Covid-19: statutory means of scrutinizing workers' deaths and disease.

BACKGROUND: By law, covid-19 disease and deaths in workers may lead to coroners' inquests and/or Health and Safety Executive (HSE) investigations. AIMS: This study assesses the adequacy of these statutory means to yield recommendations for prevention of acquiring covid-19 infection from work. METHODS: Covid-19 guidance from the chief coroner and the HSE was appraised, including using Office for National Statistics (ONS) data. Practitioners were asked to estimate the likelihood that covid-19 disease may have arisen from 'near-miss' scenarios. Data from the judiciary and the HSE were analysed. RESULTS: The coroners' guidance allowed a wider range of reports of death than did the HSE and conformed better with ONS data on covid-19 mortality by occupation. In the practitioner survey, 62 respondents considered a higher likelihood that reported covid-19 cases would have arisen from the scenario deemed unreportable as a 'dangerous occurrence' by HSE than the reportable scenario (P < 0.001). On average there was only one coroner's report to prevent future death from occupational disease every year in England and Wales. The HSE dealt with a yearly average of 1611 reports of work-related disease including 104 on biological agents, but has received about 9000 covid-19 reports. CONCLUSIONS: Current HSE guidance for reporting work-related covid-19 may miss many thousands of cases and needs further iteration. Coroners have very limited experience of inquiry into occupational disease caused by biological agents compared with the HSE. Concerns regarding national policy such as on protective equipment warrant a full public inquiry.

Work-related ill-health in radiographers.

BACKGROUND: In the UK in 2015/16, 1.3 million workers self-reported a work-related illness (WRI) of which an estimated 41% were due to musculoskeletal disorders (incidence rate 550 cases per 100000 people) and 37% were related to stress, anxiety and depression. Little is known about the incidence of WRIs in radiographers. AIMS: To analyse the medically reported incidence of WRIs among radiographers in the UK between 1989 and 2015. METHODS: Incident cases reported by physicians to The Health and Occupation Research (THOR) network through its specialist schemes from 1989 to 2015 were analysed, using the Labour Force Survey as denominator where appropriate. RESULTS: In total, 218 cases (966 estimated cases) were reported. Of these 190 were in women. The mean age was 40.2 (20-91 years) SD ± 11.8 years. Most cases were reported to the Occupational Physicians Reporting Activity (OPRA) scheme (n = 92). A skin diagnosis was the most frequently reported (n = 77), followed by musculoskeletal (n = 60). Within the EPIDERM scheme, radiographers had the highest incidence rate when compared to all other occupations. CONCLUSIONS: Radiographers had a higher incidence of WRI compared to all other occupations. The most frequently reported WRI was skin conditions. The observed increase in incidence is likely to be due to the increase in the number of radiographers over that time period, although there was no evidence that WRI within radiographers are declining.

The impact of national-level interventions to improve hygiene on the incidence of irritant contact dermatitis in healthcare workers: changes in incidence from 1996 to 2012 and interrupted times series analysis.

BACKGROUND: Reducing healthcare-associated infections (HCAI) has been a priority in the U.K. over recent decades and this has been reflected in interventions focusing on improving hygiene procedures. OBJECTIVES: To evaluate whether these interventions coincided with an increased incidence of work-related irritant contact dermatitis (ICD) attributed to hand hygiene or/and other hygiene measures in healthcare workers (HCWs). METHODS: A quasi-experimental (interrupted time series) design was used to compare trends in incidence of ICD in HCWs attributed to hygiene before and after interventions to reduce HCAI with trends in the same periods in control groups (ICD in other workers). Cases of ICD reported to a U.K. surveillance scheme from 1996 to 2012 were analysed. The time periods compared were defined objectively based on the dates of the publication of national evidence-based guidelines, the U.K. Health Act 2006 and the Cleanyourhands campaign. RESULTS: The reported incidence of ICD in HCWs attributed to hygiene has increased steadily from 1996 to 2012 [annual incidence rate ratio (95% confidence interval): hand hygiene only 1.10 (1.07-1.12); all hygiene 1.05 (1.03-1.07)], whereas the incidence in other workers is declining. An increase in incidence of ICD in HCWs attributed to hand hygiene was observed at the beginning of the Cleanyourhands campaign. CONCLUSIONS: The increasing incidence of ICD in HCWs combined with the popularity of interventions to reduce HCAI warrants increased efforts towards identifying products and implementing practices posing the least risk of ICD.

The utility of information collected by occupational disease surveillance systems.

BACKGROUND: The Health and Occupation Research (THOR) network in the UK and the Republic of Ireland (ROI) is an integrated system of surveillance schemes collecting work-related ill-health (WRIH) data since 1989. In addition to providing information about disease incidence, trends in incidence and the identification of new hazards, THOR also operates an ad hoc data enquiry service enabling interested parties to request information about cases of WRIH reported to THOR. AIMS: To examine requests for information made to a network of surveillance schemes for WRIH in the UK. METHODS: Analysis via SPSS of data requests received by THOR between 2002 and 2014. RESULTS: A total of 631 requests were received by THOR between 2002 and 2014. Requests were predominantly submitted by participating THOR physicians (34%) and the main THOR funder-the UK Health & Safety Executive (HSE) (31%). The majority (67%) of requests were for information about work-related respiratory or skin disease with relatively few requests for other diagnoses, such as musculoskeletal or mental ill-health. Requests frequently related to a specific industry and/or occupation (42%) and/or a specific causal agent (58%). CONCLUSIONS: Data collected by occupational disease surveillance systems such as THOR are an extremely useful source of information, the use of which extends beyond informing government on disease incidence and trends in incidence. The data collected provide a framework that can assist a wide range of enquirers with clinical diagnoses, identification of suspected causative agents/exposures and to highlight growing risks in particular industrial and occupational sectors.

Isocyanate exposure and asthma in the UK vehicle repair industry.

BACKGROUND: Organic diisocyanates are a common cause of occupational asthma, particularly in motor vehicle repair (MVR) workers. The UK Health & Safety Laboratory provides screening for urinary hexamethylenediamine (UHDA), a biomarker of exposure to 1,6-hexamethylene diisocyanate (HDI). The UK Surveillance of Work-related and Occupational Respiratory Disease scheme (SWORD) has collected reports of occupational asthma since 1996. AIMS: To compare trends in HDI exposure with trends in the incidence of work-related asthma attributed to isocyanates or paint spraying in MVR workers reported to SWORD. METHODS: Two-level regression models were used to estimate trends in UHDA levels and work-related asthma in MVR workers reported to SWORD. The direction and magnitude of the trends were compared descriptively. RESULTS: From 2006 to 2014, there was a significant decline in the number of urine samples with detectable levels of UHDA (odds ratio = 0.96; 95% confidence intervals 0.94-0.98) and minimal change in those over the guidance value (1.03; 1.00-1.06). Over the same period, there was a significant decline in all asthma cases attributed to isocyanates or paint spraying reported to SWORD (0.90; 0.86-0.94) and a non-significant decline among MVR workers (0.94; 0.86-1.02). CONCLUSIONS: The simultaneous decrease in HDI exposure and incident cases of asthma reported to SWORD is temporally consistent with a reduction in exposure to airborne isocyanate leading to a reduction in asthma. Although this is not direct evidence of a causal relationship between the two trends, it is suggestive.

Chemical determinants of occupational hypersensitivity pneumonitis.

BACKGROUND: Workplace inhalational exposures to low molecular weight (LMW) chemicals cause hypersensitivity pneumonitis (HP) as well as the more common manifestation of respiratory hypersensitivity, occupational asthma (OA). AIMS: To explore whether chemical causation of HP is associated with different structural and physico-chemical determinants from OA. METHODS: Chemical causes of human cases of HP and OA were identified from searches of peer-reviewed literature up to the end of 2011. Each chemical was categorized according to whether or not it had been the attributed cause of at least one case of HP. The predicted asthma hazard was determined for each chemical using a previously developed quantitative structure-activity relationship (QSAR) model. The chemicals in both sets were independently and 'blindly' analysed by an expert in mech anistic chemistry for a qualitative prediction of protein cross-linking potential and determination of lipophilicity (log K ow). RESULTS: Ten HP-causing chemicals were identified and had a higher median QSAR predicted asthma hazard than the control group of 101 OA-causing chemicals (P < 0.01). Nine of 10 HP-causing chemicals were predicted to be protein cross-linkers compared with 24/92 controls (P < 0.001). The distributions of log K ow indicated higher values for the HP list (median 3.47) compared with controls (median 0.81) (P < 0.05). CONCLUSIONS: These findings suggest that chemicals capable of causing HP tend to have higher predicted asthma hazard, are more lipophilic and are more likely to be protein cross-linkers than those causing OA.

A refined QSAR model for prediction of chemical asthma hazard.

BACKGROUND: A previously developed quantitative structure-activity relationship (QSAR) model has been extern ally validated as a good predictor of chemical asthma hazard (sensitivity: 79-86%, specificity: 93-99%). AIMS: To develop and validate a second version of this model. METHODS: Learning dataset asthmagenic chemicals with molecular weight (MW) <1 kDa were identified from reports published in the peer-reviewed literature before the end of 2012. Control chemicals for which no reported case(s) of occupational asthma had been identified were selected at random from UK and US occupational exposure limit tables. MW banding was used in an attempt to categorically match the control group for MW distribution of the asthmagens. About 10% of chemicals in each MW category were excluded for use as an external validation set. An independent researcher utilized a logistic regression approach to compare the molecular descriptors present in asthmagens and controls. The resulting equation generated a hazard index (HI), with a value between zero and one, as an estimate of the probability that the chemical had asthmagenic potential. The HI was determined for each compound in the external validation set. RESULTS: The model development sets comprised 99 chemical asthmagens and 204 controls. The external validation showed that using a cut-point HI of 0.39, 9/10 asthmagenic (sensitivity: 90%) and 23/24 non-asthmagenic (specificity: 96%) compounds were correctly predicted. The new QSAR model showed a better receiver operating characteristic plot than the original. CONCLUSIONS: QSAR refinement by iteration has resulted in an improved model for the prediction of chemical asthma hazard.

Assessing the impact of national level interventions on workplace respiratory disease in the UK: part 2--regulatory activity by the Health and Safety Executive.

OBJECTIVE: To investigate whether interventions implemented by the UK Health and Safety Executive addressing exposure to isocyanate-based spray paints in motor vehicle repair (MVR), flour dust in craft bakeries, rosin-based solder flux fume (RBSFF) in the electronics industry, metalworking fluids and wood dust coincided with a decline in incidence of work-related short latency respiratory disease (SLRD) or asthma in the target groups. METHOD: Changes in the incidence of SLRD reported to a UK-based surveillance scheme were compared using a longitudinal, negative binomial regression model with ß distributed random effects. An interrupted time series design was used and comparisons according to inclusion or exclusion in the target group were made by including a statistical interactions expressed as a ratio of incidence rate ratios (RIRRs) in the model. RESULTS: The incidence of SLRD attributed to flour dust significantly increased relative to all other agents (RIRR: 1.10; 95% CI 1.06 to 1.16) whereas SLRD attributed to RBSFF significantly declined relative to all other agents (0.94; 0.90 to 0.99). No significant changes in the incidence of SLRD attributed to wood dust (1.03; 0.91 to 1.16) or spray paints (1.03; 0.95 to 1.11) relative to all other agents were observed. A higher proportion of reports originated from the industries targeted by the intervention for RBSFF (65/107; 61%) than spray painting (27/93; 27%) or wood dust (16/42; 38%). CONCLUSIONS: These data support a beneficial effect of interventions to reduce exposure to RBSFF but an increase in SLRD attributed to flour dust may indicate increased exposure or increased awareness of the problem.

Assessing the impact of national level interventions on workplace respiratory disease in the UK: part 1--changes in workplace exposure legislation and market forces.

OBJECTIVE: The 2004 amendment to the Control of Substances Hazardous to Health 2002 regulations (COSHH 2004) introducing workplace exposure limits (WELs) was enacted in the UK in 2005. This study aimed to determine whether introducing this legislation coincided with a reduction in the incidence of work-related short latency respiratory disease (SLRD) attributed to the agents with a WEL. The second objective was to determine whether changes in legislation, WELs and market forces coincided with a reduction in the incidence of SLRD attributed to glutaraldehyde and latex. METHOD: Reports of SLRD made to the Surveillance of Work-related and Occupational Respiratory Disease scheme were used to estimate the change in incidence within reporters between two time periods (interrupted time series design) using a longitudinal, negative binomial regression model with ß distributed random effects. A statistical interaction term was included in the model to make comparisons between the groups defined by suspected causal agent and/or occupation, essentially comparing two interrupted time series. Time periods were defined prospectively representing the changes in legislation or market forces. RESULTS: The introduction of the COSHH 2004 legislation in the UK coincided with a significant reduction in reports of SLRD attributed to agents with a WEL relative to those without a WEL (ratio of incidence rate ratios: 0.70; 95% CI 0.52 to 0.93) and a significant reduction in SLRD attributed to glutaraldehyde in healthcare workers (0.20; 0.07 to 0.57) and latex in all workers (0.37; 0.16 to 0.85). CONCLUSIONS: These data are consistent with a beneficial effect of legislation aiming to reduce workplace exposures.

Development of mechanism-based structural alerts for respiratory sensitization hazard identification.

This study outlines how mechanistic organic chemistry related to covalent bond formation can be used to rationalize the ability of low molecular weight chemicals to cause respiratory sensitization. The results of an analysis of 104 chemicals which have been reported to cause respiratory sensitization in humans showed that most of the sensitizing chemicals could be distinguished from 82 control chemicals for which no clinical reports of respiratory sensitization exist. This study resulted in the development of a set of mechanism-based structural alerts for chemicals with the potential to cause respiratory sensitization. Their potential for use in a predictive algorithm for this purpose alongside an externally validated quantitative structure-activity relationship model is discussed.

Has European Union legislation to reduce exposure to chromate in cement been effective in reducing the incidence of allergic contact dermatitis attributed to chromate in the UK?

OBJECTIVE: Hexavalent chromate (chromate) in cement is a well-recognised cause of allergic contact dermatitis (ACD). Consequently in January 2005, following European Union legislation (EU Directive 2003/53/EC), the use or supply of cement containing >2 ppm of chromate was prohibited in the UK (COSHH 2004). This analysis of work-related ill-health surveillance aims to evaluate the effectiveness of this legislation. METHOD: Changes in the incidence of work-related ACD cases returned to The Health and Occupation Reporting network by dermatologists were analysed taking in to account attribution to chromate and occupation. RESULTS: There was a significant decline in the incidence of both ACD attributed to chromate (incidence rate ratio 0.48, 95% CI 0.36 to 0.64) and ACD not-attributed chromate (0.76, 95% CI 0.69 to 0.85) between the time period preceding the EU legislation (2002-2004) and the postlegislation period (2005-2009). However, the decline in ACD attributed to chromate was significantly greater (p=0.006). This decline was further increased in workers potentially exposed to cement (incidence rate ratio 0.37, p=0.001). The majority of the decline in incidence occurred during 2005. CONCLUSION: The timing of this significant decline in the UK incidence of chromate attributed ACD, and the greater decline in workers potentially exposed to cement strongly suggests that the EU Directive2003/53/EC was successful in reducing exposure to chromate in cement in the UK.

Occupation and work-related ill-health in UK construction workers.

BACKGROUND: Construction workers are at increased risk of work-related ill-health (WRI) worldwide. AIMS: To compare the incidence of medically reported WRI in occupations within the UK construction industry according to job title. METHODS: We calculated standardized incidence rate ratios (SRRs) using WRI cases for individual job titles returned to The Health and Occupation Reporting network by clinical specialists and UK population denominators. We counted frequencies of reported causal exposures or tasks reported by clinical specialists, occupational physicians and general practitioners. RESULTS: We found significantly increased incidence of WRI compared with other workers in the same major Standard Occupational Classification, i.e. workers with similar levels of qualifications, training, skills and experience, for skin neoplasia in roofers (SRR 6.3; 95% CI: 3.1-13.1), painters and decorators (2.1; 95% CI: 1.2-3.6) and labourers in building and woodworking trades (labourers, 6.6; 95% CI: 3.2-13.2); contact dermatitis in metal workers (1.4; 95% CI: 1.1-1.7) and labourers (1.6; 95% CI: 1.1-2.3); asthma in welders (3.8; 95% CI: 2.8-5.0); musculoskeletal disorders in welders (1.7; 95% CI: 1.1-2.8), road construction operatives (6.1; 95% CI: 3.8-9.6) and labourers (2.5; 95% CI: 1.7-3.7); long latency respiratory disease (mesothelioma, pneumoconiosis, lung cancer, non-malignant pleural disease) in pipe fitters (4.5; 95% CI: 3.2-6.2), electrical workers (2.7; 95% CI: 2.4-3.2), plumbing and heating engineers (2.3; 95% CI: 1.9-2.7), carpenters and joiners (2.7; 95% CI: 2.3-3.1), scaffolders (12; 95% CI: 8-18) and labourers (3.3; 95% CI: 2.6-4.1). CONCLUSIONS: UK construction industry workers have significantly increased risk of WRI. These data in individual construction occupations can be used to inform appropriate targeting of occupational health resources.

The incidence of medically reported work-related ill health in the UK construction industry.

OBJECTIVE: Self-reported work-related ill health (SWI) data show a high incidence of occupational ill health and a high burden of cancer attributable to occupational factors in the UK construction industry. However, there is little information on the incidence of medically reported work-related ill health (WRI) within this industry. This study aims to examine the incidence of WRI within the UK construction industry. METHOD: Standardised incidence rate ratios (SRRs) were used to compare incidence rates of reports of medically certified work-related ill health returned to The Health and Occupation Reporting network (THOR) within the UK construction industry with all other UK industries combined. RESULTS: Male UK construction industry workers aged under 65 years had significantly raised SRRs for respiratory (3.8, 95% CI 3.5 to 4.2), skin (1.6, 1.4 to 1.8) and musculoskeletal disorders (MSD; 1.9, 1.6 to 2.2). These SRRs were further raised for those working within a construction trade. The increased SRRs for skin disease within male construction industry workers were due to contact dermatitis (1.4, 1.2 to 1.6) and neoplasia (4.2, 3.3 to 5.3). For respiratory disease, the increased SRRs were due to non-malignant pleural disease (7.1, 6.3 to 8.1), mesothelioma (7.1, 6.0 to 8.3), lung cancer (5.4, 3.2 to 8.9) and pneumoconiosis (5.5, 3.7 to 8.0), but the SRRs for asthma (0.09, 0.06 to 0.11) and mental ill health (0.3, 0.1 to 0.4) were significantly reduced. CONCLUSION: The significantly raised SRRs for medically reported MSD and significantly reduced SRRs for mental ill health in construction workers confirm self-reported UK data. These SRRs provide a baseline of the incidence of WRI in the UK construction industry from which to monitor the effects of changes in policy or exposures.

Does deprivation index modify the acute effect of black smoke on cardiorespiratory mortality?

OBJECTIVES: To investigate whether deprivation index modifies the acute effect of black smoke on cardiorespiratory mortality. METHODS: Generalised linear Poisson regression models were used to investigate whether deprivation index (as measured by the Carstairs deprivation index) modified the acute effect of black smoke on mortality in two largest Scottish cities (Glasgow and Edinburgh) between January 1981 and December 2001. Lag periods of up to 1 month were assumed for the effects of black smoke. RESULTS: Deprivation index significantly modified the effect of black smoke on mortality, with black smoke effects generally increasing as level of deprivation increased. The interaction coefficient from a parametric model assuming a linear interaction between black smoke (microg/m(-3)) and deprivation in their effect on mortality--equivalent to a test of 'linear trend' across Carstairs categories--was significant for all mortality outcomes. In a model where black smoke effects were estimated independently for each deprivation category, the estimated increase in respiratory mortality over the ensuing 1-month period associated with a 10 microg/m(3) increase in the mean black smoke concentration was 8.0% (95% CI 5.1 to 10.9) for subjects residing in the 'most' deprived category (Carstairs category 7) compared to 3.7% (95% CI -0.7 to 8.4) for subjects residing in the 'least' deprived category (Carstairs category 1). CONCLUSIONS: The results suggest a stronger effect of black smoke on mortality among people living in more deprived areas. The effect was greatest for respiratory mortality, although significant trends were also seen for other groups. If corroborated, these findings could have important public health implications.

Alkylation of sperm DNA is associated with male factor infertility and a reduction in the proportion of oocytes fertilised during assisted reproduction.

Approximately one-third of IVF cases in the UK are attributed to male factor infertility and in the majority of cases the origin of male infertility is unknown. The integrity of sperm DNA is important both for the success of assisted reproduction and the implications for the off-spring. One type of DNA damage that has not been investigated with respect to fertility outcomes is the adduct N7-methyldeoxyguanosine (N7-MedG), a biomarker for exposure to alkylating agents. A prospective cohort of couples attending for IVF had their N7-MedG levels in sperm measured using an immunoslot blot technique to examine whether sperm N7-MedG levels are associated with male factor infertility, semen quality measures or assisted reproduction outcomes. Sufficient DNA for analysis was obtained from 67/97 couples and N7-MedG was detected in 94% of sperm samples analysed. Men diagnosed with male factor infertility had significantly higher mean levels of N7-MedG in their sperm DNA (P=0.03). Logistic regression analysis showed that N7-MedG levels were significantly negatively associated with the proportion of oocytes successfully fertilised irrespective of the method of fertilisation used (IVF or intra-cytoplasmic sperm injection; ICSI, P<0.001). Therefore exposure to DNA alkylating agents is significantly associated with male infertility and the proportion of oocytes fertilised during assisted reproduction. Reducing such exposure may improve male fertility but further work is required to determine the relative importance of exogenous and endogenous sources of exposure.

Medically reported work-related ill-health in the UK agricultural sector.

BACKGROUND: Self-reported work-related ill-health (WRI) statistics suggest that agricultural workers in the UK are at an increased risk of musculoskeletal disorders (MSD), skin and respiratory disease. However, there is little comprehensive medically reported information on WRI in the UK agricultural sector. METHODS: Cases of WRI within the UK from 2002 to 2008, as reported to The Health and Occupation Reporting (THOR) network by occupational physicians, clinical specialists and general practitioners, were analysed. Directly standardized incidence rate ratios (SRRs) for the agricultural sector versus all other sectors were calculated for dermatological, musculoskeletal, respiratory and psychological illness, using as the standard population the UK working population as estimated from the Labour Force Survey. RESULTS: During 2002-08, 471 cases within the agricultural sector were reported to THOR (2% of all cases). Based on reports by clinical specialists, male agricultural workers aged <65 years had significantly raised SRRs for MSD (2.3, 95% CI 1.6-3.3), allergic alveolitis (32, 95% CI 19-51), asthma (1.9, 95% CI 1.2-3.0) and skin neoplasia (7.9, 95% CI 5.8-10.9) and a significantly reduced SRR for asbestos-related respiratory disease (0.4, 95% CI 0.2-0.7). Reports of mental ill-health in agricultural workers were low. CONCLUSIONS: These medically reported incidence data provide information on WRI in the UK agricultural sector. Consistent with other sources, there are increased risks for asthma, allergic alveolitis and MSD and a reduced risk for mental ill-health. The raised incidence of skin cancer requires confirmation and further comparison with reliable estimates of the incidence in the UK workforce.

A time-series study of the health effects of water-soluble and total-extractable metal content of airborne particulate matter.

OBJECTIVES: To assess whether adverse acute cardiopulmonary health outcomes are associated with concentration of trace metals in airborne particulate matter. METHODS: Daily PM(10) and PM(2.5) were collected for 1 year in Edinburgh, UK, and the water-soluble and total-extractable content of 11 trace metals determined in each sample. Time series were analysed using generalised additive Poisson regression models, including adjustment for minimum temperature and less smoothing of trends. Methods were explored of extending the time series of metal concentration in daily PM(10) for the previous 7 years using multiple regression of the variation in metal content for the 1 year of measurements and the associated variation in air mass source region and other concurrently-measured potential predictor variables. RESULTS: The 1 year of direct measurements showed no evidence of significant associations of particle-bound metal concentration with health outcomes beyond that expected by chance. Analysis of the extended time series showed significant positive associations with cardiovascular admissions both for total PM(10) and for a number of the metals (eg, Cu, Fe, Ni, V, Zn) but the metal effects were no longer significant after adjusting for PM(10). CONCLUSIONS: Within the limitations of the study power, the epidemiological results have not provided evidence for associations between particle-bound metal concentrations and adverse health outcomes that are substantially greater than for total PM. The generally strong correlations between metal and total PM suggest that quantifying independent effects of PM metal exposure on health will be difficult, even using more powerful time series of direct measurements.