Occupational Medicine and Total Worker Health®: from preventing health and safety risks in the workplace to promoting health for the total well-being of the worker.

The COVID-19 pandemic has highlighted the importance of Public Health interventions for global social and economic development. Still, the community's well-being depends on each individual's health. In addition to pandemics, health conditions can be altered by chronic degenerative diseases, aging, disabilities, and work. Personal behaviors such as poor nutrition, lack of physical activity, tobacco use, excessive alcohol consumption, and drug use can also affect health and safety at work. In the last twenty years, we have witnessed rapid changes in the nature of work, workplace and workforce. In parallel, there is increasing attention to fatigue, psychosocial risks and the achievement of decent, sustainable and healthy work as societal goals. Consequently, in 2011, NIOSH developed Total Worker Health®, a holistic approach to worker well-being to help improve worker health and safety. More recently, in Italy, the Ministry of Health has provided for the preparation of projects according to the "Total Worker Health (TWH)" approach in the National Prevention Plan for the five years 2020-2025. As indicated by the Ministry, the strategic role of the occupational physician is fundamental, being the only figure of occupational safety and health professionals able to integrate the health and safety of workers with their well-being to reach the Total Worker Health.

Occupational Safety and Health Staging Framework for Decent Work.

The 2030 United Nations Goal 8 for sustainable development focuses on decent work. There is utility in identifying the occupational safety and health aspects of Goal 8, as they pertain to the four pillars of decent work: job creation, social protection, rights of workers, and social dialogue. A workgroup of the International Commission on Occupational Health and collaborators addressed the issue of decent work and occupational safety and health (OSH) with the objective of elaborating a framework for guidance for practitioners, researchers, employers, workers, and authorities. This article presents that framework, which is based on an examination of the literature and the perspectives of the workgroup. The framework encompasses the intersection of the pillars of decent (employment creation, social protection, rights of workers, and social dialogue) work with new and emerging hazards and risks related to various selected determinants: new technologies and new forms of work; demographics (aging and gender); globalization; informal work; migration; pandemics; and OSH policies and climate change. The OSH field will need an expanded focus to address the future of decent work. This focus should incorporate the needs of workers and workforces in terms of their well-being. The framework identifies a starting point for the OSH community to begin to promote decent work.

Public Health Impacts of Underemployment and Unemployment in the United States: Exploring Perceptions, Gaps and Opportunities.

BACKGROUND: Unemployment, underemployment, and the quality of work are national occupational health risk factors that drive critical national problems; however, to date, there have been no systematic efforts to document the public health impact of this situation. METHODS: An environmental scan was conducted to explore the root causes and health impacts of underemployment and unemployment and highlight multilevel perspectives and factors in the landscape of underemployment and unemployment. METHODS: included a review of gray literature and research literature, followed by key informant interviews with nine organizational representatives in employment research and policy, workforce development, and industry to assess perceived needs and gaps in practice. RESULTS: Evidence highlights the complex nature of underemployment and unemployment, with multiple macro-level underlying drivers, including the changing nature of work, a dynamic labor market, inadequate enforcement of labor protection standards, declining unions, wage depression, and weak political will interacting with multiple social determinants of health. Empirical literature on unemployment and physical, mental, and psychological well-being, substance abuse, depression in young adults, and suicides is quite extensive; however, there are limited data on the impacts of underemployment on worker health and well-being. Additionally, organizations do not routinely consider health outcomes as they relate to their work in workforce or policy development. DISCUSSION AND CONCLUSIONS: Several gaps in data and research will need to be addressed in order to assess the full magnitude of the public health burden of underemployment and unemployment. Public health needs to champion a research and practice agenda in partnership with multisector stakeholders to illuminate the role of employment quality and status in closing the gap on health inequities, and to integrate workforce health and well-being into labor and economic development agendas across government agencies and industry.

An Exploratory Assessment of Applying Risk Management Practices to Engineered Nanomaterials.

The widespread industrial application of nanotechnology has increased the number of workers exposed to engineered nanomaterials (ENMs), but it is not clear to what extent prevention guidance is practiced. Our aim was to explore the extent that companies manufacturing and/or using ENMs apply risk assessment and management measures. Thirty-four companies were surveyed with an international 35-item questionnaire investigating company and workforce features, types of ENM handled, and risk evaluation and preventive measures adopted. Among participating companies, 62% had a maximum of 10 employees. Metal-based nanomaterials were most frequently identified (73%). Environmental monitoring was performed by 41% of the companies, while engineering exposure controls were approximately reported by 50%. Information and training programs were indicated by 85% of the sample, only 9% performed specific health surveillance for ENM workers. Personal protective equipment primarily included gloves (100%) and eye/face protection (94%). This small-scale assessment can contribute to the limited amount of published literature on the topic. Future investigations should include a greater number of companies to better represent ENM workplaces and a direct access to industrial settings to collect information on site. Finally, deeper attention should be paid to define standardized frameworks for ENM risk assessment that may guide nano-specific preventive actions.

Methodological, political and legal issues in the assessment of the effects of nanotechnology on human health.

Engineered nanomaterials (ENMs) raise questions among the scientific community and public health authorities about their potential risks to human health. Studying a prospective cohort of workers exposed to ENMs would be considered the gold standard for identifying potential health effects of nanotechnology and confirming the 'no effect' levels derived from cellular and animal models. However, because only small, cross-sectional studies have been conducted in the past 5 years, questions remain about the health risks of ENMs. This essay addresses the scientific, methodological, political and regulatory issues that make epidemiological research in nanotechnology-exposed communities particularly complex. Scientific challenges include the array of physicochemical parameters and ENM production conditions, the lack of universally accepted definitions of ENMs and nanotechnology workers, and the lack of information about modes of action, target organs and likely dose-response functions of ENMs. Standardisation of data collection and harmonisation of research protocols are needed to eliminate misclassification of exposures and health effects. Forming ENM worker cohorts from a combination of smaller cohorts and overcoming selection bias are also challenges. National or international registries for monitoring the exposures and health of ENM workers would be helpful for epidemiological studies, but the creation of such a registry and ENM worker cohorts will require political support and dedicated funding at the national and international levels. Public authorities and health agencies should consider carrying out an ENM awareness campaign to educate and engage all stakeholders and concerned communities in discussion of such a project.

Characterizing the Interrelationships of Prescription Opioid and Benzodiazepine Drugs With Worker Health and Workplace Hazards.

OBJECTIVE: Prescription opioid and benzodiazepine drug use, which has risen significantly, can affect worker health. Exploration of the scientific literature assessed (1) interrelationships of such drug use, occupational risk factors, and illness and injury, and (2) occupational and personal risk factor combinations that can affect their use. METHODS: The scientific literature from 2000 to 2015 was searched to determine any interrelationships. RESULTS: Evidence for eight conceptual models emerged based on the search yield of 133 articles. These models summarize interrelationships among prescription opioid and benzodiazepine use with occupational injury and illness. Factors associated with the use of these drugs included fatigue, impaired cognition, falls, motor vehicle crashes, and the use of multiple providers. CONCLUSION: Prescription opioid and benzodiazepine drugs may be both a personal risk factor for work-related injury and a consequence of workplace exposures.

The Next Generation of Risk Assessment Multi-Year Study-Highlights of Findings, Applications to Risk Assessment, and Future Directions.

BACKGROUND: The Next Generation (NexGen) of Risk Assessment effort is a multi-year collaboration among several organizations evaluating new, potentially more efficient molecular, computational, and systems biology approaches to risk assessment. This article summarizes our findings, suggests applications to risk assessment, and identifies strategic research directions. OBJECTIVE: Our specific objectives were to test whether advanced biological data and methods could better inform our understanding of public health risks posed by environmental exposures. METHODS: New data and methods were applied and evaluated for use in hazard identification and dose-response assessment. Biomarkers of exposure and effect, and risk characterization were also examined. Consideration was given to various decision contexts with increasing regulatory and public health impacts. Data types included transcriptomics, genomics, and proteomics. Methods included molecular epidemiology and clinical studies, bioinformatic knowledge mining, pathway and network analyses, short-duration in vivo and in vitro bioassays, and quantitative structure activity relationship modeling. DISCUSSION: NexGen has advanced our ability to apply new science by more rapidly identifying chemicals and exposures of potential concern, helping characterize mechanisms of action that influence conclusions about causality, exposure-response relationships, susceptibility and cumulative risk, and by elucidating new biomarkers of exposure and effects. Additionally, NexGen has fostered extensive discussion among risk scientists and managers and improved confidence in interpreting and applying new data streams. CONCLUSIONS: While considerable uncertainties remain, thoughtful application of new knowledge to risk assessment appears reasonable for augmenting major scope assessments, forming the basis for or augmenting limited scope assessments, and for prioritization and screening of very data limited chemicals. Citation: Cote I, Andersen ME, Ankley GT, Barone S, Birnbaum LS, Boekelheide K, Bois FY, Burgoon LD, Chiu WA, Crawford-Brown D, Crofton KM, DeVito M, Devlin RB, Edwards SW, Guyton KZ, Hattis D, Judson RS, Knight D, Krewski D, Lambert J, Maull EA, Mendrick D, Paoli GM, Patel CJ, Perkins EJ, Poje G, Portier CJ, Rusyn I, Schulte PA, Simeonov A, Smith MT, Thayer KA, Thomas RS, Thomas R, Tice RR, Vandenberg JJ, Villeneuve DL, Wesselkamper S, Whelan M, Whittaker C, White R, Xia M, Yauk C, Zeise L, Zhao J, DeWoskin RS. 2016. The Next Generation of Risk Assessment multiyear study-highlights of findings, applications to risk assessment, and future directions. Environ Health Perspect 124:1671-1682; http://dx.doi.org/10.1289/EHP233.

Assessing the protection of the nanomaterial workforce.

Responsible development of any technology, including nanotechnology, requires protecting workers, the first people to be exposed to the products of the technology. In the case of nanotechnology, this is difficult to achieve because in spite of early evidence raising health and safety concerns, there are uncertainties about hazards and risks. The global response to these concerns has been the issuance by authoritative agencies of precautionary guidance to strictly control exposures to engineered nanomaterials (ENMs). This commentary summarizes discussions at the "Symposium on the Health Protection of Nanomaterial Workers" held in Rome (25 and 26 February 2015). There scientists and practitioners from 11 countries took stock of what is known about hazards and risks resulting from exposure to ENMs, confirmed that uncertainties still exist, and deliberated on what it would take to conduct a global assessment of how well workers are being protected from potentially harmful exposures.

Characterizing adoption of precautionary risk management guidance for nanomaterials, an emerging occupational hazard.

Exposure to engineered nanomaterials (substances with at least one dimension of 1-100 nm) has been of increased interest, with the recent growth in production and use of nanomaterials worldwide. Various organizations have recommended methods to minimize exposure to engineered nanomaterials. The purpose of this study was to evaluate available data to examine the extent to which studied U.S. companies (which represent a small fraction of all companies using certain forms of engineered nanomaterials) follow the guidelines for reducing occupational exposures to engineered nanomaterials that have been issued by the National Institute for Occupational Safety and Health (NIOSH) and other organizations. Survey data, field reports, and field notes for all NIOSH nanomaterial exposure assessments conducted between 2006 and 2011 were collected and reviewed to: (1) determine the level of adoption of precautionary guidance on engineering controls and personal protective equipment (PPE), and (2) evaluate the reliability of companies' self-reported use of engineering controls and PPE. Use of PPE was observed among 89% [95% confidence interval (CI): 76%-96%] of 46 visited companies, and use of containment-based engineering controls for at least some processes was observed among 83% (95% CI: 76%-96%). In on-site evaluations, more than 90% of the 16 engineered carbonaceous nanomaterial companies that responded to an industrywide survey were observed to be using engineering controls and PPE as reported or more stringently than reported. Since PPE use was slightly more prevalent than engineering controls, better communication may be necessary to reinforce the importance of the hierarchy of controls. These findings may also be useful in conducting exposure assessment and epidemiologic research among U.S. workers handling nanomaterials.

Risk assessment and risk management of nanomaterials in the workplace: translating research to practice.

In the last decade since the rise in occupational safety and health (OSH) research focusing on nanomaterials, some progress has been made in generating the health effects and exposure data needed to perform risk assessment and develop risk management guidance. Yet, substantial research gaps remain, as do challenges in the translation of these research findings to OSH guidance and workplace practice. Risk assessment is a process that integrates the hazard, exposure, and dose-response data to characterize risk in a population (e.g. workers), in order to provide health information needed for risk management decision-making. Thus, the research priorities for risk assessment are those studies that will reduce the uncertainty in the key factors that influence the estimates. Current knowledge of OSH in nanotechnology includes the following: (i) nanomaterials can be measured using standard measurement methods (respirable mass or number concentration), (ii) workplace exposures to nanomaterials can be reduced using engineering controls and personal protective equipment, and (iii) current toxicity testing and risk assessment methods are applicable to nanomaterials. Yet, to ensure protection of workers' health, research is still needed to develop (i) sensitive and quantitative measures of workers' exposure to nanomaterials, (ii) validation methods for exposure controls, and (iii) standardized criteria to categorize hazard data, including better prediction of chronic effects. This article provides a state-of-the-art overview on translating current hazard research data and risk assessment methods for nanomaterials to the development and implementation of effective risk management guidance.

Focused actions to protect carbon nanotube workers.

There is still uncertainty about the potential health hazards of carbon nanotubes (CNTs) particularly involving carcinogenicity. However, the evidence is growing that some types of CNTs and nanofibers may have carcinogenic properties. The critical question is that while the carcinogenic potential of CNTs is being further investigated, what steps should be taken to protect workers who face exposure to CNTs, current and future, if CNTs are ultimately found to be carcinogenic? This paper addresses five areas to help focus action to protect workers: (i) review of the current evidence on the carcinogenic potential of CNTs; (ii) role of physical and chemical properties related to cancer development; (iii) CNT doses associated with genotoxicity in vitro and in vivo; (iv) workplace exposures to CNT; and (v) specific risk management actions needed to protect workers.

Occupational fatalities, injuries, illnesses, and related economic loss in the wholesale and retail trade sector.

BACKGROUND: The wholesale and retail trade (WRT) sector employs over 21 million workers, or nearly 19% of the annual average employment in private industry. The perception is that workers in this sector are generally at low risk of occupational injury and death. These workers, however, are engaged in a wide range of demanding job activities and are exposed to a variety of hazards. Prior to this report, a comprehensive appraisal of the occupational fatal and nonfatal burdens affecting the retail and wholesale sectors was lacking. The focus of this review is to assess the overall occupational safety and health burden in WRT and to identify various subsectors that have high rates of burden from occupational causes. Ultimately, these findings should be useful for targeted intervention efforts. METHODS: We reviewed Bureau of Labor Statistics (BLS), 2006 fatality, injury, and illness data for the WRT sector and provide comparisons between the WRT sector, its' subsectors, and private industry, which serves as a baseline. The BLS data provide both counts and standardized incidence rates for various exposures, events, and injury types for fatalities, injuries, and illnesses. In an effort to estimate the economic burden of these fatalities, injuries, and illnesses, a focused review of the literature was conducted. RESULTS AND CONCLUSION: In 2006, WRT workers experienced 820,500 injuries/illnesses and 581 fatalities. The total case injury/illness rate for the retail sector was 4.9/100 FTE and for the wholesale sector 4.1/100 FTE. The WRT sector represents 15.5% of the private sector work population in 2006, yet accounts for 20.1% of nonfatal injuries and illnesses of the private sector. In 2003, the disparity was only 2% but increased to 3% in 2004 and 2005. Three WRT subsectors had injury/illness rates well above the national average: beer/wine/liquor (8.4/100); building materials/supplies (7.6/100); and grocery-related products (7.0/100). Occupational deaths with the highest rates were found in gasoline stations (9.8/100,000), convenience stores (6.1/100,000), and used car dealers (5.5/100,000). In terms of actual numbers, the category of food and beverage stores had 82 fatalities in 2006. Based on 1993 data, costs, both direct and indirect, in the WRT sector for fatal injuries were estimated to exceed $8.6 billion. The full economic loss to society and the family has not been adequately measured. Overexertion and contact with objects/equipment represent the top two events or exposures leading to injury or illness. Together they account for 57% of the events or exposures for nonfatal WRT injuries and illnesses. This sector is important because it is large and pervasive as a result, even a relatively small increase in injury rates and accompanying days away from work will have significant impact on working families and society.

A bibliometric analysis of scientific production in cancer molecular epidemiology.

OBJECTIVES: The main purpose of this research was to compare the scientific production in the field of cancer molecular epidemiology among countries and to evaluate the publication trend between 1995 and 2004. METHODS: A bibliometric study was carried out searching the PubMed database with a combined search strategy based on the keywords listed in the medical subject headings and a free text search. Only articles from a representative subset of 92 journals--accounting for 80% of papers identified--were selected for the analysis, and the resulting 13,240 abstracts were manually checked according to a list of basic inclusion criteria. The study evaluated the number of publications and the impact factor (mean and sum), absolute and normalized by country population and gross domestic product. RESULTS: A total of 3,842 citations were finally selected for the analysis. Thirty-seven percent came from the European Union (UK, Germany, Italy, France and Sweden ranking at the top), 31.6% from USA and 9.7% from Japan. The highest mean impact factor was reported for Canada (6.3), USA (5.9), Finland (5.8) and UK (5.2). Finland, Sweden and Israel had the best ratio between scientific production and available resources. 'Genetic polymorphism, glutathione transferase, breast neoplasm, risk factors, case-control studies and polymerase chain reaction' were the most used keywords in each of the subgroups evaluated, although inclusion criteria may have privileged studies dealing with exogenous carcinogens. CONCLUSION: Cancer molecular epidemiology is an expanding area attracting an increasing interest. The identification of an operative definition is a necessary condition to give to this discipline a unique scientific identity.

Work, obesity, and occupational safety and health.

There is increasing evidence that obesity and overweight may be related, in part, to adverse work conditions. In particular, the risk of obesity may increase in high-demand, low-control work environments, and for those who work long hours. In addition, obesity may modify the risk for vibration-induced injury and certain occupational musculoskeletal disorders. We hypothesized that obesity may also be a co-risk factor for the development of occupational asthma and cardiovascular disease that and it may modify the worker's response to occupational stress, immune response to chemical exposures, and risk of disease from occupational neurotoxins. We developed 5 conceptual models of the interrelationship of work, obesity, and occupational safety and health and highlighted the ethical, legal, and social issues related to fuller consideration of obesity's role in occupational health and safety.

Ethical and scientific issues of nanotechnology in the workplace.

In the absence of scientific clarity about the potential health effects of occupational exposure to nanoparticles, a need exists for guidance in decision making about hazards, risks, and controls. An identification of the ethical issues involved may be useful to decision makers, particularly employers, workers, investors, and health authorities. Because the goal of occupational safety and health is the prevention of disease in workers, the situations that have ethical implications that most affect workers have been identified. These situations include the a) identification and communication of hazards and risks by scientists, authorities, and employers; b) workers' acceptance of risk; c) selection and implementation of controls; d) establishment of medical screening programs; and e) investment in toxicologic and control research. The ethical issues involve the unbiased determination of hazards and risks, nonmaleficence (doing no harm), autonomy, justice, privacy, and promoting respect for persons. As the ethical issues are identified and explored, options for decision makers can be developed. Additionally, societal deliberations about workplace risks of nanotechnologies may be enhanced by special emphasis on small businesses and adoption of a global perspective.

Emerging issues in occupational safety and health.

In developed countries, changes in the nature of work and the workforce may necessitate recalibrating the vision of occupational safety and health (OSH) researchers, practitioners, and policymakers to increase the focus on the most important issues. New methods of organizing the workplace, extensive labor contracting, expansion of service and knowledge sectors, increase in small business, aging and immigrant workers, and the continued existence of traditional hazards in high-risk sectors such as construction, mining, agriculture, health care, and transportation support the need to address: 1) broader consideration of the role and impact of work, 2) relationship between work and psychological dysfunction, 3) increased surveillance basis for research and intervention, 4) overcoming barriers to the conduct and use of epidemiologic research, 5) information and knowledge transfer and application, 6) economic issues in prevention, and 7) the global interconnectedness of OSH. These issues are offered to spur thinking as new national research agendas for OSH are considered for developed countries.

Characterizing the burden of occupational injury and disease.

OBJECTIVES: To review the literature on the burden of occupational disease and injury and to provide a comprehensive characterization of the burden. METHODS: The scientific and governmental literature from 1990 to the present was searched and evaluated. Thirty-eight studies illustrative of the burden of occupational disease were reviewed for findings, methodology, strengths, and limitations. RESULTS: Recent U.S. estimates of occupational mortality and morbidity include approximately 55,000 deaths (eighth leading cause) and 3.8 million disabling injuries per year, respectively. Comprehensive estimates of U.S. costs related to these burdens range between dollar 128 billion and dollar 155 billion per year. Despite these significant indicators, occupational morbidity, mortality, and risks are not well characterized in comparative burden assessments. CONCLUSIONS: The magnitude of occupational disease and injury burden is significant but underestimated. There is a need for an integrated approach to address these underestimates.

Integrating occupational safety and health information into vocational and technical education and other workforce preparation programs.

The high rates of injury among young workers are a pressing public health issue, especially given the demand of the job market for new workers. Young and new workers experience the highest rates of occupational injuries of any age group. Incorporating occupational safety and health (OSH) information into the more than 20 000 vocational and other workforce preparation programs in the United States might provide a mechanism for reducing work-related injuries and illnesses among young and new workers. We assessed the status of including OSH information or training in workforce preparation programs and found there is an inconsistent emphasis on OSH information.

Enhancing occupational safety and health through use of the national skill standards.

In a voluntary national effort, U.S. industry, education, labor, and government have initiated the development of standards for job skills and competencies in jobs in 15 economic sectors. The aim of the skill standards is to maintain a globally competitive workforce. Efforts to include occupational safety and health knowledge and skills as core elements in these standards are described. The first skill standards to include occupational safety and health competencies were developed for the manufacturing sector, evaluated by 3,800 workers in 700 companies, and published. National skill standards can stimulate extensive training in occupational safety and health, with resultant application to a larger percentage of workers than ever before.