The surveillance of occupational diseases in Italy: the MALPROF system.

BACKGROUND: Occupational diseases data can guide efforts to improve worker's health and safety. AIMS: To describe MALPROF, the Italian system for surveillance of work-related diseases collected by the subregional Department of Prevention. METHODS: The MALPROF system started in 1999 with contributions from Lombardy and Tuscany and spread in the following years to collect contributions from 14 out of the 20 Italian regions. MALPROF data were explored to follow-up work-related diseases and to detect emerging occupational health risks by calculating proportional reporting ratio (PRR), as in pharmacosurveillance. It classified work-related diseases according to economic sector and job activity in which the exposure occurred. Occupational physicians of the Italian National Health Service evaluate the possible causal relationship with occupational exposures and store the data in a centralized database. RESULTS: From 1999 to 2012, the MALPROF system collected about 112000 cases of workers' diseases. In 2010, more than 13000 cases of occupational diseases were reported. The most frequently reported diseases were hearing loss (n = 4378, 32%), spine disorders (n = 2394, 17%) and carpal tunnel syndrome (n = 1560, 11%). The PRR calculated for cervical disc herniation, a disease whose occupational origin has to be studied, in 1999-2010 was 2.47 [95% confidence interval (CI) 1.76-3.47] for drivers and 36.64 (95% CI 22.03-60.93) for air transport workers. CONCLUSIONS: MALPROF is a sensitive system for identifying possible associations between occupational risks and diseases, it can contribute to the development of preventive measures, to evaluate the effectiveness of preventive interventions and to stimulate research on new occupational risks and diseases.

[Burden of disease of occupational asthma in Tuscany: methodological aspects and preliminary results]. / Il calcolo del Burden of disease dell'asma da lavoro in Toscana: aspetti metodologici e risultati preliminari.

In Italy, unlike in other European countries, the public health burden of work-related asthma (WRA) has not yet be defined by means of a standardized validated epidemiological metric. The aim of the present study is to describe the methodology for the calculation of the Burden of Disease of WRA in Tuscany on the grounds of available healthcare and health survey data. The paper is particularly intended to illustrate the methodological approach to estimate the prevalence of the disease.

[Occupational injuries and sickness absence: association with job demand, decision latitude, and life style in 2174 workers in the Veneto Region]. / Infortuni sul lavoro e assenze dal lavoro per malattia: associazioni con carico lavorativo, autonomia decisionale e stili di vita in 2174 lavoratori del veneto.

BACKGROUND: Stress was the most frequent (26,9%) health problem reported in a survey on the perception of working and health conditions in 5000 workers in the Veneto Region. OBJECTIVES: The aim of the study was to investigate in the Veneto Region the association between occupational stress and events occurred in the previous 12 months: occupational accidents, or sickness absence for 10 or more consecutive days. METHODS: Perceived occupational stress is correlated, according to Karasek's model, to high job demand (JD) and low decision latitude (DL). Using Karasek's questionnaire (to which questions on smoking and alcohol consumption were added), we examined 2174 subjects working in 30 companies with between 10 and 500 employees, who belonged to the occupational categories of industry and services that are more prevalent in the Veneto Region. The questionnaire was administered by the occupational physician during health surveillance. The subjects were classified on the basis of current exposure to psychosocial factors or, for subjects reporting an event, their exposure at that time. We identified the tertiles of JD and DL; data were submitted to the analysis of multiple logistic regression, estimating odds ratio (OR) and 95% confidence interval (CI). The population attributable risk (PAR) was calculated using the formula (pc (OR-1)/OR), where pc is the fraction of exposed cases. RESULTS: An elevated risk of occupational accidents was found in subjects with regular consumption of alcohol (OR = 2.0; IC = 1.2-3.5), in smokers smoking 10-20 (2.3; 1.3-3.8) or >20 cigarettes/day (3.8; 1.8-7.9), in the highest tertile of JD (2.29; 1.35-3.89) and in the lowest tertile of DL (1.6; 1.0-2.6). PAR was 37.6% for occupational factors (high JD and low DL), 44.5%for non-occupational factors (cigarette smoking and alcohol consumption), and 82.1% overall. The risk of sickness absence increased in subjects smoking 10-20 cigarettes (1.63 = 1.1-2.40), in the highest tertile of JD (1.5; 1.0-2.2) and in the lowest tertile of DL (1.6; 1.1-2.2). PAR was 26.1% for occupational factors (high JD and low DL), 7.6% for non-occupational factors (smoking), and 30.4% overall. While the risk of sick absence increased mainly with the reduction of DL, the risk of occupational accidents increased with increasing JD and, to a lesser extent, with decreasing DL. The current approach to accident prevention is based only on technical and administrative aspects, in spite of the fact that 80% of accidents are not attributable to malfunctioning of machinery. Injury prevention should address technical, personal and psychosocial risk factors together as a whole.

[Occupational exposure to nickel in Tuscany: analysis of a biological monitoring register for the period 1991-1998]. / Esposizione occupazionale a Nichel in Toscana: analisi di un registro di monitoraggio biologico per il periodo 1991-1998.

OBJECTIVE: The study assesses the time trend in exposure to nickel among factory workers in Florence, via data on biological monitoring. A data-base of nickel in urinary samples (Ni-U mg/l) was created for the period 1991 to 1998. METHODS: The data-base contained 2.138 samples, measured by atomic absorption (GF-AAS),from 893 workers. Subjects came from 157 factories in various manufacturing sectors, especially electroplating, mechanical workshops, jewellery. RESULTS: Ni-U levels were correlated with manufacturing sector. The highest levels were found among workers from electroplating industries, where exposure was mainly due to water-soluble nickel compounds. The eight-year time trend showed a statistically significant decrease in Ni-U values, with a sharper drop during the last two-year period. Age, sex and number of samples per subject were not statistically related to this trend. CONCLUSION: The observed Ni-U decrease could be related to the efficacy of new legislation introduced in Italy during the study period (Law 626/94 and subsequent laws), but also to the intense labour inspection activities that officials of National Health Service performed, which were rightly focused on nickel exposure in different manufacturing sectors. This study confirms the usefulness for occupational risk evaluation of a biological monitoring data-base of routinely collected data.

Respiratory risks in tunnel construction workers.

Respiratory diseases are frequent in tunnel construction workers. A group of 144 subjects randomly selected from the population of 2516 workers engaged in the construction of the railway tunnel under the Appennine Mountains, from Bologna to Firenze was investigated. A group of 69 males comparable for age, living area and habits was studied as a control group. Assessment of air pollutants (NO, NO2, SO2, total dust, silica %) was carried out by means of fixed monitoring stations as well as personal monitors. All the subjects included in the study were examined with a standardised protocol which included physical examination, lung function tests (before and after shift work) and a questionnaire to college respiratory symptoms. Low concentrations of environmental pollutants were evidenced. Significantly lower values of FEV1 and PEF were determined in the worker group pared to controls. A significant decrease in respiratory parameters was shown after shift work. Variables capable of influencing the decrease in parameters include smoking habits, work activity, presence of cough and expectoration, period of the year (spirometries resulted worse in the winter time). Significantly lower values of FEV1 and PEF were evidenced in the workers compared to controls. In spite of the present low work environmental exposure conditions, some physiologic parameters appear altered in tunnel construction workers. This may depend on a variety of noxious agents present in the working environment.

Occupational exposure to n-hexane in Italy--analysis of a registry of biological monitoring.

OBJECTIVE: This study assesses 2,5-hexanedione (2,5-HD) in the urine of subjects exposed to n-hexane solvent between 1991 and 1998, from details obtained from the Registry of Biological Monitoring (BM) at the Florence Local Health Unit, and its development over time. METHODS: The Registry contains 15,925 samples from 6,650 subjects occupationally exposed to n-hexane, especially in leather (9,099 samples; 3,607 subjects) and shoe (3,865 samples; 1,938 subjects) production. RESULTS: Over the time span studied there was a total reduction of 31.9% in urinary 2,5-HD level. The yearly decrease over the entire period was 5.4%. Dividing the 8 years into three periods: before the introduction of the new legislation for health protection in the workplace (1991-1993), during its transition (1994-1996) and after its complete enforcement (1997-1998), respectively, we observed a marked decrease in the last period. Women and young people (under 30 years) experienced significantly higher absorption levels (respectively, 7.1% and 24.4%). CONCLUSION: The data suggest that monitoring was more frequent in subjects with higher starting values, and the greatest decrease was reported in this group. Reduction may be due to less n-hexane in the products used, better structural conditions in the factories, and the effectiveness of inspections carried out by the authority for hygiene and safety in the workplace. The results confirm the usefulness of the reporting of risk levels of exposure to industrial toxicants by routine biological monitoring.

[Occupational experience, epidemiologic observations, and scientific evidence in an illustrative case: adverse effects of the production and use of aromatic amines in Italy]. / Esperienza operaia, osservazione epidemiologica ed evidenze scientifiche in un caso emblematico: gli effetti nocivi della produzione e dell'impiego di amine aromatiche in Italia.

Economical, social and technical interrelations between synthetic dyes' production and bladder cancer in workmen engaged in the manufacture are reviewed. International situation is the background of Italian situation, mainly of the Lombardy region and Turin area. For decades social actors, individuals and institutions, acted as separate bodies, contributed to delay and omit the protection of workers' health. The situation changed when scientific knowledge, technical developments and workers' commitment prioritized workers' health as a main goal. The epidemic of bladder cancers among dyestuff workers was a cornerstone in the development of a different scenario in the production responsibility, workers' participation and eventually scientific community. The authors hypothesise that in our country these events stimulated the growth of epidemiology and epidemiologists; furthermore since then institutions promulgated a new and up-to-date wave of protective legislation in the workers' H&S field.

[Exposure to carcinogens in work environment today. State of the art, problems and prospects raised by the Law 626/94]. / Esposizione a cancerogeni oggi nell'ambiente di lavoro. Stato dell'arte, problemi e prospettive introdotte dal D.lgs 626/94.

The implementation in our country of recent legislation on carcinogenic risk assessment and management (VIIth title of Law 626/94) is considered. The authors describe potentialities and limits of the new legislation and of the derived Guidelines issued by the Regions. The health policy in this field and possible evolution in the near future are outlined, bearing in mind the experience of other countries. A short list of questions is suggested as a contribution to the discussion on the future scenario: whether exposure to carcinogens should be lower in the working environment than in the general environment; what is the relative importance of multifactoriality, individual biological variability, individual life-style in the genesis of cancers; whether medical health surveillance is worthwhile in terms of primary prevention; is it always true that there is no threshold limit value for carcinogens; what is the role of individual attitudes to prevention in exposure to carcinogens compared to "objective" protection; which balance between costs and benefits should be aimed at.

[The epidemiological aspects of eye screening in occupational medicine]. / Considerazioni epidemiologiche sullo screening oculistico in medicina del lavoro.

The wide-spread use of video display units in many work places has led to an increase in ophthalmologic examinations of the operators. For this reason, instruments for visual test screening (for example Visotest) have become widely used. Nevertheless, the literature does not seem to offer any clarification about the utility of these instruments as epidemiological tools. The costs and benefits of visual screening programmes were estimated in relation to specific visual deficit prevalence in a differently age-structured population. Via epidemiological calculation, it was demonstrated that positive and negative predictive values, which are directly related to deficit prevalence, are more important than sensitivity and specificity calculations. In view of the disorders screened, a visual test with a low positive predictive value is more expensive than one with a low negative predictive value. A visual test for visual deficits screening does not appear to be advisable in young populations, where the true positives/false positives ratio is 1:4, whereas in older populations the ratio is 2:1.

[Back pain in health care workers]. / Il mal di schiena nel personale sanitario.

Back pain is a major health and economic problem for preventive medicine. It has been found to be significantly associated with nursing. The present paper reviews a number of epidemiological studies on back pain in nurses and examines the main confounding factors. The different approaches to back pain prevention are briefly discussed.

[Survival in respiratory tract tumors: Italian population-based data and international comparisons]. / La sopravvivenza per tumori dell'apparato respiratorio: dati italiani su base di popolazione e confronti internazionali.

Population survival studies are usually carried out within population-based cancer registries and are useful mainly for geographical and temporal survival comparisons. Survival studies based on clinical series of patients are traditionally executed to evaluate the efficacy of a given treatment or to analyze the prognostic role of clinical factors. Subjects from a case-control study on incidence of larynx and hypopharynx cancers in Turin, for the period 1979-82, were followed-up in order to study their survival. The analysis was based on 347 cases of larynx cancer (319 males and 28 females) and 48 cases of hypopharynx cancer (47 males and 1 female). For larynx cancer, observed five-years survival was 59% in males and 64% in females. Hypopharynx cancer had a worse prognosis (21%). In males suffering from larynx cancer, older age, extent of spread, birth in Northern Italy, and being unmarried proved to be statistically significant negative prognostic factors. The same variables were also predictive of survival for hypopharynx cancer. The one- and three-year relative survival for larynx cancer in Turin was higher than that reported by other cancer registries. For males, relative five-year survival figures range from 47% to 65%. Survival for hypopharynx cancer is considerably lower, five-year figures ranging from 13% to 35%. The survival study on lung cancer was based on all the incident cases recorded by the Lombardy Cancer Registry (L.C.R.) from 1976 to 1981; during this period there were 2042 cases of primary lung cancers occurred in males and 217 in females. Observed survival at one, three and five years from diagnosis was 29%, 8% and 5%, respectively. Survival decreased with increasing age; no important differences between sexes are evident. Information on tumor stage was available in 1904 cases and histotype was known in 1605. Three-year survival was 17% for localized tumors, 8% for tumors with regional metastasis, and 1% for tumours with distant metastasis. Epidermoid carcinomas had a better prognosis than non-epidermoid carcinomas in the first year of follow-up, survival being 38% and 29%, respectively; among non-epidermoid carcinomas the worst prognosis was for small-cell carcinomas. Comparisons between the LCR relative survival and that reported by other cancer registries did not show important differences, five-year figures ranging from 5% to 10% in males.(ABSTRACT TRUNCATED AT 400 WORDS)

Occupational exposure to cadmium and lung function.

A total of 69 male subjects occupationally exposed to cadmium fumes in a factory producing silver-cadmium-copper alloys for brazing, were subjected to lung function tests, including ventilation (FVC and FEV1), residual volume (RV) and alveolar-capillary diffusion capacity (TLCO and KCO). For each subject, the cumulative exposure to cadmium was calculated as the product of the number of years in the job and the average atmospheric concentration of cadmium (expressed in micrograms/m3) encountered each year. Cadmium-exposed subjects had moderately higher mean values of RV (+ 8%) as compared with the control group; the increase was greater (+ 10%) in the subgroup of workers with greater cumulative exposure to cadmium. No significant differences were observed in FVC, FEV1, TLCO and KCO.

Behaviour of urinary nickel in low-level occupational exposure.

The study tested the feasibility of using urinary nickel (Ni-U) as a biological indicator to assess exposure to soluble nickel compounds in electroplating departments at concentrations well below the current TLV-TWA. Two groups of workers were studied: Group A, consisting of 13 subjects and Group B consisting of 10 subjects, with an average weekly nickel exposure of nickel in air (Ni-A) greater than or equal to 10 micrograms/m3 (Group A) and less than 10 micrograms/m3 (Group B). Air samples and urine specimens were taken on 4 consecutive days from Monday to Thursday. The mean Ni-U levels in both groups were significantly higher than in the reference group. The Ni-U levels in end-of-shift spot samples showed a tendency to increase over the week; this trend was more marked in Group A. Closer correlations between Ni-A and Ni-U were found using the postshift Ni-U values of Thursday: the test was well correlated both with the Ni-A levels of the same day and with the mean levels of the previous days. The results suggest that Ni-U is a sufficiently sensitive indicator for use in monitoring low-level occupational exposure, especially if Ni-A concentrations are above 10 micrograms/m3.

Carrots, green vegetables and lung cancer: a case-control study.

A total of 417 lung cancer cases and 849 controls were interviewed on their life-long tobacco usage and their current intake of four food items rich in retinol or carotene. The study was a hospital-based case control where 'cases' were lung cancer patients diagnosed during the period 1979/80 at seven hospitals in the Lombardy region (90% pathologically confirmed) and controls were patients admitted to the same hospitals for causes unrelated to tobacco smoking (epithelial cancers being excluded from present analysis). Odds ratios (OR) have been computed for increasing frequencies of consumption of liver, cheese, carrots and leafy green vegetables, having controlled for the confounding effects of tobacco usage, residence and birthplace. Current smokers who did not consume carrots showed a three-fold risk of developing lung cancer compared with those who ate them more than once a week (OR = 2.9 less than p less than 0.01); the ORs for consumers in the categories of 1-2 and 3-4 times per month were 1.8 and 2.0 respectively, with a significant test for linear trend (p less than 0.01). Among ex-smokers or non-smokers, no decrease of lung cancer risk is evident associated with carrot consumption. An excess risk was also associated with low intake of green vegetables although it was not significant, while no excess risk was evident for non-consumers of liver and cheese. The effect of carrots is independent of histological type of lung cancer while the effect of green vegetables was confined to epidermoid carcinomas: low versus high intake group OR = 1.3.

On the causal association between exposure to leather dust and nasal cancer: further evidence from a case-control study.

A case-control study was performed on the incident cases of nasal cavity tumours which occurred between 1968 and 1982 among the residents of Vigevano (Lombardy region, northern Italy). This area is characterised by a high prevalence of shoemakers (especially in leather); the activity has predominated in Vigevano since the beginning of this century. Twenty one cases were identified (16 men and five women); 20 were histologically confirmed as nasal epithelial tumours; 17 had already died at the time of interview and the occupational history was obtained from the next of kin. Two controls per case were selected from the general population and matched by vital status, age, sex, and residence. The overall odds ratio for the subjects exposed to leather dust was 47.1 for men and 3.5 for women. The odds ratio was higher for adenocarcinoma and among the workers exposed to the worst working conditions. A significant trend for the level of exposure to leather dust was found. Nevertheless, even the jobs characterised by a relatively low exposure were found to have a significantly higher risk (OR = 7.5). Smoking habits and exposure to solvents are unlikely to confound the relation between exposure to leather and nasal tumours.