Retrospective analysis of the Italian exit strategy from COVID-19 lockdown.

After the national lockdown imposed on March 11, 2020, the Italian government has gradually resumed the suspended economic and social activities since May 4, while maintaining the closure of schools until September 14. We use a model of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission to estimate the health impact of different exit strategies. The strategy adopted in Italy kept the reproduction number Rt at values close to one until the end of September, with marginal regional differences. Based on the estimated postlockdown transmissibility, reopening of workplaces in selected industrial activities might have had a minor impact on the transmissibility. Reopening educational levels in May up to secondary schools might have influenced SARS-CoV-2 transmissibility only marginally; however, including high schools might have resulted in a marked increase of the disease burden. Earlier reopening would have resulted in disproportionately higher hospitalization incidence. Given community contacts in September, we project a large second wave associated with school reopening in the fall.

[A national survey on occupational safety and health: the role of the health and safety representatives.] / IMPAcT-RLS2: Indagine nazionale sulla salute e la sicurezza sul lavoro: il ruolo dei Rappresentanti dei Lavoratori per la Sicurezza.

SUMMARY: The IMPAcT-RLS2 survey is part of a larger context of INSuLa2 research program; its first edition was conducted in 2014 and targeted to all prevention professionals, investigating occupational health and safety (OSH) protection issues perceived by the various professionals' point of view. The survey addressed to Health and Safety Representatives (HS reps.), focused on three regional contexts, was further implemented in 2016 through the IMPAcT-RLS survey, which involved a sample representative at national level, by company size and economic activity sector consisting of about 2,100 subjects. The survey highlighted the importance of having ever more in-depth information on the role of HS reps. and monitoring their evolution over time. This study arises from the need to create periodic and replicable surveys, aimed at increasing knowledge and awareness of prevention systems and promoting increasingly targeted interventions for improving the protection of OSH.

Occupational factors in the COVID-19 pandemic in Italy: compensation claims applications support establishing an occupational surveillance system.

INTRODUCTION: The SARS-CoV-2 pandemic is an impacting challenge for occupational health. Epidemiological surveillance of COVID-19 includes systematic tracking and reporting of the total cases and deaths, but suitable experiences of surveillance systems for identifying the occupational risk factors involved in the COVID-19 pandemic are still missing, despite the interest for occupational safety and health. METHODS: A methodological approach has been implemented in Italy to estimate the occupational risk of infection, classifying each economic sector as at low, medium-low, medium-high and high risk, based on three parameters: exposure probability, proximity index and aggregation factor. Furthermore, during the epidemic emergency, the Italian Workers' Compensation Authority introduced the notation of COVID-19 work-related infection as an occupational injury and collected compensation claims of workers from the entire national territory. RESULTS: According to compensation claims applications, COVID-19 infection in Italy has been acquired at the workplace in a substantial portion of the total cases (19.4%). The distribution of the economic sectors involved is coherent with the activities classified at risk in the lockdown period. The economic sectors mostly involved were human health and social work activities, but occupational compensation claims also include cases in meat and poultry processing plants workers, store clerks, postal workers, pharmacists and cleaning workers. CONCLUSIONS: There is a need to go towards an occupational surveillance system for COVID-19 cases, including an individual anamnestic analysis of the circumstances in which the infection is acquired, for the prevention of occupational infectious risk, supporting insurance system effectiveness and managing vaccination policies.

[Nanomaterials and occupational health: the INAIL research contribution for responsible innovation and risk prevention for workers in Italy]. / Nanomateriali e salute sul lavoro: il contributo dell'INAIL alla ricerca per l'innovazione responsabile e la tutela dei lavoratori in Italia.

SUMMARY: In the last years nanotechnologies and nanoproducts are constantly growing up thanks to their promising benefits for social and economic development. Nanomaterials are increasingly used in our daily life, finding application in many sectors such as textile, automotive, electronic, food, etc. In 2012, the European Commission included nanotechnologies among the Key Enabling Technologies (KETs), which provide the basis for innovation in the present century. In parallel to the growing interest at industrial and production level (estimated at about 11 million of tons per year) the number of workers potentially exposed in all nanomaterials life cycle has increased. Concurrently, concerns about the potential effects on human health arose, attracting the attention by the scientific community, in particular on health and safety issues in workplaces. In Italy the industrial market has evolved in the same direction with important economic investments both public and private. Consequently, numerous research groups belonging to the University, Institutions and Research Centers were involved in the study of the main issues to promote a responsible development of nanomaterials. In this framework, the main aim of this study is to highlight the commitment of Italian research in the field of health and safety of engineered nanomaterials, through the initiatives of Italian Workers Compensation Authority (INAIL) for sustainable development of nanotechnologies.

Workers' Exposure to Nano-Objects with Different Dimensionalities in R&D Laboratories: Measurement Strategy and Field Studies.

With the increasing interest in the potential benefits of nanotechnologies, concern is still growing that they may present emerging risks for workers. Various strategies have been developed to assess the exposure to nano-objects and their agglomerates and aggregates (NOAA) in the workplace, integrating different aerosol measurement instruments and taking into account multiple parameters that may influence NOAA toxicity. The present study proposes a multi-metric approach for measuring and sampling NOAA in the workplace, applied to three case studies in laboratories each dedicated to materials with different shapes and dimensionalities: graphene, nanowires, and nanoparticles. The study is part of a larger project with the aim of improving risk management tools in nanomaterials research laboratories. The harmonized methodology proposed by the Organization for Economic Cooperation and Development (OECD) has been applied, including information gathering about materials and processes, measurements with easy-to-use and hand-held real-time devices, air sampling with personal samplers, and off-line analysis using scanning electron microscopy. Significant values beyond which an emission can be attributed to the NOAA production process were identified by comparison of the particle number concentration (PNC) time series and the corresponding background levels in the three laboratories. We explored the relations between background PNC and microclimatic parameters. Morphological and elemental analysis of sampled filters was done to identify possible emission sources of NOAA during the production processes: rare particles, spherical, with average diameter similar to the produced NOAA were identified in the nanoparticles laboratory, so further investigation is recommended to confirm the potential for worker exposure. In conclusion, the information obtained should provide a valuable basis for improving risk management strategies in the laboratory at work.

[The INSuLa Project: a knowledge survey among workers]. / Progetto INSuLa: I'indagine conoscitiva sui lavoratori.

The INSuLa project consisted of a national survey on health and safety at work involving all the relevant actors such as workers, employers, occupational physicians (MC), worker safety representatives (RLS), prevention and safety service in the workplace (SPSAL). The survey aimed, on one hand, at investigating workers' risk perceptions at the workplace and, on another hand, at exploring the general level of awareness about the enforcement of the Legislative Decree 81/2008 and subsequent amendments. The survey was conducted on a stratified sample of8000 workers representative of the national situation taking into consideration some of the most important socio-demographic and occupational variables, such as gender, geographic area, age, type of contract and sector of activity. The analysis of the results presented here and the subsequent secondary analyses will contribute to identify the needs and critical issues for implementing preventive interventions at the workplaces, also in consideration of the emerging risks and changes in the world of work.

Occupational Exposure during the Production and the Spray Deposition of Graphene Nanoplatelets-Based Polymeric Coatings.

Graphene-based polymer composites are innovative materials which have recently found wide application in many industrial sectors thanks to the combination of their enhanced properties. The production of such materials at the nanoscale and their handling in combination with other materials introduce growing concerns regarding workers' exposure to nano-sized materials. The present study aims to evaluate the nanomaterials emissions during the work phases required to produce an innovative graphene-based polymer coating made of a water-based polyurethane paint filled with graphene nanoplatelets (GNPs) and deposited via the spray casting technique. For this purpose, a multi-metric exposure measurement strategy was adopted in accordance with the harmonized tiered approach published by the Organization for Economic Co-operation and Development (OECD). As a result, potential GNPs release has been indicated near the operator in a restricted area not involving other workers. The ventilated hood inside the production laboratory guarantees a rapid reduction of particle number concentration levels, limiting the exposure time. Such findings allowed us to identify the work phases of the production process with a high risk of exposure by inhalation to GNPs and to define proper risk mitigation strategies.

Covid-19 Occupational Risk Incidence and Working Sectors Involved During the Pandemic in Italy.

Background: Starting from March 2020 until December 2021, different phases of Covid-19 pandemic have been identified in Italy, with several containing/lifting measures progressively enforced by the National government. In the present study, we investigate the change in occupational risk during the subsequent pandemic phases and we propose an estimate of the incidence of the cases by economic sector, based on the analysis of insurance claims for compensation for Covid-19. Methods: Covid-19 epidemiological data available for the general population and injury claims of workers covered by the Italian public insurance system in 2020-2021 were analyzed. Monthly Incidence Rate of Covid-19 compensation claims per 100,000 workers (MIRw) was calculated by the economic sector and compared with the same indicator for general population in different pandemic periods. Results: The distribution of Covid-19 MIRw by sector significantly changed during the pandemic related to both the strength of different waves and the mitigation/lifting strategies enforced. The level of occupational fraction was very high at the beginning phase of the pandemic, decreasing to 5% at the end of 2021. Healthcare and related services were continuously hit but the incidence was significantly decreasing in 2021 in all sectors, except for postal and courier activities in transportation and storage enterprises. Conclusion: The analysis of compensation claim data allowed to identify time trends for infection risk in different working sectors. The claim rates were highest for human health and social work activities but the distribution of risk among sectors was clearly influenced by the different stages of the pandemic.

Airborne LTA Nanozeolites Characterization during the Manufacturing Process and External Sources Interaction with the Workplace Background.

Engineered nanoscale amorphous silica nanomaterials are widespread and used in many industrial sectors. Currently, some types of silicon-based nanozeolites (NZs) have been synthesized, showing potential advantages compared to the analogous micro-forms; otherwise, few studies are yet available regarding their potential toxicity. In this respect, the aim of the present work is to investigate the potential exposure to airborne Linde Type A (LTA) NZs on which toxicological effects have been already assessed. Moreover, the contributions to the background related to the main emission sources coming from the outdoor environment (i.e., vehicular traffic and anthropogenic activities) were investigated as possible confounding factors. For this purpose, an LTA NZ production line in an industrial factory has been studied, according to the Organisation for Economic Cooperation and Development (OECD) guidelines on multi-metric approach to investigate airborne nanoparticles at the workplace. The main emission sources of nanoparticulate matter within the working environment have been identified by real-time measurements (particle number concentration, size distribution, average diameter, and lung-deposited surface area). Events due to LTA NZ spillage in the air during the cleaning phases have been chemically and morphologically characterized by ICP-MS and SEM analysis, respectively.

Global Policy Responses to the COVID-19 Pandemic: Results of the ICOH Survey.

Background: On the basis of its role for the development of occupational health research, information, good practices, the International Commission on Occupational Health (ICOH) launched the present survey to collect information on public health and prevention policies put in place by the governments of the countries in the world to contain the pandemic. Methods: A cross-sectional study was conducted through an online questionnaire focused on COVID-19 data, public health policies, prevention measures, support measures for economy, work, and education, personal protective equipment, intensive care units, contact tracing, return to work, and the role of ICOH against COVID-19. The questionnaire was administered to 113 ICOH National Secretaries and senior OSH experts. Collected data refer to the period ranging from the beginning of the pandemic in each country to June 30, 2020. Results: A total of 73 questionnaires from 73 countries around the world were considered valid, with a 64.6% response rate. Most of the respondents (71.2%) reported that the state of emergency was declared in their country, and 86.1% reported lockdown measures. Most of the respondents (66.7%) affirmed that the use of face masks was compulsory in their country. As for containment measures, 97.2% indicated that mass gatherings (meetings) were limited. Regarding workplace closing, the most affected sector was entertainment (90.1%). Conclusion: The results of this survey are useful to gain a global view on COVID-19 policy responses at country level.

The Impact of COVID-19 Pandemics on the Development of Health Risk Communication: Challenges and Opportunities.

Starting from an analysis of communication in Italy during the COVID-19 emergency period (February-June 2020), this paper provides an overview of the main challenges and opportunities for communication during pandemics. The purpose of this study is to perform a literature review contributing to the identification of practical recommendations for the improvement of current risk communication strategies. Given the variety of the parties involved in communication and the peculiarity of the theme, an integrated analysis approach was adopted, based on the connections between institutional, scientific and mass communication. On one hand, the "emotional" character of Italian institutional communication aimed at promoting solidarity and unity among citizens. On the other hand, scientific communication played a key role both as a technical and scientific consultation for the policymaker, and as a guide for mass communication. Nevertheless, a lack of awareness emerged from the institutional and scientific side of the importance of an interface between science and effective, transparent policy. It thus becomes necessary to develop new and effective communication strategies aimed at facing uncertainties and the challenges of risk communication in epidemics and pandemics. Such strategies should consider interaction between public health, human and social sciences, political science, law, ethics, communication and media studies, as each of these areas may give an important contribution to the understanding of the context in which communication occurs.

A follow-up study on workers involved in the graphene production process after the introduction of exposure mitigation measures: evaluation of genotoxic and oxidative effects.

During nanomaterial (NM) production, workers could be exposed, particularly by inhalation, to NMs and other chemicals used in the synthesis process, so it is important to have suitable biomarkers to monitor potential toxic effects. Aim of this study was to evaluate the effectiveness of the introduction of exposure mitigation measures on workers unintentionally exposed to graphene co-pollutants during production process monitoring the presumable reduction of workplace NM contamination and of early genotoxic and oxidative effects previously found on these workers. We used Buccal Micronucleus Cytome (BMCyt) assay and Fpg-comet test, resulted the most sensitive biomarkers on our first biomonitoring work, to measure the genotoxic effects. We also detected urinary oxidized nucleic acid bases 8-oxoGua, 8-oxoGuo and 8-oxodGuo to evaluate oxidative damage. The genotoxic and oxidative effects were assessed on the same graphene workers (N = 6) previously studied, comparing the results with those found in the first biomonitoring and with the control group (N = 11). This was achieved 6 months after the installation of a special filter hood (where to perform the phases at higher risk of NM emission) and the improvement of environmental and personal protective equipment. Particle number concentration decreased after the mitigation measures. We observed reduction of Micronucleus (MN) frequency and oxidative DNA damage and increase of 8-oxodGuo excretion compared to the first biomonitoring. These results, although limited by the small subject number, showed the efficacy of adopted exposure mitigation measures and the suitability of used sensitive and noninvasive biomarkers to bio-monitor over time workers involved in graphene production process.

Assessing the quality of evidence in studies estimating prevalence of exposure to occupational risk factors: The QoE-SPEO approach applied in the systematic reviews from the WHO/ILO Joint Estimates of the Work-related burden of disease and Injury.

BACKGROUND: The World Health Organization (WHO) and the International Labour Organization (ILO) have produced the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury (WHO/ILO Joint Estimates). For these, systematic reviews of studies estimating the prevalence of exposure to selected occupational risk factors have been conducted to provide input data for estimations of the number of exposed workers. A critical part of systematic review methodology is to assess the quality of evidence across studies. In this article, we present the approach applied in these WHO/ILO systematic reviews for performing such assessments on studies of prevalence of exposure. It is called the Quality of Evidence in Studies estimating Prevalence of Exposure to Occupational risk factors (QoE-SPEO) approach. We describe QoE-SPEO's development to date, demonstrate its feasibility reporting results from pilot testing and case studies, note its strengths and limitations, and suggest how QoE-SPEO should be tested and developed further. METHODS: Following a comprehensive literature review, and using expert opinion, selected existing quality of evidence assessment approaches used in environmental and occupational health were reviewed and analysed for their relevance to prevalence studies. Relevant steps and components from the existing approaches were adopted or adapted for QoE-SPEO. New steps and components were developed. We elicited feedback from other systematic review methodologists and exposure scientists and reached consensus on the QoE-SPEO approach. Ten individual experts pilot-tested QoE-SPEO. To assess inter-rater agreement, we counted ratings of expected (actual and non-spurious) heterogeneity and quality of evidence and calculated a raw measure of agreement (Pi) between individual raters and rater teams for the downgrade domains. Pi ranged between 0.00 (no two pilot testers selected the same rating) and 1.00 (all pilot testers selected the same rating). Case studies were conducted of experiences of QoE-SPEO's use in two WHO/ILO systematic reviews. RESULTS: We found no existing quality of evidence assessment approach for occupational exposure prevalence studies. We identified three relevant, existing approaches for environmental and occupational health studies of the effect of exposures. Assessments using QoE-SPEO comprise three steps: (1) judge the level of expected heterogeneity (defined as non-spurious variability that can be expected in exposure prevalence, within or between individual persons, because exposure may change over space and/or time), (2) assess downgrade domains, and (3) reach a final rating on the quality of evidence. Assessments are conducted using the same five downgrade domains as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach: (a) risk of bias, (b) indirectness, (c) inconsistency, (d) imprecision, and (e) publication bias. For downgrade domains (c) and (d), the assessment varies depending on the level of expected heterogeneity. There are no upgrade domains. The QoE-SPEO's ratings are "very low", "low", "moderate", and "high". To arrive at a final decision on the overall quality of evidence, the assessor starts at "high" quality of evidence and for each domain downgrades by one or two levels for serious concerns or very serious concerns, respectively. In pilot tests, there was reasonable agreement in ratings for expected heterogeneity; 70% of raters selected the same rating. Inter-rater agreement ranged considerably between downgrade domains, both for individual rater pairs (range Pi: 0.36-1.00) and rater teams (0.20-1.00). Sparse data prevented rigorous assessment of inter-rater agreement in quality of evidence ratings. CONCLUSIONS: We present QoE-SPEO as an approach for assessing quality of evidence in prevalence studies of exposure to occupational risk factors. It has been developed to its current version (as presented here), has undergone pilot testing, and was applied in the systematic reviews for the WHO/ILO Joint Estimates. While the approach requires further testing and development, it makes steps towards filling an identified gap, and progress made so far can be used to inform future work in this area.

Risk assessment at work and prevention strategies on COVID-19 in Italy.

The COVID-19 pandemic has spread worldwide, with considerable public health and socio-economic impacts that are seriously affecting health and safety of workers, as well as their employment stability. Italy was the first of many other western countries to implement extended containment measures. Health workers and others employed in essential sectors have continued their activity, reporting high infection rate with many fatalities. The epidemiological trend highlighted the importance of work as a substantial factor to consider both when implementing strategies aimed at containing the pandemic and shaping the lockdown mitigation strategy required for sustained economic recovery. To support the decision-making process, we have developed a strategy to predict the risk of infection by SARS-CoV-2 in the workplace based on the analysis of the working process and proximity between employees; risk of infection connected to the type of activity; involvement of third parties in the working processes and risk of social aggregation. We applied this approach to outline a risk index for each economic activity sector, with different levels of detail, also considering the impact on mobility of the working population. This method was implemented into the national epidemiological surveillance model in order to estimate the impact of re-activation of specific activities on the reproduction number. It has also been adopted by the national scientific committee set up by the Italian Government for action-oriented policy advice on the COVID-19 emergency in the post lockdown phase. This approach may play a key role for public health if associated with measures for risk mitigation in enterprises through strategies of business process re-engineering. Furthermore, it will make a contribution to reconsidering the organization of work, including also innovation and fostering the integration with the national occupational safety and health (OSH) system.

Contribution of ICOH to Address the Different OSH Needs among Countries: Results of a Survey.

The aim of this study is to map the coverage of occupational safety and health (OSH) rules and provisions and their enforcement at a country level worldwide. Members' participation in the International Commission on Occupational Health (ICOH) activities was also investigated. We used a questionnaire-based survey to collect data. An online questionnaire was administered from February 14 to March 18, 2018 to all ICOH members for the triennium 2015 to 2017 (n = 1929). We received 384 completed questionnaires from 79 countries, with a 20% response rate. To synthesize information about the coverage of OSH rules and provisions and their level of enforcement, a synthetic coverage index was calculated and combined with country, gross domestic product (GDP) per capita and the human development index (HDI). We used multiple correspondence analysis (MCA) to analyze the members' participation in ICOH activities. More than 90.0% of the sample declared that in their own country there is a set of rules and provisions regulating OSH in the workplace, and training procedures and tools to improve workers' awareness. However, these rules and training procedures are mainly "partially" enforced and utilized (39.0% and 45.4%). There was no statistically significant association between country and GDP per capita and the synthetic coverage index, whilst controlling for HDI. The level of engagement in ICOH activities is higher in senior members (aged 65 years or older), coming from high-income countries, having held a position within ICOH, with a higher level of education and a researcher position. An integrated and multidisciplinary approach, which includes research, education and training, is needed to address OSH issues and their impact both at global and country level.

An integrated and multi-technique approach to characterize airborne graphene flakes in the workplace during production phases.

Graphene is a one-atom-thick sheet of carbon atoms arranged in a honeycomb pattern and its unique and amazing properties make it suitable for a wide range of applications ranging from electronic devices to food packaging. However, the biocompatibility of graphene is dependent on the complex interplay of its several physical and chemical properties. The main aim of the present study is to highlight the importance of integrating different characterization techniques to describe the potential release of airborne graphene flakes in a graphene processing and production research laboratory. Specifically, the production and processing (i.e., drying) of few-layer graphene (FLG) through liquid-phase exfoliation of graphite are analysed by integrated characterization techniques. For this purpose, the exposure measurement strategy was based on the multi-metric tiered approach proposed by the Organization for Economic Cooperation and Development (OECD) via integrating high-frequency real-time measurements and personal sampling. Particle number concentration, average diameter and lung deposition surface area time series acquired in the worker's personal breathing zone (PBZ) were compared simultaneously to background measurements, showing the potential release of FLG. Then, electron microscopy techniques and Raman spectroscopy were applied to characterize particles collected by personal inertial impactors to investigate the morphology, chemical composition and crystal structure of rare airborne graphene flakes. The gathered information provides a valuable basis for improving risk management strategies in research and industrial laboratories.

A Human-Relevant 3D In Vitro Platform for an Effective and Rapid Simulation of Workplace Exposure to Nanoparticles: Silica Nanoparticles as Case Study.

In this contribution, we show the suitability of a 3D airway model, when coupled with a nebulizer system, for simulating workplace exposure to nanoparticles. As a proof of concept, workplace exposure to silica nanoparticles was experimentally measured in an occupational facility where nanoparticles are produced weekly, and compared with the official limit value for bulk silica materials. These values of potential exposure were simulated in a 3D airway model by nebulizing low doses (from 0.90 to 55 µg/cm2) of silica nanoparticles over a prolonged period (12 weeks of repeated exposure, 5 days per week). Overall, the results suggest the efficiency of the defense mechanisms of the respiratory system and the clearance of the breathed silica nanoparticles by the mucociliary apparatus in accordance with the recent in vivo data. This in vitro platform shows that the doses tested may correlate with the occupational exposure limit values. Such relationship could provide regulatory-oriented data useful for risk classification of nanomaterials.

Occupational exposure to graphene and silica nanoparticles. Part I: workplace measurements and samplings.

Few-Layers Graphene (FLG) are able to improve the performance of materials, due to their chemical-physical properties. Engineered amorphous silica nanoparticles (SiO2NPs) are among the most widespread nanomaterials (NMs) in the world. Such nanomaterials are two case studies of the research project 'NanoKey' that integrated the exposure assessment through personal measurements and sampling in the workplace, as described in the present work (part I), with the biomonitoring of exposed workers (reported in part II). Measurement campaigns were conducted according to OECD and WHO harmonized approach in two production sites. The set of instruments included real-time devices for high-resolution measurements at the nanoscale and time-integrated samplers for the off-line gravimetric analysis and chemical and morphological (SEM-EDS) characterization of exposure in order to identify the contribution of production compared to the background. Values of particle number concentration (PNC) and lung deposited surface area (LDSA) within the FLG production resulted higher than the background far field (FF), even if they are always similar to the near field (NF) ones: the average diameter (Davg) during the production was higher than the NF background but always lower than the FF values. SEM-EDS analysis highlighted the presence of structures comparable to those produced. During the SiO2NPs production, the PBZ values showed PNC and LDSA levels higher than the background, with a decrease in the Davg probably due to NPs emission. SEM-EDS confirms the presence of rare silica nanoparticles. Since the exposure to airborne NMs cannot be excluded in both production sites, a prevention-through-design approach to mitigate the potential risk for workers has been recommended.

Workers' Exposure Assessment during the Production of Graphene Nanoplatelets in R&D Laboratory.

Widespread production and use of engineered nanomaterials in industrial and research settings raise concerns about their health impact in the workplace. In the last years, graphene-based nanomaterials have gained particular interest in many application fields. Among them, graphene nanoplatelets (GNPs) showed superior electrical, optical and thermal properties, low-cost and availability. Few and conflicting results have been reported about toxicity and potential effects on workers' health, during the production and handling of these nanostructures. Due to this lack of knowledge, systematic approaches are needed to assess risks and quantify workers' exposure to GNPs. This work applies a multi-metric approach to assess workers' exposure during the production of GNPs, based on the Organization for Economic Cooperation and Development (OECD) methodology by integrating real-time measurements and personal sampling. In particular, we analyzed the particle number concentration, the average diameter and the lung deposited surface area of airborne nanoparticles during the production process conducted by thermal exfoliation in two different ways, compared to the background. These results have been integrated by electron microscopic and spectroscopic analysis on the filters sampled by personal impactors. The study identifies the process phases potentially at risk for workers and reports quantitative information about the parameters that may influence the exposure in order to propose recommendations for a safer design of GNPs production process.

The effect of exposure to long working hours on stroke: A systematic review and meta-analysis from the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury.

BACKGROUND: The World Health Organization (WHO) and the International Labour Organization (ILO) are developing joint estimates of the work-related burden of disease and injury (WHO/ILO Joint Estimates), with contributions from a large network of individual experts. Evidence from mechanistic data and prior studies suggests that exposure to long working hours may cause stroke. In this paper, we present a systematic review and meta-analysis of parameters for estimating the number of deaths and disability-adjusted life years from stroke that are attributable to exposure to long working hours, for the development of the WHO/ILO Joint Estimates. OBJECTIVES: We aimed to systematically review and meta-analyse estimates of the effect of exposure to long working hours (three categories: 41-48, 49-54 and ≥55 h/week), compared with exposure to standard working hours (35-40 h/week), on stroke (three outcomes: prevalence, incidence, and mortality). DATA SOURCES: A protocol was developed and published, applying the Navigation Guide to systematic reviews as an organizing framework where feasible. We searched electronic databases for potentially relevant records from published and unpublished studies, including Ovid MEDLINE, PubMed, EMBASE, Scopus, Web of Science, CISDOC, PsycINFO, and WHO ICTRP. We also searched grey literature databases, Internet search engines, and organizational websites; hand-searched reference lists of previous systematic reviews; and consulted additional experts. STUDY ELIGIBILITY AND CRITERIA: We included working-age (≥15 years) individuals in the formal and informal economy in any WHO and/or ILO Member State but excluded children (aged < 15 years) and unpaid domestic workers. We included randomized controlled trials, cohort studies, case-control studies and other non-randomized intervention studies with an estimate of the effect of exposure to long working hours (41-48, 49-54 and ≥55 h/week), compared with exposure to standard working hours (35-40 h/week), on stroke (prevalence, incidence or mortality). STUDY APPRAISAL AND SYNTHESIS METHODS: At least two review authors independently screened titles and abstracts against the eligibility criteria at a first review stage and full texts of potentially eligible records at a second stage, followed by extraction of data from qualifying studies. Missing data were requested from principal study authors. We combined relative risks using random-effects meta-analysis. Two or more review authors assessed the risk of bias, quality of evidence and strength of evidence, using the Navigation Guide and GRADE tools and approaches adapted to this project. RESULTS: Twenty-two studies (20 cohort studies, 2 case-control studies) met the inclusion criteria, comprising a total of 839,680 participants (364,616 females) in eight countries from three WHO regions (Americas, Europe, and Western Pacific). The exposure was measured using self-reports in all studies, and the outcome was assessed with administrative health records (13 studies), self-reported physician diagnosis (7 studies), direct diagnosis by a physician (1 study) or during a medical interview (1 study). The outcome was defined as an incident non-fatal stroke event in nine studies (7 cohort studies, 2 case-control studies), incident fatal stroke event in one cohort study and incident non-fatal or fatal ("mixed") event in 12 studies (all cohort studies). Cohort studies were judged to have a relatively low risk of bias; therefore, we prioritized evidence from these studies, but synthesised evidence from case-control studies as supporting evidence. For the bodies of evidence for both outcomes with any eligible studies (i.e. stroke incidence and mortality), we did not have serious concerns for risk of bias (at least for the cohort studies). Eligible studies were found on the effects of long working hours on stroke incidence and mortality, but not prevalence. Compared with working 35-40 h/week, we were uncertain about the effect on incidence of stroke due to working 41-48 h/week (relative risk (RR) 1.04, 95% confidence interval (CI) 0.94-1.14, 18 studies, 277,202 participants, I2 0%, low quality of evidence). There may have been an increased risk for acquiring stroke when working 49-54 h/week compared with 35-40 h/week (RR 1.13, 95% CI 1.00-1.28, 17 studies, 275,181participants, I2 0%, p 0.04, moderate quality of evidence). Compared with working 35-40 h/week, working ≥55 h/week may have led to a moderate, clinically meaningful increase in the risk of acquiring stroke, when followed up between one year and 20 years (RR 1.35, 95% CI 1.13 to 1.61, 7 studies, 162,644 participants, I2 3%, moderate quality of evidence). Compared with working 35-40 h/week, we were very uncertain about the effect on dying (mortality) of stroke due to working 41-48 h/week (RR 1.01, 95% CI 0.91-1.12, 12 studies, 265,937 participants, I2 0%, low quality of evidence), 49-54 h/week (RR 1.13, 95% CI 0.99-1.29, 11 studies, 256,129 participants, I2 0%, low quality of evidence) and 55 h/week (RR 1.08, 95% CI 0.89-1.31, 10 studies, 664,647 participants, I2 20%, low quality of evidence). Subgroup analyses found no evidence for differences by WHO region, age, sex, socioeconomic status and type of stroke. Sensitivity analyses found no differences by outcome definition (exclusively non-fatal or fatal versus "mixed") except for the comparison working ≥55 h/week versus 35-40 h/week for stroke incidence (p for subgroup differences: 0.05), risk of bias ("high"/"probably high" ratings in any domain versus "low"/"probably low" in all domains), effect estimate measures (risk versus hazard versus odds ratios) and comparator (exact versus approximate definition). CONCLUSIONS: We judged the existing bodies of evidence for human evidence as "inadequate evidence for harmfulness" for all exposure categories for stroke prevalence and mortality and for exposure to 41-48 h/week for stroke incidence. Evidence on exposure to 48-54 h/week and ≥55 h/week was judged as "limited evidence for harmfulness" and "sufficient evidence for harmfulness" for stroke incidence, respectively. Producing estimates for the burden of stroke attributable to exposures to working 48-54 and ≥55 h/week appears evidence-based, and the pooled effect estimates presented in this systematic review could be used as input data for the WHO/ILO Joint Estimates. PROTOCOL IDENTIFIER: https://doi.org/10.1016/j.envint.2018.06.016. PROSPERO REGISTRATION NUMBER: CRD42017060124.