Pollution in the Americas: a leading cause of disease burden and an opportunity for cancer prevention.

OBJECTIVE: Environmental and occupational agents are causes of cancer and disease worldwide while their control and the reduction of the associated disease burden remains complex. MATERIALS AND METHODS: This paper summarizes the current status of the burden of environmental and occupational causes of disease in the Americas based on presentations from a panel on environment, occupation and other environmental risk factors for cancer in the Americas, delivered in Panama, at the international conference Promoting Health Equity and Transnational Collaborations for the Prevention and Control of Cancer in the Americas. RESULTS: Three case studies are presented to illustrate the impact of specific environmental and occupational agents and the challenge of control. CONCLUSIONS: There are still fully avoidable exposures to carcinogens, as well documented in the case of asbestos in Brazil. Thus, there are abundant targets for intervention to reduce cancer in the Americas.

OBJETIVO: Los agentes ambientales y ocupacionales son causas de cáncer y enfermedades en todo el mundo, mientras que su control y reducción de la carga de enfermedad asociada siguen siendo puntos complejos. MATERIAL Y MÉTODOS: Este documento resume el estado actual de la carga de las causas ambientales y ocupacionales de las enfermedades en las Américas a partir de las presentaciones de un panel sobre medio ambiente, ocupación y otros factores de riesgo ambientales para el cáncer en las Américas, realizado en Panamá, en la conferencia internacional Promoviendo la Equidad en Salud y las Colaboraciones Transnacionales para la Prevención y el Control del Cáncer en las Américas. RESULTADOS: Se presentan tres estudios de caso para ilustrar el impacto de agentes ambientales y ocupacionales específicos y el desafío del control. CONCLUSIONES: Todavía hay exposiciones totalmente evitables a los carcinógenos, como está bien documentado en el caso del asbesto en Brasil. Hay abundantes puntos estratégicos de intervención para reducir el cáncer en las Américas.

Recovering missing mesothelioma deaths in death certificates using hospital records.

BACKGROUND: In Brazil, underreporting of mesothelioma and cancer of the pleura (MCP) is suspected to be high. Records from death certificates (SIM) and hospital registers (SIH-SUS) can be combined to recover missing data but only anonymous databases are available. This study shows how common data can be used for linkage and as an assessment of accuracy. METHODS: Mesothelioma (all sites, ICD-10 codes C45.0-C45.9) and cancer of the pleura (C38.4) were retrieved from both information systems and combined using a linkage algorithm. Accuracy was examined with non-anonymous databases, limited to the state of São Paulo. RESULTS: We found 775 cases in death certificates and 283 in hospital registers. The linkage matched 57 cases, all accurately paired. Three cases, 0.4% in SIM and 1.3% in SIH-SUS, could not be matched because of data inconsistencies. CONCLUSIONS: A computer linkage can recover MCP cases from hospital records not found in death certificates in Brazil.

Interaction between noise and cigarette smoking for the outcome of hearing loss among women: a population-based study.

BACKGROUND: We investigated the interaction between exposure to noise and smoking in relation to prevalence of hearing loss among women. METHODS: A sample of women aged 20-49 years (n = 1,723) from a population-based cross-sectional study carried out in Brazil in 2006 was examined. Hearing loss was assessed using a yes-no validated question. Biological interaction was analyzed using the additive scale and measured with interaction contrast ratio (ICR) and assessment of dose-response relationship. RESULTS: The combined effect of exposure to noise and cigarette smoking on hearing loss (adjusted prevalence ratio (PRadj) = 3.94, 95% confidence interval (CI): 2.81, 5.52) was greater than expected based on the additive single effects of smoking (PRadj = 1.39, 95% CI: 1.07, 1.81) and noise (PRadj = 2.66, 95% CI: 1.86, 3.82). ICR estimates were not statistically significant. The prevalence of hearing loss among noise-exposed women increased with duration of smoking (P trend = 0.026), number of cigarettes smoked per day (P trend = 0.034), cumulative tobacco use (P trend = 0.030), and early age at smoking initiation (P trend = 0.047). CONCLUSIONS: Noise and smoking may have a combined effect on hearing loss but further studies are still needed. A dose-response relation of smoking for the noise effect among women is suggested.

Incidence of severe work-related injuries among young adult workers in Brazil: analysis of compensation data.

OBJECTIVES: To obtain national estimates of the annual cumulative incidence and incidence density of severe non-fatal injuries using compensation benefits data from the Brazilian National Social Security Institute (INSS), and to describe their sociodemographic distribution among workers aged under 25 years. METHODS: Data are records of health-related compensation benefits from the Ministry of Social Insurance's information system of compensation benefits of the INSS recorded in 2006. Injuries were cases classified under chapter XIX, ICD-10. The assessment of their relation with work was made by INSS's occupational physician experts. The study population comprised young workers aged 16-24 years. RESULTS: 59,381 workers received compensation benefits for injuries in the study year. Among them 14,491 (24.4%) were work related, 12,501 (86.3%) were male and 1990 were female workers (13.7%). The annual cumulative incidence rate of work-related injuries (ACI-WI) was 2.9×1000 workers, higher among men (4.2×1000) than women (1.0×1000). The incidence density rate (IDR-WI) was 0.7/1000 full-time equivalent (FTE), higher for men (0.97/1000 FTE) than women (0.24/1000 FTE). Both morbidity measures were higher in the younger group (16-19 years), and inversely related to wage, especially for women in the younger group. Logging, extraction, food/beverage and construction industries had higher ACI-WI and IDR-WI for adolescents and young adult workers of both sex groups. CONCLUSIONS: These findings suggest that the Brazilian labour laws limiting young adult workers in hazardous settings need to be expanded, adding occupations in other extractive industries and certain types of work in the food/beverage manufacturing industries. Social inequalities associated with sex need to be examined further with more detailed data.

Workdays lost due to occupational injuries among young workers in Brazil.

BACKGROUND: The severity of non-fatal work-related injuries has seldom been examined among young workers. We estimated the extent and distribution of workdays lost due to non-fatal work injuries using compensation data. METHODS: Data are from the Brazilian Institute of Social Insurance, for 2006. The study population is comprised of all insured workers of age 16-24. Descriptive statistics reflect workdays lost due to health-related disability, according to sex, age group, wage, and trade. RESULTS: Out of 4.8 million insured workers ages 16-24 years, we estimated 1,282,940 workdays lost. We observed a larger number of median workdays lost among males age 20-24 in retail and service trades (83 days) and among 16-19-year-old females in the agriculture/fish/forestry/cattle (142 days). CONCLUSIONS: Young workers experience a heavy burden of work-related injuries. Disability workdays may compromise school attendance and performance. Other potential impacts affect productivity and social insurance costs.

Analysis of Mortality from Asbestos-Related Diseases in Brazil Using Multiple Health Information Systems, 1996-2017.

Background: In Brazil, asbestos was intensively used from the 1960s until its ban in 2017. Mesothelioma, asbestosis, and pleural plaques are typical asbestos-related diseases (ARD-T). To create an ARD-T national database, death records from 1996-2017 were retrieved from several health information systems (HIS). Methods: All national HIS containing coded diagnoses (ICD-10) and death information were obtained. Linkage was performed to create a single database of ARD-T death records, either as underlying or contributory causes, in adults aged 30 years and older. Results: A total of 3,057 ARD-T death records were found, 2,405 (76.4%) of which being malignant mesotheliomas (MM). Pleural MM (n = 1,006; 41.8%) and unspecified MM (n = 792; 32.9%) prevailed. Male to female MM ratio (M:F) was 1.4:1, and higher ratios were found for non-malignant ARD-T: 3.5:1 for asbestosis and 2.4:1 for pleural plaques. Male crude annual mesothelioma mortality (CMmm x1,000,000) was 0.98 in 1996 and 2.26 in 2017, a 131.1% increment, while for females it was 1.04 and 1.25, a 20.2% increase, correspondingly. The small number of deaths with asbestosis and pleural plaques records precluded conclusive interpretations. Conclusions: Even with the linkage of several HIS, ARD-T in death records remained in low numbers. MM mortality in men was higher and showed a rapid increase and, along with non-malignant ARD-T, higher M:F ratios suggested a predominant pattern of work-related exposure. The monitoring of workplace and environmental asbestos exposure needs to be improved, as well as the workers surveillance, following the recent Brazilian ban.

Occupational cancer burden in developing countries and the problem of informal workers.

Most workplaces in developing countries are "informal", i.e. they are not regularly surveyed/inspected and laws for workers' protection are not implemented. Research on occupational risks in informal workplaces and the related cancer burden is needed. The results of studies addressing exposures among informal workers are difficult to generalize because of the specificities of social contexts, and study populations are small. The estimation of the burden of cancers attributable to occupational exposures is also made difficult by the fact that occupational cancers are usually clinically indistinguishable from those unrelated to occupation.

Recovering records on cancer of the larynx from anonymous health information databases.

OBJECTIVE: To develop a linkage algorithm to match anonymous death records of cancer of the larynx (ICD-10 C32X), retrieved from the Mortality Information System (SIM) and the Hospital Information System of the Brazilian Unified National Health System (SIH-SUS) in Brazil. METHODOLOGY: Death records containing ICD-10 C32X codes were retrieved from SIM and SIH-SUS, limited to individuals aged 30 years and over, between 2002 and 2012, in the state of São Paulo. The databases were linked using a unique key identifier developed with sociodemographic data shared by both systems. Linkage performance was ascertained by applying the same procedure to similar non-anonymous databases. True pairs were those having the same identification variables. RESULTS: A total of 14,311 eligible death records were found. Most records, 10,674 (74.6%), were exclusive to SIM. Only 1,853 (12.9%) deaths were registered in both systems, representing true pairs. A total of 1,784 (12.5%) cases of laryngeal cancer in the SIH-SUS database were tracked in SIM with different causes of death. The linkage failed to match 167 (9.4%) records due to inconsistencies in the key identifier. CONCLUSION: The authors found that linking anonymous data from mortality and hospital records is a feasible measure to track missing records and may improve cancer statistics.

Child and adolescent labor, socioeconomic status, and reduced adult height.

This population-based cross-sectional study of 3262 individuals aged 18 to 65 years from Aracaju, Brazil investigates the effects of child/adolescent labor (CAL) experience on adult height, considering gender, socioeconomic status (SES), and skin color. We hypothesized that the younger children are at their first job, the greater the negative effects will be on their later growth as adults. Child/adolescent laborers reported having paid jobs before 14 years of age. Among males in the low and medium SES strata, CAL experience was negatively associated with adult height independent of skin color; among females, this inverse association was observed for those in the low and high SES strata. Among males in the low and medium SES strata, there was a linear inverse relation between age at first job and adult height. CAL could reduce height in adulthood, suggesting a need for programs that reduce the impact of CAL on future physical development.

Introduction to the WHO Commission on Social Determinants of Health Employment Conditions Network (EMCONET) study, with a glossary on employment relations.

Although the conditions and power relations of employment are known to be crucial health determinants for workers and their families, the nature of these relations and their effects on health have yet to be fully researched. Several types of employment--precarious employment in developed countries; informal sectors, child labor, slavery, and bonded labor in developing countries--expose workers to risky working conditions. Hazardous work and occupation-related diseases kill approximately 1,500 workers, globally, every day. Growing scientific evidence suggests that particular employment conditions, such as job insecurity and precarious employment, create adverse health effects; yet the limited number of studies and the poor quality of their methods prevent our understanding, globally, the complexity of employer-employee power relations, working conditions, levels of social protections, and the reality of employment-related health inequalities. This article introduces a special section on employment-related health inequalities, derived from the EMCONET approach, which focuses on (1) describing major methods and sources of information; (2) presenting theoretical models at the micro and macro levels; (3) presenting a typology of labor markets and welfare states worldwide; (4) describing the main findings in employment policies, including four key points for implementing strategies; and (5) suggesting new research developments, a policy agenda, and recommendations. This introduction includes a glossary of terms in the emerging area of employment conditions and health inequalities.

Conclusions and recommendations for the study of employment relations and health inequalities.

This article synthesizes and extends the central conclusions and recommendations to be drawn from the study on the role of employment relations in reducing health inequalities presented in the special section of this issue of the Journal, and identifies future directions in research and policy derived from the broader work of the EMCONET network. The authors also argue that adopting an appropriate theoretical framework is essential to both comprehending and extending knowledge and action on employment conditions and health inequalities.

A macro-level model of employment relations and health inequalities.

The authors develop a macro-social theoretical framework to explain how employment and working conditions affect health inequalities. The theoretical framework represents the social origins and health consequences of various forms of employment conditions. The emphasis is thus on determinants and consequences of employment conditions, not on social determinants of health in general. The framework tries to make sense of the complex link between macro-social power relations among employers, government, and workers' organizations, labor market and social policies, employment and working conditions, and the health of workers. It also suggests further testing of hypothetical causal pathways not covered in the literature. This macro-social theoretical framework might help identify the main "entry points" through which to implement policies and interventions to reduce employment-related health inequalities. The theoretical framework should be approached from a historical perspective.

A micro-level model of employment relations and health inequalities.

Theoretical models are a way of visualizing, in context, the many factors that contribute to inequalities in health. This article presents a model showing the micro-level pathways relating employment and working conditions to health inequalities. A first important (indirect) pathway runs through the unequal distribution of harmful working conditions. Both employment and working conditions tend to be unequally distributed along the same social axes: social class, gender, ethnicity/race, immigration/migration status, territory, and so forth. Underlying mechanisms are exploitation, domination, and discrimination. Material deprivation and economic inequalities constitute a second direct pathway linking (nonstandard) employment conditions to health inequalities. In a third pathway, employment conditions may have an important effect on health inequalities via several psychosocial, behavioral, and physiopathological pathways. Although these several pathways are separated for analytical purposes, they are largely intertwined and, ideally, should be studied in an integrated way. The theoretical model presented in this article serves three main purposes: providing analytical clarity for organizing scientific data, encouraging further observation and causal testing, and identifying policy entry points.

Six employment conditions and health inequalities: a descriptive overview.

Standard full-time permanent employment-providing a minimal degree of stability, income sustainability, workers' empowerment, and social protection-has declined in the high-income countries, while it was never the norm in the rest of the world. Consequently, work is increasingly affecting population health and health inequalities, not only as a consequence of harmful working conditions, but also because of employment conditions. Nevertheless, the health consequences of employment conditions are largely neglected in research. The authors describe five types of employment conditions that deviate from standard full-time permanent employment--precarious employment, unemployment, informal employment, forced employment or slavery, and child labor--and their health consequences, from a worldwide perspective. Despite obvious problems of measurement and international comparability, the findings show that, certainly in the low-income countries, these conditions are largely situated in informality, denying any possible standard of safety, protection, sustainability, and workers' rights. Considerable numbers of the world's working people are affected in geographically and socioeconomically unequal ways. This clearly relates nonstandard employment conditions to health equity consequences. In the future, governments and health agencies should establish more adequate surveillance systems, research programs, and policy awareness regarding the health effects of these nonstandard employment conditions.

Unemployment, informal work, precarious employment, child labor, slavery, and health inequalities: pathways and mechanisms.

The study explores the pathways and mechanisms of the relation between employment conditions and health inequalities. A significant amount of published research has proved that workers in several risky types of labor--precarious employment, unemployment, informal labor, child and bonded labor--are exposed to behavioral, psychosocial, and physio-pathological pathways leading to physical and mental health problems. Other pathways, linking employment to health inequalities, are closely connected to hazardous working conditions (material and social deprivation, lack of social protection, and job insecurity), excessive demands, and unattainable work effort, with little power and few rewards (in salaries, fringe benefits, or job stability). Differences across countries in the social contexts and types of jobs result in varying pathways, but the general conceptual model suggests that formal and informal power relations between employees and employers can determine health conditions. In addition, welfare state regimes (unionization and employment protection) can increase or decrease the risk of mortality, morbidity, and occupational injury. In a multilevel context, however, these micro- and macro-level pathways have yet to be fully studied, especially in middle- and low-income countries. The authors recommend some future areas of study on the pathways leading to employment-related health inequalities, using worldwide standard definitions of the different forms of labor, authentic data, and a theoretical framework.

Policies and interventions on employment relations and health inequalities.

The association between certain increasingly pervasive employment conditions and serious health inequalities presents a significant policy challenge. A critical starting point is the recognition that these problems have not arisen in a policy vacuum. Rather, policy frameworks implemented by governments over the past 35 years, in conjunction with corporate globalization (itself facilitated by neoliberal policies), have undermined preexisting social protection policies and encouraged the growth of health-damaging forms of work organization. After a brief description of the context in which recent developments should be viewed, this article describes how policies can be reconfigured to address health-damaging employment conditions. A number of key policy objectives and entry points are identified, with a summary of policies for each entry point, relating to particular employment conditions relevant to rich and poor countries. Rather than trying to elaborate these policy interventions in detail, the authors point to several critical issues in relation to these interventions, linking these to illustrative examples.

Occupation and maternal mortality in Brazil.

OBJECTIVE: To estimate maternal mortality ratio according to occupation in Brazil. METHODS: This is a mortality study conducted with national data from the Mortality Information System (SIM) and the Live Birth Information System (SINASC) in 2015. Maternal mortality ratios were estimated according to the occupation recorded in death certificates, using the Brazilian Classification of Occupation (CBO), version 2002. RESULTS: A total of 1,738 maternal deaths records were found, corresponding to a maternal mortality ratio of 57.6/100,000 live births. It varied among occupational groups, with higher estimates among service and agricultural workers, particularly for domestic workers (123.2/100,000 live births), followed by general agricultural workers (88.3/100,000 live births). Manicurists and nursing technicians also presented high maternal mortality ratio. Maternal occupation was not reported in 17.0% of SIM registers and in 13.2% of SINASC data. Inconsistent records of occupation were found."Housewife" prevailed in SIM (35.5%) and SINASC (39.1%). CONCLUSIONS: Maternal mortality ratio differs by occupation, suggesting a work contribution, which requires further research focusing occupational risk factors. Socioeconomic factors are closely related to occupation, and their combination with work exposures and the poor access to health services need to be also addressed.

Occupational exposure to organophosphate pesticides and hematologic neoplasms: a systematic review. / Exposição ocupacional a agrotóxicos organofosforados e neoplasias hematológicas: uma revisão sistemática.

OBJECTIVE: To update findings of observational analytical studies on the association between occupational exposure to organophosphates and hematologic malignancies. METHODOLOGY: Systematic literature review, including cohort and case-control studies, without limitation of publication time, in Portuguese and English. The articles were traced from June 2017 to July 2019 in PubMed, MEDLINE, LILACS, Web of Science, and Scopus databases. The qualitative bias risk assessment was performed using the Newcastle-Ottawa Scale and the Downs and Black Checklist. Results were presented according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). RESULTS: Seventeen studies evaluated as good/high methodological quality were eligible. Exposure to diazinon (1 cohort), phonophos (1 cohort), dichlorvos, crotoxiphos and famphur (1 case control) was associated with leukemia, while exposure to organophosphate was associated to lymphomas (6 case control); the risk of non-Hodgkin's lymphoma was higher in those exposed to diazinon (1 control case) and malathion (3 control case) than non-exposed ones. Multiple myeloma occurred more commonly in organophosphate exposed than in non-exposed individuals (1 case-control). CONCLUSION: Occupational exposure to organophosphates increases the risk of hematologic malignancies, especially among individuals with longer exposure periods. Worker monitoring and exposure control measures are recommended.

[Factors associated with quality of work accident records in Brazil's Mortality Information System]. / Fatores associados à qualidade de registros de acidentes de trabalho no Sistema de Informações sobre Mortalidade no Brasil.

This study aimed to identify factors associated with the quality of fatal work accident records in the Brazilian Mortality Information System in individuals 18 to 65 years of age from 1998 to 2013. The quality of the record of possible causal relationship between accidents and the work , a field that appears on death certificates and is exclusive to accidents among external causes, was analyzed with two variables: (1) record "ignored" (R-IGN, yes/no); (2) missing or inconsistent records (R-AUS, yes/no). A total of 665,531 deaths were located, of which 67.7% of the records showed poor quality. Factors associated with record "ignored" were: male sex; white skin color; schooling less than university; non-blue-collar workers or non-farmers; death certificate issued by the Forensic Medical Office (IML); Southeast and Northeast regions of the country; and death in hospital. Missing or inconsistent records were associated with: age greater than 34 years; non-white skin color; no schooling; all regions of Brazil except the Southeast; death in hospital or at home; police report as the source of information; and death certificate issued by the IML. The factors independently associated with poor quality of completion of the field included individual dimensions, source issuing the death certificate, place of death, and geographic variables. The findings reveal the need to improve the quality of death records in hospitals, the IML, and police reports, besides training and supervising teams throughout Brazil.

Este estudo teve como objetivo identificar fatores associados à qualidade do registro de acidentes de trabalho fatais no Sistema de Informações sobre Mortalidade (SIM), ocorridos com pessoas de 18 a 65 anos, entre 1998 e 2013, no Brasil. A qualidade do registro da possível relação causal de acidentes com o trabalho , campo existente em declarações de óbitos, exclusivo para acidentes dentre as causas externas, foi analisada com duas variáveis: (1) registro "ignorado" (R-IGN, sim/não); (2) registros ausentes ou inconsistentes (R-AUS, sim/não). Foram encontrados 665.531 óbitos dentre os quais 67,7% dos registros de eram de má qualidade. Fatores associados a registro "ignorado" foram: sexo masculino; cor da pele branca; escolaridade menor que a superior; não operários ou não agricultores; atestante Instituto Médico Legal (IML); regiões Sudeste e Nordeste; e óbito em hospital. Registros ausentes ou inconsistentes se associaram: à idade acima de 34 anos; à cor da pele não branca; a sem escolaridade; a todas as regiões, exceto à Sudeste; a óbito em hospital ou no domicílio; a boletim de ocorrência como fonte; e a atestante IML. Esses fatores, independentemente associados à má qualidade de preenchimento do campo , compreendiam dimensões individuais, da fonte de emissão, do local do óbito e geográficas. Isso revela a necessidade de melhoria da qualidade de declarações de óbito em hospitais, IML e boletins de ocorrência, treinando e supervisionando equipes em todo o Brasil.

El objetivo de este estudio fue identificar factores asociados a la calidad del registro de accidentes de trabajo fatales en el Sistema de Información sobre Mortalidad (SIM), ocurridos con personas de 18 a 65 años, entre 1998 y 2013, en Brasil. La calidad del registro de la posible relación causal de accidentes con el trabajo , campo existente en las declaraciones de fallecimiento, exclusivo para accidentes entre las causas externas, se analizó con dos variables: (1) registro "ignorado" (R-IGN, sí/no); (2) registros ausentes o inconsistentes (R-AUS, sí/no). Se encontraron 665.531 óbitos entre los cuales un 67,7% de los registros de eran de mala calidad. Los factores asociados al registro "ignorado" fueron: sexo masculino; color de piel blanco; escolaridad menor que la superior; no obreros o no agricultores; con atestado del Instituto Médico Legal (IML); región sudeste y nordeste; y fallecimiento en hospital. Los registros ausentes o inconsistentes se asociaron a: edad por encima de 34 años; color de piel no blanca; sin escolaridad; todas las regiones, excepto la sudeste; fallecimiento en hospital o en el domicilio; boletín de ocurrencia como fuente; y con atestado IML. Estos factores independientemente asociados a la mala calidad en la cumplimentación del campo incluían dimensiones individuales, de la fuente de emisión, del lugar del fallecimiento y geográficas. Esto revela la necesidad de mejora en la calidad de las declaraciones de óbito en hospitales, IML y boletines de ocurrencia, entrenando y supervisando equipos en todo Brasil.