Some of these conditions are just as likely to arise from other factors in the social history, including hobbies and travel.

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1 SECTION 3: COMMON OCCUPATIONAL DISEASES N.B. you re going to see these cases everywhere in medicine where the patients are of working or retired age. Some of these conditions are just as likely to arise from other factors in the social history, including hobbies and travel. Aims of this section: A) Broaden things included in general medical diagnosis B) Understand the difference between hazard and risk-use this knowledge to apply to explanations to patients e.g. consent for procedure/operation. And to answer patient questions such as Has x caused y? 1. There are 4 categories of hazard: chemical, biological, psychological and physical. The latter includes heat, vibration, radiation, light, manual handling, heights, confined spaces, ergonomics, pressure, mechanics etc. 2. THERE IS NO SUCH THING AS RSI. Instead use the term UPPER LIMB DISORDERS (ULD) Terminology in this area has been attended by difficulty and change. The term workrelated upper limb disorder, previously widely used, has been superseded by the term upper limb disorder (the use of work-related can be associated with legal difficulties in a particular case unless a link with work has been demonstrated unequivocally).often, but not always, there are multiple causative factors i.e. those that predispose, trigger and maintain. It may be that factors other than the physical work involved play a part and these could include previous injuries, the physical environment (for example, a low working temperature) and psychosocial factors such as low job satisfaction. Upper limb disorders (ULD), like many of its synonyms, is a descriptive term only. It provides as much guidance as the term sports injury might, in that it is not a diagnosis but describes a collection of syndromes. Repetition strain injury (RSI) is another frequently used term, which originated in Australia. It is misleading in that it implies repetition is the only cause, and that an injury has occurred, both of which may not be true in individual cases. Whilst it is a term strongly discouraged in occupational health, it has become part of the lay vocabulary, as a result of continued use in the popular press. ULD describes conditions characterised by discomfort or persistent pain in the soft tissue structures of the neck and upper limb regions where the condition has been either caused or aggravated by work factors. These conditions can be further divided, into Those with a clear diagnosis and pathology, such as tenosynovitis, carpal tunnel syndrome and lateral epicondylitis 1

2 Those with no proven pathology, such as tendinitis or myofascial pains of the upper limb. It is thought t hat t here may be, broadly, t hree mechanisms responsible for causing pain: static muscle activity, repeated and forceful dynamic activity. In the experience of many occupational health professionals, factors such as mental tension play a part in the causation of such problems. 3. The main OCCUPATIONAL RESPIRATORY DISORDERS (ORD) in the United Kingdom 2012 are: 1. Pneumoconiosis (fibrosis), due to a variety of dusts (e.g. silica, coal and asbestos); approx. 30% ORD notifications. 2. Asthma, resulting from sensitisation or irritation; 30% ORD notificationsisocyanate spray paints (commonest), latex, flour dust, chemicals, cleaning agents. 1:6 (approx 15%) of new cases of adult onset asthma are occupational! Ref: BTS/RCGP/RCP guidelines. Occupational asthma must be suspected in these cases and referred early to a specialist! 3. Extrinsic allergic alveolitis (type 3 immune reaction) from organic dusts of biological origin; <30% ORD notifications. a. Acute (flu-like illness, dyspnoea) history of occupation, hobbies is allimportant b. Chronic-if not recognised, leads to recurrent acute episodes, then fibrosis. c. Often misdiagnosed as asthma, COPD 4. COPD (coal dust, some chemicals) 5. Irritation due to inhalation of gases or fumes, such as chlorine, HCl mist, and oxides of nitrogen. 2

3 Occupational diseases 2012 PHOTOGRAPHS AND TUTOR NOTES 1 Air hostess Would have access to occupational health services Physical (P) Biological (B) Intoxicated/aggressive customers? Time zone changes Shift work No-they tend to enjoy what they do, or leave the job Intoxicated/aggressive customers? Disruption of all circadian rhythms-leads to range of health effects. Known increase in miscarriage rate; breast cancer (shift-work now classified as IARC group 2A carcinogen) NOTES Allowed to be grounded as soon as they know they are pregnant. Questions for students: work out how shift-work may be related to cancer IARC (International Agency for Research on Carcinogens): Agents Classified by the IARC Monographs Group 1 Carcinogenic to humans 108 agents Group 2A Probably carcinogenic to humans 64 Group 2B Possibly carcinogenic to humans 271 Group 3 Not classifiable as to its carcinogenicity to humans 508 Group 4 Probably not carcinogenic to humans 1 Shift work which disrupts circadian rhythms has been classed as a class 2 carcinogen. Why? Because it probably increases the risk for breast cancer (hormone dependent ones) but the association is not huge, and is dose and duration-dependent (around 30 years exposure to rapidly changing shift patterns) for reference, see Danish nurses study Useful discussion with students about the explanation of hazard and risk e.g. when patients ask Has this illness been caused by smoking? or How likely is this side-effect to happen? 3

4 2. Airport worker airside May/should have access to occupational health services Physical (P) Poor pay and working conditions Manual handling (heavy and awkward); N.B. this is the most likely problem to arisebeing knocked over very busy, fast-moving environment, lots of vehicles + people; injury, death Deafness (high-frequency; sensorineural) High noise levels (peak - 140dB); Musculo-skeletal problems e.g. shoulder/back Chemical (C) Petrol spillage asphyxiation, dizziness, collapse anxiety/depression Questions for students during debrief- What can you do to protect the workers-what are they wearing? How is personal protective equipment (PPE) not a very effective control?-it can fail/not be used/they are still exposed e.g. to noise. However, can t remove the noise from planes-they could, however, rotate the workers in and out of the noisy areas during each shift i.e. vary the duties and monitor their health e.g. audiometry 4

5 3 Business (around table) e.g. advertising, management consultancy or other corporate environments-common job Would possibly have access to occupational health services Tightly-driven targets; competitive culture; long hours; money = bottom line Py: Anxiety, depression, burnout N.B. Most professions are required to work far longer hours than doctors. 5

6 4 Call centre worker N.B. This case must be discussed as it is commonest job in UK (2012)- 10% of population. Conditions of work and work environment vary. Likely to have access to occupational health services Physical (P) Awkward, sustained postures Musculoskeletal problems-back, neck, upper limbs Tightly-driven targets; lack of breaks, even for toilet anxiety/depression Questions for students during debrief Have students worked in one-what was it like? A.K.A. The new factories -why do you think they have been dubbed as this? N.B. there is no such things as RSI!!-see page 1 of these notes. 6

7 5 Chef/Cook-common job Unlikely to have access to occupational health Physical (P) Wet floors Heat Knives Awkward postures (in picture) Heavy manual handling Injuries: burns slips/trips/falls Cuts Musculoskeletal problems e.g. pain, tendinitis. Chemical (C) Foodstuffs Asthma Dermatitis Time pressure Working hours Anxiety/depression Notes: Look at their postures/ask patients about postures if they present with musculoskeletal problems. 7

8 6 Chimney sweep Rare but important job now (in the past common, comes up in exams) Will not have access to occupational health services Chemical (C) Coal products-polyaromatic hydrocarbons (PAHs) Squamous cell scrotal skin cancer DISCUSSION POINTS The first-discovered occupational disease in 18 th century. (Pott s tumour) Always occupational. Questions for students: Work out how it occurs. Boys/men used to go up the chimney-gravity makes suit fall down. Collects in groin area which may be sweaty. In olden times, people doing this sort of job may not have had a change of clothes or access to washing. We see it much less because of a) recognising occupational diseases b) preventative measures/public health medicine e.g. clean water reduces cholera infections. c) The job is done differently now...how? Environmental/public health now PAH s in the environment. These are an important thing for all doctors to know about, regularly in journals: -link between PAHs (what are they? Benzene ring structures, products of combustion, oil refining etc, traffic fumes, rubber manufacture, chemical manufacture) and population health. Direct link between these respirable (less than 10 micron particles) and rates of: Cardiovascular mortality Respiratory mortality Hospital admissions Especially vulnerable are those with pre-existing respiratory/cardiac disease/elderly/children. Cancers (esp. Haematological, lung, skin) Levels rise when there is excess traffic pollution, heat, low air movement e.g. Easter 2011, UK government advised those with asthma etc. not to go outdoors. 8

9 7 Construction site common jobs-multiple hazards In the UK, an example of a high-hazard, high-risk industry. Still high rates of death, injury, cancers. May/may not have access to occupational health services Physical (P) Dusts Incl. Asbestos Falls into holes/from heights Confined spaces Pneumoconiosis-DEFINITION = pulmonary fibrosis caused by exposure to mineral dusts Commonest three in UK: Asbestosis Silicosis Coal worker s pneumoconiosis Bronchial carcinoma Mesothelioma Death/injury Chemical (C) Gases Explosives Chemicals of all sorts Death Injury Asthma Dermatitis-cement is commonest cause of allergic dermatitis in men in UK (nickel from jewellerynon-occupational in women) Biological (B) Less common Legionnaire s disease; Leptospirosis Short-term, casual labour often Job insecurity at all levels of staff incl. directors 9

10 8 Dentist May/may not have access to occupational health services, depending on local arrangements Physical (P) Awkward, sustained postures. Especially of neck and shoulders Radiation Back/neck pain, upper limb disorders No need to cover radiation issues at this stage Chemical (C) Acrylic glues (for crowns, dentures etc.) Hand dermatitis (can be severe and threaten livelihood); Asthma Biological (B) Needle/sharps injury, bites Blood-borne viruses Self-employed?isolated High suicide rates, anxiety/depression; NOTES Acrylics/acrylates generally commonly cause severe dermatitis/asthma which means people have to leave their job and livelihood-e.g. nail technicians-they literally cannot move their hands. Students will say How could anyone do that job? -discuss how we may enjoy different things... 10

11 9 Farmer common job No access to occupational health services Physical (P) Handling/herding animals Injury incl. Crushing Hip arthritis (reason unknown) Chemical (C) Pesticides see sheep-dipping photo Biological (B) See under vet Zoonoses Isolation; economic insecurity (various High suicide rates reasons) 11

12 10 Fisherman (North Sea) Unlikely to have access to occupational health services Physical (P) Weather Manual handling, incl. With ropes/machinery Repetitive activities High death rate (drowning) Injury-cut/amputation Chemical (C) Biological (B) Animal antigens Can rarely develop type 1 (immediate) allergies to animals e.g. fish Type 4 immune reaction can also occur (allergic dermatitis) Long hours Isolation Economic restrictions (EU quotas) May be on/off shore for extended periods Drug abuse in some isolated but wealthy communities Depression/anxiety 12

13 11 Hairdresser-common job Do not generally have access to occupational health services Physical (P) Chemical (C) Repetitive postures Prolonged raised arm postures Hair dyes Perming solutions Upper limb disorders including shoulder disorders; tendinitis Dermatitis Dermatitis often severe-leave jobs and livelihood (refer them back to first exercise) Sprays Asthma Biological (B) Bits of hair Irritant dermatitis N.B. there is no such things as RSI!! Refer early to a dermatologist if they develop dermatitis -no access to OH-you must recognise it! Refer early to dermatologist for patch-testing. 13

14 12 Healthcare workers-common Would have access to occupational health services HOPEFULLY YOU HAVE DISCUSSED HAZARDS AND HEALTH RISKS FOR HEALTHCARE WORKERS IN THE EARLIER PART OF THE DAY. Physical (P) Chemical (C) Biological (B) Radiation Awkward postures Manual handling of patients Anaesthetic gases Glues (acrylates, surgeons) Biocides Hand-washing Infected aerosol exposure/skin contact (contagious) exposure Needlestick/splash/other injury Rapid and repeated pace of change (same as all public sector) Work demands, responsibility etc. Patients violence/aggression Factors in the way doctors react to own illness Factors in personalities of doctors Dermatitis Asthma Risks from anaesthetic gases? TB infection rates 2-3 rates c.f. general population Scabies URTI D+V etc. Hepatitis B/C/HIV; Musculoskeletal-back pain If cough lasts > 3 weeks, report to OH. c.f. general population significantly increased rates: Anxiety/depression Alcohol/drug abuse Suicide rates 14

15 13 Lawyer Could access occupational health services if wanted Long hours, competition etc Anxiety, depression 15

16 14 Musician (bar) Would not generally have access to occupational health services This picture is to illustrate something which may reduce in the future, as a result of the legal prohibition of smoking in public places. There has been shown to be a definite link between passive smoke inhalation and lung cancer. Famous examples include Louis Armstrong and Roy Castle, who both died from this combination, and who had been life-long non-smokers. We would hope to see a reduction in secondary-smoke-related bronchial carcinoma rates in the future. 16

17 15 Printing press NOTES: this example has been put in to demonstrate that Health and Safety Legislation and knowledge have significantly reduced rates of occupational disease. The safest and most effective way of preventing occupational diseases is to totally remove use of the offending substance (aniline dyes) and replace it with something safer. Printing chemicals now are water-based. In the past toxic (aniline) dyes and inks were used, and are strongly associated with the development of bladder cancer. 17

18 16 Sheep-dipping Farmers do not generally have access to occupational health services. This problem needs to be suspected and identified by their GP or specialist doctors, especially in rural areas. Chemical (C) Pesticides-organophosphates (gardeners are also exposed at work) Absorbed through the skin. Neurological effects Acute (CNS): death Coma, fits, dizziness, headache Chronic (peripheral NS) affect acetylcholinesterase levels Neuropathies 18

19 17 Somebody soldering NOTES: this is a common part of someone s work. May/may not have access to occupational health services Physical (P) Chemical (C) Static posture Awkward postures Heat source Various chemicals, traditionally lead Also, respiratory sensitisers e.g. rosin (pine tree extract) Musculoskeletal disorders Burns Lead poisoning Asthma 19

20 18 Soldier, Armed Forces Common job. Will have access to occupational health services when in-service; probably will not if no longer in Forces. Physical (P) Chemical (C) Biological (B) Explosives etc. Many awkward postures; need high level of physical fitness Chemicals Abnormal experiences e.g. witnessing death, mutilation, torture etc. isolation Muscloskeletal disorders Range of psychological problems including PTSD 20

21 19 Teacher Usually have access to occupational health services via Local Authority (employer) Reduced range of methods of classroom control-can discuss why, rapid change; national curriculum; OFSTED Health Risks Resulting Anxiety, depression n 21

22 20 Vet or anyone who works with animals Would not usually have access to occupational health services NOTES: there is a lot to talk about with this one. Physical (P) Chemical (C) Biological (B) Awkward postures; handling large and small animals Anaesthetic agents Animal pathogens Injury, bites, musculoskeletal disorders?neurological, headache, drowsiness etc. Zoonoses Tick-borne diseases, Bacterial diseases etc tick-borne, viral orf, rickettsial etc. ZOONOSES A zoonosis can be defined as an infection which is normally present in animals but occasionally transfers to humans. Transmission is most likely to occur when in close or regular contact with animals. This can occur at home, on holiday and at work. This section of the day should be used to widen the students differential diagnoses generally, to include disorders that are often forgotten about e.g. Lyme disease fairly common, and increasing in UK-New Forest, Highlands and Islands, Devon, Northumberland-history of work near deer, holidays Weil s disease-travel in UK/abroad, hobbies/sports e.g. canoeing, occupationssewage workers, police, underground workers etc. Q-fever-Chlamydia pneumonia, sheep farmers Brucellosis Rabies etc. 22

23 21 Welder-this is an extremely common part of jobs in UK. May/may not have access to occupational health services Ask students What is welding? Some will have done it. If not, it is basically a way of fusing metals together and there are many types. All involve metal, a heat source and a chemical cocktail. Some forms involve electricity. Physical (P) Chemical (C) Heat Manual handling Awkward postures Metal fume Heavy metal poisoning Cocktail of chemicals Burns-A/E-WELDER S EYE (WELDER S ARC=CORNEAL BURN). What should you ask in A/E? - Were you wearing your eye protection? - an opportunity for health promotion. Skin burns Musculoskeletal disorders Metal fume fever (mild, flu-like) Poisoning and long-term effects ASTHMA-difficult to tell what causes it-there are so many probable culprits-welders with asthma must be referred early to a specialist N.B. Welders + new respiratory symptoms=asthma until proved otherwise. 23