Statutory prevention of work injuries in Italy: an effectiveness evaluation with interrupted time series analysis in a sample of 5000 manufacturing plants from the Veneto region.

OBJECTIVES: According to Italian law, prevention of injuries in the workplace falls under the National Health System Service of Prevention, Health and Safety at Work (SPISAL). In a sample of about 5000 industrial firms in the Veneto region (North-Eastern Italy), the study examines the impact of SPISAL safety programmes on injuries. METHODS: The study is based on the before-and-after comparison of injury rates in 795 industrial settings that were subject to SPISAL interventions and 4186 reference firms, which were all manufacturing industries with >10 employees; construction companies were excluded. The time window (2001-2007) was chosen in order to have 8 quarters of observation before and 8 after the intervention. The National Institute for Workers' Compensation provided data on injuries and plants, while SPISAL gave information on interventions carried out. The preintervention and postintervention rates of injuries were compared by means of interrupted time series analyses, estimating the rate ratio (RR) with a 95% CI. RESULTS: Inspection after injury reduced by 24% (RR=0.76; 95% CI 0.65 to 0.90; p=0.001) all injuries, and by 36% (RR=0.64; 95% CI 0.50 to 0.83; p=0.001) severe injuries (fatalities, lost workdays >30, degree of permanent disability >0). These changes occurred immediately and persisted for 2 years. The effects of programmed inspections were never significant. CONCLUSIONS: It can be presumed that, after a severe injury, the employees raised their standard of what they considered good work safety and, at the same time, the employers were pushed to improve the work environment as a result of the sudden attention from the workplace hygiene and safety authority and court authority. Inspection after injury was an effective strategy; however, confirmatory evidence is needed.

Post-occupational health surveillance of asbestos workers.

BACKGROUND: Italian law requires an extensive health surveillance of workers after cessation of their employment status in the case of occupational exposure to carcinogens, including asbestos. Nonetheless, Italian law does not specify the timeframe of these clinical checks, nor who has financial and organizational responsibility for this surveillance. A literature search confirmed a lack of consensus around the objectives and methods to follow up workers with past occupational exposure to asbestos. OBJECTIVES: To develop an updated evidence-based methodology for an appropriate health surveillance programme. METHODS: We present an overview of the field experience developed by the Veneto Region from 2000 to 2011, and new studies that could contribute to establishing a national policy for the medical surveillance of workers with past asbestos exposure. RESULTS: There were three specific topics: (1) definition of a reliable method to identify asbestos workers (through multiple sources and procedures that meet current confidentiality regulations); (2) detection of asbestos fibres in biological media (to support the etiological diagnosis of asbestos-related diseases); (3) creation of a national protocol of health surveillance (through the assessment of policies developed by other Regions in this field, and recruiting from these regions a cohort of past-exposed workers: the epidemiological study should offer relevant suggestions for specific surveillance approaches, based on either estimated cumulative asbestos exposure or detection of x-ray patterns of pleural plaques and/or asbestosis). CONCLUSIONS: These studies will support the Regions in setting up health care policies directed at workers with past asbestos exposure.

[Changes in risk factors for spontaneous abortion in an area with high concentrations of shoe manufacture after a preventive intervention]. / Evoluzione dei fattori di rischio per l'aborto spontaneo in un'area ad alta concentrazione di calzaturifici dopo un intervento di prevenzione.

Risk factors of spontaneous abortion were investigated in two matched case-control studies in 1987-88 and 1997-99. An history of previous abortions significantly increased the risk in both studies. Lifestyle (coffee) and occupational (exposure to organic solvents) factors were associated with a significantly increased risk in the first but not in the second calendar period, following a community intervention with advice given to workers, employers, and physicians; the latter also counseled a greater use of medicines against spontaneous abortion.

[Decrease in the n-hexane risk in shoe manufacturing industry]. / Ridimensionamento del rischio da n-esano nei calzaturifici.

In recent years the composition of the glues used in the shoe manufacturing industry in the "Riviera del Brenta" area (northern Italy) has changed considerably, with a gradual reduction of n-hexane. This fact emerged from a survey of 337 gluing stations in 105 shoe factories where 104 different commercial products containing organic solvents were found. The determining element in this change was the substitution of technical hexane with other refinery products which have a low n-hexane content (< 5%). There was a possible health risk due to n-hexane exposure in about only 10% of the gluing stations and in about 8% of commercial products, where mixtures of technical hexane are used. Ethyl acetate, cyclo-hexane, hexane isomers, methyl ethyl ketone, heptane and acetone are among the solvents most frequently used. This change means that assessment of glue composition will be necessary before beginning a health monitoring programme of the exposed population.

[Ulnar neuropathy at the elbow in workers using column sewing machines: case reports and follow-up]. / Neuropatia del nervo ulnare a livello del gomito in addette all'uso di macchine per cucire a colonna: casistica e follow-up.

Fifteen cases of ulnar nerve neuropathy at cubital tunnel level were observed in women aged between 16 and 37 years employed in shoe factories. The women operated column sewing machines resting their elbows on the work table. Past evidence showed that the interval between the beginning of work and onset of neuropathy was generally more than one year but less than that for similar diseases observed in other jobs where arthritis of the elbow played a more important role and the average age was higher. It can therefore be supposed that arthritis in these shoes workers was of less significance, whereas local trauma, which was not prevented by the use of small soft cushions under the elbows (4 out of the 15 subjects had been using them for some time), seemed of greater importance. A period of less than one year (in one case only a few days) was deemed due to the presence of a pre-existing neuropathy of the elbow which had so far been asymptomatic. Cases treated within six months of onset showed marked improvement. However, rapidly worsening symptoms, independent of the degree of damage reached, often led to early treatment with favourable outcome in a short time, while slow and insidious onset brought a longer prognosis. The primary prevention suggested is to instruct workers as to the correct work posture, i.e., avoiding resting the elbows on the work table. As a secondary preventive measure, bearing in mind the need of early diagnosis and treatment, medical check-ups every six months are proposed.

[Exposure to glues containing technical heptane: a clinical and electrophysiological study]. / Esposizione a collanti contenenti eptano tecnico: studio clinico ed elettroneurofisiologico.

Polyneuropathy caused by n-hexane contained in glues was, until recently, the typical occupational disease of shoemakers. Glues no longer contain large concentrations of this solvent, and in some cases, it as been completely replaced by other hydrocarbons. The authors investigated the health status in a group of shoemakers using glues containing 35% technical heptane. The same glue, not containing n-hexane, was used by a shoemaker who worked at home; she developed an otherwise unexplainable peripheral polyneuropathy. For each of the 16 subjects, the following procedures were carried out: environmental sampling, biological monitoring for Mek and heptane metabolites, a neurological and electromyographic examination. No neurological abnormalities were found in the workers that could be attributable to occupational exposure, probably due to the low level environmental contamination (< 100 mg/m3 n-heptane) found in the 7 factories and workshops studied where acceptable hygiene conditions existed. The time course and ratio of urinary metabolites of heptane were also studied, the latter showing a predominance of 2- and 3- heptanol in the initial phase and 2-5 heptandione at the end of the work week; probably, the presence of other solvents, such as Mek, can modify the ratio of metabolites and consequently the formation of neurotoxic compounds could result.

Risk of spontaneous abortion and maternal exposure to organic solvents in the shoe industry.

OBJECT: A high risk of spontaneous abortion was observed in women exposed to organic solvents during pregnancy. Since this risk was not found in the shoe industry, where these solvents are widely used, we carried out a case-control study on the risk of spontaneous abortion in a health district (Veneto, Northern Italy) where about 8,000 people work in shoe manufacturing. Aliphatic hydrocarbons were generally used; their concentrations were repeatedly below the mixture TLVs in the observation period. METHODS: Cases (clinically recognized spontaneous abortion, ICD codes 632-634-636) and age-/year-/residence-matched controls (admitted for normal delivery) were traced in the files of the regional hospital discharges register. Data on 108 cases (81% response) and the same number of reference subjects were collected on questionnaires completed by nurses trained in occupational medicine. There were questions on confounding and occupational factors, and an open question to ensure a complete description of work done during pregnancy. An occupational physician, working blind, then coded exposure to organic solvents according to a three-level polytomous variable (no, low, high exposure). RESULTS: The cases/controls not exposed, exposed to low levels and exposed to high levels of organic solvents were 78/88, 12/12, and 18/8 respectively. Adjusted for the confounding factors, the relative risk (RR) of spontaneous abortion for high exposure to organic solvents during pregnancy was 3.85, with 95% confidence intervals (CI) ranging from 1.24 to 11.9. RR was 1.58 (CI = 0.62-4.06) in women exposed to low solvent concentrations. CONCLUSIONS: Our results support the hypothesis that spontaneous abortion may be an adverse effect of exposure to high levels of organic aliphatic solvents in women employed in shoe manufacture.

Does n-heptane cause peripheral neurotoxicity? A case report in a shoemaker.

Subjective and electrophysiological signs relating to the central and peripheral nervous systems developed in a shoemaker, a few months after beginning work at home. Signs of central nervous system involvement rapidly disappeared after the end of the exposure, whereas those of mild peripheral neuropathy lasted for several months. The glue used contained a variety of solvents including ethylacetate, cyclohexane, methylcyclohexane, methylethylketone and others; n-hexane was not detected, whereas, unusually, n-heptane was. This exposure was reproduced experimentally in the same work room and the solvent air level did not exceed the American Conference of Governmental Industrial Hygienists threshold values. A tentative conclusion is that the toxic effects on the peripheral nerve are likely to be due to n-heptane.

A new color vep procedure discloses asymptomatic visual impairments in optic neuritis and glaucoma suspects.

OBJECTIVE: To evaluate the reliability of visual evoked potentials obtained with a set of multiple chromatic and achromatic patterns (C-VEPs) in differentiating asymptomatic perifoveal retinal impairment from central conduction impairment. METHODS: We propose a set of colored pattern stimuli that allows relatively differential activation of the magnocellular and parvocellular pathways. The system runs on a standard Pentium PC with peripherals that present stimuli and collect, analyze and print data. P1 latencies of C-VEPs obtained with achromatic (black/white) and chromatic (blue/black and red/black isocontrast) checkerboards were evaluated in normal subjects and patients with subclinical retinal impairment (glaucoma suspects) or mild neural conduction impairment (optic neuritis), none of whom had subjective visual defects. RESULTS: The procedure evoked robust cortical signals and statistically distinguished the 3 groups of subjects. The achromatic and chromatic stimuli used distinguished controls from glaucoma suspects and patients with optic neuritis. Glaucoma suspects had greater impairment of C-VEPs to blue/black checkerboards whereas patients with optic neuritis had greater impairment of responses to red/black stimuli. CONCLUSIONS: Our data suggest that chromatic patterns (color/ black, red and blue), that may activate the parvocellular and magnocellular systems differentially but not selectively, can distinguish between mild perifoveal or foveal conduction impairment. They have the additional advantage of evoking large, stable responses across all the subjects.