International Journal of Biometeorology

https://doi.org/10.1007/s00484-018-1651-y

CORRESPONDENCE

The significant role of health surveillance in the occupational heat

stress assessment
Francesco Chirico 1,2 & Nicola Magnavita 2

Received: 5 November 2018 / Revised: 27 November 2018 / Accepted: 27 November 2018

# ISB 2018

Abstract
In order to address the heat stress hazard, the worker health surveillance makes a difference by providing information about
individual factor, feedback, and evidence about efficacy of preventive measures and activities carried out through the risk
assessment process, at individual and group levels. Every technical, procedural, or organizational measures could be ineffective
without taking into account the results provided by health surveillance.

Keywords Health surveillance . Heat stress–related illness . Occupational physicians . Outdoor workers . Risk assessment process

Dear Editor,
We have read with great interest the review by Gao et al.
(2018) about the challenges posed by heat stress hazards to
outdoor workers, particularly in the context of climate change.
In their paper, authors underlined the importance of the ther-
mal risk assessment and many types of preventive measures
highlighted by scholars so far, in order to propose a more
systematic and holistic approach to climatic heat stress re-
search composed by several protective strategies (Gao et al.
2018). Indeed, climate change is a global emergency that can
have negative consequences for occupational health and safe-
ty, affecting health and productivity of indoor, and especially
outdoor workers. Gao et al. considered the importance of the
Bindividual heat strain monitoring^ in order to detect early
thermal physiological and psychological responses in vulner-
able workers (e.g., un-acclimatized, untrained, frail, aging
workers, and workers with chronic diseases and disabilities)
and to provide timely and targeted personal protection and
* Francesco Chirico
medlavchirico@gmail.com
Nicola Magnavita
nicola.magnavita@unicatt.it
1 hol and caffeine consumption), in presence of some medical
Health Service Department, State Police, Ministry of Interior, Via
Umberto Cagni, 21, 20162 Milan, Italy
2 assumption of drugs altering the body’s temperature regula-
Occupational Health Section of the Department of Life Sciences and
Public Health, Università Cattolica del Sacro Cuore, Largo F. Vito 1,
00168 Rome, Italy
health care when confronted with heat waves. In this regard,
we agree with Gao et al. that as suggested by ISO 12894
(2001), appropriate medical supervision of workers must be
performed prior to and during severe heat stress.
However, we were wondering why health surveillance has
not been included among the protective strategies.
Occupational health surveillance is a secondary prevention
measure required by national law whenever workers are liable
to be exposed to occupational risks that primary measures
cannot eliminate (Magnavita 2011; Magnavita et al. 2011).
In this regard, we believe that primary prevention measures
will never be able to eliminate all the health risks posed by
climate change to workers’ health and productivity.
Indeed, heat stress hazard can cause several effects ranging
from mild discomfort to serious illnesses like heat exhaustion
and heat stroke, despite the adoption or implementation of
primary preventive measures. Studies on outdoor workers
showed that during heatwave periods, one degree increase of
maximal temperature over the threshold of 35.5 °C was asso-
ciated with a 13% increase of occupational heat illness claims
(Xiang et al. 2015).
It is well recognized, indeed, that acceptable climatic con-
ditions may be intolerable and facilitate heat stress–related
illnesses in presence of certain individual factors that may
cause dehydration (e.g., poor diet, vomiting, diarrhea, or alco-
conditions (e.g., heart problems, diabetes, hypertension, or
tion) or in presence of physiological factors related to age
(young and older workers), general physical fitness, and

weight (e.g., obesity or overweight), which may increase sus-
ceptibility to heat stress–related conditions (Acharya et al.
2018; Chirico and Rulli 2015).
Therefore, the risk assessment of this physical hazard has
not only to focus on environmental (climatic conditions) or
other general (intensity of physical work, insufficient water
consumption, inadequate cooling off or rest periods, and in-
appropriate clothing) factors, but has to consider certain indi-
vidual factors that are subject of evaluation by occupational
physicians as well (Acharya et al. 2018; Chirico 2018).
In next years, the risk of heat stress will be increasingly
more important, because climate change may negatively im-
pact on large healthy population, such as older, pregnant, and
young employees as well as on workers with chronic health
conditions. According to the ISO 12984 standard, medical
examination of workers must be given careful consideration.
Last but not least, the worker health surveillance may be
able to give an added value to heat stress risk assessment, by
providing feedback and evidence about effectiveness of pre-
ventive measures, at both individual (e.g., use and fitness to
use of PPEs) and group (epidemiological report on collective
data) levels (Magnavita 2011; Magnavita et al. 2011). Indeed,
the aim of occupational health surveillance is not only to
check the worker’s fitness to work, but also to evaluate and
to provide the entire evaluation process with epidemiological
information, which may be ultimately useful for improving
the efficacy of preventative measures (Magnavita 2011;
Magnavita et al. 2011).
For all these reasons, we believe that every technical, pro-
cedural, or organizational measures could be ineffective with-
out taking into account the results provided by health surveil-
lance, which may inform and drive the whole risk assessment
process, according to the PDCA (Plan-Do-Check-Act) cycle
of Deming, which is the most used methodology across the
world to implement an occupational health system (Chirico
and Rulli 2017; Magnavita 2011; Magnavita et al. 2011). In
our experience, this method has been applied in the last
20 years, under the name of A.S.I.A.©, to many working
conditions, including outdoor work with exposure to heat
stress (Cannas et al. 2003).
In Italy, as in many European Union countries, regular
health surveillance is mandatory for outdoor workers and is
aimed not only at formulating the individual fitness to work,
Int J Biometeorol
but also at giving to the employees precious medical sugges-
tions about good practices and correct behaviors (e.g., eating,
drinking, and lifestyle) to follow during their work.
In other words, health surveillance and surveillance of the
work environment (occupational hazard identification, risk
assessment) are two different but inter-related aspects of oc-
cupational risk management, and we believe that health sur-
veillance has an essential role against heat stress–related dis-
orders.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
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