beneIIcIaI Io workers. The beneIIIs Io empIoyers are equaIIy sIgnIIIcanI and are boIh vIsIbIe and measurabIe In Ierms oI Increased eIIIcIency, hIgher producIIvIIy, reducIIon In work IIme IosI due Io IIIness or Injury and decreased Insurance cosIs. A IundamenIaI prIncIpIe oI ergonomIcs Is IhaI aII work acIIvIIIes cause Ihe worker Io experIence some IeveI oI physIcaI and menIaI sIress. As Iong as IhIs sIress Is kepI wIIhIn reasonabIe IImIIs, work perIormance shouId be saIIsIacIory and Ihe worker's heaIIh and weIIbeIng shouId be maInIaIned. II sIress Is excessIve, however, undesIrabIe ouIcomes may occur In Ihe Iorm oI errors, accIdenIs, InjurIes or decreases In physIcaI or menIaI heaIIh. LrgonomIcaIIy reIaIed InjurIes and IIInesses range Irom eye sIraIn and headaches Io muscuIoskeIeIaI aIImenIs such as chronIc back, neck and shouIder paIn, cumuIaIIve 2 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers Irauma dIsorders (CTDs), repeIIIIve sIraIn InjurIes (RSIs) and repeIIIIve moIIon InjurIes (RMIs)-Ihree Ierms whIch are used InIerchangeabIy. PrevenIIng eyesIraIn, headaches and muscuIoskeIeIaI dIsorders and obIaInIng opIImaI perIormance can be achIeved when equIpmenI, worksIaIIons, producIs and workIng meIhods are desIgned accordIng Io human capabIIIIIes and IImIIaIIons, I.e. by appIyIng prIncIpIes oI ergonomIcs. The cosIs oI IgnorIng Ihese basIc prIncIpIes IncIude: InjurIes and occupaIIonaI dIseases (IncIudIng RSI, CTD and RMI) Increased absenIeeIsm hIgher medIcaI and Insurance cosIs Increased probabIIIIy oI accIdenIs and errors hIgher Iurnover oI workers Iess producIIon ouIpuI IawsuIIs IowquaIIIy work Iess spare capacIIy Io deaI wIIh emergencIes. The goaI oI an occupaIIonaI ergonomIcs programme Is Io esIabIIsh a saIe work envIronmenI by desIgnIng IacIIIIIes, IurnIIure, machInes, IooIs and job demands Io be compaIIbIe wIIh workers' aIIrIbuIes (such as sIze, sIrengIh, aerobIc capacIIy and InIormaIIon processIng capacIIy) and expecIaIIons. A successIuI ergonomIcs programme shouId sImuIIaneousIy Improve heaIIh and enhance producIIvIIy. Examples Ic\cnton o nccdcnt: DesIgnIng a machIne guard IhaI wIII aIIow a worker Io operaIe a pIece oI equIpmenI wIIh smooIh, nonawkward, IImeeIIIcIenI moIIons. ThIs mInImIzes any InconvenIence InIroduced by Ihe guard and decreases Ihe IIkeIIhood IhaI II wIII be bypassed or removed. SIudyIng Ihe bIomechanIcs oI Ihe human waIk Io deIermIne Iorces and Iorques acIIng aI Ihe InIerIace beIween Ihe IIoor and Ihe soIe oI Ihe shoe. ThIs InIormaIIon can be used Io Improve Ihe IrIcIIon characIerIsIIcs oI IIoor surIaces and shoe soIes Io reduce Ihe rIsk oI a sIIp or IaII. Ic\cnton o ntguc DesIgnIng a compuIer work sIaIIon (equIpmenI and IurnIIure) so IhaI an operaIor can use a vIdeo dIspIay unII (VDU) Ior an exIended perIod oI IIme wIIhouI experIencIng vIsuaI or posIuraI IaIIgue. LvaIuaIIng Ihe meIaboIIc demands oI a job perIormed In a hoI, humId envIronmenI Io recommend a work-resI regImen IhaI wIII prevenI heaI sIress. OccuntonnI ergononcs: ModuIe 4 3 Ic\cnton o nu:cuo:cctn d:odc: LvaIuaIIng IIIIIng Iasks Io deIermIne bIomechanIcaI sIresses acIIng on Ihe Iower back and desIgnIng IIIIIng Iasks Io ensure IhaI Ihese sIresses wIII noI cause back InjurIes. LvaIuaIIng hIghIy repeIIIIve manuaI assembIy operaIIons and deveIopIng aIIernaIIve hand IooIs and work meIhods Io reduce Ihe rIsk oI cumuIaIIve Irauma dIsorders such as IendonIIIs, epIcondyIIIIs, IenosynovIIIs and carpaI IunneI syndrome. 3. ERGONOMlCS: A MULTlDlSClPLlNARY SClENCE LrgonomIcs Is a muIIIdIscIpIInary scIence wIIh Iour major areas: human IacIors engIneerIng work physIoIogy occupaIIonaI bIomechanIcs anIhropomeIry. 3.1 Human lacIors engineering Human IacIors engIneerIng, someIImes caIIed engIneerIng psychoIogy, Is concerned wIIh Ihe InIormaIIon processIng aspecIs oI work. O]cct\c: o Iunnn ncto: cngnccng BroadIy, Ihe objecIIves are Io desIgn procedures, equIpmenI and Ihe work envIronmenI Io mInImIze Ihe IIkeIIhood oI an accIdenI caused by human error. BasIc operaIIonaI objecIIves: reduce errors Increase saIeIy Improve sysIem perIormance ObjecIIves bearIng on reIIabIIIIy, maInIaInabIIIIy and avaIIabIIIIy (RMA) and InIegraIed IogIsIIc supporI (ILS): Increase reIIabIIIIy Improve maInIaInabIIIIy reduce personneI requIremenIs reduce IraInIng requIremenIs ObjecIIves aIIecIIng users and operaIors: Improve Ihe workIng envIronmenI reduce IaIIgue and physIcaI sIress Increase human comIorI reduce boredom and monoIony 4 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers Increase ease oI use Increase user accepIance OIher objecIIves: reduce Ioss oI IIme and equIpmenI Increase economy oI producIIon. Connon cnu:c: o \o nccdcnt: cnu:cd ) Iunnn co (a) IaIIure Io perceIve or recognIze a hazardous condIIIon or sIIuaIIon To reacI Io a dangerous sIIuaIIon II Is necessary Io perceIve IhaI Ihe danger exIsIs. Many workpIace hazards are noI perceIved Ihrough human sensory channeIs, e.g. excessIve pressure InsIde a boIIer IhaI couId cause an expIosIon a IorkIIII Iruck approachIng Irom behInd In a noIsy IacIory unguarded machInery In a poorIy III room Ihe sudden reIease oI an odourIess IoxIc gas. In Ihese sIIuaIIons II Is necessary Io suppIemenI Ihe sensory IuncIIons wIIh specIaI InIormaIIonaI dIspIays, e.g. a pressure gauge wIIh redIIne marks Io IndIcaIe a dangerous condIIIon InsIde Ihe boIIer a horn or beeper on Ihe IorkIIII Iruck IhaI sounds auIomaIIcaIIy whIIe II Is In moIIon a weIIIII warnIng sIgn aI Ihe enIrance Io a poorIy III equIpmenI room an emergency aIarm sysIem IhaI IndIcaIes Ihe reIease oI IoxIc gases. (b) IaIIure In Ihe InIormaIIon processIng or decIsIonmakIng processes DecIsIonmakIng InvoIves combInIng new InIormaIIon wIIh exIsIIng knowIedge Io provIde a basIs Ior acIIon. Lrrors can occur aI IhIs sIage II Ihe InIormaIIon processIng Ioad Is excessIve, e.g. In Ihe accIdenI aI Ihe Three MIIe IsIand nucIear power pIanI In Ihe USA In Ihe 1970s, operaIors were requIred Io reacI Io muIIIpIe sImuIIaneous aIarms. Lrrors can aIso occur II prevIous IraInIng was IncorrecI or InapproprIaIe Ior handIIng a specIIIc sIIuaIIon. (c) IaIIure In moIor acIIons IoIIowIng correcI decIsIons IoIIowIng a decIsIon, II Is IrequenIIy necessary Ior a worker Io perIorm some moIor acIIon by usIng a conIroI Io ImpIemenI Ihe desIred change, e.g. IIIppIng a swIIch or adjusIIng a knob. IaIIures can occur II conIroIs are noI desIgned Io be consIsIenI wIIh human moIor abIIIIIes, e.g. Ihe Iorce requIred Io adjusI a conIroI vaIve In a chemIcaI pIanI shouId noI exceed human sIrengIh abIIIIy, or II manIpuIaIIon oI Ihe conIroI causes an unexpecIed response. OccuntonnI ergononcs: ModuIe 4 5 ConIroIs IhaI sIarI poIenIIaIIy dangerous machInery or equIpmenI shouId be guarded Io prevenI accIdenIaI acIIvaIIon, usuaIIy by coverIng Ihe conIroI or pIacIng II In a IocaIIon where II cannoI be accIdenIaIIy Iouched. Tn:: o tnncc: Look around your envIronmenI and IdenIIIy Ihree IooIs, sysIems, processes or combInaIIons IhereoI IhaI are IauIIy Irom a human IacIors perspecIIve. Ior each, descrIbe why you IhInk Ihere Is a probIem and suggesI how Ihe probIem mIghI be IIxed. LImII your response Io a Iew senIences per probIem. 3.2 Work physiology Work physIoIogy Is Ihe subdIscIpIIne oI ergonomIcs concerned wIIh sIress IhaI occurs durIng Ihe meIaboIIc conversIon oI bIochemIcaI energy sources, such as gIucose, Io mechanIcaI work. II IhIs sIress Is excessIve, Ihe worker wIII experIence IaIIgue. IaIIgue may be IocaIIzed Io a reIaIIveIy smaII number oI muscIes or may aIIecI Ihe enIIre body. 5tntc \o nnd ocn nu:cc ntguc SIaIIc work occurs when a muscIe or muscIe group remaIns In a conIracIed sIaIe Ior an exIended perIod oI IIme wIIhouI reIaxaIIon. HIgh IeveIs oI sIaIIc work can be caused by: susIaIned awkward posIure, e.g. a mechanIc who musI conIInuousIy IwIsI hIs body Io perIorm repaIrs Io an auIomobIIe engIne hIgh sIrengIh demands assocIaIed wIIh a specIIIc Iask, e.g. usIng a wrench Io undo a badIy rusIed wheeInuI when changIng a Iyre. When a muscIe conIracIs, Ihe bIood vesseIs IhaI suppIy nuIrIenIs and remove meIaboIIc wasIes are compressed by Ihe adjacenI conIracIIIe IIssue. As a resuII, vascuIar resIsIance Increases wIIh Ihe IeveI oI muscIe IensIon, and Ihe bIood suppIy Io Ihe workIng muscIe decreases. II Ihe muscIe Is noI aIIowed Io reIax perIodIcaIIy, Ihe demand Ior meIaboIIc nuIrIenIs may exceed Ihe suppIy. MeIaboIIc wasIes can aIso accumuIaIe. The shorIIerm eIIecIs oI IhIs condIIIon IncIude IschaemIc paIn, Iremor or a reduced capacIIy Io produce IensIon. Any oI Ihese eIIecIs can severeIy InhIbII work perIormance. SIaIIc work aIso causes a Iemporary Increase In Ihe perIpheraI resIsIance oI Ihe cardIovascuIar sysIem. SIgnIIIcanI Increases In hearI raIe and mean arIerIaI bIood pressure have been observed In conjuncIIon wIIh shorI duraIIon sIaIIc conIracIIons. CauIIon shouId be exercIsed Io avoId pIacIng a person wIIh a hIsIory oI cardIovascuIar dIsease on a job IhaI requIres moderaIe Io heavy sIaIIc exerIIons. In mosI sIIuaIIons, dynamIc acIIvIIIes InvoIvIng cycIIcaI conIracIIon and reIaxaIIon oI workIng muscIe are preIerabIe Io sIaIIc work. II, however, Ihe job requIres hIghIy repeIIIIve or IorceIuI exerIIons, a varIeIy oI IocaIIzed cumuIaIIve Irauma InjurIes may occur Io muscuIoskeIeIaI IIssue or perIpheraI nerves. b OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers I)nnnc \o nnd \Ioc-od) ntguc DynamIc, whoIebody work occurs when muIIIpIe groups oI Iarge skeIeIaI muscIes repeaIedIy conIracI and reIax In conjuncIIon wIIh Ihe perIormance oI a Iask, e.g. waIkIng on a IeveI surIace, pedaIIIng a bIcycIe, cIImbIng sIaIrs and movIng a Ioad (by carryIng, pushIng, puIIIng, or shoveIIIng) Irom one IocaIIon Io anoIher. The InIensIIy oI whoIebody, dynamIc work Is prImarIIy IImIIed by Ihe capacIIy oI Ihe puImonary and cardIovascuIar sysIems Io deIIver suIIIcIenI oxygen and gIucose Io workIng muscIes and Io remove producIs oI meIaboIIsm. WhoIebody IaIIgue occurs when Ihe coIIecIIve meIaboIIc demands oI workIng muscIes IhroughouI Ihe body exceed IhIs capacIIy. Common sympIoms oI whoIe body IaIIgue IncIude shorIness oI breaIh, weakness In workIng muscIes and a generaI IeeIIng oI IIredness. These sympIoms wIII conIInue and may Increase unIII Ihe work acIIvIIy Is sIopped or decreased In InIensIIy. Ior exIremeIy shorI duraIIons oI whoIebody dynamIc acIIvIIy (IypIcaIIy 4 mInuIes or Iess), a person can work aI InIensIIy equaI Io hIs or her aerobIc capacIIy. As Ihe duraIIon oI Ihe work perIod Increases, Ihe work InIensIIy musI be adjusIed downward. II a Iask Is Io be perIormed conIInuousIy Ior 1 hour, Ihe average energy expendIIure Ior IhIs perIod shouId noI exceed S0 oI Ihe worker's aerobIc capacIIy. Ior a job IhaI Is perIormed Ior an 8 hour shIII, Ihe average energy expendIIure shouId noI exceed SS oI Ihe worker's aerobIc capacIIy. AerobIc capacIIy varIes consIderabIy wIIhIn Ihe popuIaIIon. IndIvIduaI IacIors IhaI deIermIne aerobIc capacIIy IncIude age, sex, weIghI, heredIIy and currenI IeveI oI physIcaI IIIness. The prevenIIon oI whoIebody IaIIgue Is besI accompIIshed Ihrough good job desIgn. The energy expendIIure requIremenIs oI a job shouId be suIIIcIenIIy Iow Io accommodaIe Ihe aduII workIng popuIaIIon, IncIudIng Ihose IndIvIduaIs wIIh IImIIed aerobIc capacIIy. These requIremenIs can be meI by desIgnIng Ihe workpIace Io mInImIze unnecessary body movemenIs (excessIve waIkIng or cIImbIng) and provIdIng mechanIcaI assIsIs (such as hoIsIs or conveyors) Ior handIIng heavy maIerIaIs. II Ihese approaches are noI IeasIbIe, II may be necessary Io provIde addIIIonaI resI aIIowances Io prevenI excessIve IaIIgue, parIIcuIarIy In hoI, humId work envIronmenIs because oI Ihe meIaboIIc conIrIbuIIon Io heaI sIress. To assess Ihe poIenIIaI Ior whoIebody IaIIgue, II Is necessary Io measure or esIImaIe Ihe energy expendIIure raIe Ior a specIIIc job, whIch Is usuaIIy done In one oI Ihree ways: 1. TabIe reIerence: exIensIve IabIes oI Ihe energy cosIs oI varIous work acIIvIIIes have been deveIoped. 2. IndIrecI caIorImeIry: energy expendIIure can be esIImaIed by measurIng a worker's oxygen upIake whIIe perIormIng Ihe job. S. ModeIIIng: Ihe job Is anaIysed and broken down InIo IundamenIaI Iasks such as waIkIng, carryIng and IIIIIng. ParameIers descrIbIng each Iask are measured and subsIIIuIed InIo equaIIons Io predIcI energy expendIIure. OccuntonnI ergononcs: ModuIe 4 7 3.3 OccupaIional biomechanics BIomechanIcs Is Ihe subdIscIpIIne oI ergonomIcs concerned wIIh Ihe mechanIcaI properIIes oI human IIssue, parIIcuIarIy Ihe resIsIance oI IIssue Io mechanIcaI sIress. A major Iocus oI occupaIIonaI bIomechanIcs Is Ihe prevenIIon oI Ihe Iower back and upper exIremIIIes. MccInncn :tc:: OverI accIdenIs: some oI mechanIcaI sIresses IhaI cause Injury In Ihe work envIronmenI are assocIaIed wIIh overI accIdenIs, e.g. crushed bones In Ihe IeeI resuIIIng Irom Ihe ImpacI oI a dropped objecI. The hazards IhaI cause Ihese InjurIes can usuaIIy be conIroIIed Ihrough saIeIy engIneerIng IechnIques. CumuIaIIve Irauma InjurIes: oIher InjurIous mechanIcaI sIresses are more subIIe and can cause cumuIaIIve Irauma InjurIes. Such sIress can be exIernaI, such as a vIbraIIng chaIn saw IhaI causes Raynaud syndrome, or InIernaI, such as compressIon oI spInaI dIscs durIng sIrenuous IIIIIng. Such sIress Is mosI eIIecIIveIy conIroIIed Ihrough ergonomIcs, I.e. desIgnIng job demands so IhaI resuIIIng mechanIcaI sIress can be IoIeraIed wIIhouI Injury. onccInnc: o tng, u:Ing nnd ung (a) PrIncIpIes oI IIIIIng TesI your personaI sIrengIh IImIIs and make sure Ihe Ioad Io be IIIIed Is beIow S0 oI IhaI IImII. AvoId IIIIIng Ioads IhaI exceed Ihe generaI sIrengIh IImIIs caIcuIaIed Ior varIous Iypes oI IIIIIng. MInImIze IwIsIIng wIIh a Ioad, and, when II Is necessary Io IwIsI, roIaIe Ihe peIvIs. Keep Ihe Ioad cIose Io Ihe body when IIIIIng II. LxercIse cauIIon when workIng In sIIppery or cIuIIered areas. (b) PrIncIpIes oI pushIng and puIIIng Make cerIaIn IhaI Ihe area ahead oI Ihe Ioad Is IeveI and cIear oI obsIacIes; II II Is noI IeveI, some sysIem oI brakIng shouId be avaIIabIe. Push Ihe Ioad raIher Ihan puII II; IhIs wIII reduce spInaI sIress, and In mosI cases wIII Improve Ihe vIsIbIIIIy ahead. Wear shoes IhaI provIde good IooI IracIIon; Ihe coeIIIcIenI oI IrIcIIon beIween Ihe IIoor and Ihe soIe oI Ihe shoes shouId be aI IeasI 0.8 wherever heavy Ioads are moved. When sIarIIng Io push a Ioad, brace one IooI and use Ihe back, raIher Ihan Ihe hands and arms, Io appIy Iorce; II Ihe Ioad does noI sIarI Io move when a reasonabIe amounI oI Iorce Is appIIed, geI heIp Irom a coworker or use a powered vehIcIe. OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers PushIng or puIIIng Is easIer when Ihe handIes oI Ihe Ioaded carI are aI abouI hIp heIghI (91-114 cm Ior men) Ihan Ihey are aI shouIder heIghI or above. HandIes Iower Ihan Ihe hIps are awkward and unsaIe Io use. 3.4 Use ol anIhropomeIric daIa One oI Ihe prImary reasons Ior physIcaI sIress on Ihe job Is Ihe mIsmaIch In sIze beIween Ihe worker and Ihe workpIace, equIpmenI or machInery. ThIs mIsmaIch may resuII In havIng Io work benI over, havIng Io work wIIh one or boIh arms and shouIders heId hIgh Ior Iong perIods or havIng Io sII on a sIooI or bench IhaI Is Ioo Iow or Ioo hIgh. AnIhropomeIry Is concerned wIIh IIIIIng IooIs and workspaces Io Ihe dImensIons oI Ihe human body. SInce humans come In a Iremendous range oI shapes and sIzes, IhIs Is oIIen a dIIIIcuII Iask. KnowIng Ihe dIsIrIbuIIon oI shapes and sIzes Is Ihe IIrsI sIep In anIhropomeIrIc desIgn. There are Ihousands oI dIIIerenI measuremenIs on Ihe human body IhaI are reIevanI Io Ihe desIgn oI IooIs, workpIaces and even cIoIhIng. AntIoonctc tnc: AnIhropomeIrIc IabIes IIsI summarIes oI Ihese measuremenIs across dIIIerenI popuIaIIon groups. Numerous anIhropomeIrIc daIa sources are avaIIabIe, each represenIaIIve oI Ihe dIIIerenI popuIaIIons measured, e.g. Ihere are anIhropomeIrIc daIabases avaIIabIe on mIIIIary personneI, AmerIcan IndusIrIaI popuIaIIons and dIIIerenI counIrIes and regIons oI Ihe worId. KcncI nnd t The concepIs oI reach and III are essenIIaI Io anIhropomeIry and Ihey appIy In many dIIIerenI sIIuaIIons IncIudIng desIgn oI aImosI any producI or IechnoIogy peopIe use: chaIrs and seaIIng baIhs, showers, kIIchens workpIaces In generaI compuIer worksIaIIons cars and oIher vehIcIes corrIdors, sIaIrways and buIIdIng InIerIors In generaI IooIs. A generaI ruIe oI anIhropomeIrIc desIgn Is IhaI IaII peopIe esIabIIsh III requIremenIs, shorI peopIe esIabIIsh reach requIremenIs. 5tc: n dc:gn 1. DeIInIng who Io desIgn Ior (deIIne Ihe popuIaIIon) OccuntonnI ergononcs: ModuIe 4 9 Many companIes and IacIorIes have a dIverse popuIaIIon, boIh wIIhIn and across workpIaces. ThereIore Ihe popuIaIIon beIng desIgned Ior musI be deIIned Io ensure IhaI Ihe desIgn IIIs Ihe physIcaI characIerIsIIcs oI Ihe acIuaI workpIace popuIaIIon. 2. DeIermInIng Ihe ImporIanI parIs and dImensIons Io use Ior desIgn or redesIgn oI equIpmenI, IooIs, worksIaIIons or jobs, body dImensIons IhaI specIIIcaIIy reIaIe Io Ihe Iasks beIng perIormed shouId be used, e.g. desIgnIng Ior shorIreach dIsIances Io obIaIn parIs Irom bIns aI a worksIaIIon aIIows smaIIer empIoyees Io reach wIIhouI IormIng awkward posIures; Ior a seaIed worksIaIIon, usIng cIearance dImensIons Ior Ihe IargesI maIe aIIows mosI empIoyees Io pIace IheIr Iegs under Ihe worksIaIIon wIIhouI IormIng awkward posIures, such as IeanIng or IwIsIIng Ihe back. Ior Ihe desIgn oI new jobs, empIoyers musI aIso deIermIne: how Ihe job Is goIng Io be perIormed (IdenIIIIcaIIon oI Ihe Iasks); how any new equIpmenI or IooIs wIII be used (e.g. IocaIIon oI conIroIs, reach requIremenIs); and whaI body dImensIons are ImporIanI Io use Ior Ihe desIgn. As a mInImum, Ihe dImensIons reIaIed Io work heIghI (Ihe acIuaI heIghI aI whIch Ihe hands perIorm Ihe work), reach and III (cIearance) shouId be addressed. S. DesIgnIng Ior adjusIabIIIIy ThIs sIraIegy accommodaIes nearIy aII Ihe workIorce, e.g. an exIsIIng work surIace IhaI aIIows a shorIer IndIvIduaI Io sIand and work wIIhouI bendIng over mIghI requIre IhaI a IaIIer IndIvIduaI bend Iorward Io work on Ihe same work surIace. A work surIace IhaI Is adjusIabIe In heIghI aIIows Ihe IaIIer IndIvIduaI Io sIand and work wIIhouI bendIng. AI a compuIer worksIaIIon, adjusIabIIIIy may be consIdered Ior Ihe chaIr, work surIace and monIIor. 4. DesIgnIng Ior exIremes An aIIernaIIve approach Io desIgnIng Ior adjusIabIIIIy Is Io desIgn Ior Ihe exIreme (9SIh percenIIIe maIe or SIh percenIIIe IemaIe) and accommodaIe Ihe resI oI Ihe popuIaIIon, e.g. desIgn Ihe work surIace heIghI Ior Ihe 9SIh percenIIIe maIe and accommodaIe shorIer IndIvIduaIs Ihrough work sIands. 4. TASKS lOR TRAlNEES 1. VIsII IocaI workpIaces Ior dIIIerenI occupaIIons and record your observaIIons oI ergonomIc probIems. 2. PrIorIIIze your observaIIons and make acIIon pIans In IIghI oI Ihe dIscussIon In secIIon 2 oI IhIs moduIe. S. DeveIop, In cIose cooperaIIon wIIh managemenI and workers, correcIIve measures/advIce/suggesIIons In order Io Improve aI IeasI Ihe mosI harmIuI aspecIs oI Ihe work sIIuaIIon. 9U OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 4. Ior probIems whIch cannoI be soIved, IInd ouI where you can reIer Ihem Io, IncIudIng specIaIIzed cenIres where possIbIe. S. TraIn managemenI and workers how Io work wIIh Ihe correcIIons InIroduced and encourage IoIIowup. 6. Check up on exacIIy how your suggesIed correcIIve measures have been ImpIemenIed. 7. LducaIe managemenI and workers on whaI Io do In order Io avoId physIcaIIy and psychosocIaIIy harmIuI work sIIuaIIons. 8. DocumenI Iasks 1-7. MODULE 5 Stress and adverse psychological factors at work 1. OB|ECTlVES Learn how Io IdenIIIy workers wIIh psychoIogIcaI probIems Learn how Io encourage workers wIIh psychoIogIcaI probIems Io manage IheIr sIress by seekIng Ihe heIp oI IheIr reIaIIves and IrIends Know how Io keep records and wrIIe reporIs AssIsI In sImpIe psychomeIrIc IesIs SpoI sIressors. 2. lNTRODUCTlON AND BASlC CONCEPTS 2.1 DeliniIions SIress: a (perceIved) subsIanIIaI ImbaIance beIween demand and response capabIIIIy under condIIIons where IaIIure Io meeI demand has ImporIanI (perceIved) consequences. SIress Is aIso deIIned as Ihe sequence Irom sIressors Io sIress reacIIons and IongIerm consequences. SIressor: envIronmenIaI evenI or condIIIon IhaI resuIIs In sIress. SIresslul: perIaInIng Io an envIronmenI IhaI has many sIressors. SIrain (or sIress reacIion): shorIIerm physIoIogIcaI, psychoIogIcaI or behavIouraI manIIesIaIIons oI sIress. Modilier: IndIvIduaI characIerIsIIc or envIronmenIaI IacIor IhaI may acI on each sIage oI Ihe sIress response Io produce IndIvIduaI varIaIIon. Psychosocial lacIors: IacIors InIIuencIng heaIIh, heaIIh servIces and communIIy weIIbeIng sIemmIng Irom Ihe psychoIogy oI Ihe IndIvIduaI and Ihe sIrucIure and IuncIIon oI socIaI groups. They IncIude socIaI characIerIsIIcs such as paIIerns oI InIeracIIon wIIhIn IamIIy or occupaIIonaI groups, cuIIuraI characIerIsIIcs such as IradIIIonaI ways oI soIvIng conIIIcIs, and psychoIogIcaI characIerIsIIcs such as aIIIIudes, beIIeIs and personaIIIy IacIors. 92 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 2.2 Common workplace sIressors Ognnzntonn change InadequaIe communIcaIIon InIerpersonaI conIIIcI conIIIcI wIIh organIzaIIonaI goaIs Cncc dc\concnt Iack oI promoIIonaI opporIunIIy new responsIbIIIIIes beyond IeveI unempIoymenI Koc roIe conIIIcI roIe ambIguIIy InadequaIe resources Io accompIIsh job InadequaIe auIhorIIy Io accompIIsh job Tn: quanIIIaIIve and quaIIIaIIve overIoad quanIIIaIIve and quaIIIaIIve underIoad responsIbIIIIy Ior Ihe IIves and weIIbeIng oI oIhers Iow decIsIon makIng IaIIIude Wo cn\onncnt poor aesIheIIcs physIcaI exposures ergonomIc probIems noIse odours saIeIy hazards 5tress nnd ndverse sychoIogcnI ]nctors nt work: ModuIe 5 93 5It \o 2.3 ComponenIs ol Ihe sIress process 5tc::o: |ob sIrucIure overIIme shIII work machIne pacIng pIecework |ob conIenI quanIIIaIIve overIoad quaIIIaIIve underIoad Iack oI conIroI PhysIcaI condIIIons unpIeasanI IhreaI oI physIcaI or IoxIc hazard OrganIzaIIon roIe conIIIcI compeIIIIon rIvaIry LxIraorganIzaIIonaI job InsecurIIy career deveIopmenI commuIIng OIher sources personaI IamIIy communIIy Outconc: PhysIoIogIcaI ShorIIerm caIechoIamInes corIIsoI bIood pressure Increases LongIerm hyperIensIon hearI dIsease uIcers asIhma 94 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers PsychoIogIcaI (cognIIIve and aIIecIIve) ShorIIerm anxIeIy dIssaIIsIacIIon mass psychogenIc IIIness LongIerm depressIon burnouI menIaI dIsorders BehavIouraI ShorIIerm job: absenIeeIsm, reduced producIIvIIy and parIIcIpaIIon communIIy: decreased IrIendshIps and parIIcIpaIIon personaI: excessIve use oI aIcohoI and drugs, smokIng LongIerm "Iearned heIpIessness" Modc: IndIvIduaI behavIouraI sIyIe personaI resources SocIaI supporI emoIIonaI vaIue or seIIesIeem InIormaIIonaI 3. PREVENTlON AND CONTROL Ol STRESS Tcnt tIc nd\dun MedIcaI IreaImenI hyperIensIon backache depressIon CounseIIIng servIce LmpIoyee assIsIance programmes smokIng aIcohoI drugs 5tress nnd ndverse sychoIogcnI ]nctors nt work: ModuIe 5 95 Kcducc nd\dun \uncnt) CounseIIIng IndIvIduaI group programmes TraInIng programmes reIaxaIIon medIcaIIon bIoIeedback GeneraI supporI exercIse programmes recreaIIonaI acIIvIIIes Tcnt tIc ognnznton DIagnosIs aIIIIude survey rap sessIons DeveIop IIexIbIe and responsIve managemenI sIyIe Improve InIernaI communIcaIIons Kcducc ognnzntonn :tc:: VarIabIe work scheduIes |ob resIrucIurIng enIargemenI enrIchmenI Increased conIroI SupervIsor IraInIng and managemenI deveIopmenI 4. PRlNClPLES Ol |OB DESlGN Wo :cIcduc A work scheduIe shouId be desIgned Io avoId conIIIcIs wIIh demands and responsIbIIIIIes ouIsIde Ihe job. When roIaIIng shIII scheduIes are used, Ihe raIe oI roIaIIon shouId be sIabIe and predIcIabIe. Intcnton,conto Workers shouId be abIe Io provIde InpuI InIo decIsIons or acIIons aIIecIIng IheIr jobs and Ihe perIormance oI IheIr Iasks. 9b OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers Woond Demands shouId noI exceed Ihe capabIIIIIes oI IndIvIduaIs. Work shouId be desIgned Io aIIow recovery Irom demandIng physIcaI or menIaI Iasks. Contcnt Work Iasks shouId be desIgned Io provIde meanIng, sIImuIaIIon, a sense oI compIeIeness and an opporIunIIy Ior Ihe use oI skIIIs. Wo oc: RoIes and responsIbIIIIIes aI work shouId be weII deIIned. 5ocn cn\onncnt OpporIunIIIes shouId be avaIIabIe Ior socIaI InIeracIIon, IncIudIng emoIIonaI supporI and acIuaI heIp as needed In accompIIshIng Iasks. ]o utuc AmbIguIIy shouId be avoIded In maIIers oI job securIIy and career deveIopmenI opporIunIIIes. 5. TASKS lOR TRAlNEES 1. Survey workpIaces usIng sImpIe meIhods and IechnIques and IdenIIIy possIbIe and poIenIIaI sIressors In Ihe area. 2. CoIIecI bIoIogIcaI and envIronmenIaI sampIes concernIng physIcaI, chemIcaI, bIoIogIcaI and ergonomIc sIressors. S. Keep sImpIe records oI IndIvIduaI workers as weII as oI workIng groups and surveys. 4. In coIIaboraIIon wIIh Ihe sIIe physIcIan, IdenIIIy and documenI workers wIIh psychoIogIcaI probIems In Ihe workpIace wIIh Ihe heIp oI socIaI workers where avaIIabIe. S. AssIsI In sImpIe psychomeIrIc anaIyses and IechnIques. 6. PracIIse heaIIh educaIIon oI Ihe workers concernIng heaIIh probIems reIaIed Io work condIIIons, personaI IIIesIyIes, and menIaI and psychoIogIcaI sIaIes. 7. Try Io heIp peopIe wIIh drug or subsIance addIcIIons. MODULE 6 Occupational safety and accident prevention 1. OB|ECTlVES UndersIand Ihe ImporIance oI prevenIIng accIdenIs In Ihe workpIace and supporI saIeIy proIessIonaIs' eIIorIs In IhIs regard ParIIcIpaIe In educaIIng and IraInIng workers Keep records and anaIyse Ihe daIa obIaIned ConIrIbuIe Io Ihe daIIy work oI Ihe occupaIIonaI saIeIy commIIIee GIve advIce on reducIng morbIdIIy, dIsabIIIIy and morIaIIIy due Io occupaIIonaI accIdenIs and Irauma. 2. lNTRODUCTlON AND BASlC CONCEPTS 2.1 DeliniIions AccidenI: a sudden evenI IhaI resuIIs In an undesIred ouIcome such as properIy damage, bodIIy Injury or deaIh. OccupaIional accidenI: accIdenI occurrIng aI Ihe workpIace whIch may cause damage Io machInery, IooIs or peopIe. lnjury: physIcaI damage Io body IIssues caused by an accIdenI or by exposure Io envIronmenIaI sIressors. ThIs Injury may Iead Io deaIh and Is Ihen caIIed a "IaIaI accIdenI" or may cause parIIaI dIsabIIIIy or Iead Io sIck Ieave Ior a perIod oI IIme. Hazard: any exIsIIng or poIenIIaI condIIIon In Ihe workpIace whIch, by IIseII or by InIeracIIng wIIh oIher varIabIes, can resuII In deaIh, Injury, properIy damage or oIher Ioss. SImpIy, hazard Is a poIenIIaI source oI harm. Risk: Ihe IIkeIIhood oI harm (In deIIned cIrcumsIances). Harm: Ihe Ioss Io a person (or peopIe) as a consequence oI damage. Damage: Ihe Ioss oI InherenI quaIIIy suIIered by an enIIIy (physIcaI or bIoIogIcaI). Danger: Ihe degree oI exposure Io a hazard. SaleIy: Ihe absence oI danger. OccupaIional saleIy: rIsk IdenIIIIcaIIon aI Ihe workpIace and prevenIIve measures Iaken Io reduce or eIImInaIe Ihe hazard whIch may Iead Io accIdenIs. 9 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers Sale behaviour: acIIng In such a way IhaI no rIsk oI Injury Is caused by one's behavIour. SaleIy prolessional: a person whose basIc job IuncIIon and responsIbIIIIy Is Io prevenI accIdenIs and oIher harmIuI exposures and Ihe personaI Injury, dIsease or properIy damage IhaI may ensue. 2.2 Aim ol occupaIional saleIy The occupaIIonaI saIeIy phIIosophy has been deveIoped In order Io: prevenI needIess desIrucIIon oI heaIIh and wasIe oI human and oIher resources raIse Ihe moraIe oI workers prevenI IneIIIcIency In Ihe workpIace due Io Ihe eIIecIs oI accIdenIs prevenI socIaI harm caused by accIdenIs promoIe accIdenI prevenIIon. 2.3 ClassilicaIion ol Iypes ol occupaIional accidenI T)c o nccdcnt IaIIs or beIng sIruck by maIerIaIs sIrIkIng agaInsI objecIs beIng caughI In, under or beIween objecIs overexerIIon or sIrenuous movemenIs exposure Io or conIacI wIIh exIreme IemperaIures exposure Io or conIacI wIIh eIecIrIc currenI exposure Io or conIacI wIIh harmIuI subsIances or radIaIIon oIher Iypes oI accIdenI. Agcnc) machInes means oI IransporI and IIIIIng equIpmenI oIher equIpmenI maIerIaIs, subsIances and radIaIIon work envIronmenI oIher agencIes noI eIsewhere cIassIIIed agencIes noI cIassIIIed Ior Iack oI suIIIcIenI daIa. OccuntonnI sn]ety nnd nccdent reventon: ModuIe b 99 Nntuc o n]u) wounds, IracIures, dIsIocaIIons burns, poIsonIngs dIseases. od) ocnton o tIc n]u) head Irunk upper exIremIIIes Iower exIremIIIes body sysIem. Occunton o nccdcnt \ctn/:) Icononc nct\t) n tIc cou:c o \IcI tIc nccdcnt occucd 2.4 Causes ol occupaIional accidenIs and injuries Hunnn ncto: There are many varyIng human IacIors IhaI have an eIIecI on Ihe accIdenIrIsk oI Ihe IndIvIduaI aI cerIaIn IImes and In cerIaIn sIIuaIIons. Some oI Ihese IacIors are: age, experIence, use oI medIcInes or drugs, moIIvaIIon, eIc. BuI mosI human acIIvIIy requIres avoIdance oI errors IhaI couId resuII In InjurIes or maIerIaI damage. To avoId an accIdenI an IndIvIduaI musI observe and recognIze danger, decIde on a course oI acIIon and acI suIIIcIenIIy vIgorousIy Io avoId Ihe danger. The accIdenI may occur II a hazard Is noI seen, recognIzed or undersIood as dangerous, or II one does noI Iake responsIbIIIIy Ior personaI acIIon, or II one does noI know how Io acI or Ior oIher reasons does noI decIde Io acI. Lven II Ihe rIghI decIsIon Is made, Ihe muscuIar response may be IncorrecI, IneIIecIuaI or Ioo sIow. In\onncntn ncto: These IncIude boIh Ihe ouIsIde agenI oI Injury and oIher IacIors oI Ihe physIcaI workIng envIronmenI: IIghIIng, noIse, IemperaIure, eIc. A necessary cause oI Injury Is conIacI wIIh a harmIuI objecI, subsIance or energy. An Injury may aIso be caused by a Iack oI energy, e.g. Iack oI oxygen In Ihe envIronmenI. These Injury agenIs are caIIed hazards. II Ihere Is a hazard In Ihe workIng envIronmenI Ihere Is aIways some possIbIIIIy oI an accIdenI. ThIs Is Ihe reason why saIeIy IechnoIogy has Ihe IIrsI prIorIIy In accIdenI prevenIIon. Hazards shouId be eIImInaIed or IsoIaIed so IhaI Ihere Is no rIsk oI accIdenI. The Injury agenI, Ihe kInd and amounI oI hazardous energy, Is Ihe maIn deIermInanI oI Ihe severIIy oI Injury. The IoIIowIng IabIe IIIusIraIes some exampIes. 1UU OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers Selected examples of overt and cumulative trauma commonly affecting occupational groups Cnuse Inury or dsorder A]]ected occupnton Overt trauma MechanIcaI energy LaceratIons Sheet metaI workers, butchers, press operators, sawyers, IabrIc cutters Fractures MaterIaIs handIers, mIners, constructIon workers ContusIons MaterIaIs handIers, any worker exposed to Iow energy Impacts AmputatIons Press operators, butchers, machIne operators CrushIng InjurIes MaterIaIs handIers, press operators, constructIon workers, rubber workers Eye InjurIes MIners, grInders, saw mIII (struck by IoreIgn objects) operators, machIne shop empIoyees StraIns or spraIns (overt) MaterIaIs handIers, mIners, baggage handIers, maII handIers, constructIon workers ThermaI energy urns Foundry workers, smeIter workers, weIders, gIass workers, Iaundry workers Heat straIn FIreIIghters, steeIworkers, smeIter workers CoId straIn UtIIIty workers, Iumberjacks, butchers ChemIcaI energy urns Masons, process workers, (IncIudIng acute toxIcIty) hazardous waste workers AsphyxIatIon, acute toxIcIty FIreIIghters, conIIned space workers, hazard ous waste workers EIectrIcaI energy EIectrocutIon, shocks, burns UtIIIty workers, constructIon workers, eIectrIcIans, users oI eIectrIc hand tooIs or machInes NucIear energy RadIatIon burns, IIIness HospItaI workers, IndustrIaI radIographers, nucIear workers Cumulative trauma Heavy IIItIng, proIonged ack paIn MaterIaIs handIers, sIttIng, awkward posture nurses, truck drIvers, sewIng machIne operators Frequent or repetItIve Upper extremIty AssembIy IIne workers; IorceIuI hand motIons cumuIatIve trauma dIsorders garment workers; wIth awkward posture (tendonItIs, carpaI tunneI pouItry, meat, or IIsh syndrome, epIcondyIItIs, processors; cIerIcaI degeneratIve joInt dIsease) workers; press operators; IruIt pIckers; musIcIans VIbratIon Raynaud syndrome Lumberjacks, grIndIng machIne operators, jackhammer operators OccuntonnI sn]ety nnd nccdent reventon: ModuIe b 1U1 Ognnzntonn ncto: The socIaI envIronmenI has a greaI eIIecI on human perIormance. The saIeIy managemenI approach Io accIdenIs Is IhaI Ihe ImmedIaIe causes (unsaIe condIIIons and unsaIe acIs) are onIy sympIoms oI rooI causes IhaI exIsI In Ihe managemenI IuncIIon. These may be errors In Ihe area oI managemenI poIIcy, conIusIon oI goaIs, sIaIIIng, housekeepIng, responsIbIIIIy, use oI auIhorIIy, IIne and sIaII reIaIIonshIps, accounIabIIIIy, ruIes, InIIIaIIve, eIc. ConIroIIIng Ihe Irequency and severIIy oI accIdenI occurrence and conIroIIIng Ihe quaIIIy and quanIIIy oI producI have much In common. In many cases Ihe same IauIIy pracIIce Is InvoIved, IeadIng Io boIh accIdenI occurrence and unsaIIsIacIory producIIon. 3. RECORDlNG AND lNVESTlGATlNG ACClDENTS CompanIes and communIIy heaIIh workers need Io record and InvesIIgaIe occupaIIonaI accIdenIs In order Io: IdenIIIy Ihe reaI causes oI Injury, properIy damage and nearmIsses deveIop eIIecIIve meIhods oI prevenIIng IuIure sImIIar accIdenIs meeI IegIsIaIIve requIremenIs. The accIdenI or Injury reporI shouId IncIude Ihe IoIIowIng InIormaIIon: cIrcumsIances oI Ihe accIdenI cause oI Ihe accIdenI avaIIabIe daIa Ior assessIng Ihe cause oI Ihe accIdenI and IheIr eIIecIs on Ihe person and Ihe envIronmenI emergency measures Iaken sIeps Io be Iaken In Ihe IuIure Io prevenI IurIher accIdenIs. AccIdenIs may be reporIed accordIng Io: cause oI accIdenI pIace oI Ihe accIdenI Iype oI Injury personaI characIerIsIIcs such as age, sex and Ihe IeveI oI educaIIon oI Ihe Injured IIme oI Ihe accIdenI. The IoIIowIng poInIs shouId be consIdered when deveIopIng an accIdenI recordIng and InvesIIgaIIng sysIem: WhaI reporIs are requIred7 Who Is responsIbIe Ior conducIIng Ihe InvesIIgaIIon7 1U2 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers Who do reporIs go Io7 WhaI IImeIrame shouId be aIIowed Io compIeIe InvesIIgaIIons7 Are Ihere IoIIowup procedures Io ensure IhaI reporI recommendaIIons are ImpIemenIed7 Have Ihe approprIaIe auIhorIIIes been noIIIIed7 WhaI accIdenIs wIII be recorded and InvesIIgaIed7 Is a cusIomdesIgned Iorm needed7 Are aII InjurIes recorded In Ihe recordIng sysIem7 WhaI IraInIng wIII InvesIIgaIors need7 Where wIII records oI accIdenIs and InvesIIgaIIons be kepI7 Does reguIar anaIysIs IdenIIIy sImIIar accIdenIs recurrIng or oIher Irends7 4. ACClDENT RATES ComparIson oI accIdenIs beIween IImeperIods, IndusIrIes, occupaIIons and counIrIes can be made onIy II Ihe IndusIrIaI accIdenI sIaIIsIIcs are consIdered In conjuncIIon wIIh daIa, IncIudIng empIoymenI, work hours, producIIon, eIc. Ior such purposes II Is useIuI Io caIcuIaIe reIaIIve measures such as Irequency, IncIdence, and severIIy raIes. Irequency raIe = IoIaI number oI accIdenIs 10 S - IoIaI number oI workhours worked IncIdence raIe = IoIaI number oI accIdenIs 10 S - IoIaI number oI workers exposed. Two dIIIerenI severIIy IndIcaIors are recommended: Ihe average number oI days IosI per accIdenI Ihe number oI days IosI per day worked by persons exposed Io rIsk, or, IaIIIng IhaI, per person exposed Io rIsk. In some counIrIes Ihe severIIy raIe Is deIIned as Ihe number oI days IosI per 1000 workhours. DeaIh and permanenIIy dIsabIIng InjurIes are deaII wIIh separaIeIy Irom oIher accIdenIs In sIaIIsIIcs. II Is aIso possIbIe Io converI Ihem InIo IosI workIng days, Ior exampIe, so IhaI deaIh and IoIaIIy dIsabIIng permanenI Injury are equaI Io 6000 IosI days. OccuntonnI sn]ety nnd nccdent reventon: ModuIe b 1U3 5. PREVENTlON AND CONTROL Ol OCCUPATlONAL ACClDENTS The basIc accIdenI prevenIIon acIIvIIIes are as IoIIows: LIImInaIe Ihe hazard Irom Ihe machIne, meIhod, maIerIaI or IacIIIIy sIrucIure. ConIroI or conIaIn Ihe hazard by encIosIng or guardIng II aI IIs source or aIIachIng an exhausI pIpe Io remove aIrborne hazards Irom Ihe operaIor. TraIn operaIIng personneI Io be aware oI Ihe hazard and Io IoIIow saIe job procedures Io avoId II. PrescrIbe personaI proIecIIve equIpmenI Ior personneI Io shIeId Ihem Irom Ihe hazard. ProvIde advIsory servIces on saIeIy and heaIIh probIems and oIher maIIers reIaIed Io accIdenI prevenIIon. DeveIop a cenIraIIzed programme Io conIroI accIdenI and IIre hazards. Keep InIormed oI changes In IegIsIaIIon and saIeIy codes and communIcaIe such InIormaIIon Io managemenI. DeveIop and appIy saIeIy sIandards boIh Ior producIIon IacIIIIIes (equIpmenI, IooIs, work meIhods and saIeguardIng) and Ior producIs, based on appIIcabIe IegaI and voIunIary codes, ruIes and sIandards. Work cIoseIy wIIh Ihe engIneerIng, IndusIrIaI hygIene, medIcaI, and purchasIng deparImenIs Io ensure IhaI onIy saIe IooIs, equIpmenI and suppIIes are purchased. DeveIop, pIan and ImpIemenI a saIeIy and heaIIh InspecIIon programme Io be carrIed ouI by Ihe operaIIng supervIsors and IIeId saIeIy personneI Io IdenIIIy poIenIIaI hazards, boIh In Ihe workpIace and In Ihe use oI Ihe company's producIs. AIong wIIh represenIaIIves Irom engIneerIng, operaIIng and personneI, InspecI aII new equIpmenI Io ensure adequaIe heaIIh and saIeIy saIeguards. GuIde operaIIng supervIsIon In accIdenI InvesIIgaIIon Io deIermIne Ihe accIdenI's cause and Io prevenI recurrence. RevIew nondIsabIIngInjury accIdenI reporIs on a sampIe basIs Io check Ihe Ihoroughness oI Ihe accIdenI InvesIIgaIIon and correcIIve acIIons Iaken. CoIIecI and anaIyse daIa on IIIness and accIdenIs Ior Ihe purpose oI InsIIIuIIng correcIIve acIIon and Io deIermIne accIdenI Irends and provIde IargeIs Ior correcIIve acIIon. Lnsure educaIIon and IraInIng oI empIoyees In generaI as weII as specIIIc heaIIh and saIeIy prIncIpIes and IechnIques. MaInIaIn supervIsory conIacIs Ior new InsIrucIIons, IoIIowup and generaI heaIIh and saIeIy moIIvaIIon. 1U4 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers CooperaIe wIIh IndusIrIaI hygIene or envIronmenIaI quaIIIy conIroI personneI on IndusIrIaI hygIene probIems. 6. TASKS lOR TRAlNEES 6.1 EducaIion The aIm oI saIeIy educaIIon Is Io do work In a saIe way unIII II becomes a habII. AudIovIsuaI aIds, e.g. IecIures, posIers, IIIms, vIdeos, sIIdes, radIo and IeIevIsIon programmes, are very ImporIanI In saIeIy educaIIon. U:c nnd,o dc\co nudo\:un nd: o cducntng tnncc: nccodng to :nct) ncc: nnd ocn:. 6.2 Training A IraInIng programme Is needed Ior new empIoyees when new equIpmenI or processes are InIroduced, when procedures have been revIsed or updaIed, when new InIormaIIon musI be made avaIIabIe and when perIormance oI empIoyees needs Io be Improved. ReIraInIng Is IndIcaIed In Ihe IoIIowIng sIIuaIIons: hIgh accIdenI or Injury raIe hIgh Iabour Iurnover excessIve wasIe and scrap company expansIon (pIanIs or equIpmenI). Ic:gn nnd,o n) n tnnng cou:c o nc\ cno)cc: n n cctnn ndu:t) n coocnton \tI tIc :nct) c:onnc \ong n tIc tngctcd nct). 6.3 EvaluaIion ol saleIy legislaIion OccupaIIonaI saIeIy Iaws, reguIaIIons and codes oI pracIIce are needed Ior Ihe workers' saIeIy IakIng InIo consIderaIIon Ihe responsIbIIIIy oI managemenI and workers wIIh cIarIIIcaIIon oI responsIbIIIIIes and job anaIysIs. These Iaws shouId IncIude measures Io be Iaken Io prevenI occupaIIonaI accIdenIs. SaIeIy IegIsIaIIon wouId be IneIIecIIve unIess some means couId be Iound Io enIorce II. I\nuntc ocn o nntonn :nct) cg:nton nnd t: cnoccncnt n tIc gIt o nnnngcncnt nnd \oc c:on:tc:. 6.4 Personal proIecIion devices PersonaI proIecIIon devIces are Ihe second IIne oI deIence and musI be used when engIneerIng conIroIs cannoI be used or are InadequaIe. These IncIude: masks, goggIes, saIeIy shoes, heImeIs, ear pIugs, ear muIIs, gIoves and aprons. OccuntonnI sn]ety nnd nccdent reventon: ModuIe b 1U5 CIcc on tIc n\nnt) o c:onn otccton dc\cc: n cctnn ndu:tc: nnd c\nuntc tIc nnnngcncnt': nnd tIc \oc:' no\cdgc, ntttudc: nnd nctcc: conccnng tIc oc o tIc:c ncnn: n c\cntng occuntonn nccdcnt: nnd n]uc:. 6.5 ConIrol ol elecIrical hazards Many accIdenIs occur due Io deIecIIve eIecIrIcaI apparaIus, especIaIIy porIabIe eIecIrIcaI apparaIus, e.g. sockeIs, pIugs and IIexIbIe cabIe. AII swIIches musI have approved voIIage and amperage raIIng compaIIbIe wIIh InIended use. CIrcuII breakers shouId be used when needed. AII eIecIrIcaI equIpmenI musI be InspecIed and maInIaIned reguIarIy. Innnzc )ou:c \tI tIc conto :):tcn: o ccctcn Inznd: n n cctnn ndu:t) nnd cnc n cot c\nuntng tInt :):tcn. 6.6 ConIrol ol lire hazards OrdInary IIre resuIIs Irom Ihe combInaIIon oI IueI, heaI and oxygen. Common IIre hazards IncIude smokIng, IIammabIe IIquIds, naked IIames, poorIy maInIaIned and overheaIIng machInes, eIecIrIcaI wIrIng, sIaIIc eIecIrIcIIy, weIdIng and soIderIng equIpmenI. The prIncIpIes oI IIre conIroI are Io: prevenI IgnIIIon sIore chemIcaIs and expIosIve maIerIaIs properIy InsIaII and use IIre aIarms provIde IIre exIInguIshIng equIpmenI and reguIarIy InspecI and maInIaIn II IraIn every worker Io use Ihe avaIIabIe IIre conIroI equIpmenI InspecI Ihe workpIace aI reguIar InIervaIs Ior IIre rIsks conducI reguIar IIre drIIIs cooperaIe wIIh Ihe IocaI IIre brIgade. Innnzc )ou:c \tI tIc c Inznd conto :):tcn n n cctnn ndu:t) nnd cnc n cot c\nuntng tInt :):tcn. 6.7 Purposes ol occupaIional accidenI invesIigaIion InvesIIgaIIon and anaIysIs are used Io prevenI accIdenIs, boIh Ihose IhaI resuII In Injury Io personneI and Ihose IhaI do noI. The InvesIIgaIIon or anaIysIs oI an accIdenI can produce InIormaIIon IhaI Ieads Io counIermeasures Io prevenI accIdenIs or reduce IheIr number and IheIr severIIy. An InvesIIgaIIon oI every accIdenI IhaI causes dIsabIIIIy or IIIness shouId be carrIed ouI. IncIdenIs resuIIIng In nondIsabIIng InjurIes or no InjurIes and "near accIdenIs" shouId aIso be InvesIIgaIed Io evaIuaIe IheIr causes In reIaIIon Io InjuryproducIng accIdenIs or 1Ub OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers breakdowns. Ior purposes oI accIdenI prevenIIon, InvesIIgaIIons musI be IacI IIndIng, noI IauII IIndIng. I:cu:: tIc no\c ncntoncd :tntcncnt n tIc gIt o tIc nctun occuntonn nccdcnt ccodng nnd n\c:tgntng :):tcn nt tIc ocn nnd nntonn c\c:. 6.8 Types ol occupaIional accidenI invesIigaIion These are severaI accIdenI InvesIIgaIIon and anaIysIs IechnIques avaIIabIe. The choIce oI a parIIcuIar meIhod depends on Ihe purpose and orIenIaIIon oI Ihe InvesIIgaIIon. The accIdenI InvesIIgaIIon and anaIysIs procedure Iocuses prImarIIy on unsaIe cIrcumsIances surroundIng Ihe occurrence oI an accIdenI and Is Ihe mosI oIIen used IechnIque. OIher sImIIar IechnIques InvoIve InvesIIgaIIon wIIhIn Ihe Iramework oI deIecIs In Ihe Iour Ms: man, machIne, medIa and managemenI, or Ihe Ihree Ls oI saIeIy: educaIIon, enIorcemenI and engIneerIng. Connc nnd c\nuntc tIc cx:tng t)c: o occuntonn nccdcnt n\c:tgnton n tIc gIt o tIc t)c: ncntoncd no\c. MODULE 7 First aid and its practice 1. OB|ECTlVES Become acquaInIed wIIh IIrsI aId IechnIques Be abIe Io provIde emergency care In Ihe workpIace Know how Io decIde Io reIer cases Io a hospIIaI or a specIaIIzed heaIIh cenIre Know how Io perIorm and pracIIse heaIIh educaIIon Learn how Io keep records and wrIIe reporIs. 2. lMPORTANCE Ol llRST AlD IIrsI aId Is Ihe ImmedIaIe care gIven Io vIcIIms oI accIdenIs beIore IraIned medIcaI workers arrIve. IIs goaI Is Io sIop and, II possIbIe, reverse harm. II InvoIves rapId and sImpIe measures such as cIearIng Ihe aIr passageway, appIyIng pressure Io bIeedIng wounds or dousIng chemIcaI burns Io eyes or skIn. The crIIIcaI IacIors whIch shape IIrsI aId IacIIIIIes In a workpIace are workspecIIIc rIsk and avaIIabIIIIy oI deIInIIIve medIcaI care, e.g. Ihe care oI a hIghpowered saw Injury Is obvIousIy radIcaIIy dIIIerenI Irom IhaI oI a chemIcaI InhaIaIIon. IIrsI aId Is a IIuId concepI noI onIy In whaI musI be done (how Iong, how compIex) buI In who can do II. AIIhough a very careIuI aIIIIude Is requIred, every worker can be IraIned In Ihe Iop 10 crucIaI sIeps oI IIrsI aId. In some sIIuaIIons ImmedIaIe acIIon can save IIIe, IImb or eyesIghI. Coworkers oI vIcIIms shouId noI remaIn paraIysed whIIe waIIIng Ior IraIned personneI Io arrIve. The Iop 10 crucIaI sIeps wIII vary wIIh each workpIace and musI be IaughI accordIngIy. IIrsI aId personneI are persons on Ihe spoI, generaIIy workers who are IamIIIar wIIh Ihe specIIIc condIIIons oI work. They mIghI noI be medIcaIIy quaIIIIed buI Ihey musI be IraIned and prepared Io perIorm very specIIIc Iasks. IIrsI aId personneI shouId be seIecIed careIuIIy, IakIng InIo accounI aIIrIbuIes such as reIIabIIIIy, moIIvaIIon and Ihe abIIIIy Io cope wIIh peopIe In a crIsIs sIIuaIIon. 3. lN|URlES 3.1 DeliniIions lnjury: a physIcaI damage Io body IIssues caused by an accIdenI or by exposure Io envIronmenIaI sIressors. Wound: a break In Ihe conIInuIIy oI body IIssue or openIng In Ihe skIn. A wound may be an Injury buI noI aII InjurIes are wounds. 1U OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 3.2 Head injuries Cucn :tc: 1. MaInIaIn an aIrway. 2. ConIroI bIeedIng. S. ProIecI agaInsI InIecIIon. 4. PrevenI IurIher Injury. Then: In cases oI shock, Iook Ior oIher InjurIes whIch may be causIng bIood Ioss. In case oI cIosed braIn InjurIes, Iook Ior sympIoms such as unusuaI behavIour, Ioss oI memory, drowsIness, excIIabIIIIy or deIIrIum. Be aware IhaI bruIsIng Io Ihe braIn may cause convuIsIon, drowsIness or Ioss oI conscIousness. Be aware IhaI bIeedIng Irom Ihe ears, nose and IhroaI Is a resuII oI a IracIure aI Ihe base oI Ihe skuII. Do noI aIIempI Io remove IoreIgn objecIs embedded In Ihe head as IhIs may cause unconIroIIabIe bIeedIng. AppIy head dressIngs In such a manner IhaI Ihey wIII noI sIIp oII durIng IransporIaIIon Io hospIIaI. PIace Ihe paIIenI on hIs/her sIde Io aIIow proper draInage. In cases oI respIraIory cenIre damage, appIy mouIhIomouIh resuscIIaIIon Io ensure an adequaIe suppIy oI oxygen. 3.3 lacial injuries Cucn :tc: 1. Check Ior obsIrucIed aIrway as IacIaI InjurIes may cause exIernaI bIeedIng resuIIIng In bIockage oI aIrway. The bIeedIng Irom Ihe oraI cavIIy can be parIIcuIarIy heavy. 2. ConIroI bIeedIng by reaIIgnIng Ihe jaw, I.e. by graspIng Ihe chIn and puIIIng II sIraIghI ouI. S. MaInIaIn Ihe aIrway by IurnIng Ihe vIcIIm on hIs/her sIde. 3.4 ChesI injuries Cucn :tc: 1. SeaI Ihe chesI wound Irom Ihe ouIsIde as quIckIy as possIbIe. 2. Never exIracI IoreIgn objecIs Irom Ihe chesI wound. Irst nd nnd ts rnctce: ModuIe 7 1U9 S. MaInIaIn aIrway. 4. AdmInIsIer oxygen. S. AppIy mouIhIomouIh resuscIIaIIon and exIernaI hearI massage II necessary. 6. TransporI Ihe paIIenI In a sIIIIng posIIIon unIess he/she Is In shock. 3.5 Abdominal injuries Cucn :tc: 1. Cover Ihe wound wIIh a sIerIIe dressIng; appIy a compressIon bInder Io conIroI haemorrhagIng. 2. Look Ior any peneIraIIng wounds and oIher sympIoms such as vomIIIng, abdomInaI paIn and Ienderness. S. Never aIIempI Io repIace proIrudIng organs, cover Ihem wIIh sIerIIe gauze and keep Ihe cIoIh moIsI. 4. PIace Ihe paIIenI In a semIsIIIIng posIIIon unIess he/she Is In shock. S. Keep Ihe paIIenI warm wIIh bIankeIs. 6. Never gIve Ihe paIIenI anyIhIng Io drInk or eaI. 3.6 Eye injuries Do noI InIerIere wIIh eye InjurIes excepI In mInor cases. ReIer Ihe vIcIIm Io hospIIaI ImmedIaIeIy. SympIoms oI serIous eye Injury are: bIurred vIsIon IhaI does noI cIear wIIh bIInkIng Ioss oI aII or parI oI Ihe vIsuaI IIeId oI an eye sharp sIabbIng or deep IhrobbIng paIn doubIe vIsIon. SIgns oI eye Injury IhaI requIre ophIhaImoIogIcaI evaIuaIIon are: bIack eye red eye an objecI on Ihe cornea one eye IhaI does noI move as compIeIeIy as Ihe oIher one eye proIrudIng more Ihan Ihe oIher one eye wIIh an abnormaI pupII sIze, shape or reacIIon Io IIghI a Iayer oI bIood beIween Ihe cornea and Ihe IrIs (hyphaema) IaceraIIon oI Ihe eyeIId, especIaIIy II II InvoIves Ihe IId margIn IaceraIIon or perIoraIIon oI Ihe eye. Cucn :tc: 1. Any chemIcaI spIashed InIo Ihe eye(s) musI be consIdered a vIsIonIhreaIenIng emergency. IorcIbIy keep Ihe paIIenI's eyeIIds open whIIe IrrIgaIIng wIIh waIer 11U OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers Ior aI IeasI IIve mInuIes, Ihen reIer Ihe paIIenI Io an ophIhaImoIogIsI. InIorm Ihe ophIhaImoIogIsI oI Ihe naIure oI Ihe chemIcaI conIamInanI. 2. PaIch Ihe Injured eye IIghIIy wIIh a dry, sIerIIe eye pad. II IaceraIIon oI Ihe eye Is suspecIed, add a proIecIIve shIeId over Ihe sIerIIe eye pad. InsIrucI Ihe paIIenI noI Io squeeze Ihe eye IIghIIy shuI because II greaIIy eIevaIes Ihe InIraocuIar pressure. CaImIy IransporI Ihe paIIenI Io Ihe ophIhaImoIogIsI. 3. ConjuncIIvIIIs, wIIh normaI vIsIon and a cIear cornea, may be IreaIed wIIh an anIIbIoIIc eye oInImenI Ior severaI days. II Ihere Is no ImprovemenI, reIerraI Io Ihe ophIhaImoIogIsI Is IndIcaIed. 4. Never puI eye oInImenI In an eye abouI Io be seen by Ihe ophIhaImoIogIsI. The oInImenI makes cIear vIsuaIIzaIIons oI Ihe reIIna very dIIIIcuII. 5. Never gIve a paIIenI a IopIcaI anaesIheIIc Io reIIeve paIn, such as Irom a IIash burn. The proIonged use oI IopIcaI anaesIheIIc can resuII In bIIndness Irom corneaI breakdown. 6. Never IreaI a paIIenI wIIh a IopIcaI sIeroId unIess dIrecIed by Ihe ophIhaImoIogIsI. TopIcaI sIeroIds can make severaI condIIIons much worse, such as herpes sImpIex, keraIIIIs, IungaI InIecIIons and some bacIerIaI InIecIIons. 7. II In doubI as Io how severe an ocuIar sympIom sIgn Is, aIways err on Ihe sIde oI cauIIon and reIer Ihe empIoyee Io an ophIhaImoIogIsI Ior dIagnosIs and IreaImenI. 4. lRACTURES 4.1 DeliniIions lracIure: any break In a bone. Simple lracIure (cIosed IracIure): Ihe skIn covers Ihe IracIure. Compound lracIure (open IracIure): Ihe skIn Is broken and Ihe bone has dIrecI conIacI wIIh Ihe open aIr. II Is essenIIaI Io remember Ihe IoIIowIng: 1. Do noI harm. UnwIse aIIempIs by Ihe paIIenI Io conIInue Io use a IracIured exIremIIy may cause IaceraIIon oI Ihe soII IIssues and may Iead Io Ihe broken bone peneIraIIng Ihe skIn or Io Ihe onseI oI shock. 2. ProIecI and ImmobIIIze. AppIy a spIInI Io Ihe IracIure so Ihe vIcIIm can be moved more comIorIabIy and wIIhouI causIng any IurIher InjurIes. 4.2 lracIures ol Ihe exIremiIies Cucn :tc: 1. PIace Ihe Injured IImb In as naIuraI a posIIIon as possIbIe beIore paddIng and spIInIIng. Irst nd nnd ts rnctce: ModuIe 7 111 2. II Ihe broken bone Is noI proIrudIng above Ihe skIn, appIy IracIIon Io overcome Ihe muscIe and Io sIraIghIen Ihe IImb wIIh mInImum paIn. II Ihe broken bone Is proIrudIng above Ihe skIn, do noI appIy IracIIon Io avoId conIamInaIIng deep IIssues. S. To conIroI bIeedIng, appIy genIIe pressure by coverIng Ihe wound wIIh a sIerIIe dressIng and wrappIng wIIh an eIasIIc bandage. 4. Never aIIempI Io seI an open IracIure. AppIy Ihe proper spIInI beIore movIng Ihe paIIenI. 4.3 lracIure ol Ihe spine and pelvis A spInaI IracIure may occur In Ihe neck and upper or Iower spIne and may aIIecI Ihe spInaI cord. SympIoms oI IracIure Io Ihe spIne IncIude severe back paIn and numbness and IIngIIng In Ihe arms and Iegs. PeIvIc IracIures are common buI hard Io spoI. They are usuaIIy assocIaIed wIIh oIher InjurIes whIch may be severe and cause shock. A IracIured peIvIc bone may pIerce Ihe bIadder and may cause InIesIInaI obsIrucIIon. Cucn :tc: Unc:: )ou In\c ccn tnncd n tIc cocct \n) to no\c n :u:cctcd :nn nctuc, do not nttcnt to no\c tIc \ctn unc:: cn\ng In \oud cxo:c In to utIc dnngc. 1. Lnsure IhaI Ihe vIcIIm has an adequaIe aIrway. 2. TransporI a paIIenI wIIh a (suspecIed) broken neck on hIs/her back on a rIgId supporI. S. The paIIenI musI be moved as a unII by S-S men, one oI whom musI IIrmIy hoId Ihe paIIenI's head. 4. To prevenI unnecessary movemenI, pIace bIankeI roIIs or pIIIows aIong Ihe sIde oI Ihe paIIenI. S. PIace a paIIenI wIIh a (suspecIed) IracIured peIvIs genIIy on hIs/her back on a IIrm sIreIcher. 6. ImmobIIIze Ihe peIvIc regIon by bandagIng Ihe knee and ankIe IogeIher IIrmIy wIIh paddIng pIaced beIween Ihe knees Ior comIorI. 7. Wrap a broad bandage or IoIded bIankeI around Ihe paIIenI's hIps Irom jusI above Ihe hIp bone Io approxImaIeIy S cm down on Ihe IhIghs. 8. PrevenI shock. 5. THERMAL lN|URlES 5.1 Burns There are Ihree maIn Iypes oI burn: IhermaI, eIecIrIcaI and chemIcaI. 112 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers LsIImaIe Ihe serIousness oI Ihe burns by usIng Ihe RuIe oI NIne: Ihe head and neck comprIse 9 oI Ihe skIn area; Ihe chesI, 18; Ihe back, 18; each arm, 9; and each Ieg 18 (Ior Ihe sake oI compIeIeness Ihe genIIaIs/perIneum comprIse 1). IIrsI degree burns are superIIcIaI wIIh reddenIng oI Ihe skIn. Second degree burns exIend deepIy InIo Ihe skIn wIIh redness. ThIrd degree burns InvoIve Ihe enIIre IhIckness oI Ihe skIn. Cucn :tc: 1. PrevenI shock. 2. Do noI aIIempI Io remove paIIenI's cIoIhes excepI In case oI a chemIcaI burn. S. Wrap Ihe paIIenI In a cIean sheeI Io prevenI InIecIIon. 4. MaInIaIn body IemperaIure. S. NeuIraIIze Ihe chemIcaI agenI II a neuIraIIzer Is avaIIabIe. 6. DeIermIne whaI chemIcaI agenIs have been Ihe cause oI Ihe burns beIore IransIerrIng Ihe paIIenI Io hospIIaI. 5.2 Cold Long exposure Io exIreme coId resuIIs In hypoIhermIa and coma. The InIIIaI sympIoms oI IrosIbIIe are IIngIIng, numbness, paIn, vIoIaIed red skIn IoIIowed by a consIanI burnIng and IIchIng sensaIIon and Ihen Ioss oI aII sensaIIon In Ihe aIIecIed area. ProIonged exposure Io exIreme coId resuIIs In Ihe onseI oI hypoIhermIa and uIIImaIeIy, Ihe vIcIIm wIII Iapse InIo a coma. Cucn :tc: 1. Immerse Ihe aIIecIed parI In waIer heaIed Io beIween 40 C and 42 C. 2. Do noI aIIempI Io Ihaw Ihe aIIecIed area. S. Do noI pIace Ihe vIcIIm cIose Io IIre. 4. Do noI massage Ihe aIIecIed area. 5.3 HeaI sIroke IacIors conIrIbuIIng Io heaI sIroke are: workIoad, IhermaI envIronmenI, sIress, non accIImaIIzaIIon, poor work condIIIons, overweIghI, unsuIIabIe cIoIhIng, poor venIIIaIIon, dehydraIIon or shorIage oI waIer, aIcohoI consumpIIon, hIsIory oI cardIovascuIar dIseases or recenI prIckIy heaI. Cucn :tc: 1. ConIIrm suspecIed cases oI heaI sIroke by measurIng Ihe body IemperaIure. A person wIIh a IemperaIure beIween 40 C and 4S C wouId be consIdered a vIcIIm oI heaI sIroke. Irst nd nnd ts rnctce: ModuIe 7 113 2. Sponge wIIh cooI waIer, wrap In cooI sheeIs or IoweIs or bIow cooI aIr over paIIenI. 6. POlSONlNG Cucn :tc: 1. Induce vomIIIng as quIckIy as possIbIe by admInIsIerIng a IabIespoon oI Ipecac syrup excepI In InsIances oI IngesIIon oI acIds, aIkaIIs and peIroIeum producIs. AdmInIsIer waIer, mIIk or unIversaI anIIdoIes; waIer shouId be used II Ihere Is noIhIng eIse avaIIabIe. Do noI gIve IIuId Io an unconscIous person. 2. In InsIances oI IngesIIon oI acIds, aIkaIIs, peIroIeum producIs and oIher causIIcs: aIIempI Io IdenIIIy Ihe specIIIc producI, Ihe concenIraIIon oI Ihe acIIve IngredIenIs and Ihe esIImaIed voIume IngesIed. The producI conIaIner or IabeIs may be avaIIabIe. A dIIuIenI may be beneIIcIaI II gIven wIIhIn S0 mInuIes oI a soIId or granuIar aIkaIIne IngesIIon. WaIer or mIIk may be admInIsIered, dosages oI 2S0 mI In aduIIs and 1S mI/kg In chIIdren. lnduced emesis and aIIempIs aI neuIralizing Ihe subsIance by using a weak acid or alkali are absoluIely conIraindicaIed. S. AdmInIsIer mouIhIomouIh or mechanIcaI resuscIIaIIon II Ihere Is dIIIIcuIIy In breaIhIng. 4. II poIson Is In conIacI wIIh Ihe skIn, remove aII conIamInaIed cIoIhIng and IIood Ihe aIIecIed area wIIh waIer. S. II poIson Is In conIacI wIIh Ihe eyes, IrrIgaIe boIh eyes wIIh Iarge quanIIIIes oI waIer. 6. IdenIIIy Ihe poIsonIng maIerIaI or coIIecI aII vomIIed maIerIaI In a conIaIner and IransporI II Io Ihe hospIIaI wIIh Ihe paIIenI Ior IaboraIory anaIysIs. 7. HAEMORRHAGE Haemorrhage may be arIerIaI, venous or capIIIary. Cucn :tc: 1. AppIy pressure wIIh IIngerIIps Io Ihe pressure poInIs and a bandage as necessary. 2. AppIy IournIqueI only when oIher meIhods IaII and In Ihe case oI a IIIe IhreaIenIng haemorrhage. S. A IournIqueI shouId consIsI oI a IIaI band aI IeasI one Inch wIde such as a IIe, handkerchIeI, IoweI, scarI or beII. Never use rope or wIre. II shouId onIy be appIIed In Iwo pIaces dependIng on Ihe sIIe oI Ihe Injury: Ihe arm, a hand's wIdIh beIow Ihe eIbow; or Ihe Ieg, a hand's wIdIh beIow Ihe groIn. 114 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 8. SHOCK Shock means Ihere Is noI enough bIood cIrcuIaIIng Ihrough Ihe body. SympIoms oI shock IncIude: paIe, coId and moIsI skIn, shaIIow breaIhIng, bIuIsh IIngernaIIs and IIps, IhIrsI and resIIessness. Cucn :tc: 1. TreaI shock by removIng Ihe cause: sIop Ihe bIeedIng, reIIeve Ihe paIn, spIInI Ihe IracIure. 2. PrevenI InIecIIon and maInIaIn body heaI. S. Lay Ihe paIIenI IIaI. 4. Burn vIcIIms suIIerIng Irom shock shouId be gIven IIquIds In smaII amounIs. 9. lMPAlRED BREATHlNG MoutI-to-noutI c:u:ctnton 1. CIear Ihe mouIh and Ihe IhroaI oI any denIures, mucus, Iood, bIood or oIher obsIrucIIons. 2. TIII Ihe head back as Iar as possIbIe and sIreIch Ihe neck. S. LIII Ihe Iower jaw Iorward. 4. PInch Ihe nose. S. Open your mouIh wIde seaIIng your IIps over Ihose oI Ihe vIcIIm, Iake deep breaIh and bIow IorceIuIIy unIII you see Ihe vIcIIm's chesI rIse. 6. Remove your mouIh when you see Ihe vIcIIm's chesI rIse; IIsIen Ior exhaIaIIon. 7. ConIInue Ihe same procedure 12-20 IImes per mInuIe. 10. TASKS lOR TRAlNEES 1. IamIIIarIze yourseII wIIh Ihe Iheory oI IIrsI aId. 2. PracIIse IIrsI aId procedures wIIh Ihe workers. S. Know how Io perIorm IIrsI aId IechnIques and arIIIIcIaI respIraIIon. 4. Know how Io decIde Io reIer cases Io Ihe hospIIaIs or emergency heaIIh cenIres when requIred. S. Keep heaIIh records oI IndIvIduaI workers. MODULE 8 Health education in occupational health 1. OB|ECTlVES DescrIbe paIIerns oI occupaIIonaI dIseases and accIdenIs DescrIbe how dIIIerenI condIIIons wIIhIn work envIronmenIs may be reIaIed Io occupaIIonaI dIseases and how Io reduce Ihe rIsk IdenIIIy causes oI work accIdenIs and meIhods oI prevenIIon DescrIbe how dIIIerenI sIyIes oI work pracIIces mIghI aIIecI Ihe heaIIh oI Ihe worker, coIIeagues and oIhers DIscuss rIsk reducIIon oI occupaIIonaI dIseases and accIdenIs wIIh workers and managers In Ihe workpIace and IdenIIIy suIIabIe procedures Io maInIaIn a heaIIhy work envIronmenI DIscuss how IIIesIyIe and behavIour mIghI aIIecI heaIIh DescrIbe varIous new meIhods oI heaIIh educaIIon and how, when and where Io appIy Ihem as weII as ways oI moIIvaIIon DescrIbe Ihe heaIIh educaIIon Iasks Ihe heaIIh worker Is goIng Io appIy and perIorm In dIIIerenI heaIIh probIem sIIuaIIons In Ihe workpIace IdenIIIy psychoIogIcaI, cuIIuraI, reIIgIous and eIhIcaI vaIues whIch mIghI aIIecI Ihe communIIy heaIIh worker's abIIIIy Io educaIe workers or workpIace managers on Ihe work envIronmenI and prevenIIon and conIroI oI occupaIIonaI dIseases and accIdenIs. 2. OCCUPATlONAL DlSEASES 2.1 lirsI sIeps LxpIaIn Io Ihe IraInees Ihe deIInIIIon oI occupaIIonaI dIsease and IIs causes: chemIcaI agenIs: gases, vapours, mIsIs, pesIIcIdes, eIc. physIcaI agenIs: noIse, vIbraIIon, heaI and coId sIress, radIaIIon, IIghI, eIc. bIoIogIcaI agenIs: bacIerIa, parasIIes, IungI, aIIergens, eIc. psychoIogIcaI IacIors: InIerpersonaI and socIaI eIIecIs, reIaIIonshIp wIIh managemenI, shIIIwork, eIc. ergonomIc IacIors. 11b OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers DIscuss Ihe rouIes oI enIry oI noxIous agenIs (skIn, InhaIaIIon, IngesIIon) and IheIr Iorms (dusIs, gases, vapours, IIuIds eIc.). ReIer Io Ihe ImporIance oI Ihe earIy deIecIIon oI heaIIh ImpaIrmenI and Ihe maIn sIgns and sympIoms oI some common occupaIIonaI dIseases In Ihe IocaIIIy. DIscuss Ihe Iypes oI medIcaI examInaIIons (prepIacemenI, perIodIc and rouIIne), IheIr ImporIance and meIhods oI ImpIemenIaIIon. 2.2 MeIhodology Ask Ihe IraInees Io paIr up wIIh someone In Ihe group. Then dIrecI Ihem (In Ihe paIrs) Io dIscuss Ihe IoIIowIng quesIIons. One member oI each paIr shouId wrIIe down IheIr answers. QuesIIons: 1. In your opInIon, whaI are Ihe occupaIIonaI dIseases you wouId expecI Io IInd In your dIsIrIcI and why7 2. Do you IhInk IhaI II Is ImporIanI Io prevenI occupaIIonaI dIseases7 S. WheIher you answer yes or no, expIaIn why. NexI, ask each paIr Io joIn up wIIh anoIher paIr In Ihe room. Any IeIIover paIr can joIn any oI Ihe groups oI Iour. GIve Ihem some IurIher IIme Io conIInue IheIr dIscussIon In Ihe smaII groups. Then ask Ior Ieedback Io Ihe cIass concernIng: 1. The occupaIIonaI dIseases Ihey expecI Io be Iound In IheIr dIsIrIcIs and why. 2. The socIaI and economIc eIIecIs oI occupaIIonaI dIseases. 3. OCCUPATlONAL ACClDENTS 3.1 lirsI sIeps LxpIaIn Ihe deIInIIIon and Ihe causes oI occupaIIonaI accIdenIs, e.g. sIIppIng, IrIppIng up, IaIIs oI maIerIaI and peopIe, machInery, IransporI, eIecIrIcIIy aI work, conIIned spaces, IIres and expIosIons, personaI IacIors. LxpIaIn IhaI Ihere are ways oI mInImIzIng Ihe rIsk oI accIdenIs. DIscuss saIe and unsaIe worker behavIour. SIress Ihe ImporIance oI IIdIness and hygIene In Ihe workpIace In accIdenI prevenIIon. LxpIaIn prImary IIrsI aId sIeps In Ihe case oI work accIdenIs and how Io reIer cases urgenIIy Ior medIcaI supporI. DIscuss rehabIIIIaIIon, compensaIIon and economIc Ioss due Io accIdenIs. DIscuss Ihe roIes oI Ihe empIoyer, workers and governmenI In accIdenI reducIIon. HenIth educnton n occuntonnI henIth: ModuIe 117 3.2 MeIhodology 1. SIIck sIgns readIng "Dangerous" and "SaIe" on Ihe board some dIsIance aparI. Prepare In advance a Iarge number oI cards or sIrIps oI paper. On each card wrIIe or draw a parIIcuIar sIIuaIIon, eIIher dangerous or saIe, e.g. oII spIIIs on Ihe workpIace IIoor covered machInery exposed eIecIrIcaI wIres heavy boxes whIch are precarIousIy pIaced on a movIng IorkIIII wearIng oI Ioose cIoIhIng wIIh Ioose beIIs or sIrIps oI IabrIc near revoIvIng machIne wheeIs oIher sIIuaIIons whIch may be reIevanI Io your group oI IraInees. 2. Hand ouI Ihe cards aI random Io members oI Ihe groups and ask Ihem Io sIIck IheIr cards on Ihe board aI a poInI under Ihe sIgn Io whIch Ihey IeeI II beIongs. You can heIp II Ihe group cannoI decIde where Io III a cerIaIn card. Lach person who goes up Io Ihe board Is encouraged Io say wheIher he dIsagrees wIIh Ihe posIIIon oI any cards IhaI are aIready Ihere. S. IInaIIy, move any cards IhaI are IncorrecIIy pIaced and expIaIn your reasons Ior doIng so. 3.3 Case hisIory TIcc nc \c \oc: n n cn cn \o:Io n )ou to\n. Onc o tIc:c \oc: Ind nn nccdcnt \Ic tc:tng tIc c\o\ng nt: o n tuc cngnc. Hc Ind n dcc cut n I: ct Innd, \n: o:ng n ot o ood nnd \n: n :c\cc nn. 3.4 MeIhodology DIvIde Ihe cIass InIo groups oI IIve wIIh an eIecIed Ieader and a reporIer and acquaInI Ihem wIIh Ihe case hIsIory. Ask Ihe cIass Io dIscuss Ihe necessary sIeps IhaI Ihe coIIeagues oI Ihe Injured worker shouId Iake In order Io heIp hIm. GIve enough IIme Ior group dIscussIon and joIIIng down oI commenIs, Ihen ask Ihe reporIers Io gIve Ieedback Io Ihe cIass. IoIIowIng Ihe Ieedback Irom Ihe groups, Iead Ihe cIass In a generaI dIscussIon on Ihe IopIc. ConIIrm IhaI onIy essenIIaI IIrsI aId shouId be gIven, I.e. Io sIop bIeedIng by wrappIng Ihe hand wIIh a pIece oI cIean cIoIh above Ihe wound sIIe. Then, eIIher an ambuIance shouId have been caIIed or Ihe vIcIIm shouId have been IransporIed as quIckIy as possIbIe Io Ihe nearesI cIInIc or hospIIaI Ior IurIher medIcaI IreaImenI. 11 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 4. WORK ENVlRONMENT AND CONTROL MEASURES lN THE WORKPLACE 4.1 lirsI sIeps LxpIaIn Io Ihe IraInees Ihe deIInIIIon oI Ihe work envIronmenI and Ihe IacIors whIch aIIecI II: physIcaI, chemIcaI, bIoIogIcaI and ergonomIc. DIscuss Ihe rIsks InvoIved when Ihere are unconIroIIed condIIIons. DescrIbe Ihe meIhods oI evaIuaIIon oI Ihe work envIronmenI (measuremenIs and InIerpreIaIIon oI resuIIs) Ior noIse, heaI and coId, IIIumInaIIon, radIaIIon, aIr poIIuIanIs, gases, vapours and parIIcIes (aIr sampIIng). DIscuss ways oI mInImIzIng Ihe heaIIh rIsks In aII Iypes oI envIronmenI Ihrough conIroI measures (anIIcIpaIIon, recognIIIon, evaIuaIIon and conIroI) and accIdenI prevenIIon. PoInI ouI IhaI IhreshoId vaIues shouId be IoIIowed. DIscuss Ihe ImporIance oI perIodIc InspecIIon oI Ihe workpIace. Use oI sIandard Iorms and quesIIonnaIres shouId be hIghIIghIed. 4.2 MeIhodology V:t to nn occuntonn I)gcnc nonto) The hygIenIsI or responsIbIe IechnIcIan aI Ihe IaboraIory shouId brIeI Ihe IraInees on Ihe equIpmenI used Ior work envIronmenI measuremenIs, e.g. noIse IeveI meIers, IIghI IeveI meIers, dusI sampIers, gas sampIers, eIc. V:t to nctoc:,\oncc: SeIecI Ihree or Iour IacIorIes/workpIaces whIch have dIIIerenI IndusIrIaI acIIvIIIes and work envIronmenI hazards. ObIaIn permIssIon Irom Ihe IacIory managemenI Io brIng Ihe IraInees on a vIsII and IIx Ihe daIe and IIme. Prepare a Iorm Ior Ihe IacIory/workpIace InspecIIon usIng Ihe IacIory InspecIIon GuIdeIInes beIow. On Ihe vIsII day, dIsIrIbuIe a copy oI Ihe Iorm Io each group oI IraInees. InsIrucI each group Io nomInaIe a Ieader and a reporIer. On arrIvaI aI Ihe IacIory, InsIrucI Ihe group Io quesIIon Ihe desIgnaIed IacIory conIacI person usIng Ihe prepared Iorm. The groups Ihen Iour Ihrough Ihe dIIIerenI parIs oI Ihe IacIory, IIIIIng In Ihe resI oI Ihe Iorm as Ihey go. AII groups reIurn Io Ihe cIassroom and Ihe reporIers Irom each group provIde Ieedback on IheIr IIndIngs. HenIth educnton n occuntonnI henIth: ModuIe 119 Lead a cIass dIscussIon emphasIzIng Ihe IoIIowIng poInIs: Ihe work envIronmenI workpIace hygIene workIng condIIIons use oI proIecIIve equIpmenI need Ior heaIIh educaIIon programmes Ieedback Io managemenI 4.3 lacIory,workplace inspecIion guidelines Name and address oI Ihe IacIory/workpIace IndusIrIaI acIIvIIy Raw maIerIaIs used IInaI producIs Number oI workers GeneraI hygIene oI Ihe workpIace SaIepIace approach equIpmenI machInery "guardIng encIosure" venIIIaIIon oIhers Lxposure hazards and rIsks physIcaI chemIcaI bIoIogIcaI ergonomIcaI SaIeperson approach sysIems oI work onIhejob IraInIng personaI proIecIIon PrepIacemenI and perIodIc medIcaI examInaIIons AppIIed heaIIh educaIIon programmes Need Ior heaIIh educaIIon programmes OIher poInIs. 12U OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 5. PREVENTlON Ol OCCUPATlONAL DlSEASES AND ACClDENTS 5.1 lirsI sIeps DIscuss wIIh Ihe IraInees Ihe ImporIance oI Ihe workpIace sIIe, Ihe buIIdIng engIneerIng pIan and Ihe IayouI oI machInery (saIepIace approach). Ask Ihe IraInees whIch meIhods wouId be suIIabIe Io maInIaIn heaIIh sIandards In Ihe workpIace. DIscuss Ihe ImporIance oI work pracIIces educaIIon and job IraInIng Ior workers (saIeperson approach). LmphasIze Ihe ImporIance oI maInIaInIng good workpIace hygIene and personaI hygIene. SIaIe Ihe beneIIIs oI prepIacemenI and perIodIc medIcaI examInaIIons. DIscuss Ihe roIes oI empIoyer, worker and governmenI. LxpIaIn Ihe vIIaI roIe oI heaIIh educaIIon In occupaIIonaI dIsease and accIdenI prevenIIon. 5.2 MeIhodology Iquncnt BrIng Io cIass a coIIecIIon oI personaI proIecIIve equIpmenI, e.g. gIoves, masks, goggIes, heImeIs, booIs, aprons, eIc., and dIscuss wIIh Ihe IraInees Ihe varIous Iypes oI equIpmenI and IheIr beneIIIs In prevenIIon oI occupaIIonaI dIsease and accIdenI. InvIIe Ihe IraInees Io Iry on Ihe equIpmenI In order Ior Ihem Io undersIand how Ihey are used. Io:tc: Prepare and dIspIay posIers showIng workers IoIIowIng saIe work pracIIces: correcI meIhod oI weIghI IIIIIng, wearIng masks, goggIes and gIoves, eIc., and poor work pracIIces: workers sIandIng In IronI oI unproIecIed revoIvIng machInery parIs, workers wIIhouI proIecIIve equIpmenI whIIe exposed Io gases, dusIs, noIse eIc. I:cu::on Lead Ihe cIass In dIscussIon oI Ihese posIers. Lncourage Ihe IraInees Io commenI on each posIer and wheIher or noI Ihey agree wIIh Ihe work pracIIce IndIcaIed by Ihe educaIIonaI message. II Ihey don'I agree wIIh Ihe work pracIIce, InvIIe Ihem Io suggesI ImprovemenIs. HenIth educnton n occuntonnI henIth: ModuIe 121 6. LEGlSLATlON 6.1 lirsI sIeps InIorm IraInees oI Ihe Iaws governIng work envIronmenI and work pracIIces wrIIIen by Ihe mInIsIry oI Iabour, mInIsIry oI heaIIh, mInIsIry oI IndusIry, mInIsIry oI socIaI securIIy, eIc. DIscuss work accIdenIs and occupaIIonaI dIsease compensaIIon and rehabIIIIaIIon IegIsIaIIon. MenIIon Ihe roIe oI Ihe worker, empIoyer and Ihe governmenI In Ihe seIIIemenI oI Ihese Issues. 6.2 Case hisIory M A : n \oc n nn on \o:Io. Hc Ind n \o nccdcnt n \IcI Ic dnnngcd t\o onc: n I: gIt ndcx ngc. Hc Ind to c tcntcd n tIc d:tct Io:tn. 6.3 MeIhodology DIvIde Ihe cIass InIo smaII groups wIIh an eIecIed Ieader and a reporIer. AcquaInI Ihe IraInees wIIh Ihe case hIsIory ouIIIned above. InsIrucI IraInees Io dIscuss Ihe advIce Ihey wouId gIve Mr A on any admInIsIraIIve or IegIsIaIIve sIeps he shouId Iake. Ask Ihe groups Ior Ieedback. The IraInees shouId concIude IhaI aIIer Mr A has compIeIed hIs IreaImenI, he shouId Iorward documenIaIIon ouIIInIng hIs Injury Io Ihe Iabour oIIIce or Ihe socIaI Insurance deparImenI In order Io cIaIm compensaIIon and/or rehabIIIIaIIon IreaImenI. 7. EllECTS Ol LllESTYLE AND BEHAVlOUR ON HEALTH 7.1 lirsI sIeps TeII Ihe cIass IhaI In IhIs sessIon Ihey are goIng Io Iearn abouI Ihe eIIecIs oI IndIvIduaI/communIIy IIIesIyIes and behavIour on heaIIh condIIIons. In many InsIances, wheIher aI home or aI work, peopIe can become III or remaIn heaIIhy as a resuII oI IheIr behavIour and aIIIIudes. Lncourage IraInees Io gIve exampIes oI correcI heaIIh behavIour, e.g. washIng oI hands and uIensIIs wIIh soap; sIorIng oI InIIammabIe maIerIaIs away Irom worksIIes, wearIng proIecIIve cIoIhIng when requIred and coverIng Iood agaInsI IIIes. 122 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers Ask Ihe IraInees Io dIscuss whaI makes peopIe behave In cerIaIn ways. Ask Ihem Io gIve exampIes oI Ihe causes oI such behavIour and suggesI possIbIe reasons behInd Ihe causes. MenIIon Ihe maIn IacIors IhaI InIIuence and dIrecI peopIe's behavIour: knowIedge, beIIeIs, aIIIIudes and vaIues. TeII Ihe cIass IhaI II Is essenIIaI Io undersIand Ihe reasons behInd a communIIy adopIIng a parIIcuIar behavIour whIch may proIecI II Irom or cause dIsease, In order Io eIIecIIveIy use heaIIh educaIIon Io encourage changes In behavIouraI paIIerns. Ask Ihe IraInees Io name a currenI heaIIh probIem In IheIr workpIace or communIIy and Ihen consIder, In a cIass dIscussIon, Ihe mosI suIIabIe educaIIonaI meIhods Io deaI wIIh IhIs probIem mosI eIIecIIveIy. 7.2 Case hisIory In n gn:: nnnunctung ncto) cncd X tIcc : n o\cu ccctct) gcncnto \IcI :uc: tIc ncto) \tI ccctct) n cn:c o nn]o o\c cut: o nccd o noc o\c :u). TIc tIcc ocnto: o tIc gcncnto Ind n cou:c n IcntI cducnton co\cng no:c Icnng o:: nnd no:c conto ncn:uc:. Iung \o :It: tIc) cgun) u:c cnnu: nnd :cIcduc tIc no:c cxo:uc tnc. AnotIc ncto) Y n:o In: n gcncnto o tIc :nnc :zc \IcI : u:cd o tIc :nnc uo:c:. ut tIc tIcc gcncnto ocnto: In\c not Ind n cou:c n IcntI cducnton nout no:c Icnng o:: nnd no:c conto ncn:uc:. TIc) do not u:c cnnu: cgun) no do tIc) :cIcduc tIc no:c cxo:uc tnc. Atc 5 )cn: tIc gou n ncto) Y In\c :tntcd In\ng Icnng ocn: nnd dccct:. 7.3 MeIhodology DIvIde Ihe cIass InIo smaII groups wIIh an eIecIed Ieader/reporIer. AcquaInI each group wIIh Ihe case hIsIory ouIIIned above. InsIrucI Ihe groups Io dIscuss Ihe IoIIowIng: Ihe behavIour oI boIh groups oI IacIory workers and IheIr hearIng probIems Ihe personaI behavIour In boIh sIIuaIIons Ihe IInk, II any, beIween Ihe behavIour oI each group and Ihe condIIIons In Ihe IacIory. 8. HEALTH EDUCATlON lN THE WORKPLACE 8.1 lirsI sIeps RemInd Ihe IraInees IhaI Ihe work envIronmenI can aIIecI workers' heaIIh Ihrough exposure Io chemIcaI, physIcaI, bIoIogIcaI and ergonomIc hazards. LxpIaIn IhaI a successIuI heaIIh educaIor: HenIth educnton n occuntonnI henIth: ModuIe 123 IaIks Io managers and workers and IIsIens careIuIIy Io IheIr probIems IhInks abouI aIIIIudes whIch can cause such probIems or soIve Ihem or proIecI Ihem dIscovers Ihe reasons Ior peopIe's behavIour and heaIIh probIems InvIIes workers Io gIve IheIr Ideas on soIvIng Ihe probIems In conjuncIIon wIIh Ihe workers, Iooks aI Ihese Ideas and decIdes whIch ones are beneIIcIaI, pracIIcaI and easy Io appIy encourages IacIory managers and workers Io seIecI Ideas approprIaIe Io IheIr cIrcumsIances. DIscuss Ihe IoIIowIng poInIs whIch are ImporIanI when esIabIIshIng a heaIIh educaIIon programme: esIabIIshIng good workIng reIaIIonshIps: how Io encourage cooperaIIon and parIIcIpaIIon heaIIh educaIIon pIannIng In PHC: InIormaIIon coIIecIIon, probIem IdenIIIIcaIIon and undersIandIng, prIorIIIzaIIon, objecIIves and procedures Io be IoIIowed, resource IdenIIIIcaIIon and mobIIIzaIIon, encouragIng proper acIIon and IoIIowup, seIecIIon oI suIIabIe heaIIh educaIIon meIhods, resuIIs evaIuaIIon and revIsIon oI pIannIng procedures IndIvIduaI heaIIh educaIIon: counseIIIng group heaIIh educaIIon communIIy heaIIh educaIIon Ihe ImporIance oI conveyIng Ihe educaIIonaI message aI Ihe rIghI IIme and pIace wIIh worker parIIcIpaIIon and good subjecI preparaIIon and Ihe need Io IesI II In smaII groups beIore generaI appIIcaIIon. TeII Ihe cIass abouI Ihe prIncIpIes on whIch PHC and heaIIh educaIIon In Ihe workpIace can be organIzed. LmphasIze IhaI Ihe aIms oI workers' educaIIon shouId be Io deveIop Ihe capacIIy Io consIrucI an operaIIonaI sysIem capabIe oI reducIng occupaIIonaI hazards. The eIIecIIveness oI such a sysIem shouId be assessed by deIermInIng Io whaI exIenI Ihe IncIdence oI heaIIh InjurIes, dIsease or dIsorders Is dImInIshed. LxpIaIn IhaI Io eIIecI IhIs a number oI sIeps shouId be Iaken: provIde Ihe necessary documenIaIIon make use oI Ihe workers' experIence deIIne prIorIIy hazards draw up Ihe crIIerIa Ior workpIace ImprovemenIs seI Ihe specIIIc objecIIves Io be achIeved IesI Ihe eIIecIIveness oI conIroI measures. InIroduce Ihe Idea IhaI heaIIh educaIIon saIeIy courses shouId be specIIIcaIIy desIgned and heId Ior Ioremen and group Ieaders. PerIodIc meeIIngs shouId be heId by Ihem wIIh IacIory managers, IacIory heaIIh personneI and saIeIy oIIIcers Io sIudy Ihe preparaIIon made Ior saIeIy campaIgns and Io consIder accIdenI sIaIIsIIcs, Ihe causes oI accIdenIs, rIsks Io heaIIh and how Io eIImInaIe Ihem. 124 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers RevIew Ihe brIeIIng IhaI workers shouId receIve when Ihey joIn Ihe workpIace, IncIudIng an InIormaIIon IeaIIeI InIormIng Ihem oI: InIernaI IraIIIc rouIes (II appIIcabIe) deIaIIed descrIpIIons oI Ihe work Ihey wIII be doIng and Ihe IooIs and raw maIerIaIs Ihey wIII be handIIng, as weII as IheIr dangers and Ihe precauIIons IhaI need Io be Iaken generaI saIeIy reguIaIIons specIaI saIeIy ruIes Ior dIIIerenI Iypes oI work IndIvIduaI and group saIeIy equIpmenI Ihe need Io caII Ior IIrsI aId aI once In Ihe evenI oI an accIdenI and where such heIp can be Iound a baIanced dIeI and saIe sanIIaIIon. ThIs InIormaIIon IeaIIeI shouId be revIewed Irom IIme Io IIme and commenIed on by Ihe shop IIoor. Any reIevanI IncIdenIs shouId be used by Ihe IraIner as a basIs Ior a saIeIy Iesson, reInIorcIng Ihe saIeIy and heaIIh InsIrucIIons. 8.2 Case hisIory TIcc nc 2 \oc: n n ccncnt ncto) n )ou d:tct. Iung tIc :unnc nontI: \oc: connn o nu:cc nn /cnn:), IcndncIc: nnd ntguc. In tIc n:t nontI o tIc :unnc, ou \oc: nc dngno:cd ) tIc d:tct I):cnn n: :ucng on Icnt cxInu:ton. 8.2 MeIhodology DIvIde Ihe cIass InIo smaII groups wIIh an eIecIed Ieader/reporIer. AcquaInI Ihe cIass wIIh Ihe case sIudy above. InsIrucI Ihe groups Io sIudy Ihe case hIsIory and pIan a heaIIh educaIIon programme Ior Ihe workers oI Ihe IacIory. RemInd Ihem Io menIIon aII Ihe necessary sIeps Ihey Iook In order Io ImpIemenI a successIuI programme. AIIer suIIIcIenI dIscussIon IIme, Ihe reporIers shouId provIde Ieedback Io Ihe group and generaI dIscussIon shouId IoIIow. 9. HEALTH EDUCATlON METHODS AND AlDS 9.1 lirsI sIeps LxpIaIn Ihe Iwo meIhods oI heaIIh educaIIon-dIrecI and IndIrecI-and dIscuss Ihe merIIs and drawbacks oI boIh. DIrecI meIhod: a person gIvIng InIormaIIon Io IndIvIduaIs or groups who are presenI In Ihe same pIace. IndIrecI meIhod: Ihe person conveyIng Ihe message Is remoIe Irom Ihose who are receIvIng II, e.g. IeIevIsIon, broadcasIIng, InIerneI magazInes, books. HenIth educnton n occuntonnI henIth: ModuIe 125 DIscuss Ihe InIeracIIve IeachIng sIraIegIes requIred In order Io aIIow InsIrucIIon, pracIIce, Ieedback and moIIvaIIon Io Iake pIace: presenIaIIon Iarge group dIscussIons smaII group dIscussIons roIe pIay case sIudIes IacI IIndIng projecI work quesIIons. DIscuss Ihe dIIIerenI aIds by whIch a heaIIh educaIIon message can be conveyed: VIsuaI aIds: boards or Iarge sheeIs oI paper or IIIpcharIs, phoIographs, posIers, pubIIcaIIons, newspapers, magazInes, IransparencIes used on an overhead projecIor, sIIdes and sIIde projecIors, reaI objecIs, modeIs. AudIo aIds: recorded Iapes. AudIovIsuaI aIds: vIdeo Iapes, cInema IIIms, roIe pIay, exhIbIIIons, dummIes. 9.2 Case hisIory TIc nn:t) o ngcutuc In: nn ngcutun :cIcnc n )ou d:tct ncn. TIc :cIcnc u:c: dccnt gou: o c:tcdc: n odc to conto n:cct: tInt nc Innu to tIc nnt:. TIc cIcncn: nc n:o u:cd ngnn:t c:t: :ucI n: nt:, d: ctc. In:t \cc tIc :n)ng tcnn:, con::tng o 15 \oc: c tcnn, :tntcd nn ognnoIo:Intc n:cctcdc nnt :n)ng cnnngn. TIc) \cc o\dcd \tI otcct\c cotIng ut :onc \oc: dd not \cn t. TIc) Ind cnn:t nnd uncI cn: dung tIc cou:c o tIc dn). WIcn tIc \o \n: conctc :onc o tIcn \cnt Ionc :t \cnng tIc cotIc: tIc) Ind \on \Ic :n)ng. T\o dn): ngo, ou o tIc:c \oc: cotcd to tIc nu:c o tIc ocn o]cct cnc \tI c:nto) ocn: nnd IcndncIc:. TIc o\:onn dngno:: \n: n:cctcdc ntoxcnton. TIcc \cc no nntdotc: to ognnoIo:Intc n:cctcdc n tIc cnc. TIc ncctcd \oc: \cc cccd to tIc d:tct Io:tn, 5 onctc: n\n), o utIc oo\-u nnd tcntncnt. 9.3 MeIhodology HoId a pracIIcaI cIass sessIon demonsIraIIng Ihe use oI IeachIng aIds. AIIernaIIveIy arrange a vIsII Io Ihe nearesI heaIIh educaIIon cenIre where Ihe IraInees can see Ihe educaIIonaI aIds In use. AcquaInI Ihe IraInees wIIh Ihe case sIudy above and dIvIde Ihem InIo Ihree groups wIIh a Ieader/reporIer. Ask each group Io deveIop a heaIIh educaIIon programme Ior IhIs sIIuaIIon. 12b OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers The IraInees musI use aI IeasI one aId (more II desIred) Irom each oI Ihe educaIIonaI aId caIegorIes: vIsuaI, audIo, audIovIsuaI. Ask Ihe IraInees Io consIder Ihe IoIIowIng: WhaI InIormaIIon are you conveyIng Ihrough Ihese aIds7 To whIch groups7 How are you pIannIng Io use Ihese aIds7 GIve Ihe groups suIIIcIenI IIme Io deveIop IheIr programmes and Io prepare IheIr aIds. Move beIween Ihe groups oIIerIng dIrecIIon and advIce. Ask Ihe groups Io presenI IheIr heaIIh educaIIon programmes usIng Ihe Ihree Iypes oI aIds as requIred. IoIIowIng IhIs, hoId a cIass dIscussIon on how weII each group arranged and presenIed Ihe requIred programme and how weII Ihey made use oI Ihe avaIIabIe educaIIonaI aIds. 10. COMMUNlCATlON SKlLLS lN HEALTH EDUCATlON 10.1 The communicaIion process LxpIaIn Io Ihe cIass IhaI when we wanI Io convey a heaIIh message Io a person or a group oI persons, we need a communIcaIIon process. When Ihe IargeI audIence undersIands Ihe message In Ihe way we wanI, Ihen Ihe communIcaIIon process has been successIuI. LducaIIon Is prImarIIy a maIIer oI communIcaIIon. The mosI ImporIanI communIcaIIon skIIIs are: esIabIIshIng good reIaIIonshIps wIIh peopIe speakIng cIearIy and makIng use oI reIevanI vocabuIary IIsIenIng aIIenIIveIy ensurIng IhaI Ihe message has been cIearIy undersIood and expIaInIng IurIher II necessary usIng nonverbaI communIcaIIon IooIs eIIIcIenIIy reIraInIng Irom bIas and prejudIce reIraInIng Irom dIrecI crIIIcIsm oI oIhers and hurIIuI commenIs maInIaInIng conIIdenIIaIIIy II necessary beIng IuIIy prepared when communIcaIIng Ihe message adjusIIng Ihe IeveI oI IeachIng Io suII Ihe recIpIenIs usIng suIIabIe educaIIonaI aIds IeadIng meeIIngs compeIenIIy. 10.2 MeIhodology WrIIe Iwo sIgns on Ihe bIackboard: "CorrecI" and "Wrong". Prepare cards, each namIng a Iype oI behavIour In communIcaIIon skIIIs, and perhaps a Iew words oI expIanaIIon (see IIsI beIow). Hand Ihe cards ouI randomIy Io Ihe IraInees. HenIth educnton n occuntonnI henIth: ModuIe 127 Ask Ihe IraInees Io pIace IheIr card on Ihe bIackboard under Ihe reIevanI sIgn. II Ihey are unsure Ihey can pass IheIr card on Io someone eIse. The IraInees are Iree Io dIsagree wIIh each oIher. IInaIIy, remove any cards whIch are cIearIy IncorrecIIy pIaced and hoId a generaI dIscussIon on Ihe dIIIerenI sIIuaIIons and Ihe correcI opIIons. 10.3 LisI ol communicaIion skills and behaviour 1. SpeakIng In a posIIIve manner when addressIng a Iarge group. 2. ShouIIng angrIIy aI an audIence. S. IaIIIng Io respond when asked a vaIId quesIIon abouI a work envIronmenI. 4. TakIng sIdes wIIh one or Iwo persons In a group even when Ihey are noI gIvIng suIIabIe answers. S. OpenIy crIIIcIzIng sIudenIs who gIve IncorrecI answers. 6. GIvIng correcI InIormaIIon In a IogIcaI caIm manner aIIer a sIudenI's IncorrecI answer. 7. DIscussIng openIy conIIdenIIaI maIIers made known Io Ihe IraIner durIng a personaI counseIIIng sessIon wIIh a sIudenI. 8. Thorough preparaIIon oI Iessons beIore Ihe cIass begIns. 9. UsIng unusuaI Ierms In a Iarmers' heaIIh educaIIon sessIon. 10. SpeakIng above Ihe educaIIonaI and comprehensIon IeveI oI Ihe IargeI group. 11. LIecIIng a weII InIormed sIudenI Io Iead a group dIscussIon. 12. UsIng roIepIay as a IooI Io educaIe IIIIIeraIe Iarmers on Ihe conIroI oI bIoIogIcaI work hazards. 11. TASKS lOR TRAlNEES 1. Show skIIIs In gIvIng heaIIh educaIIon Io workers In a workpIace. 2. Know Ihe Iypes oI occupaIIonaI dIseases and accIdenIs IhaI occur In your dIsIrIcI. S. Show skIIIs In desIgnIng posIers and preparaIIon oI handouIs Io workers. 4. Show skIIIs In group dIscussIons. S. Show good communIcaIIon skIIIs wIIh workers, managers and empIoyers. 6. Know how Io use and appIy suIIabIe aIds Ior use In heaIIh educaIIon programmes. 7. Know how Io gIve and dIscuss Ihe maIn poInIs Iound In work IegIsIaIIon wIIh regards Io work reIaIIons, occupaIIonaI dIseases and accIdenIs, rehabIIIIaIIon, compensaIIon, workpIace InspecIIon, eIc. MODULE 9 Epidemiology and biostatistics in occupational health 1. OB|ECTlVES UndersIand Ihe purpose and accepI Ihe ImporIance oI occupaIIonaI epIdemIoIogy and bIosIaIIsIIcs In dIscoverIng causes, measurIng rIsks and deIermInIng prIorIIIes In InIervenIIon and evaIuaIIon; SIaIe Ihe characIerIsIIcs oI epIdemIoIogy whIch dIsIInguIshes II Irom oIher perspecIIves; DIscuss Ihe appIIcaIIon oI bIosIaIIsIIcs In epIdemIoIogIcaI sIudIes; DescrIbe Ihe maIn Iypes oI sIudy desIgn used In occupaIIonaI epIdemIoIogy. 2. DEllNlTlONS OccupaIIonaI heaIIh may be consIdered Io be a componenI oI pubIIc heaIIh. LpIdemIoIogy and bIosIaIIsIIcs are key dIscIpIInes In pubIIc heaIIh. Whereas cIInIcaI medIcIne Iends Io be concerned wIIh Ihe InvesIIgaIIon and managemenI oI an IndIvIduaI paIIenI's probIem, popuIaIIonbased sIudIes are an InIegraI parI oI occupaIIonaI heaIIh pracIIce. Epidemiology: Ihe sIudy oI Ihe dIsIrIbuIIon and deIermInanIs oI heaIIhreIaIed sIaIes and evenIs In popuIaIIons and Ihe appIIcaIIon oI IhIs sIudy Io Ihe conIroI oI heaIIh probIems. 1 The IundamenIaI goaI oI Ihese InvesIIgaIIons Is Io obIaIn a vaIId and reasonabIy precIse esIImaIe oI exposure-dIsease assocIaIIon In groups. "As appIIed Io occupaIIonaI heaIIh, epIdemIoIogy Ihus has Ihe duaI Iask oI descrIbIng Ihe dIsIrIbuIIon oI deaIhs, accIdenIs, IIInesses and IheIr precursors . In Ihe workIorce . and oI searchIng Ior Ihe deIermInanIs oI heaIIh, Injury and dIsease In Ihe occupaIIonaI envIronmenI." 1 OccupaIional epidemiology: Ihe sIudy oI Ihe occurrence oI dIsease In reIaIIon Io workreIaIed deIermInanIs. II IoIIows IhaI, In revIewIng any IndIvIduaI wIIh a heaIIh reIaIed probIem or any workpIace wIIh a hazardous envIronmenI, Ihe InvesIIgaIor musI ask Ihe IoIIowIng quesIIons: Who Is aI rIsk7 Where7 1 Idcnoog) o \o-cntcd d:cn:c: nnd nccdcnt:. TcntI cot o tIc ]ont IIO,WHO Connttcc on Occuntonn HcntI. Geneva, WorId HeaIIh OrganIzaIIon, 1989 (WHO TechnIcaI ReporI SerIes No.777). 13U OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers When7 How7 BiosIaIisIics: Ihe dIscIpIIne oI sIaIIsIIcs concerned wIIh Ihe descrIpIIon, summarIzaIIon and InIerpreIaIIon oI daIa as weII as Ihe deveIopmenI oI procedures Io accompIIsh Ihese objecIIves. OccupaIional biosIaIisIics: an ImporIanI IooI In Ihe quanIIIaIIve sIudy oI morbIdIIy and morIaIIIy In humans, reIaIIve Io exposure In Ihe workpIace. Random sample: a sampIe oI sIze n seIecIed Irom a Iarger popuIaIIon Is random II each IndIvIduaI wIIhIn Ihe popuIaIIon has equaI probabIIIIy oI beIng seIecIed. When a sampIe Is noI random, Ihe occurrence oI Ihe characIerIsIIc beIng InvesIIgaIed may be reIaIed Io Ihe IIkeIIhood IhaI an IndIvIduaI was seIecIed Ior Ihe sampIe. ThereIore, II Is necessary Io assess bIas and seIecIIon IacIors careIuIIy beIore generaIIzIng Irom Ihe resuIIs oI a sIudy based on nonrandom sampIes. AriIhmeIic mean: usuaIIy denoIed as x - , Ihe arIIhmeIIc mean Is a measure oI Ihe cenIraI Iendency oI Ihe daIa. II Is gIven by Ihe IormuIa: n x x x x n + + + = ... 2 1 II Ihe sampIe Is randomIy seIecIed Irom a Iarge popuIaIIon, x - esIImaIes a popuIaIIon mean usuaIIy desIgnaIed as . The arIIhmeIIc mean Is sIrongIy aIIecIed by exIreme vaIues In Ihe daIa. II a varIabIe has a IaIrIy symmeIrIc dIsIrIbuIIon, Ihe mean Is used as Ihe approprIaIe measure oI cenIraI Iendency. Median: Ihe "mIddIe" observaIIon, or S0Ih percenIIIe, I.e. haII oI Ihe observaIIons IIe above Ihe medIan and haII beIow. Mode: Ihe mosI IrequenIIy occurrIng observaIIon. II Is rareIy used excepI when Ihere are a IImIIed number oI possIbIe ouIcomes. SIandard deviaIion: usuaIIy denoIed as 5, Ihe sIandard devIaIIon Is a measure oI Ihe "spread" oI Ihe daIa abouI x. II Is gIven by Ihe IormuIa: 1 ) ( 2
n x x
The square oI Ihe sIandard devIaIIon, :
2 , Is Ihe varIance. II Ihe sampIe Is randomIy seIecIed Irom a Iarger popuIaIIon, : and : 2 esIImaIe Ihe popuIaIIon parameIers and 2 . Bias or sysIemaIic error: usuaIIy a resuII oI IIaws In Ihe sIudy desIgn or daIa coIIecIIon. Conlounding: Ihe eIIecI oI an exIraneous varIabIe IhaI may parIIaIIy or compIeIeIy accounI Ior an apparenI assocIaIIon beIween a sIudy exposure and dIsease. denoIogy nnd bostntstcs n occuntonnI henIth: ModuIe 9 131 3. BlOSTATlSTlCAL DATA 3.1 Types ol daIa DaIa coIIecIed In medIcaI research can be dIvIded InIo Ihree Iypes: nomInaI (caIegorIcaI), ordInaI and InIervaI (conIInuous). Nominal (caIegorical) daIa: daIa IhaI can be dIvIded InIo Iwo or more unordered caIegorIes, e.g. sex, race, reIIgIon. In occupaIIonaI heaIIh, many ouIcome measures such as cancer raIes are consIdered separaIeIy Ior dIIIerenI sex and race caIegorIes. Ordinal daIa: one sIep up Irom nomInaI daIa, Ihe dIIIerence beIng a predeIermIned orderIng underIyIng Ihe caIegorIes. LxampIes oI ordInaI daIa are cIInIcaI severIIy, socIoeconomIc sIaIus and ILO proIusIon caIegory Ior pneumoconIosIs on chesI Xray. BoIh nomInaI and ordInaI daIa are exampIes oI dIscreIe daIa. lnIerval daIa: AIso caIIed conIInuous daIa, InIervaI daIa are measured on an arIIhmeIIc scaIe. LxampIes IncIude heIghI, weIghI, bIood Iead and Iorced expIraIory voIume. The accuracy oI Ihe number recorded depends on Ihe measurIng InsIrumenI and Ihe varIabIe can Iake on an InIInIIe number oI vaIues wIIhIn a deIIned range. 3.2 Sample size The number oI subjecIs needed Io assess Ihe poIenIIaI exposure-dIsease reIaIIonshIp Is a IundamenIaI Issue when pIannIng a sIudy. The Iarger Ihe sampIe sIze, Ihe greaIer Ihe power Io deIecI a specIIIed dIIIerence In magnIIude beIween an exposure and a dIsease when II exIsIs. 3.3 Chance variaIion ThIs reIers Io Ihe naIuraI varIaIIon In heaIIh ouIcomes observed among sImIIarIy exposed IndIvIduaIs. Two sIaIIsIIcaI IooIs used Ior assessIng Ihe roIe oI chance are Ihe I vaIue and Ihe conIIdence InIervaI. The I vaIue Is Ihe probabIIIIy oI obIaInIng by chance aIone a dIIIerence In dIsease raIes beIween Ihe exposed and unexposed as Iarge as or more exIreme Ihan whaI was observed. A I vaIue oI 0.00S means IhaI Ihe probabIIIIy oI obIaInIng by chance aIone an exposure eIIecI as Iarge as or more exIreme Ihan whaI was observed Is onIy S per 1000. SmaII I vaIues (beIow 0.0S) are someIImes reIerred Io as sIaIIsIIcaIIy sIgnIIIcanI. The conIIdence InIervaI (CI) gIves Ihe pIausIbIe vaIues Ior Ihe acIuaI eIIecI oI exposure wIIh a desIred degree oI conIIdence, e.g. Ihe 9S conIIdence InIervaI Ior Ihe rIsk assocIaIed wIIh an occupaIIonaI exposure Is an InIervaI In whIch Ihe Irue reIaIIve rIsk wIII be IncIuded 9S oI Ihe IIme. A 9S conIIdence InIervaI IhaI IncIudes 1.0 ImpIIes IhaI a vaIue oI 1.0 Ior Ihe reIaIIve rIsk Is pIausIbIe and Ihus Ihe nuII hypoIhesIs oI no exposure eIIecI Is consIsIenI wIIh Ihe daIa. 132 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 3.4 2 2 Iable The sImpIesI sIaIIsIIcaI IechnIque, Ihe 2 2 IabIe, Is useIuI when occupaIIonaIIy exposed and unexposed IndIvIduaIs are IoIIowed Ior equaI amounIs oI IIme Ior dIsease IncIdence. 4. TYPES Ol EPlDEMlOLOGlCAL STUDY LpIdemIoIogIcaI sIudIes measure Ihe rIsk oI dIsease dIrecIIy In human popuIaIIons. There Is no need Io reIy on quesIIonabIe exIrapoIaIIons across anImaI specIes Io esIImaIe Ihe ImpacI oI an exposure In humans. II Is possIbIe In epIdemIoIogy Io examIne Ihe consequences oI an occupaIIonaI and envIronmenIaI exposure In Ihe manner In whIch II acIuaIIy occurs In humans, noI Ihe arIIIIcIaI manner In whIch IaboraIory sIudIes oI anImaIs are done. The Issue oI dose, rouIe oI exposure, concomIIanI exposures and hosI IacIors are aIso dIrecIIy assessed. In essence Ihere are Ihree Iypes oI epIdemIoIogIcaI sIudy aIIhough, In pracIIce, Ihe IhIrd Is underIaken rareIy, Ior eIhIcaI reasons. DescripIive sIudies: Ihese descrIbe evenIs based on observaIIon and shouId Iead Io Ihe deveIopmenI oI causaI hypoIheses, whIch can be IesIed. AnalyIical sIudies: Ihese InvoIve Ihe IesIIng oI hypoIheses. II a hypoIhesIs seems Io be supporIed, aIIempIs shouId be made Io reIuIe II In IurIher sIudIes and/or Io underIake InIervenIIon sIudIes. lnIervenIion sIudies: Ihese are underIaken Io see wheIher an aIIeraIIon oI exposure produces a change In Ihe heaIIh ouIcome oI Ihe exposed popuIaIIon. The cohorI sIudy Is Ihe mosI common Iype oI sIudy In occupaIIonaI epIdemIoIogy. InIormaIIon on a IacIor (or IacIors) Is coIIecIed In a deIIned popuIaIIon IhaI Is IoIIowed over IIme Ior Ihe occurrence oI a dIsease (or dIseases). The dIsease raIe among Ihose exposed Is compared Io Ihe raIe among Ihe nonexposed Io assess II Ihere Is an assocIaIIon beIween Ihe sIudy IacIor and dIsease. ThIs sIudy Iakes a Iong IIme Io compIeIe as InvesIIgaIors have Io waII someIImes years beIore acquIrIng enough cases oI dIsease (or deaIh). A reIrospecIIve cohorI sIudy may be used Io eIImInaIe IhIs Iong IoIIowup perIod. PasI records oI IndIvIduaIs are used Io characIerIze Ihe exposure sIaIus oI Ihe sIudy objecIs and Ihe dIsease sIaIus Is deIermIned unIII a parIIcuIar daIe. The major meIhodoIogIcaI advanIage oI Ihe cohorI sIudy Is IhaI InIormaIIon on exposure Is recorded beIore Ihe deveIopmenI oI dIsease. ThIs eIImInaIes recaII bIas. The case-conIrol sIudy examInes Iwo groups. One group consIsIs oI peopIe wIIh a parIIcuIar dIsease and Ihe oIher consIsIs oI Ihose Irom Ihe source popuIaIIon or sIudy base wIIhouI Ihe dIsease. InIormaIIon regardIng pasI exposures and habIIs Is obIaIned Irom each person In Ihe Iwo groups. II Ihe exposure oI InIeresI Is reporIed by a Iarger proporIIon oI cases Ihan conIroIs, an assocIaIIon beIween Ihe exposure and dIsease can be saId Io exIsI. Case-conIroI sIudIes are more eIIIcIenI and suIIabIe Ior Ihe sIudy oI rare dIseases and dIseases wIIh Iong IaIency perIods. In Ihe cross-secIional sIudy peopIe are seIecIed regardIess oI exposure or dIsease sIaIus. ThIs sIudy desIgn Is oIIen caIIed a survey or prevaIence sIudy. denoIogy nnd bostntstcs n occuntonnI henIth: ModuIe 9 133 5. COMMON MEASURES Ol DlSEASE lREQUENCY 5.1 lnIroducIion The number oI IndIvIduaIs wIIh a dIagnosed dIsease or wIIh abnormaI IesI resuIIs, In generaI, cannoI be InIerpreIed wIIhouI some addIIIonaI InIormaIIon. An excepIIon Io IhIs ruIe Is Ihe occurrence oI a dIsease IhaI Is so rare IhaI any case Is unusuaI, e.g. Ihree cases oI hepaIIc angIosarcoma dIagnosed among abouI 270 workers durIng a Ihreeyear perIod were suIIIcIenI Io make a pIanI physIcIan suspecI IhaI Ihe vInyI chIorIde Ihey were exposed Io was a carcInogen. 5.2 Crude raIes A raIe Is Ihe Irequency oI a dIsease per unII sIze oI Ihe group (or popuIaIIon) beIng sIudIed. PoinI prevalence raIe: Ihe sImpIesI raIe based on Ihe number oI cases presenI aI one poInI In IIme. PrevaIence raIe = Ihe number oI cases presenI aI a gIven poInI In IIme Ihe IoIaI popuIaIIon aI rIsk aI IhaI gIven poInI In IIme ThIs raIe can be compared wIIh a generaI popuIaIIon raIe or raIe Irom an approprIaIe conIroI group Io deIermIne II II Is excessIve. A IImIIaIIon oI prevaIence raIe aIone, however, Is IhaI II counIs aII cases oI Ihe dIsease wIIhouI dIIIerenIIaIIng beIween oId and new cases. lncidence raIe: a raIe IhaI removes Ihe background cases and Iocuses more cIearIy on new or recenI evenIs. II Is based on Ihe number oI new cases occurrIng over a specIIIed perIod oI IIme. IncIdence raIe = Ihe number oI new cases oI dIsease durIng a gIven perIod oI IIme Ihe IoIaI popuIaIIon aI rIsk durIng IhaI IIme Person-years: When Ihe IncIdence raIe Is InIended Io measure dIsease onseI occurrIng In Ihe group aI rIsk over Ihe course more Ihan 1 year Ihe approprIaIe denomInaIor Is person-years. ThIs vaIue sImuIIaneousIy Iakes InIo consIderaIIon Ihe number oI IndIvIduaIs and Ihe IIme perIod over whIch Ihey were observed and consIdered aI rIsk oI deveIopIng Ihe dIsease. II IhereIore permIIs Ihe IncIusIon oI IndIvIduaIs who were noI aI rIsk Ior Ihe whoIe IIme perIod. ThIs Is parIIcuIarIy ImporIanI when new empIoyees or IermInaIIons oI conIracI are counIed or when rIsk In a specIIIc IIme perIod Is evaIuaIed. 5.3 Specilic raIes In some InsIances, a crude or adjusIed raIe Ior Ihe enIIre popuIaIIon may obscure an ImporIanI assocIaIIon. When opposIIe Irends exIsI In dIIIerenI parIs oI Ihe age specIrum, Ihese Irends may oIIseI each oIher and be masked by a summary raIe. 134 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 5.4 Comparison ol raIes IndependenI oI wheIher raIes are represenIed by homogeneous subgroups or adjusIed Ior approprIaIe varIabIes In Ihe enIIre group, Ihe raIes musI be IransIaIed InIo rIsks Io evaIuaIe Ihe eIIecIs oI exposure. The Iwo major Iypes oI rIsk esIImaIes based on comparIsons oI raIes are Ihe raIIo oI raIes (reIaIIve rIsk) and Ihe dIIIerence beIween raIes (aIIrIbuIabIe rIsk). The relaIive risk, or raIe raIIo, Is desIgned Io communIcaIe Ihe reIaIIve ImporIance oI an exposure by comparIng raIes Irom an exposed popuIaIIon Io an unexposed or normaI popuIaIIon. In IIs sImpIesI Iorm, II Is Ihe raIIo oI Iwo raIes. The aIIribuIable risk, or rIsk dIIIerence, Is desIgned Io communIcaIe Ihe amounI oI dIsease IhaI can be aIIrIbuIed Io Ihe exposure under sIudy. ThIs concepI Is parIIcuIarIy useIuI and necessary In occupaIIonaI dIsease sIudIes because Iew dIseases can be aIIrIbuIed soIeIy Io an occupaIIonaI exposure. The aIIrIbuIabIe rIsk Is caIcuIaIed by subIracIIng Ihe raIe oI parIIcuIar dIsease In Ihe normaI or unexposed popuIaIIon Irom IhaI In Ihe exposed popuIaIIon. 6. TASKS lOR TRAlNEES 6.1 QuesIion 1 The daIa In Ihe IabIe beIow show Ihe dIsIrIbuIIon oI days absenI Irom work among workers In Iour seIecIed IndusIrIes. CaIcuIaIe Ihe mean, medIan and mode duraIIon oI absence In each IndusIry. CommenI on Ihe dIIIerence beIween IndusIrIes. Ferod o] nbsence (dnys) U 1 2 3 4 5 b 7 9 1U TotnI Industry A - - T6 TT3 36 5 4 2 T - T T78 - T T 2 2 - 27 - - - - 33 C - - T2 33 20 28 35 7 T 4 6 T46 D - 97 6 2 6 28 TT 27 2 T 4 T84 6.2 QuesIion 2 A survey oI IemaIe IexIIIe workers showed IhaI 8 had bacIerIa In IheIr urIne. IormuIaIe Ihe sIudy quesIIon. SpecIIy addIIIonaI InIormaIIon you need Io deIermIne II a heaIIh probIem exIsIs. IdenIIIy wheIher or noI Ihe sIudy quesIIons are epIdemIoIogIcaI Issues. denoIogy nnd bostntstcs n occuntonnI henIth: ModuIe 9 135 6.3 Answer Io quesIion 1 6.4 Answer Io quesIion 2 WhaI Is Ihe prevaIence raIe oI bacIerIurIa In IemaIe IexIIIe workers7 The expecIed prevaIence raIe Ior a comparabIe group oI women Is needed. II Is an epIdemIoIogIcaI probIem. Industry Menn Mednn Mode A 3.35 3 3 5.42 6 6 C 4.84 5 6 D 3.26 T T MODULE 10 Record keeping 1. OB|ECTlVES Be aware oI Ihe ImporIance oI record keepIng and reporIIng In occupaIIonaI heaIIh; Keep records on workers' heaIIh and reporI Ihe resuIIs oI InvesIIgaIIons as requIred; Be acquaInIed wIIh Ihe codIng sysIems used In record keepIng. 2. PURPOSE AND TYPES Ol RECORD 2.1 Purpose No maIIer how smaII an occupaIIonaI heaIIh servIce Is, record keepIng Is a necessary parI oI IIs acIIvIIIes. Records are never an end In IhemseIves; Ihey are IooIs IhaI IIII a need. In an occupaIIonaI heaIIh servIce, records are used Ior: documenIaIIon oI an empIoyee's exposure Io hazards empIoyee heaIIh daIa Ior job pIacemenI documenIaIIon oI empIoyee heaIIh overIIme provIsIon oI empIoyee heaIIh overIIme IuIIIImenI oI reguIaIory requIremenIs. 2.2 Types There are seven Iypes oI basIc record on workers' heaIIh. The keepIng oI some oI Ihese records may be requIred by Iaw In some counIrIes. PHC workers musI be IoId Ihe sIaIuIory requIremenIs wIIh respecI Io keepIng records on workers' heaIIh. HcntI nnd :nct) n:ccton These records musI conIaIn Ihe daIe, Ihe person carryIng ouI Ihe InspecIIon and Ihe IIndIngs oI Ihe InspecIIon. In desIgnIng Ihe InspecIIon record Iorm, II Is advIsabIe Io consuII wIIh Ihe dIsIrIcI heaIIh cenIre as II may be InIeresIed In producIng a Iorm Ior aII workpIaces In Ihe area. In\onncntn nontong ThIs Is onIy appIIcabIe Io pIaces whIch requIre envIronmenIaI monIIorIng on a rouIIne basIs. The scheme oI monIIorIng Is devIsed by eIIher Ihe occupaIIonaI heaIIh and saIeIy commIIIee In Ihe workpIace or by Ihe dIsIrIcI heaIIh cenIre. ThIs IncIudes 13 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers Ihe Iorm Ior keepIng records. The PHC workers are IraIned Io Iake readIngs wIIh sImpIe InsIrumenIs and record Ihem sysIemaIIcaIIy. The records are handed over perIodIcaIIy Io experIs Ior InIerpreIaIIon. HcntI nontong ThIs Is onIy appIIcabIe Io cerIaIn groups oI workers In some workpIaces. The PHC workers are IraIned eIIher Io coIIecI specImens perIodIcaIIy and send Ihem Io Ihe desIgnaIed IaboraIorIes Ior anaIysIs, or Io arrange Ior Ihe workers Io have IheIr specImens Iaken and examInaIIons done perIodIcaIIy In desIgnaIed IaboraIorIes. The PHC workers are responsIbIe Ior keepIng Ihe records suppIIed by Ihe desIgnaIed IaboraIorIes sysIemaIIcaIIy and Ior submIIIIng Ihem Io Ihe occupaIIonaI heaIIh and saIeIy commIIIee In Ihe workpIace or Ihe dIsIrIcI heaIIh cenIre Ior InIormaIIon and any acIIon whIch may be requIred. I:t nd o\dcd n tIc \oncc IIrsI aId IreaImenI records are oIIen kepI aI Ihe IIrsI aId sIaIIon aI each work sIIe raIher Ihan aI a cenIraI occupaIIonaI heaIIh cIInIc In a pIanI or In Ihe dIsIrIcI PHC cenIre. ThIs permIIs accIdenIaI InjurIes Io be recorded aI Ihe work sIIes where Ihey occur, eIImInaIIng Ihe need Ior an empIoyee wIIh a IrIvIaI Injury Io Ieave work and go Io Ihe cIInIc sImpIy Io record Ihe occurrence. The occupaIIonaI heaIIh cIInIc/ dIsIrIcI PHC cenIre shouId receIve and keep copIes oI Ihese records and a record oI aII IIrsI aId IreaImenI whIch II has IIseII provIded. ThIs record Is caIIed Ihe acuIe care regIsIer. IIrsI aId records are someIImes mandaIed by governmenI reguIaIIon and are aIways ImporIanI Io Ihe assessmenI oI compensaIIon cIaIms. They aIso provIde daIa vIIaI Io Ihe assessmenI oI Ihe accIdenI prevenIIon programmes. Accdcnt n\c:tgnton: There are Ihree reasons why companIes need Io record and InvesIIgaIe occupaIIonaI accIdenIs: Io IdenIIIy Ihe reaI causes oI Injury and IIIness, properIy damage and near mIsses (accIdenIs IhaI mIghI have happened) Io deveIop eIIecIIve meIhods oI prevenIIng IuIure sImIIar accIdenIs Io meeI IegIsIaIIve requIremenIs. ThIs Is usuaIIy done by an experI on Ihe occupaIIonaI heaIIh and saIeIy commIIIee In Ihe workpIace or a Iabour InspecIor. These records musI be kepI sysIemaIIcaIIy. The PHC workers musI read Ihe records IhoroughIy so IhaI Ihe knowIedge on Ihe IIndIngs can be appIIed. 5cnc:: cctcnton ThIs recordIng Is usuaIIy done by medIcaI pracIIIIoners and kepI by Ihe managemenI. The PHC workers musI be suppIIed wIIh absIracIs oI Ihese records on a perIodIc basIs. ThIs wIII enabIe Ihe PHC workers Io reIaIe any common sIcknesses among workers Io Ihe IIndIngs oI Ihe heaIIh and saIeIy InspecIIon and Ihe heaIIh educaIIon programme. Record keeng: ModuIe 1U 139 Ic:onn IcntI ccod: ThIs seI oI records concerns Ihe heaIIh sIaIus oI each IndIvIduaI worker. II InevIIabIy conIaIns personaI, prIvIIeged InIormaIIon whIch has specIaI sIgnIIIcance In Iaw. PersonaI heaIIh records shouId be kepI In IheIr orIgInaI handwrIIIen Iorm even II Iyped or compuIerIzed versIons aIso exIsI. A worker's personaI heaIIh record shouId onIy reIIecI hIs/her heaIIh sIaIus InsoIar as II appIIes Io Ihe job. The conIenI may IhereIore vary a greaI deaI. The InIormaIIon whIch Is usuaIIy Iound In Ihe record IncIudes: resuIIs oI physIcaI examInaIIons Xray and IaboraIory reporIs IncIudIng LCG puImonary IuncIIon resuIIs and audIograms ImmunIzaIIons occupaIIonaI and medIcaI hIsIory parIIcIpaIIon In heaIIh programmes workers' compensaIIon and medIcaI Insurance InIormed consenI Iorms and auIhorIzaIIons Ior reIease oI InIormaIIon documenIaIIon oI reIusaIs Io undergo examInaIIon, IesIIng and programme parIIcIpaIIon progress noIes Ior rehabIIIIaIIon consuIIanI reporIs. 3. RECORD KEEPlNG The besI way Io keep records Is Ihe sImpIesI manner consIsIenI wIIh convenIenI, economIcaI and eIIIcIenI buI conIroIIed access. DedIcaIed Iorms are parIIcuIarIy useIuI buI a IrIaI In use shouId aIways be carrIed ouI beIore Ihey are InIroduced InIo IuII servIce. II codIng sysIems are used Ihey shouId be compaIIbIe wIIh exIsIIng, wIdeIy recognIzed sysIems, e.g. codIng oI IIIness and Injury shouId be In accordance wIIh Ihe InIernaIIonaI SIaIIsIIcaI CIassIIIcaIIon oI DIseases and ReIaIed HeaIIh ProbIems oI Ihe WorId HeaIIh OrganIzaIIon. II Is recommended (In some counIrIes II Is mandaIed by Iaw) IhaI records be reIaIned Ior aI IeasI S0 years. ThIs Is In Ihe evenI oI subsequenI heaIIh probIems beIng IdenIIIIed. These records musI be IransIerred Io a responsIbIe recIpIenI or a governmenI agency II Ihe empIoyer, cIInIc or dIsIrIcI cenIre goes ouI oI busIness. CompuIer sIorage permIIs auIomaIIc and very rapId reIrIevaI oI daIa In any combInaIIon and desIred sequence. ThIs Is InvaIuabIe noI onIy Ior worker heaIIh evaIuaIIon buI Ior heaIIh programme operaIIons and audII. When consIderIng Ihe possIbIIIIy oI recordIng specIIIc InIormaIIon or ceasIng Io record II, Ihe IoIIowIng quesIIons shouId be asked: 14U OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers Is IhIs InIormaIIon requIred by reguIaIIon7 WIII IhIs InIormaIIon be used7 WIII IIs use jusIIIy Ihe cosI oI maInIaInIng II7 Can Ihe InIormaIIon be obIaIned easIIy and wIIh accuracy7 WIII Ihe process oI obIaInIng Ihe InIormaIIon conIravene or compromIse IegIsIaIed human rIghIs7 Are secure IacIIIIIes avaIIabIe Io sIore Ihe record Ior Ihe requIred reIenIIon perIod7 In generaI, a good occupaIIonaI heaIIh record aIIows a reader Io pIece IogeIher a cIear and coherenI pIcIure oI workers' exposure on Ihe job, heaIIh sIaIus, IreaImenIs and job assIgnmenIs Ior a perIod oI aI IeasI S0 years. Many assocIaIIons beIween chronIc dIsease and occupaIIonaI exposures have been made usIng such records, and Ihey are aIways ImporIanI IegaI documenIs. 4. TASKS lOR TRAlNEES 1. VIsII Ihe medIcaI poInI aI Ihe workpIace: check Ihe records avaIIabIe and evaIuaIe Ihe quaIIIy oI Ihe recordIng. 2. IamIIIarIze yourseII wIIh Ihe Iorms used by Ihe dIsIrIcI heaIIh care cenIre Io coIIecI InIormaIIon on workers' heaIIh. S. RevIew Ihe naIIonaI reguIaIIons regardIng Ihe recordIng sysIem oI occupaIIonaI accIdenIs and IIInesses. 4. DesIgn a Iorm Ior coIIecIIng InIormaIIon Ior each Iype oI proposed record In Ihe moduIe. S. IamIIIarIze yourseII wIIh Ihe soIIware used Ior recordIng occupaIIonaI accIdenIs and IIInesses. 6. IamIIIarIze yourseII wIIh Ihe InIernaIIonaI SIaIIsIIcaI CIassIIIcaIIon oI DIseases and ReIaIed HeaIIh ProbIems oI Ihe WorId HeaIIh OrganIzaIIon. MODULE 11 Occupational health in special areas 1. MlNlNG 1.1 ObjecIives Be aware oI and be abIe Io descrIbe Ihe specIaI probIems oI mInes: physIcaIIy, chemIcaIIy, bIoIogIcaIIy and socIaIIy Learn how Io seI prIorIIIes In order Io rank workreIaIed acIIons and acIIons reIaIed Io sanIIary servIces Be IamIIIar wIIh IypIcaI sIIuaIIons and IheIr probIems: specIIIcaIIy, overIoadIng, unheaIIhy condIIIons and dusI exposure Learn where and Io whom Io reIer Ior envIronmenIaI monIIorIng consuIIaIIons Have IIrsIaId knowIedge Know Ihe heaIIh sysIem, socIaI weIIare and heaIIh IegIsIaIIon Learn Io use approprIaIe IIIeraIure, checkIIsIs and daIa sheeIs IInd ways Io promoIe Ihe heaIIh oI Ihe worker, Io creaIe awareness and Io Improve Ihe workIng envIronmenI Learn accIdenI reporIIng, accIdenI InvesIIgaIIon and sImpIe accIdenI prevenIIon. 1.2 lnIroducIion MIneraIs and mIneraI producIs are Ihe backbone oI mosI IndusIrIes. Ior many counIrIes mInIng accounIs Ior a sIgnIIIcanI proporIIon oI Ihe gross domesIIc producI and Ior Ihe buIk oI IoreIgn exchange earnIngs and IoreIgn InvesImenI. MIneworkers Iace a consIanIIy changIng combInaIIon oI workpIace cIrcumsIances, boIh daIIy and IhroughouI Ihe work shIII. Some work In an aImosphere IhaI Is wIIhouI naIuraI IIghI or venIIIaIIon. DespIIe Ihe consIderabIe eIIorIs In many deveIopIng counIrIes, Ihe IoII oI deaIh, Injury and dIsease among mIneworkers means IhaI, In mosI counIrIes, mInIng remaIns Ihe mosI hazardous occupaIIon when Ihe number oI peopIe exposed Io rIsk Is Iaken InIo accounI. 142 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 1.3 RecogniIion, evaluaIion and simple conIrol ol harmlul lacIors in mines II):cn Inznd: (a) NoIse deIInIIIon eIIecI on humans, e.g. deaIness, hearIng Ioss and psychoIogIcaI InconvenIence prevenIIon and conIroI measures, e.g. InsIrumenI InspecIIon, encIosIng oI source oI noIse, acousIIc barrIers Ior noIsy IooIs and ear proIecIIon devIces. (b) VIbraIIon deIInIIIon and exampIes oI vIbraIIng InsIrumenIs Iypes oI vIbraIIon: nuIsance, segmenIaI and whoIe body vIbraIIon, hand-arm vIbraIIon syndrome basIs oI prevenIIon and conIroI measures: repaIrIng, ImprovIng or changIng IooIs and machInery, use oI personaI proIecIIve devIces and deIermInIng oI work and resI IIme. (c) HeaI and humIdIIy deIInIIIon and heaI sources eIIecIs on humans: IaIIgue, heaI rashes, heaI exhausIIon, heaI cramps prevenIIon and conIroI measures: use oI cooI and saIIy IIquIds, deIermInIng oI work and resI IIme. (d) HarmIuI radIaIIon deIInIIIon oI IonIzIng radIaIIon nonIonIzIng radIaIIon eIIecIs on human organs, eyes and skIn prevenIIon and conIroI measures: suIIabIe cIoIhIng, personaI proIecIIve equIpmenI monIIorIng oI exIernaI radIaIIon by IIIm dosImeIers. CIcncn Inznd: deIInIIIon and characIerIsIIcs oI dusIs, Iumes and gases dusIs whIch cause pneumoconIosIs, sIIIcosIs, sIIIcoIubercuIosIs chemIcaIs whIch may mIx wIIh oxygen Io cause expIosIon hazards oI smokIng among mIners Ihe eIIecIs oI carbon dIoxIde, meIhane and hydrogen suIIIde on heaIIh (carbon monoxIde, nIIrogen oxIdes) OccuntonnI henIth n secnI nrens: ModuIe 11 143 dIeseI exhausI gases: nIIrogen oxIdes, IIne parIIcuIaIes, suIIur oxIdes, poIycycIIc aromaIIc hydrocarbons prevenIIon and conIroI measures: weI processes, Iess dusI producIIon, personaI proIecIIve equIpmenI deIermInIng oI work and resI IImes adequaIe venIIIaIIon Ior mIners IdenIIIIcaIIon and monIIorIng oI Ihe conIamInanIs by deIecIIon Iubes bIoIogIcaI hazards, occupaIIonaI InIecIIons, IubercuIosIs. Accdcnt: causes oI accIdenIs In mInes, e.g. IIre, expIosIon unsaIe mechanIcaI and physIcaI condIIIons unsaIe acIs unsaIe personaI IacIors rIsk assessmenI and appraIsIng saIeIy perIormance prIncIpIes oI accIdenI prevenIIon. Igononc: bIomechanIcaI background physIoIogIcaI background posIure (sIIIIng, sIandIng) change oI posIure hand and arm posIures movemenIs IIIIIng, carryIng, puIIIng, pushIng psychosocIaI (urbanIzaIIon oI ruraI areas, nIghI shIII, conIInuous work). HcntI nctc: n nnc: hygIenIc IavaIory baIh resIauranI dressIngroom saIe drInkIng waIer wasIe and sewage managemenI. 144 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers HcntI :u\cnncc preempIoymenI examInaIIon, perIodIc examInaIIon IesIs Ior assessmenI oI heaIIh ImpaIrmenI, e.g. Iorced vIIaI capacIIy, Iorced expIraIory voIume, peak expIraIory IIow raIe, bIood pressure, body IemperaIure, puIse raIe, weIghI and heIghI measuremenI. 1.4 Tasks lor Irainees 1. VIsII Ihe workpIace, coIIecI daIa abouI Ihe workers, Ihe work and work envIronmenI. 2. SeI prIorIIIes based on observaIIons, measuremenIs, dIscussIons, eIc. S. OIIer advIce on some sImpIe prevenIIon and conIroI measures. 4. ReIer probIems Io Ihe reIerraI sysIem whIch cannoI be soIved by Ihe communIIy heaIIh care workers. S. LducaIe workers on heaIIh and saIeIy. 6. AppIy IIrsI aId. 2. SMALL-SCALE lNDUSTRY 2.1 ObjecIives Be aware oI aII heaIIh and saIeIyreIaIed hazards; Iearn how Io deIIne probIems and specIaI needs DescrIbe Ihe physIcaI hazards and IheIr conIroI (see 1.S) Learn how Io seI prIorIIIes In order Io rank acIIons IamIIIarIze yourseII wIIh Ihe IypIcaI probIems assocIaIed wIIh smaIIscaIe IndusIry, e.g. Iong workIng hours, absence oI hoIIdays, Iack oI medIcaI care and socIaI Insurance Know Ihe heaIIh sysIem, socIaI weIIare and IegIsIaIIon Have IIrsI aId knowIedge Learn how Io use approprIaIe IIIeraIure, checkIIsIs and daIa sheeIs IInd ways Io promoIe Ihe heaIIh oI Ihe worker, Io creaIe awareness and Io Improve Ihe workIng envIronmenI. 2.2 DeliniIion There Is no InIernaIIonaIIy agreed deIInIIIon oI a smaIIscaIe IndusIry. VarIous parameIers can be used Io deIIne II, e.g. number oI empIoyees OccuntonnI henIth n secnI nrens: ModuIe 11 145 amounI oI capIIaI InvesIed annuaI Iurnover or saIes amounI oI raw maIerIaIs used degree oI mechanIzaIIon and auIomaIIon. 2.3 Working condiIions In mosI InsIances, workIng condIIIons In smaIIscaIe enIerprIses do noI compare IavourabIy wIIh Ihe Iarger and more aIIIuenI IndusIrIes: Iow wages, poor workIng pracIIces, Iack oI resources and a reIaIIveIy hazardous work envIronmenI are Ihe major IacIors aIIecIIng condIIIons In Ihe IndusIrIaI secIor. The hours oI work are Iong. A 12hour work shIII and a 7day week are common. Young chIIdren may be empIoyed, even In heavy work. MachInery used may be obsoIeIe In desIgn and noI properIy maInIaIned, IncreasIng Ihe possIbIIIIy oI accIdenIs and exposure Io hazards. Work sIIes may be sIIuaIed In IamIIy dweIIIngs, posIng hazards noI onIy Io Ihe workers buI Io Ihe oIher IamIIy members as weII, or In sIum areas where overcrowdIng, heaI, dusI and poor venIIIaIIon are consIanI probIems. The sIandards oI sanIIaIIon, hygIene, IIre saIeIy, proIecIIve equIpmenI and IIrsI aId are generaIIy Iow. Workers who suIIer accIdenIs may noI be covered by compensaIIon and workers may noI even be paId on IIme. These condIIIons conIrIbuIe Io Ihe generaIIy poor workIng envIronmenI oI Ihese IndusIrIes. The IypIcaI worker In a smaIIscaIe enIerprIse In deveIopIng counIrIes has a Iow IeveI oI educaIIon and comes Irom Ihe IowesI economIc IeveI oI socIeIy. HIs/her nuIrIIIonaI IeveI and generaI sIaIe oI heaIIh are usuaIIy beIow IdeaI. ThIs, combIned wIIh a work envIronmenI IhaI Is oIIen hoI, humId, overcrowded and where hazardous subsIances are oIIen handIed and processed wIIhouI even eIemenIary saIeIy precauIIons, creaIes a sIIuaIIon wIIh an overwheImIng need Ior occupaIIonaI heaIIh servIces. 2.4 HealIh condiIions ol workers Incto: ncctng tIc IcntI o \oc: sIaIe oI Ihe heaIIh oI Ihe worker beIore he/she sIarIed workIng workIng condIIIons prevaIIIng In Ihe workpIace avaIIabIIIIy and accessIbIIIIy oI heaIIh and saIeIy servIces aI Ihe workpIace, IncIudIng provIsIons Ior perIodIc medIcaI examInaIIons awareness oI Ihe worker and hIs/her manager oI Ihe hazards InherenI In Ihe work envIronmenI degree oI enIorcemenI and compIIance wIIh Ihe IegaI provIsIons Ior occupaIIonaI heaIIh and saIeIy servIces. 14b OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers Innnctc: n tIc n::c::ncnt o tIc IcntI condton: o \oc: AIIer IIndIng Ihese IacIors Io be adverse and unIavourabIe In many smaIIscaIe IacIorIes, one can expecI IhaI Ihe heaIIh oI workers In Ihese IacIorIes wIII be graveIy aIIecIed. VarIous parameIers have been used Io assess workers' heaIIh: IncIdence oI accIdenIs and InjurIes sympIoms reIaIed Io occupaIIons Iung IuncIIon IesIs audIomeIry urIne and bIoodIead examInaIIons. 2.5 MeIhods ol prevenIion and inIervenIion Increase awareness In occupaIIonaI heaIIh and saIeIy among managers oI smaIIscaIe IndusIrIes as weII as Ihe workers IhemseIves IInd IowcosI aIIernaIIves Io heaIIh care deIIvery In Ihe IndusIrIaI secIor LnacI enIorceabIe Iaws appIIcabIe Io IhIs probIem where none exIsI as yeI ProvIde IncenIIves and moIIvaIIon Io compIy wIIh such Iaws and enIorce Ihem wIIh penaI provIsIons II necessary. 2.6 Tasks lor Irainees 1. VIsII a workpIace, coIIecI daIa abouI workers, Ihe work and Ihe work envIronmenI. 2. SeI prIorIIIes based on observaIIons, measuremenIs, dIscussIons, eIc. S. OIIer advIce on some sImpIe prevenIIve and conIroI measures. 4. IInd ouI where Io reIer probIems IhaI cannoI be soIved by Ihe communIIy heaIIh worker. S. LducaIe workers on heaIIh and saIeIy. 6. AppIy IIrsI aId. 3. AGRlCULTURAL AND RURAL AREAS 3.1 ObjecIives Have an Idea abouI generaI work condIIIons, envIronmenIaI hazards and Ihe maIn heaIIh probIems In Ihe agrIcuIIure and ruraI areas Know how Io survey workpIaces usIng sImpIe meIhods Know how Io decIde Io reIer cases Io Ihe hospIIaI or heaIIh cenIre II requIred OccuntonnI henIth n secnI nrens: ModuIe 11 147 Know how Io recognIze generaI heaIIh probIems oI workers wheIher or noI Ihey are workreIaIed Know how Io keep records and wrIIe reporIs. 3.2 General condiIions and problems ol lile in rural areas IcnognIc hIgh proporIIon oI chIIdren dIsproporIIonaIe Iow number oI young aduII maIes women and chIIdren parIIcIpaIe Io a greaI exIenI In Ihe workIorce. 5ococcononc decrease In Ihe agrIcuIIuraI Iand avaIIabIe wIIh Ihe conIInuous and progressIve Increase In Ihe sIze oI Ihe popuIaIIon soII Ioss deserIIIIcaIIon mIgraIIon oI Iarmers. Hou:ng poor buIIdIng maIerIaIs Iack oI InIernaI pIannIng and sanIIary prIncIpIes poIenIIaI Ior ouIbreak oI IIre and IgnIIIon sources IIvesIock and pouIIry housed In Ihe same dweIIIng as Ihe Iarmer. Wntc prevaIence oI waIerborne dIseases Iack oI ruraI waIer suppIy sysIem. 5c\ngc nnd \n:tc d:o:n dung mIxed wIIh garbage as manure poor baIhIng and washIng IacIIIIIes use oI rIvers and canaIs as dIsposaI IacIIIIIes. Nutton undernuIrIIIon due Io overpopuIaIIon/Iand area poor nuIrIIIonaI habIIs mIcronuIrIenI deIIcIency 14 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers prevaIence oI endemIc parasIIIc dIsease hIgh meIaboIIc requIremenIs due Io hIgh meIaboIIc expendIIure In agrIcuIIuraI acIIvIIIes. Iducnton poor and InadequaIe educaIIon scarce IeachIng IacIIIIIes hIgh absenIee raIes oI ruraI chIIdren Iack oI IransporIaIIon IacIIIIIes and bad weaIher. Tnn:otnton nnd connuncnton poor sIaIe oI counIry roads and IeIephone servIces Iack oI markeIIng and medIcaI care. CotIng poor quaIIIy Iack oI personaI proIecIIon equIpmenI. 3.3 CharacIerisIics ol agriculIural work Iype oI work pIace oI work Ihe agrIcuIIuraI worker: sharecropper seIIempIoyed paIdworker mobIIe Iemporary worker. 3.4 OccupaIional hazards in agriculIure II):cn Inznd: heaI and humIdIIy coId soIar rays noIse vIbraIIon (segmenIaI or whoIe body). CIcncn Inznd: pesIIcIdes OccuntonnI henIth n secnI nrens: ModuIe 11 149 IerIIIIzers anImaI Ieed addIIIves. oogcn Inznd: zoonoses snakebIIes and InsecI and scorpIon sIIngs major communIcabIe occupaIIonaI dIseases. Iu:t Inznd: Irom soII, pIanIs or anImaIs may conIaIn sIIIca, IungaI maIIer, anImaI maIIer, IncIudIng InsecIs and excreIa, sIorage mIIes, graIn dusI and IIour dusI aIso may conIaIn agrIcuIIuraI chemIcaIs such as IerIIIIzers and pesIIcIdes. Igononc Inznd: heavy work repeIIIIve Iasks poor ergonomIc desIgn oI IooIs and equIpmenI IncorrecI workIng habIIs. Occuntonn nccdcnt: nnd Inznd: The raIe oI accIdenIaI deaIh In agrIcuIIure Is one oI Ihe hIghesI compared wIIh oIher branches oI producIIon. The raIe oI serIous as weII as mInor accIdenIs Is, on average, hIgher In agrIcuIIure Ihan In aII oIher occupaIIons. IaIaIIIIes are caused mosI oIIen by machInes, especIaIIy IracIors; anImaIs, e.g. buIIs, horses; IaIIs; snakebIIes; IIre and chemIcaIs, e.g. pesIIcIdes. NonIaIaI InjurIes are oIIen caused by Iarm machInes, hand IooIs, physIcaI sIraIn, anImaIs, sIIppIng and IaIIs. MuscuIoskeIeIaI dIsorders due Io ergonomIc hazards are common. 3.5 PrevenIion envIronmenIaI conIroI heaIIh educaIIon personaI proIecIIon equIpmenI. 15U OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers 3.6. Tasks lor Irainees 1. AssIsI In perIormIng sImpIe dIagnosIIc IesIs Ior zoonoIIc dIseases. 2. AssIsI IaboraIory IechnIcIans In sIooI and urIne anaIysIs Ior parasIIIc and endemIc dIseases. S. HeIp In assessmenI oI pesIIcIdes or IheIr end producIs and meIaboIIIes In bIoIogIcaI sampIes. 4. RecognIze specIIIc anIIdoIes Ior pesIIcIdes and cerIaIn oIher agrochemIcaIs. S. Carry ouI IIrsI aId IreaImenI Ior cases InIoxIcaIed by chemIcaIs or pesIIcIdes. 6. Survey workpIaces usIng sImpIe meIhods and IechnIques. 7. CoIIecI bIoIogIcaI and envIronmenIaI sampIes. 8. IdenIIIy possIbIe and poIenIIaI sources oI Injury In Ihe agrIcuIIuraI workpIace. 9. RecognIze generaI heaIIh probIems oI agrIcuIIuraI workers and wheIher or noI Ihey are workreIaIed. 10. ReIer paIIenIs when necessary Io Ihe approprIaIe unII In Ihe heaIIh servIce sysIem. 11. LducaIe and advIse workers on heaIIh and saIeIy probIems In agrIcuIIure. 12. Keep records oI IndIvIduaI workers as weII as records oI workIng groups and surveys. 1S. AssocIaIe wIIh members oI Ihe occupaIIonaI heaIIh Ieam, reporI IheIr observaIIons and consuII wIIh Ihem regardIng conIroI measures, Ihe need Ior envIronmenIaI and bIoIogIcaI monIIorIng and Ihe managemenI oI cerIaIn work reIaIed or occupaIIonaI heaIIh probIems where appIIcabIe. 14. AssIsI In sanIIaIIon oI Ihe workpIace wIIh regard Io waIer, wasIe, Iood, eIc. 1S. DeIecI and reporI on communIcabIe, endemIc, parasIIIc, occupaIIonaI and workreIaIed dIseases In Ihe workpIace. 16. MaInIaIn consIanI surveIIIance and checkIng oI proper usage oI personaI proIecIIve equIpmenI and measurIng devIces. 17. ParIIcIpaIe wIIh Ihe managers and saIeIy personneI In ImpIemenIaIIon oI occupaIIonaI heaIIh programmes. 18. RecognIze earIy sIgns oI poIsonIng and respond approprIaIeIy. 19. Check anImaIs In Ihe area daIIy In order Io deIecI any dIseased anImaIs as earIy as possIbIe. 20. Be capabIe oI exIracIIng an Injured worker Irom agrIcuIIuraI equIpmenI wIIhouI IurIher Injury. 21. SIudy and consIder Ihe possIbIIIIy oI Ihe human IacIor In any occupaIIonaI accIdenI. OccuntonnI henIth n secnI nrens: ModuIe 11 151 22. LducaIe agrIcuIIuraI workers abouI Ihe causes oI heaI sIroke. 2S. SpoI cases oI heaI sIroke and Ihen conIIrm by IakIng body IemperaIure and observIng physIcaI sympIoms. 24. Know how Io admInIsIer ImmedIaIe IIrsI aId IreaImenI Ior cases wIIh heaI sIroke. 2S. HeIp wIIh Ihe appIIcaIIon oI research projecIs accordIng Io esIabIIshed prIorIIIes usIng Ihe sImpIesI meIhods and IechnIques. 26. Make a heaIIh map oI an area, hIghIIghIIng rIsk areas and IdenIIIyIng rIsk IacIors In order Io ImpIemenI approprIaIe meIhods Io conIroI and soIve probIems. MODULE 12 Occupational health for women and children 1. WORKlNG WOMEN 1.2 ObjecIives Know Ihe ImpacI oI occupaIIonaI hazards on workIng women's heaIIh Have approprIaIe IraInIng on prImary heaIIh care Ior workIng women ApprecIaIe Ihe ImporIance oI Ihe exIensIon oI maIernaI and chIId heaIIh as componenIs oI prImary heaIIh care InIo Ihe workpIace Be acquaInIed wIIh Ihe reproducIIve heaIIh probIems oI workIng women In varIous occupaIIons Know Ihe prevenIIve heaIIh measures IhaI wIII have an ImpacI on workIng women's heaIIh. 1.2 OccupaIional hazards The number oI women joInIng Ihe workIorce has sIeadIIy Increased aII over Ihe worId durIng Ihe IasI Iew decades. ThroughouI hIsIory, women In deveIopIng counIrIes have aIways worked hard, noI onIy as wIves and moIhers buI aIso as workers In dIIIerenI secIors. OIIen encumbered wIIh many chIIdren and weakened by excessIve and IrequenI pregnancIes, workIng women are subjecI Io numerous rIsks e.g. IaIIgue, maInuIrIIIon, undue menIaI sIress and exposure Io varIous hazards aI IheIr workpIaces. DomesIIc work exposes women Io many hazards whIch may undermIne IheIr heaIIh, e.g. accIdenIs, burns, backache Irom bendIng, and chemIcaI exposure Irom deIergenIs, resuIIIng In skIn probIems such as dermaIIIIs. In many counIrIes, IndusIrIaI expansIon has occurred wIIhouI suIIIcIenI proIecIIve measures Ior workers. Women are under specIaI pressure sInce, In many InsIances, IheIr jobs are consIdered by managemenI Io be oI secondary ImporIance and medIcaI IacIIIIIes are consequenIIy InadequaIe. IemaIe workers dIIIer Irom maIe workers In IhaI Ihey are generaIIy physIcaIIy smaIIer and are subjecI Io specIIIc sIressIuI condIIIons pecuIIar Io Ihem, e.g. mensIruaIIon, pregnancy and IacIaIIon. PHC workers carIng Ior workIng women shouId be aware oI such condIIIons and IheIr possIbIe eIIecIs on work perIormance, and Ihe eIIecI oI Ihe work envIronmenI on Ihe heaIIh oI women aI Ihese IImes, e.g. Ihere Is a progressIve Increase In respIraIory venIIIaIIon durIng pregnancy whIch may Iead Io Increased upIake oI InhaIed chemIcaIs Irom Ihe aIr. 154 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers I:)cIo:ocn ocn: SIressreIaIed Issues are encounIered In nearIy aII jobs heId by workIng women. The majorIIy oI women are sIIII empIoyed In IowpayIng jobs. Ior a sIngIe moIher, a Iow wage and Ihe home obIIgaIIons oI carIng Ior chIIdren and doIng Ihe housework can be parIIcuIarIy serIous causes oI sIress. SIress aI work can come Irom many sources, e.g.: oIIIce workers and assembIy IIne workers In IacIorIes have demandIng and repeIIIIve jobs, whIch cause sIress nurses oIIen experIence sIress because IheIr work Is physIcaIIy heavy and hecIIc. CIcncn ngcnt: Due Io Ihe hIgher conIenI oI body IaI In women Ihan men, IoxIc subsIances such as organIc soIvenIs are reIaIned more easIIy by women. Some sIudIes suggesI IhaI exposure Io organIc soIvenIs causes mensIruaI dIsIurbances. Some meIaIs, e.g. Iead, can cause sponIaneous aborIIon. AIso some chemIcaIs used In hospIIaIs, e.g. eIhyIene oxIde, are known Io cause aborIIon. Many women are engaged In agrIcuIIuraI acIIvIIIes whIch means Ihey are exposed Io pesIIcIdes and IerIIIIzers. Some oI Ihe pesIIcIdes used In agrIcuIIure are suspecIed Io cause reproducIIve damage In women. Women workIng In IexIIIe mIIIs are exposed Io organIc dusIs, e.g. coIIon, whIch causes byssInosIs. II):cn ngcnt: Women workIng In Ihe IexIIIe IndusIry are exposed Io noIse, vIbraIIon and heaI sIress, parIIcuIarIy In Ihe spInnIng and weavIng secIIons. NoIse causes vasoconsIrIcIIon whIch may Iead Io Iow bIrIh weIghI oI babIes. SIudIes have shown IhaI women are more suscepIIbIe Io whoIe body vIbraIIon and heaI sIress. WhoIe body vIbraIIon may damage Ihe reproducIIve sysIem. RadIaIIon may aIso cause a probIem. In addIIIon poor IIghIIng Is noI uncommon In many jobs IeadIng Io eye damage. oogcn ngcnt: Nurses may be exposed Io IubercuIosIs, hepaIIIIs B, rubeIIa vIrus, Toxon:nn gond, AIDS, eIc. Women empIoyed In agrIcuIIure are exposed Io snake bIIes, schIsIosoma, worm InIesIaIIon, IeIanus, eIc. Igononc ocn: BodIIy dImensIons are an ImporIanI consIderaIIon In physIcaI work perIormance and machIne desIgn and operaIIon. Many IndusIrIaI and agrIcuIIuraI processes and machInery are desIgned Ior maIe workers makIng many machInes dIIIIcuII Ior IemaIe workers Io operaIe. OccuntonnI henIth ]or wonen nnd chIdren: ModuIe 12 155 1.3 OccupaIional healIh services lor working women OccupaIIonaI heaIIh servIces shouId be esIabIIshed aI aII workpIaces Io ensure IhaI Ihe IoIaI heaIIh and saIeIy needs oI workIng women are meI. UnIorIunaIeIy, In many counIrIes Ihey are noI accessIbIe Io Iarge numbers oI workers, especIaIIy In agrIcuIIure and smaIIscaIe IndusIrIes. In Ihese cases, PHC servIces shouId caIer Io Ihe specIIIc needs oI workIng women. GeneraIIy, Ihe IoIIowIng poInIs are oI parIIcuIar reIevance Io occupaIIonaI heaIIh care programmes Ior workIng women. 5ccn IcntI cducnton HeaIIh and saIeIy InspecIors, occupaIIonaI heaIIh InspecIors, empIoyers and heaIIh poIIcy makers shouId receIve specIaI IraInIng In heaIIh educaIIon Ior IemaIe workers. LducaIIon concernIng heaIIh rIsks, IncIudIng reproducIIve rIsks Ior men and women as weII as poIenIIaI eIIecIs on Ihe IoeIus, and IraInIng In Ihe saIe use oI chemIcaIs, musI be prIorIIIzed. Kcgunton: to :ncgund \ong \oncn ReguIaIIons and sIandards appIyIng Io Ihe enIIre Iabour Iorce shouId be revIewed conIInuousIy Ior IheIr reIevance and adequacy Io IemaIe workers. II Is oI specIaI ImporIance IhaI saIe workIng condIIIons are ensured Ior IemaIe workers, and pregnanI workers In parIIcuIar. II Is ImporIanI Io prevenI occupaIIonaI hazards IhaI are parIIcuIarIy harmIuI Io women. MInImum sIandards shouId be seI up Ior anIhropomeIrIc parameIers and physIcaI capacIIy Io be used In preempIoymenI examInaIIons. In\onncntn nontong The roIe oI Ihe IndusIrIaI hygIenIsI Is Io monIIor Ihe workIng envIronmenI Ior poIenIIaI hazards. LnvIronmenIaI monIIorIng shouId be carrIed ouI reguIarIy Io IdenIIIy probIems whIch couId aIIecI Ihe heaIIh oI workIng women. OccupaIIonaI hygIene sIandards shouId be recommended Ior varIous Iypes oI exposure, e.g. Iead, soIvenIs, pesIIcIdes, eIc. Ic-nccncnt ncdcn cxnnnnton These shouId be used Io heIp In Ihe proper pIacemenI oI women In jobs approprIaIe Io IheIr physIcaI, physIoIogIcaI and psychoIogIcaI capabIIIIIes. Icodcn ncdcn cxnnnnton: WorkIng women shouId undergo reguIar medIcaI examInaIIon, especIaIIy Ihose aI parIIcuIar rIsk. Iquncnt dc:gn The desIgn oI IooIs, machInes and equIpmenI shouId Iake InIo accounI Ihe anaIomIcaI IeaIures and physIoIogIcaI capabIIIIIes oI women. 15b OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers InIn:: on undc:c\cd \ong \oncn PHC shouId Iocus on underserved workIng women, especIaIIy Ihose empIoyed In agrIcuIIure and smaIIscaIe IndusIrIes. In addIIIon, maIernaI and chIId heaIIh servIces shouId be avaIIabIe Io such women. Kc:cncI nnd :u\c): Research shouId be carrIed ouI on Ihe eIIecIs on IemaIe workers oI specIIIc hazards assocIaIed wIIh a wIde varIeIy oI exposure condIIIons. Woncn': gIt: In addIIIon Io receIvIng InIormaIIon on occupaIIonaI heaIIh and saIeIy, workIng women shouId aIso be InIormed oI IheIr rIghIs In connecIIon wIIh heaIIh, maIernIIy and chIId care. II shouId aIso be ensured IhaI women have suIIIcIenI resI In Ihe IasI IrImesIer oI pregnancy and durIng breasIIeedIng. Woncn': ::uc: In pIannIng PHC servIces Ior workIng women II Is essenIIaI Io consIder Issues specIIIc Io Ihem and Io IncIude Ihe basIc eIemenIs oI maIernIIy proIecIIon, IamIIy pIannIng (Ihe responsIbIIIIy oI men and women) and counseIIIng. 1.4 Work exposure and pregnancy The poIenIIaI Ior reproducIIve hazards Induced by workpIace exposure Is wIdeIy recognIzed. These IncIude: InIerIIIIIy sponIaneous aborIIon maIIormaIIon perInaIaI morIaIIIy Iow bIrIh weIghI deveIopmenIaI ImpaIrmenI chIIdhood cancer. OI Ihese, sponIaneous aborIIon and maIIormaIIon In Ihe oIIsprIng have aIIracIed mosI aIIenIIon In Ihe occupaIIonaI seIIIng. Ior many ouIcomes II has been suspecIed IhaI boIh IemaIe and maIe exposure may be Ihe underIyIng cause. However, mosI sIudIes and Ihe besI evIdence reIaIe ouIcome Io Ihe exposure oI Ihe woman durIng pregnancy. 1.5 Risk lacIors ldenIilied in cerIain occupaIions and indusIries HeaIIh care occupaIIons may InvoIve exposure Io many kInds oI reproducIIve IoxIns. OccupaIIonaI IacIors whIch may carry a rIsk oI sponIaneous aborIIon IncIude: anaesIheIIc gases OccuntonnI henIth ]or wonen nnd chIdren: ModuIe 12 157 eIhyIene oxIde (sIerIIIzIng gases) anIIneopIasIIc agenIs organIc soIvenIs meIhyIene chIorIde IeIrachIoroeIhyIene aIIphaIIc hydrocarbons conIacI wIIh IurbearIng anImaIs IIIIIng heavy burdens Xrays. AnaesIheIIc gases were Ihe IIrsI gases suspecIed oI causIng harm Io Ihe IoeIus. Lxposure has been eIIecIIveIy reduced In many counIrIes. RecenI sIudIes have noI Iound a sIgnIIIcanIIy Increased rIsk Ior sponIaneous aborIIon and congenIIaI maIIormaIIon. Lxposure Io eIhyIene oxIde, a gas used Ior sIerIIIzIng, Increased Ihe rIsk oI sponIaneous aborIIons. HandIIng oI anIIneopIasIIc drugs In hospIIaIs Increases Ihe rIsk oI sponIaneous aborIIon and maIIormaIIon In Ihe oIIsprIng. OccupaIIonaI IacIors appearIng Io carry a rIsk oI maIIormaIIons or IuncIIonaI deIecIs: (a) MaIIormaIIon organIc soIvenIs anIIneopIasIIc agenIs IonIzIng radIaIIon (Xrays, radIoacIIve IsoIopes) (b) IuncIIonaI deIecI Iead (decreased cognIIIve capacIIy) noIse (hearIng Ioss). The harmIuI eIIecIs oI IonIzIng radIaIIon are known, and exposure In medIcaI occupaIIons Is conIroIIed. HeaIIh care work predIsposes personneI Io conIagIous dIseases, among whIch HIV Is a promInenI probIem. AccordIng Io severaI sIudIes, exposure Io organIc soIvenIs and/or IaboraIory work durIng pregnancy may Increase Ihe rIsk oI sponIaneous aborIIon and congenIIaI maIIormaIIon. AIIhough exposure Io soIvenIs Is common In numerous IndusIrIes and occupaIIons, II has been dIIIIcuII Io esIabIIsh wheIher specIIIc soIvenIs, or IheIr combInaIIons, or soIvenIs In generaI are responsIbIe. Lxposure Io heavy meIaIs such as Iead Is suspecIed oI causIng reproducIIve IoxIcIIy. QuIIe Iow exposure durIng pregnancy may harm Ihe cognIIIve deveIopmenI oI Ihe chIId. OIher occupaIIonaI IacIors whIch shouId especIaIIy be conIroIIed Ior durIng pregnancy IncIude: 15 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers heavy meIaIs PCBs (poIychIorInaIed bIphenyIs) pesIIcIdes carbon monoxIde carcInogens. IngesIIon oI Iood oII conIaInIng PCBs has caused dIsIurbances In chIIdren, wIIh some newborns oI exposed moIhers exhIbIIIng smaII sIze, dIscoIoraIIon oI skIn and naIIs and premaIure erupIIon oI IeeIh. ThIs sIgnaIs concern Ior occupaIIonaI exposures Ioo. Carbon monoxIde Is a known asphyxIanI Ior Ihe IoeIus. OccupaIIonaI exposure durIng pregnancy shouId be avoIded; neverIheIess, exposure occurs mosIIy vIa Ihe moIher smokIng. There are pIenIy oI oIher chemIcaIs whIch are suspecIed Io be reproducIIve IoxIns and numerous IndusIrIes are hazardous Irom Ihe poInI oI vIew oI reproducIIon. In generaI, exposure Io known carcInogenIc and muIagenIc agenIs shouId be avoIded durIng pregnancy because Ihey are poIenIIaIIy harmIuI Io Ihe IoeIus. Damage by Ihese agenIs Io Ihe gameIes Is aIso possIbIe prIor Io concepIIon. CongenIIaI maIIormaIIons and sponIaneous aborIIons are Ihe ouIcomes mosI wIdeIy InvesIIgaIed so Iar. ReporIed epIsodes oI breasI mIIk conIamInaIIon have been mosIIy due Io envIronmenIaI poIIuIIon, buI II shouId noI be overIooked In occupaIIons where exposure Io subsIances IhaI may accumuIaIe In Ihe body, e.g. PCBs and Iead, Is possIbIe. AIIenIIon shouId aIso be paId Io oIher exposures (e.g. soIvenIs) when Ihe moIher Is workIng durIng Ihe breasI IeedIng perIod. The producIIon and IabrIcaIIon oI pIasIIcs may IncIude exposure Io Ihe monomers or Io Ihe IhermodegradaIIon producIs oI Ihe pIasIIcs. The IexIIIe IndusIry has many possIbIe reproducIIve IoxIns. HaIrdressers use many chemIcaIs oI poIenIIaI IoxIcIIy and IIIghI sIewardesses suIIer more IrequenIIy Irom mensIruaI dIsorders. The agrIcuIIuraI secIor Is oIIen IhoughI oI as a saIe workpIace buI II Ioo can pose IhreaIs Io women's heaIIh. In agrIcuIIure, IIIIIe dIsIIncIIon Is made beIween workpIace envIronmenI and IIvIng envIronmenI, and Iarm workers are whoIIy dependenI on Ihe Iarmer Ior subsIsIence, IeIsure IIme and housIng. WorkIng women In agrIcuIIure Iace Ihe rIsks oI InadequaIe proIecIIon Irom IoxIc subsIances, such as pesIIcIdes, herbIcIdes, dIppIng chemIcaIs, paInI, IerIIIIzers and IueI. IarmIng aIso InvoIves exposure Io bIoIogIcaI agenIs, such as mIcrobes, mIcrobIaI IoxIns and mycoIoxIns. BIoIogIcaI exposures In agrIcuIIure Is sIgnIIIcanI and may become probIemaIIc wIIh new bIoIechnoIogy. PhysIcaI and psychophysIoIogIcaI IacIors may pIay a roIe In reproducIIve hazards. The IeraIogenIc and oIher harmIuI eIIecIs oI IonIzIng radIaIIon (e.g. Xrays, radIoIsoIopes) on Ihe IoeIus are known. ThIs InIormaIIon Is Iaken InIo accounI In many counIrIes where Ihe exposure oI pregnanI women Is resIrIcIed by Iaw. The eIIecIs oI nIghI work, heavy IIIIIng, hIgh IemperaIures and whoIe body vIbraIIon, as weII as work wIIh vIsuaI dIspIay IermInaIs, need Io be sIudIed IurIher. OccuntonnI henIth ]or wonen nnd chIdren: ModuIe 12 159 1.6 Tasks lor Ihe Irainees 1. DescrIbe Ihe maIn occupaIIons In whIch women In your area work. 2. CharacIerIze Ihe adverse heaIIh rIsks whIch workIng women are exposed Io In Ihese occupaIIons. S. LIsI Ihe mosI ImporIanI PHC servIces In your IacIIIIy whIch may be beneIIcIaI Io workIng women. 4. PrIorIIIze Ihe heaIIh educaIIon IopIcs you recommend Io educaIe workIng women wIIhIn cerIaIn occupaIIons. 2. CHlLD LABOUR 2.1 ObjecIives Know Ihe ImpacI oI occupaIIonaI hazards on Ihe growIh oI workIng chIIdren Be aware oI Ihe consequences oI chIId Iabour on Ihe communIIy In generaI Know II a chIId's Injury or IIIness Is workreIaIed Know how Io Ieach heaIIh educaIIon Io workIng chIIdren, IheIr empIoyers, parenIs, Ieachers and Ihe communIIy. 2.2 DeliniIions and basic concepIs ChIId Iabour Is deIIned as Ihe paId empIoymenI oI chIIdren younger Ihan 18 years oI age. 1 The IegaI mInImum age IImIIs Ior work dIIIer Irom counIry Io counIry and Irom acIIvIIy Io acIIvIIy. Many counIrIes make a dIsIIncIIon beIween IIghI and hazardous work wIIh Ihe mInImum age Ior Ihe Iormer generaIIy beIng 12, Ior Ihe IaIIer usuaIIy varyIng beIween 16 and 18. The InIernaIIonaI Labour OrganIsaIIon MInImum Age ConvenIIon (No. 1S8, 197S) aIso broadIy adopIs IhIs approach, aIIowIng IIghI work aI age 12 or 1S buI hazardous work noI beIore 18. NeverIheIess, Ihe ILO aIso esIabIIshes a generaI mInImum age oI 1S years, provIdIng 1S Is noI Iess Ihan Ihe age oI compIeIIon oI compuIsory schooIIng. ChIId Iabour can be broken down InIo seven maIn Iypes, none oI whIch Is unIque Io any counIry or regIon oI Ihe worId: domesIIc servIce Iorced and bonded Iabour commercIaI sexuaI expIoIIaIIon IndusIrIaI and pIanIaIIon work sIreeI work work Ior Ihe IamIIy gIrIs' work. 1 LandrIgan P| eI aI. ChIId Iabor. Icdntc nnnn:, 199S, 24:6S7-62. 1bU OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers MosI chIIdren who work do noI have Ihe power oI Iree choIce. ChIId Iabour Is assocIaIed wIIh poverIy, InadequaIe educaIIonaI opporIunIIIes and IaIIure Io enIorce reIevanI Iaws and sIandards. ParIIcuIarIy severe chIId abuses have been documenIed In socaIIed Iree enIerprIse zones, I.e. specIaI IndusIrIaI areas where Iabour and envIronmenIaI Iaws are noI enIorced. IIIegaI chIId Iabour Is wIdespread and hundreds oI mIIIIons oI chIIdren aII over Ihe worId are empIoyed under unIawIuI condIIIons. AccordIng Io Ihe ILO aI IeasI 200 mIIIIon chIIdren under Ihe age oI 14 are empIoyed worIdwIde. IIIegaI empIoymenI oI chIIdren occurs In aII IndusIrIaI secIors and oIIen under sweaIshop condIIIons. A sweaIshop Is deIIned as an esIabIIshmenI IhaI vIoIaIes wage, hour and chIId Iabour Iaws as weII as Ihe Iaws proIecIIng occupaIIonaI saIeIy and heaIIh. 2 HeaIIh and saIeIy condIIIons In sweaIshops are oIIen dangerous. A decade ago, UNICLI deIermIned IhaI chIId Iabour was expIoIIaIIve II II InvoIved: IuIIIIme work aI Ioo earIy an age Ioo many hours spenI workIng work IhaI exerIs undue physIcaI, socIaI or psychoIogIcaI sIress work and IIIe on Ihe sIreeIs In bad condIIIons InadequaIe pay Ioo much responsIbIIIIy work IhaI hampers access Io educaIIon work IhaI undermInes chIIdren's dIgnIIy and seIIesIeem, such as sIavery or bonded Iabour and sexuaI expIoIIaIIon work IhaI Is deIrImenIaI Io IuII socIaI and psychoIogIcaI deveIopmenI. 2.3 Why children work PoverIy (poor economIc and socIaI envIronmenI) has aIways been Ihe reason IhaI chIIdren work. ChIIdren oI IandIess peasanIs or oI underempIoyed parenIs are aI greaIer rIsk sInce, by workIng, Ihey can conIrIbuIe subsIanIIaIIy Io Ihe IamIIy Income. ChIIdren workIng In expIoIIaIIve, harmIuI condIIIons oIIen come Irom dIsadvanIaged and economIcaIIy vuInerabIe popuIaIIon groups, IncIudIng IemaIeheaded househoIds, Iower casIes, IndIgenous or IrIbaI peopIe and mIgranI IamIIIes. ChIIdren In IradIIIonaI socIeIIes, usuaIIy In IheIr cIoseIy knII IamIIy sIIuaIIons, are senI Io work by parenIs who consIder work an essenIIaI parI oI deveIopmenI and socIaIIzaIIon. 2 US GeneraI AccounIIng OIIIce. 5\cnt:Io: nnd cId nou \onton:: n go\ng ocn n tIc Untcd 5tntc:. WashIngIon DC, GovernmenI PrInIIng OIIIce, 1989. OccuntonnI henIth ]or wonen nnd chIdren: ModuIe 12 1b1 ChIId Iabour Is aIso generaIed by deIIcIencIes In educaIIonaI sysIems. SchooIs may noI represenI a possIbIe way Io geI ouI oI poverIy. GIven Ihe Iow quaIIIy and ImpIIed cosIs oI Ihe educaIIon servIces avaIIabIe Io Ihe poor, many parenIs, havIng IhemseIves worked as chIIdren, Iend Io consIder an earIy enIry InIo Ihe Iabour markeI, raIher Ihan schooIIng, as Ihe besI way Io equIp IheIr chIIdren wIIh skIIIs useIuI Ior IheIr IuIure as aduIIs. 2.4 Work and healIh ol a child Many oI Ihose who supporI Ihe argumenI IhaI chIIdren have Io work Io survIve In some sIIuaIIons sIrongIy beIIeve IhaI work has someIhIng Io do wIIh promoIIon oI a chIId's heaIIh. TheIr reasonIng: when a chIId earns an Income, such Income wIII be used Io buy Iood, cIoIhIng and, aI IImes, sheIIer. And, such a chIId wouId be proIecIed Irom aII Iorms oI IroubIe, e.g. roamIng Ihe sIreeIs. In a sIIuaIIon where Ihe chIId Is Ihe onIy wage earner, Ihe chIId's IamIIy Is supposed Io beneIII and be abIe Io supporI oIher IamIIy members more eIIecIIveIy. They reason IhaI work In IhIs conIexI may enhance boIh Ihe chIId's and Ihe IamIIy's capabIIIIy Iowards good heaIIh. S Con:cqucncc: o Inzndou: \o o cIdcn': IcntI WhIIe Ihe above may be Irue In an IdeaI sIIuaIIon, unIorIunaIeIy sIudIes show IhaI many chIIdren are deprIved oI opporIunIIIes Ior opIImaI educaIIon, socIaI InIervenIIon and physIcaI growIh. A revIew oI Ihe IIIeraIure and reporIs reveaI Ihe IoIIowIng as consequences oI hazardous work Ior chIIdren's heaIIh: workIng chIIdren have poorer heaIIh sIaIus Ihan nonworkIng chIIdren maInuIrIIIon Is quIIe common among workIng chIIdren ImpaIred psychosocIaI deveIopmenI oI workIng chIIdren has a IongIerm eIIecI accIdenIs among workIng chIIdren are IrequenI workIng chIIdren are noI ergonomIcaIIy compaIIbIe wIIh Ihe equIpmenI and IooIs provIded by Ihe workpIace workpIaces provIde ampIe opporIunIIy Ior acuIe and chronIc poIsonIngs. Incto: contutng to dnngc: to cIdcn ChIIdren are empIoyed In a varIeIy oI occupaIIons where dangers are noI as apparenI. These dangers couId aIIecI a chIId's heaIIh and saIeIy. IacIors IhaI conIrIbuIe Io dangers Ior chIIdren IncIude: cerIaIn work arrangemenIs (e.g. separaIIon Irom IamIIIes, IIvIng InsIde workpIaces) exposure Io specIIIc hazardous processes and Iasks (e.g. IIIIIng heavy weIghIs, workIng underground) S GusILsIreIIa DP. Case sIudIes In hazardous chIId Iabour. Intcnntonn cId IcntI: n dgc:t o cucnt nonnton. Geneva, UNICLI, 199S. 1b2 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers exposure Io hazardous maIerIaIs such as chemIcaIs (boIh In IndusIry and agrIcuIIure), dangerous machInery and dangerous IooIs exposure Io hazards In Ihe physIcaI envIronmenI, IncIudIng noIse IeveIs, radIaIIon exposure, exIreme IemperaIure oI Ihe workIng envIronmenI, poor IIghIIng, chemIcaI and bIoIogIcaI hazardous agenIs, workIng posIure and dusI generaI workIng condIIIons, IncIudIng workIng hours, wages, number oI work days (per week or per monIh), amounI oI resI and recreaIIon absence oI heaIIh and saIeIy measures IncIudIng personaI proIecIIve equIpmenI, weIIare and heaIIh IacIIIIIes, ergonomIc consIderaIIons, IIrsI aId, reguIar medIcaI IacIIIIIes, a sysIem oI reIerraIs absence oI envIronmenIaI saIeIy measures (such as saIe waIer suppIIes and IoIIeIs) and poor access Io Iood Iack oI IegIsIaIIve proIecIIon (In Ihe InIormaI secIor, In domesIIc work, eIc.) InadequaIe supervIsIon InadequaIe Iabour InspecIIon servIces. 2.5 Risks ol child labour K:: to dc\concnt Work IhaI Is harmIess Io aduIIs can be exIremeIy harmIuI Io chIIdren. Among Ihe aspecIs oI a chIId's deveIopmenI IhaI can be endangered by work are: PhysIcaI deveIopmenI: IncIudIng overaII heaIIh, coordInaIIon, sIrengIh, vIsIon and hearIng. CarryIng heavy Ioads or sIIIIng Ior Iong perIods In unnaIuraI posIIIons can permanenIIy dIsabIe growIng bodIes. Hard physIcaI Iabour over a perIod oI years can sIunI chIIdren's physIcaI sIaIure by up Io S0 per cenI oI IheIr bIoIogIcaI poIenIIaI, as Ihey expend sIores oI sIamIna IhaI shouId IasI InIo aduIIhood. 4 CognIIIve deveIopmenI: IncIudIng IIIeracy, numeracy and Ihe acquIsIIIon oI knowIedge necessary Io a normaI IIIe. LmoIIonaI deveIopmenI: IncIudIng adequaIe seIIesIeem, IeeIIng Iove and accepIance. SocIaI and moraI deveIopmenI: IncIudIng a sense oI group IdenIIIy, Ihe abIIIIy Io cooperaIe wIIh oIhers and Ihe capacIIy Io dIsIInguIsh rIghI Irom wrong. ChIId Iabour aIso InIerIeres wIIh pIay, whIch Is ImporIanI Ior normaI deveIopmenI; reIaxaIIon and Ireedom Irom IaIIgue are necessary Ior chIIdren Io grow and Iearn. 4 AIIsebrook A, SwIII A. ocn on:c. London, Hodder and SIoughIon, 1989:91. OccuntonnI henIth ]or wonen nnd chIdren: ModuIe 12 1b3 K:: o n]u) nnd dcntI The rIsk oI Injury Is aImosI 10 IImes greaIer among chIIdren empIoyed under IIIegaI condIIIons Ihan among Ihose workIng In compIIance wIIh Ihe Iaws. LxampIes are: IaceraIIons ampuIaIIons and crush InjurIes Irom machInery moIor vehIcIe accIdenIs InvoIvIng Iarm vehIcIes on pubIIc roads suIIocaIIon In graIn eIevaIors and sIIos bIunI Irauma Irom Iarge anImaIs, e.g. as a resuII oI beIng kIcked by a cow. K:: o occuntonn d:cn:c: nnd o:onng: ChIIdren are parIIcuIarIy vuInerabIe Io cerIaIn probIems and dIseases and are aI greaIer rIsk In IheIr occupaIIonaI envIronmenI due Io IheIr Iack oI experIence. The occupaIIonaI envIronmenI conIaIns a varIeIy oI chemIcaI, physIcaI, bIoIogIcaI and ergonomIc hazards, e.g. exposure Io cerIaIn dusIs can Iead Io chronIc Iung dIsease. AIso, workIng chIIdren may experIence a varIeIy oI IoxIc exposures aI work, e.g. IormaIdehyde and dyes In Ihe garmenI IndusIry, soIvenIs In paInI shops, pesIIcIdes In agrIcuIIure, asbesIos In buIIdIng abaIemenI and benzene In peIroI IIIIIng sIaIIons. Young peopIe may noI have InIormaIIon or knowIedge abouI Ihese hazards and someIImes, even II Ihey have Ihe InIormaIIon, Ihey may noI be wIIIIng or abIe Io Iake Ihe necessary sIeps Io proIecI IhemseIves. K:: to cducnton LducaIIon heIps a chIId deveIop cognIIIveIy, emoIIonaIIy and socIaIIy. InIerIerence wIIh schooI perIormance Is a serIous consequence oI chIId Iabour. WorkIng chIIdren rIsk havIng Ioo IIIIIe IIme Ior IheIr homework and beIng overIIred on schooI days. The socIaI envIronmenI oI work someIImes undermInes Ihe vaIue chIIdren pIace on educaIIon. Lack oI educaIIon condemns chIIdren Io Ihe worsI empIoymenI prospecIs and, In Iurn, Ihe sheer pressure oI survIvaI wIII resuII In Ihese chIIdren joInIng Ihe Iow wage earners. 2.6 PrevenIion and proIecIion measures Any eIIecIIve measure Io proIecI workIng chIIdren Irom workpIace hazards musI begIn by hIghIIghIIng boIh Ihe chIIdren and Ihe dangers Ihey Iace. RecognIIIon oI Ihe sIIuaIIon Is Ihe IIrsI vIIaI sIep. NexI, Ihe presence oI sIrong and deIermIned poIIIIcaI wIII Is needed In order Io IormuIaIe poIIcIes and reaIIsIIc programmes Iowards Ihe eIIecIIve IermInaIIon oI Ihe pracIIce oI chIId Iabour. However, cerIaIn heaIIh probIems oI IegaIIy workIng chIIdren can be avoIded In Ihe IIrsI pIace II Ihere Is approprIaIe job pIacemenI, I.e. a maIchIng oI Ihe needs oI Ihe job wIIh Ihe abIIIIIes and poIenIIaI oI Ihe IndIvIduaI. A prepIacemenI examInaIIon can aIso averI cerIaIn dIIIIcuIIIes, e.g. when prospecIIve empIoyees are aIIergIc Io varIous subsIances. 1b4 OccuntonnI henIth trnnng nnnunI ]or rnnry henIth cnre workers WorkIng young peopIe shouId be proIecIed, as Iar as possIbIe, Irom dangerous workIng envIronmenIs, e.g. areas where Ihere Is IasImovIng machInery. Where Ihere are IoxIc subsIances, such as Iead dusI, Ihe monIIorIng oI Ihe concenIraIIons oI Ihese subsIances In Ihe aIr, as weII as In bIood and urIne, becomes ImporIanI. Record keepIng can be used Io IndIcaIe sIckness and absenIeeIsm IhaI mIghI poInI Io specIIIc dIIIIcuIIIes. HeaIIh promoIIon In workpIaces shouId InvoIve educaIIon on Ihe broader Issues oI accIdenI prevenIIon, nuIrIIIon, heaIIhy IIIesIyIes, eIc. The earIy IreaImenI and subsequenI rehabIIIIaIIon oI young peopIe wIIh InjurIes and IIInesses, wheIher physIcaI or psychoIogIcaI, shouId be ensured. However, prevenIIon oI Injury and IIIness among workIng chIIdren, IncIudIng IIIegaI Iypes oI work, requIres a coordInaIed serIes oI acIIons In severaI areas: BeIIer educaIIon oI chIIdren, parenIs, Ieachers, physIcIans and Ihe busIness communIIy on Ihe hazards oI chIId Iabour. BeIIer meIhods oI dIagnosIs: occupaIIonaI hIsIory shouId be rouIIne In Ihe evaIuaIIon oI acuIe Irauma and shouId be used when assessIng chIIdren wIIh poIenIIaI workreIaIed condIIIons, such as repeIIIIve moIIon Injury or organophosphaIe poIsonIng. DeveIopmenI oI beIIer daIa Io deIIne Ihe exIenI and paIIerns oI chIId Iabour: beIIer sysIems are needed Io monIIor Ihe workIng paIIerns (IegaI and IIIegaI) oI chIIdren and young adoIescenIs: IheIr number, age, empIoymenI paIIerns by IndusIry and occupaIIon and Ihe number oI hours and days worked. ThIs InIormaIIon wouId heIp Iocus enIorcemenI eIIorIs and Irack Irends In chIIdhood empIoymenI. DeveIopmenI oI beIIer daIa on workreIaIed InjurIes In chIIdren and adoIescenIs: empIoyers shouId be IegaIIy requIred Io reporI aII InjurIes oI workIng chIIdren and adoIescenIs Io Ihe heaIIh and Iabour auIhorIIIes. SIrengIhenIng and ImprovIng IegIsIaIIon and enIorcemenI measures oI chIId Iabour Iaws. LnsurIng IhaI Ihe maIn pIaces where chIIdren work and Ihe worsI Iorms oI chIId Iabour are encompassed by naIIonaI IegIsIaIIon. LnsurIng IhaI naIIonaI Iabour and educaIIon Iaws are consIsIenI so as Io eIImInaIe Ihe dIscrepancIes whIch may exIsI beIween Ihe mInImum age requIred by Ihe Iaw Io work and Ihe mInImum age permIIIed Io Ieave schooI. ImprovIng schooIIng Ior Ihe poor: Ihe sIngIe mosI eIIecIIve way Io sIem Ihe IIow oI schooIage chIIdren InIo abusIve Iorms oI empIoymenI or work Is Io exIend and Improve schooIIng so IhaI II wIII aIIracI and reIaIn Ihem. OccuntonnI henIth ]or wonen nnd chIdren: ModuIe 12 1b5 2.7 Tasks lor Ihe Irainees 1. DescrIbe Ihe maIn Iypes oI empIoymenI and occupaIIons In whIch chIIdren In your area work. 2. CharacIerIze Ihe knowIedge and aIIIIudes oI IheIr IamIIIes Iowards Ihe probIem oI chIId Iabour In generaI. S. RevIew Ihe avaIIabIe daIa on workIng chIIdren aI Ihe naIIonaI IeveI and deIIne Ihe shorIcomIngs. DIscuss ways oI broadenIng Ihe sources and sIrengIhenIng Ihe vaIIdIIy oI daIa on chIId Iabour. 4. DesIgn an occupaIIonaI hIsIory quesIIonnaIre Ior approachIng chIIdren's InjurIes and IIInesses suspecIed Io be workreIaIed. S. DIscuss Ihe naIIonaI IegIsIaIIon and sIandards reIaIed Io chIId Iabour. SuggesI ways Io Improve IheIr quaIIIy and enIorcemenI. 6. DIscuss Ihe prevenIIon and proIecIIon measures IhaI can be appIIed Io cerIaIn occupaIIons where chIIdren may be workIng IegaIIy. 7. DIscuss Ihe roIe IhaI schooIs may pIay In conIronIIng Ihe chIId Iabour probIem; aIso Ihe roIe oI Ihe communIIy In generaI. OccuntonnI henIth ]or wonen nnd chIdren: ModuIe 12 1b7 lURTHER READlNG CenIers Ior DIsease ConIroI and PrevenIIon, NaIIonaI CenIer Ior OccupaIIonaI SaIeIy and HeaIIh, Iocct gudc to cIcncn Inznd:. IIasca, IIIInoIs, NaIIonaI SaIeIy CouncII Press, 2000. CIdcn nt \o: :ccn IcntI ::. Kcot o n WHO 5tud) Cou. Geneva, WorId HeaIIh OrganIzaIIon, 1987 (TechnIcaI ReporI SerIes No. 7S6). Icononcn) nct\c ounton 15-21. 4Ih ed. on dIskeIIe. Geneva, InIernaIIonaI Labour OrganIsaIIon, 1996. HarrIngIon |M eI aI. Occuntonn IcntI, 4Ih ed. OxIord, BIackweII ScIence, 1998. HcntI onoton o \ong ounton:. Kcot o n WHO Ixct Connttcc, Geneva, WorId HeaIIh OrganIzaIIon, 1988 (TechnIcaI ReporI SerIes No. 76S). |eyaraInam |, Koh D. Tcxtoo o occuntonn ncdcnc nctcc. SIngapore, WorId ScIenIIIIc PubIIshIng, 1996. |eyaraInam |. Occuntonn IcntI n dc\cong countc:. OxIord, OxIord MedIcaI PubIIcaIIons, 1992. KIIunga L|. WorkIng women. In:t Acnn nc\:cttc on occuntonn IcntI nnd :nct), 1989, 2:8-10. LaDou |. Occuntonn ncdcnc. New York, AppIeIon & Lange, 1990. LasI PA. HeaIIh proIecIIon and promoIIon. Women's heaIIh. In: SIeIIman |M, ed. Inc)concdn o occuntonn IcntI nnd :nct), 4Ih ed. Geneva, InIernaIIonaI Labour OrganIsaIIon, 1998. Levy BS, Wegman DH. Occuntonn IcntI, ccognzng nnd c\cntng \o-cntcd d:cn:c, 2nd ed. New York, LIIIIe, Brown & Company, 1988. McCunney R|, RounIree PP. Occuntonn nnd cn\onncntn ncdcnc. 5c- n::c::ncnt c\c\. PhIIadeIphIa, LIppIncoII WIIIIams & WIIkIns, 1998. OccupaIIonaI heaIIh Ior aII. In: oogcn nontong o cIcncn cxo:uc n tIc \oncc, VoI. 2, Geneva, WorId HeaIIh OrganIzaIIon, 1996. PIog BA, NIIand |, QuInIan P|. Iundnncntn: o ndu:tn I)gcnc, 4Ih ed. IIasca, IIIInoIs, NaIIonaI SaIeIy CouncII Press, 1996. Rom WN, ed. In\onncntn nnd occuntonn ncdcnc, Srd ed. PhIIadeIphIa, LIppIncoII WIIIIams & WIIkIns, 1998. Wod o \o. TIc nngnznc o tIc IIO. Geneva, InIernaIIonaI Labour OrganIsaIIon, 1996, 16. Wod o \o. TIc nngnznc o tIc IIO. Geneva, InIernaIIonaI Labour OrganIsaIIon, 1997, 19. Wod o \o. TIc nngnznc o tIc IIO. Geneva, InIernaIIonaI Labour OrganIsaIIon, 1997, 20. Young coc': IcntI: n cIncngc o :occt). Kcot o n WHO 5tud) Cou on )oung coc nnd "HcntI o A ) tIc Ycn 2. Geneva, WorId HeaIIh OrganIzaIIon, 1986 (TechnIcaI ReporI SerIes No. 7S1).