Sentinel surveillance and occupational disease

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(HSE) RIDDOR (Reporting of Injuries, Diseases and. Dangerous Occurrences Regulations) in the UK have obvious limitations because only certain health prob-.
Editorials  611

Gert van der Laan Foundation Learning and Developing Occupational Health, Speelkamp 28, 3831 PE Leusden, The Netherlands e-mail: [email protected] Present address: Foundation Learning and Developing Occupational Health Markku Sainio Finnish Institute of Occupational Health, Center of Expertise for Development of Work and Organizations, Topeliuksenkatu 41 a A, 00250 Helsinki, Finland

References 1. Hänninen H. Psychological methods in the diagnosis of industrial poisoning. Acta Neurol Scand 1967;43(Suppl. 31):135+.

doi:10.1093/occmed/kqv166

Sentinel surveillance and occupational disease Improving collection and analysis of data to measure trends in occupational diseases (ODs) has long been, and continues to be, a strategic aim of past and future European Union strategies for health and safety at work. Precision in terminology has traditionally influenced the gradual growth of science, including in the discipline of medicine. Definitions evolve over time reflecting contemporary scientific thinking and developments shaped by social, political and academic factors [1]. Sentinel surveillance systems in occupational health involve the ongoing and rapid identification of sentinel health events (cases and their corresponding occupational risks) for purposes of follow-up and for developing statistical trends [2–4]. The goal of such surveillance systems is to enhance case reporting, identify risk factors and high-risk work sites and link preventive interventions to work sites and the broader community [5]. The under-reporting of compensable and non-compensable work-related health problems by physicians is a well-documented phenomenon. Improving the reporting by physicians to surveillance systems in general and particularly health problems attributed to new and

emerging risks is a central objective for MODERNET [6]. In the MODERNET consortium, we looked specifically at the term ‘OD’ as it is applied to sentinel surveillance systems and examined if the term facilitates or hinders reporting of work-related health problems to surveillance systems. The ILO (International Labour Organization) and European commission (EU commission) are significant institutions that contribute to policy development in occupational health. In Europe, the EU commission continues to influence methods of statistical data collection that provide better evidence and monitoring tools for the prevention of work-related diseases by tackling new and emerging risks without neglecting existing risks. Better terminology to assist policymaking as it concerns workers health is vital. The scientific community must remain mindful of the importance of the coordinating role of the international institutions such as the ILO, the World Health Organization (WHO), European Union and the Organization for Economic Co-operation and Development (OECD) on shaping occupational health practice.

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Evelien van Valen Solvent Team Amsterdam, Netherlands Center for Occupational Diseases, Coronel Institute of Occupational Health, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands

2. Spurgeon A. Watching paint dry: organic solvent syndrome in late-twentieth-century Britain. Med Hist 2006;50:167–188. 3. World Health Organization (WHO). Chronic Effects of Organic Solvents on the Central Nervous System and Diagnostic Criteria. Environmental Health 5. Copenhagen, Denmark: WHO, 1985. 4. White RF, Proctor SP. Solvents and neurotoxicity. Lancet 1997;349:1239–1243. 5. van Valen E, van Thriel C, Akila R et al. Chronic solventinduced encephalopathy: European consensus of neuropsychological characteristics, assessment, and guidelines for diagnostics. Neurotoxicology 2012;33:710–726. 6. European Commission. Information Notices on Occupational Diseases: A  Guide to Diagnosis. Luxembourg: Office for Official Publications of the European Communities, 2009. 7. Furu H, Sainio M, Hyvärinen HK et  al. Detecting chronic solvent encephalopathy in occupations at risk. Neurotoxicology 2012;33:734–741. 8. Spee T, van Valen E, van Duivenbooden C, van der Laan G. A screening programme on chronic solvent-induced encephalopathy among Dutch painters. Neurotoxicology 2012;33:727–733. 9. Keski-Säntti P, Kaukiainen A, Hyvärinen HK, Sainio M. Occupational chronic solvent encephalopathy in Finland 1995–2007: incidence and exposure. Int Arch Occup Environ Health 2010;83:703–712. 10. Kim Y, Kim JW. Toxic encephalopathy. Saf Health Work 2012;3:243–256.

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It is not uncommon that some dedicated physicians report ODs that are on the national list of compensable diseases even to systems that are not primarily designed for workers compensation. Conversely, given the historical conditioning of physicians in general to the legal term OD they may in fact detect, but not report, a health problem attributed to new and emerging risks—precisely because the said work-related health problem is not on the list of compensable health problems as defined by national workers compensation legislation. This is not mere speculation on our part as ~50% of all cases reported annually to the Norwegian system for sentinel surveillance of OD (Register for Arbeidsrelaterte Sykdommer [RAS]) concern historical exposures [12]. This surveillance system is based on section 5-3 in the Working Environment Act that mandates physicians to report OD and other diseases related to work [13]. However, RAS is far from a national registry for compensable occupational diseases, rather it is a sentinel surveillance system [2]. The cases are often reported by occupational health physicians (68%) as supplementary documentation for the patients’ compensation claims rather than as a health problem caused by an ongoing known or a new exposure. Systems like the Health & Safety Executive’s (HSE) RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations) in the UK have obvious limitations because only certain health problems attributed to work are required to be reported. As a result of this, the HSE identified alternative preferred data sources for use in describing ill-health, including self reported Labour Force Survey, THOR physician reporting schemes such as Surveillance of Work-related and Occupational Respiratory Disease (SWORD), the dermatologist’s surveillance scheme (EPIDERM), Industrial Injury Disablement Benefit (IIDB), death certificates and the use of the attributable fraction (the proportion of the total number of cases of the disease that are caused by occupational exposure from epidemiological studies) [14]. Legally defined lists of notifiable or compensable diseases limit the term OD, and those who work within the structures that use the term are therefore unlikely to acknowledge new and emerging risks. New and emerging risks at work resulting in health problems may not necessarily have a novel pathology but unusual exposure pathways. For example, ‘green buildings’ is a growing phenomenon in order to protect indoor air quality for future occupants. However, this poses a new challenge for workers as air supply vents to buildings are sometimes sealed off during construction so that construction dust and emissions do not enter the building putting the health of future occupants at risk. The sealing-off of the air vents and minimizing ventilation could expose construction workers to heat stress [15]. Such cases are not necessarily legally compensable ODs but provide information on health problems where the

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The meaning of the term OD has evolved from the 1930s, when it was officially used in the ILO’s convention on compensable diseases to the modern-day application in the EU commission’s regulation on community statistics. This designated the term OD exclusively for compensable health problems attributed to work as recognized by national legislation in member countries [7,8]. Thus, OD is seen as having a specific or a strong relation to occupation generally with only one causal agent and recognized as such, whereas work-related diseases may have multiple causal agents, where factors in the work environment may play a role, together with other risk factors, in the development of such diseases. Hence, the term OD in the European context has a categorical legal connotation and not just a scientific causal one. In fact, OD is the term of choice for compens­able diseases attributed to work in policy documents and communiques across Europe [9–11]. Data systems vary across countries in terms of objectives, management, scope, criteria and probably therefore in the degree of under-reporting. This diversity makes it hard to compare statistics between countries. Moreover, the term OD alludes to different compensable work-related health problems across European member states based on workers compensation regulations in a particular member state. For example, workrelated musculoskeletal disorders are compensated health problems in Sweden and are legally an OD, but that is not the case in Norway. However, both Norway and Sweden acknowledge the serious challenge posed by musculoskeletal disorders for occupational health and target prevention programmes to address this challenge. Clearly, the overarching term OD implies two different things for reporting physicians in Sweden and Norway because reportable diseases are understood in the context of national compensation laws. Therefore, comparing trends or monitoring ODs across countries seems impracticable as the inclusion criteria for a reportable case are subject to compensability of the health condition. The somewhat varied understanding of the term OD that we observe between Scandinavian countries is even more diverse when we refer to ODs in a panEuropean context because of the cultural, social, legal and linguistic diversity across Europe. Many physicians, who could potentially report a new and emerging risk resulting in a work-related health problem, are also often involved in assessing and reporting workers’ compensation cases. These physicians may be handling cases of workers compensation as part of their regular duties or because they may be professionally and personally interested and moreover trained in occupational medicine. In either case, physicians who report work-related health problems have over the years been conditioned to report ODs as they appear on the list of compensable diseases to national systems or insurance companies.

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development initiatives or facilitation of clinical audit. It is often easier to prescribe treatment for many work-related conditions than to fully investigate the cause. Our intention is to engage the European scientific community in a healthy debate on appropriate scientific terminology—particularly in the context of sentinel surveillance for detecting new and emerging risks at work. Terminology that is more inclusive will enhance the quality of our sentinel surveillance systems and better enable them to capture early signals of new and emerging risks. Yogindra Samant Norwegian Labour Inspection Authority, Statens Hus, Trondheim 7468, Norway e-mail: [email protected] Axel Wannag Norwegian Labour Inspection Authority (Retired), Statens Hus, Trondheim 7468, Norway e-mail: [email protected] Pavel Urban Department of Occupational Medicine, Charles University, Ovocny 3-4, 116 36 Prague 1, Czech Republic e-mail: [email protected] Stefano Mattioli Department of Medical and Surgical Sciences, Academic Discipline: MED/44 Occupational Medicine, Dipartimento di Scienze Mediche e Chirurgiche Via Massarenti 9, Bologna, Italy e-mail: [email protected]

References 1. Kuhn TS. The Structure of Scientific Revolutions. Chicago, IL: University of Chicago Press, 1996. 2. Samant Y, Parker D, Wergeland E, Wannag A. The Norwegian Labour Inspectorate’s Registry for WorkRelated Diseases: data from 2006. Int J Occup Environ Health 2008;14:272–279. 3. Rutstein DD, Mullan RJ, Frazier TM, Halperin WE, Melius JM, Sestito JP. Sentinel Health Events (occupational): a basis for physician recognition and public health surveillance. Am J Public Health 1983;73:1054–1062. 4. Bonneterre V, Faisandier L, Bicout D et  al.; RNV3P. Programmed health surveillance and detection of emerging diseases in occupational health: contribution of the French national occupational disease surveillance and prevention network (RNV3P). Occup Environ Med 2010;67:178–186. 5. Curti S, Sauni R, Spreeuwers D et  al. Interventions to increase the reporting of occupational diseases by physicians. Cochrane Database Syst Rev 2015;3:CD010305. 6. ISCH COST Action IS1002. Modernet, A  Network for Development of New Techniques for Discovering Trends in Occupational and Work-Related Diseases and Tracing New and

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exposures are not novel but occurring at workplaces previously unknown to us (e.g. green buildings). In the near future, it is likely that sentinel surveillance systems such as RAS might capture the first cases of health consequences attributed to nanomaterials although presently the exact pathophysiological mechanisms remain unclear. Regulatory control and compensation follows rather than prompts such recognition and it is improbable that these first cases will be recognized for workers compensation with expediency. The status of such cases as non-compensable health problems (not an OD) will remain resolute at least until the causality between workrelated exposure to nanomaterials and harm to human health is sufficiently established. The legal recognition of a health problem as a legally compensable OD in addition to scientific evidence is also influenced by the social and political factors at play [16]. Physicians can be influenced by social factors such as the advent of new technologies; passage of laws establishing workers’ benefits; labour union or media campaigns; public outcry against environmental hazards; cultural stereotyping; medical specialization or competition; and others. Such ‘gatekeepers’ functions can influence workplace relations and industrial economies. Our reasoning guides us towards the conclusion that use of the term OD for the purpose of sentinel surveillance in occupational health and particularly for detecting new and emerging risks is impractical to be applied in the European context. To resolve this conundrum, we propose the use of the alternative term work-related ill-health particularly in the context of physician reporting to sentinel surveillance systems. Physicians would report new cases of disease that they believe to have been caused or aggravated by work. The decision as to whether the case is work related would be left to the physician, although general guidance on reporting could be provided such as in the UK THOR, Dutch or French RNV3P schemes. We believe that a more inclusive term than OD will better facilitate detection of new and emerging risks. Firstly, because the term work-related ill-health is not a legally entrenched term with regards to workers compensation. Moreover, the term work-related ill-health accounts for a range of morbidities such as diseases, illnesses, disorders, various forms of injuries, including other health problems attributed to work. Secondly, less exclusive terminology for case detection will better facilitate sentinel surveillance, but this needs to be coupled with several other efforts to yield better surveillance data. For example, emphasizing the import­ ance of occupational history in primary care settings will make our sentinel surveillance efforts more comprehensive and facilitate the detection of new and emerging risks at work [17]. However, physician’s attitudes and awareness of the links between work and health may need to be addressed through education and continuing professional

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Report_DeclarationMP_EUROGIP_102EN.pdf (7 March 2015, date last accessed). 12. Samant Y, Lysberg K, Landrø M, Eriksen T, Wergeland E. Doctors’ reports of work-related hearing loss. Tidsskr Nor Laegeforen 2014;134:1950–1955. 13. Directorate of Labour Inspection. The Working Environment Act. Trondheim, Norway: Directorate of Labour Inspection, 2015. http://www.arbeidstilsynet.no/ binfil/download2.php?tid=92156 (5 September 2015, date last accessed). 14. Waclawski ER. Disease reporting after the Reporting of Injuries, Diseases, and Dangerous Occurrence Regulations (1995) (RIDDOR) is revised. Occup Med (Lond) 2013;63:168–171. 15. Chen HJ. Green and Healthy Jobs. Maryland: The Center for Construction Research and Training, 2010. http://tcimass.org/sites/builtbest.prometheuslabor.com/files/GreenHealthy%20Jobs%20fnl%20for%20posting.pdf (4 August 2014, date last accessed). 16. Dembe PAE. Occupation and Disease: How Social Factors Affect the Conception of Work-Related Disorders. New Haven, CT: Y   ale University Press, 1996. 17. Markowitz S. Occupational diseases and reporting systems. In: Stellman JE, ed. Encyclopedia of Occupational Health and Safety. 4th edn. Geneva, Switzerland: International Labour Office, 1998. http://www.iloencyclopaedia.org/part-iv-66769/record-systems-and-surveillance-2359/50-32-record-systems-and-surveillance/ occupational-disease-surveillance-and-reporting-systems (September 2014, date last accessed).

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Emerging Risks. Brussels, Belgium: MODERNET, 2010. http://www.costmodernet.org/content/meetings (7 March 2015, date last accessed). 7. EU Commission. Regulation (EC) No 1338/2008 of the European Parliament and of the Council of 16 December 2008 on Community Statistics on Public Health and Health and Safety at Work. Official Journal of the European Union. Brussels, Belgium: European Union, 2008. 8. International Labour Organization. C018—Workmen’s Compensation (Occupational Diseases) Convention, 1925 (No. 18). Geneva, Switzerland: International Labour Office, 1993. 9. EU Commission. Report on the Current Situation in Relation to Occupational Diseases’ Systems in EU Member States and EFTA/EEA Countries, in Particular Relative Commission Recommendation 2003/670/EC Concerning the European Schedule of Occupational Diseases and Gathering of Data on Relevant Related Aspects. Brussels, Belgium: EU Commission, 2013. http://ec.europa.eu/social/Blob Servlet?docId=9982&langId=en (22 July 2015, date last accessed). 10. EUROGIP. Occupational Injuries 2012. Paris: EUROGIP, 2012. http://www.eurogip.fr/en/component/search/?theme_ document=Statistics&date_document=Select+a+ date&pays_document=Select+a+country&searchword=K eywords&type_de_document=publication (22 July 2015, date last accessed). 11. EUROGIP. Reporting of Occupational Diseases: Issues and Good Practices in Five European Countries. Paris: EUROGIP, 2015. http://www.eurogip.fr/images/publications/2015/