Health effects of exposure to chlorination by-products in swimming pools.

Concerns have been raised regarding the potential negative effects on human health of water disinfectants used in swimming pools. Among the disinfection options, the approaches using chlorine-based products have been typically preferred. Chlorine readily reacts with natural organic matter that are introduced in the water mainly through the bathers, leading to the formation of potentially harmful chlorination by-products (CBPs). The formation of CBPs is of particular concern since some have been epidemiologically associated with the development of various clinical manifestations. The higher the concentration of volatile CBPs in the water, the higher their concentration in the air above the pool, and different routes of exposure to chemicals in swimming pools (water ingestion, skin absorption, and inhalation) contribute to the individual exposome. Some CBPs may affect the respiratory and skin health of those who stay indoor for long periods, such as swimming instructors, pool staff, and competitive swimmers. Whether those who use chlorinated pools as customers, particularly children, may also be affected has been a matter of debate. In this article, we discuss the current evidence regarding the health effects of both acute and chronic exposures in different populations (work-related exposures, intensive sports, and recreational attendance) and identify the main recommendations and unmet needs for research in this area.

Are high- and low-molecular-weight sensitizing agents associated with different clinical phenotypes of occupational asthma?

BACKGROUND: High-molecular-weight (HMW) proteins and low-molecular-weight (LMW) chemicals can cause occupational asthma (OA) although few studies have thoroughly compared the clinical, physiological, and inflammatory patterns associated with these different types of agents. The aim of this study was to determine whether OA induced by HMW and LMW agents shows distinct phenotypic profiles. METHODS: Clinical and functional characteristics, and markers of airway inflammation were analyzed in an international, multicenter, retrospective cohort of subjects with OA ascertained by a positive inhalation challenge response to HMW (n = 544) and LMW (n = 635) agents. RESULTS: Multivariate logistic regression analysis showed significant associations between OA caused by HMW agents and work-related rhinitis (OR [95% CI]: 4.79 [3.28-7.12]), conjunctivitis (2.13 [1.52-2.98]), atopy (1.49 [1.09-2.05]), and early asthmatic reactions (2.86 [1.98-4.16]). By contrast, OA due to LMW agents was associated with chest tightness at work (2.22 [1.59-3.03]), daily sputum (1.69 [1.19-2.38]), and late asthmatic reactions (1.52 [1.09-2.08]). Furthermore, OA caused by HMW agents showed a higher risk of airflow limitation (1.76 [1.07-2.91]), whereas OA due to LMW agents exhibited a higher risk of severe exacerbations (1.32 [1.01-1.69]). There were no differences between the two types of agents in the baseline sputum inflammatory profiles, but OA caused by HMW agents showed higher baseline blood eosinophilia and a greater postchallenge increase in fractional nitric oxide. CONCLUSION: This large cohort study describes distinct phenotypic profiles in OA caused by HMW and LMW agents. There is a need to further explore differences in underlying pathophysiological pathways and outcome after environmental interventions.

[Health criteria and scope of workers' periodic health check-ups for selected types of work and exposure factors - Nofer Institute of Occupational Medicine guidelines]. / Kryteria zdrowotne i zakres badan profilaktycznych dla wybranych rodzajów prac i czynników narazenia ­ wytyczne Instytutu Medycyny Pracy w Lodzi.

Workers' medical prophylactic examinations referred to in the Labor Code are one of the tasks of the occupational medicine services. They are regulated by law which has been in force for more than 20 years in unchanged form. During this period, new harmful, burdensome or dangerous to health factors appeared in the workplaces, for which no preventive health check-up standard was defined. In the meantime, the health criteria for drivers and persons applying for driving licenses have also been significantly liberalized. The above changes, the authors' own experience, comments and problems reported by physicians who provide workers' prophylactic health care and employers as well as analysis of literature related to workers' health care in other countries have created the need to harmonize and update guidelines on health requirements for selected types of work. In addition the scope and frequency of prophylactic examinations for exposures, which are not included in applicable legal acts, has been developed. Med Pr. 2019;70(1):125-37.

[The usefulness of bronchial challenge tests in the diagnosis of occupational asthma]. / Ocena nadreaktywnosci oskrzeli i jej zastosowanie w diagnostyce astmy zwiazanej z praca.

Bronchial hyperresponsiveness (BHR) is the individual ability to respond with bronchoconstriction to a variety of specific and nonspecific stimuli which do not cause these symptoms among healthy subjects. Bronchial hyperresponsiveness is one of the hallmark features of asthma. The degree of bronchial hyperresponsiveness is variable among individuals with asthma and may correlate to its severity (the more severe asthma the higher bronchial hyperreactivity). Bronchial hyperresponsiveness is evaluated by performing bronchial provocation test (BPT). Provocation tests are classified - according to their mechanisms - into direct and indirect tests. Direct challenge tests are highly sensitive and they are used primarily to rule out asthma. In contrast, provocation tests with indirect stimuli are less sensitive but more specific to the direct tests; they are used generally to confirm the diagnosis of asthma and they allow for more accurate conclusions about inflammatory lesions in the case of a patient. Bronchial provocation tests play a significant role in occupational medicine. They are particularly relevant to be performed prior to employment, during periodic examinations, and to diagnose and monitor both occupational asthma and work-related asthma. This article presents selected bronchial provocation tests and their usefulness in the diagnosis of occupational asthma. Med Pr 2018;69(4):457-471.

[Late effects of mass acute phosphine poisoning - Case report]. / Pózne nastepstwa zbiorowego ostrego zatrucia fosfanem ­ opis przypadku.

This paper reports the case of collective acute phosphide (PH3) intoxication among the crew aboard a merchant ship. All the intoxicated individuals were hospitalized 3 months after the accident. The aim of examinations was to identify late health effects of the accident. Laboratory tests and consultations were performed during their stay in the hospital. There were 5 cases of toxic liver damage. other 5 patients were diagnosed with posttraumatic stress disorder and adjustment disorders. The results of the study suggest that in cases of acute phosphide intoxication, the assessment of patients' psychological functioning should be an indispensable part of diagnostic procedure. Med Pr 2018;69(3):337-344.

[Non-occupational but work-related diseases - Legislation, judicature and potential implications to employers and employees in Poland]. / Choroby niezawodowe zwiazane z praca ­ uregulowania prawne, orzecznictwo oraz potencjalne konsekwencje dla pracodawców i pracowników w Polsce.

BACKGROUND: Non-occupational work-related diseases refer to health problems of multifactorial etiology, the occurrence, development and prognosis of which may be affected by work environment or by the way the work is performed but are not treated as occupational diseases under the applicable law. When analyzing their impact on labor market, it is necessary to also consider the employees' right to put in a claim for compensation due to the consequences of the occurrence of such diseases. MATERIAL AND METHODS: Legal regulations as well as judicial decisions on the possibilities and methods of pursuing claims for compensation from an employer due to the occurrence of non-occupational work-related disease were analyzed. RESULTS: The analyzed legal regulations and judicial decisions referred to the regulations of the Labour Code, Civil Code and Resolution of the Supreme Court of 4 December 1987. The paper presents examples of non-occupational diseases considered to be work-related and conditions necessary to assert a claim by the employee at the court. CONCLUSIONS: Despite the lack of precise legal regulations in Poland, non-occupational work-related diseases may impact the legal situation of employees as well as employers. Employees are granted the right to claim for compensation from their employers in accordance with the Civil Code. Depending on the employer's legal responsibility, it is necessary to prove the meeting of the appropriate essential conditions to put in a claim for damage. Raising the employers' awareness of the legal and financial consequences shall support the occupational medicine services in intensifying their activity aimed at preventing all work-related diseases. Med Pr 2018;69(5):539-546.

[Occupational cancers - Epidemiology and certification]. / Choroby nowotworowe pochodzenia zawodowego ­ epidemiologia i aspekty orzecznicze.

The etiology of cancer is multifactorial. Malignant tumors caused by factors occurring in the work environment, classified as carcinogenic in humans, can be recognized as an occupational disease. Analysis of epidemiological data indicates a significant underestimation of occupational cancer, mainly due to long latency period of these diseases. This publication provides guidance to certify occupational etiology of malignant tumors, based on the reviews of existing legislation and medical literature, as well as on the experience of their authors. The publication presents the epidemiology of cancers, including occupational cancers, risk factors, occupational carcinogens and presents the principles of occupational cancer certification. Med Pr 2018;69(1):93-108.

[The prophylactic operational model integrated with occupational healthcare - Prophylactic of some types of cancers among women]. / Model dzialan profilaktycznych zintegrowany z opieka profilaktyczna nad pracownikami ­ zapobieganie niektórym typom nowotworów wsród kobiet.

Periodical medical examinations are mandatory for employees in Poland. This rule makes a unique opportunity during occupational health services for implementation of prophylactic activities focused on early diagnosis of various diseases, including cancers. Epidemiological data about cancers is alarming and what is more, further increase in development of cancers is being predicted in population overall. The highest incidence of cancers in the case of Polish women belongs to breast cancer (21.7% of diagnosed cancers in general), while the morbidity rate for uterine cancer, ovarian cancer and cervical cancer amounts to 7.4%, 4.7% and 3.5%, respectively. The aim of this study was to elaborate an algorithm of prophylactic activities integrated with the occupational healthcare system, based on medical literature review and guidelines concerning prophylaxis of selected cancers. Polish cancers' prophylaxis programs related to risk factors were presented in this publication and practical indications for occupational healthcare physicians were worked out. Med Pr 2018;69(4):439-455.

[Guidelines for the preventive health care of hairdressing apprentices]. / Wytyczne do opieki profilaktycznej nad uczniami szkól fryzjerskich.

Hairdressing is one of the most developing branch of the service industry in Poland. Providing representatives of this occupational group with preventive health care services it should be remembered that they are at risk of skin and respiratory diseases, which occur due to a quite frequent exposure to harmful agents in the work environment of hairdressers and hairdressing apprentices. Interestingly, a much lower number of researches concentrate on respiratory symptoms than on skin disorders in hairdressers. The authors of this article have carried out the first Polish follow-up study focused not only on skin disorders but also on respiratory tract symptoms in hairdressing apprentices. The results of the study have been reported in other publications while this paper presents a literature review based on EBSCO and PubMed databases, Elsevier and contained articles (on the subject discussed in this paper). On the basis of information obtained from the authors' own research evidence and from the literature review, the guidelines for the preventive health care of hairdressing apprentices were developed. It was confirmed that neither determination of allergen-specific immunoglobulin E (IgE) nor performance of skin prick tests (SPTs) and patch tests for hairdressing factors are necessary. They should be performed as a part of preventive medical examination only in those apprentice candidates and trainees in this profession who report work-related symptoms and it is suspected that they result from exposure to particular factor in the work environment. Med Pr 2017;68(5):677-687.

[Diagnostic accuracy of specific IgE antibodies measurements in occupational airway allergy to high molecular weight agents]. / Trafnosc diagnostyczna oznaczen alergenowo swoistych przeciwcial IgE w zawodowej alergii dróg oddechowych na czynniki o duzej masie czasteczkowej.

BACKGROUND: The performance of specific inhalation challenge test (SICT) - reference method in diagnostics of occupational allergy - has some limitations due to health status of a particular patient. Therefore, it is extremely important to identify usefulness of other tests, and the evaluation of diagnostic accuracy of commercially available serum specific immunoglobulin E (sIgE) kits to the most common high molecular weight agents has been launched. MATERIAL AND METHODS: The study group comprised 141 subjects - 110 bakers and 31 farmers - with suspicion of occupational airway allergy. All patients underwent evaluation of serum sIgE to occupational allergens with the use of Phadia and Allergopharma kits: in bakers to flour mix and α-amylase, in farmers to epithelium of cow, pig and feathers. Specific inhalation challenge test with workplace allergens performed in all subjects was a reference method for further analysis. RESULTS: Serum specific IgE to flour mix had the highest sensitivity (Phadia - 95.6%, Allergopharma - 88.3%), while its specificity was relatively low (Phadia - 47.8%, Allergopharma - 25%). There were numerous discrepancies between the results of sIgE estimation for particular single allergens (k87, e4, e83), as well as for their mixtures (fx901, fx20, ex71), performed with the kits of both companies (Phadia vs. Allergopharma). CONCLUSIONS: Evaluation of serum specific IgE is characterized by inadequate sensitivity, specificity and predictive value to take the place of specific inhalation challenge test in diagnostics of occupational respiratory allergy. Med Pr 2017;68(1):31-43.

Papain-induced occupational rhinoconjunctivitis and asthma - A case report.

This report presents a case of occupational asthma, rhinitis and conjunctivitis to papain in a 50-year-old herbs and spices packer, with documented increased eosinophilia in induced sputum and in the nasal lavage fluids after a specific inhalation challenge test (SICT) and specific nasal challenge test (SNCT) with this enzyme. Immunoglobulin E-mediated (IgE) sensitization to papain was confirmed by positive results of a skin prick test with specific solution. Specific inhalation and nasal challenge tests demonstrated a direct and significant link between the exposure to this protease and the allergic response from the respiratory system. Additionally, the SNCT induced a severe reaction of the conjunctivae and a significant increase in the count of eosinophils in tears, despite the lack of direct contact of the allergen with the conjunctiva.

[Work-related rhinitis - Is it always an occupational disease?] / Niezyt nosa zwiazany z praca ­ czy zawsze jest to choroba zawodowa?

Rhinitis is a chronic inflammatory disease of the upper respiratory tract, characterized by a high prevalence and a complex pathogenesis. Work-related rhinitis (WRR) can be divided into occupational rhinitis (OR) and work-exacerbated rhinitis (WER). It is not only considered as a disease entity but also in the context of medical certification as the allergic disease associated with occupational exposure. Epidemiology of work-related rhinitis has been found to vary depending on the occupation and specific exposure, on the other hand the prevalence data may be underestimated due to the lack of uniform diagnostic criteria. This paper reviews the issues comprising the pathogenesis, epidemiology, diagnosis and treatment of patients with work-related rhinitis. It also discusses the significance of the disease in occupational medicine, particularly in terms of preventive worker care, general principles of good practice in primary and secondary WRR prevention and the necessary directions of changes in medical certification in the cases of occupational rhinitis. Med Pr 2016;67(6):801-815.

[Physicians' knowledge on the work-related chronic obstructive pulmonary disease]. / Ocena wiedzy lekarzy na temat przewleklej obturacyjnej choroby pluc pochodzenia zawodowego.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) may be induced by the work environment conditions. According to the estimates, 10-20% of all COPD cases are associated with occupational exposure to dusts and irritant gases. However, in 2014, only 11 cases of work-related COPD were recognized in Poland. The aim of the study was to analyze the reasons for the low incidence of work-related COPD in the context of pulmonologists' knowledge about occupational risk factors and procedures on reporting suspected occupational diseases. MATERIAL AND METHODS: A survey included 94 pulmonologists randomly selected out of 225 specialists registered at the Local Physicians Chamber in Lódz. The study was performed anonymously with the use of original questionnaire. RESULTS: More than a half of the surveyed pulmonologists identified environmental risk factors for COPD correctly, while only 23.4% properly identified the main occupational risk factors as the cause of COPD. Only 58.5% of the pulmonologists always asked their patients suffering from COPD about their job/profession and 60.6% of them did not have any knowledge about procedures on reporting suspected occupational diseases. CONCLUSIONS: The physicians rarely ask patients suffering from COPD about their job/profession and the relationship between their ailments and occupational exposure. What is more, they do not know legal regulations on proper referral of a patient with a suspected case of occupational disease. The results of the study clearly indicate that there is an urgent need for increasing pulmonologists' knowledge on work-related COPD. Med Pr 2016;67(3):375-384.

[Challenges to occupational medicine in view of the problem of work-related diseases and the aging of workforce. Directions for further development and intentional changes in preventive care of employees in Poland]. / Wyzwania medycyny pracy wobec problemu chorób zwiazanych z praca oraz starzenia sie populacji osób pracujacych. Dalszy kierunek rozwoju i celowe zmiany w opiece profilaktycznej nad pracujacymi w Polsce.

The system of occupational health care in Poland, based on occupational medicine service, takes care of almost 12.5 million employees subjected to over 4.5 million obligatory periodic medical check ups. This form of providing prophylactic care comes down to examinations dictated by legal regulations, whose scope is not oriented towards a comprehensive workers' health assessment, but to the examination of the systems and organs critical to work-related dangers. Simultaneously, epidemiological data indicate a large number of chronic diseases, which may influence the professional activity, like hypertension or diabetes and a high percentage of patients not aware of their illness. Since patients participating in obligatory examinations usually feel healthy and do not use health care services on a daily basis, an occupational medicine physician has a unique opportunity to detect health disorders at an early stage, which can prevent the development of health complications affecting the condition of the patient, limiting their professional activity, but also causing additional costs of the health care system. The authors have proven the need to involve occupational medicine services in the prevention of chronic diseases and the need to introduce additional sources of financing for procedures enabling early detection of diseases the patient may not be aware of or control of the effectiveness of already diagnosed illnesses. They addressed the need to change the current legal form of establishing and announcing the range of examinations and directives for certifying the lack or presence of health contraindications to work to the specified and updated standards prepared by scientific research institutes and occupational medicine societies. Med Pr 2016;67(5):691-700.

Sensitization to occupational allergens in hairdressing apprentices diagnosed already before entering vocational training.

BACKGROUND: Hairdressers are occupationally exposed to many allergenic and irritating substances. Additionally, hairdressing apprentices are exposed to the same allergens as professional hairdressers, due to the fact that vocational training starts in the beginning of the education. This study was undertaken to investigate early occurrence of sensitization to occupational allergens in hairdressing apprentices before the onset of the vocational training. MATERIAL AND METHODS: Three hundred and seven hairdressing apprentices were assessed using a questionnaire and skin prick tests (SPTs) to common and occupational allergens. The level of total and serum specific immunoglobulin E (IgE) to occupational allergens was evaluated and spirometry was performed. RESULTS: At least one skin and/or respiratory and/or conjunctival symptom was reported by 29.9% of subjects. Among subjects with at least one symptom, 28.2% of them were atopic whereas among 43.4% of them total IgE level was elevated. Atopy was found in 20% cases. In the case of one apprentice, positive SPT for paraphenylenediamine was found. Nearly 33% of apprentices had elevated total IgE level and 5 of them had specific IgE for occupational allergens. CONCLUSIONS: The study revealed that hairdressing apprentices might be sensitized to occupational allergens even before the beginning of vocational training, due to prior non-professional exposure to hairdressing agents. Furthermore, many of them report skin, respiratory and conjunctival symptoms, often connected with chronic disease diagnosis. Thus, candidates for hairdressers should be examined thoroughly before the start of the education and tests for allergy to hairdressing substances are indicated. Med Pr 2016;67(5):567-575.

Recent Trends in Occupational Contact Dermatitis.

Occupational contact dermatitis (OCD) remains prevalent among workers and impacts quality of life and workability. The purpose of this review is to summarize the recent advances in occupational contact dermatitis as well as potential hazardous agents in the workplaces causing OCD. The review covers new developments in the epidemiology, etiology, diagnosis, and management of occupational contact dermatitis. This article also provides updated information on the prevalence of work-related skin symptoms and on new contact allergens among working population. It is emphasized that in the context of prevention of OCD, special attention should be focused on the identified high-risk occupational groups, especially healthcare workers and hairdressers starting with the apprentices. Current approaches include working out the standards and guidelines to improve the education, knowledge, diagnosis, and management of OCD based on a multidisciplinary team of medical specialists and an employer.

[Application of recombinant latex allergens in diagnostics of occupational latex allergy]. / Zastosowanie alergenów rekombinowanych w diagnostyce zawodowej alergii na lateks.

Over many years, allergy to natural rubber latex has been a major problem among health care workers (HCW). The diagnosis of occupational allergy requires methods of high diagnostic accuracy in view of certification implications (e.g., a sick worker quits a job). With the development of molecular methods, the frequency of application of recombinant allergens it the diagnostics of allergic diseases continues to increase. This paper reviews the applicability of laboratory tests which use recombinant allergens in the diagnostics of occupational allergy. The diagnosis of latex allergy is based on the presence of clinical symptoms linked with exposure to latex allergens, positive skin prick tests and detection of specific IgE antibodies to latex in serun. Moreover, in some cases specific challenge tests are conducted. The analysis of literature indicates that applying the panel of recombinant latex allergens in diagnostic tests, cross-reactivity can very likely be excluded and/or sensitization can be confirmed without the need for specific challenge tests, which in case of latex allergens carries a potential risk of aeneralized reactions.

Work-related symptoms among workers exposed to black tea dust.

BACKGROUND: Tea may be classified as unfermented green, semi-ferinented oolong and fermented black. All of these types are derived from Camellia sinensis, the Tea Plant, which contains the low molecular weight (LMW) agent Epigallocatechin gallate (EGCg), probably responsible for allergic reactions. The aim of our study was to asses the work-related allergic symptoms and IgE-mediated sensitivity among black tea packers. MATERIAL AND METHODS: Study groups comprised 26 black tea packers (group 1) and 20 office workers (group 2). A questionnaire, skin prick tests (SPTs) to common allergens and black tea, evaluation of specific IgE (asIgF) to Camellia sinensis and moulds, pre- and post-work-shift spirometry were performed. RESULTS: At least I symptom suggesting allergic disease was reported by 85% of the tea packers and 60% of the office workers. The most frequent positive results of SPTs were obtained with moulds (8%). A small decline in FE%1 (forced expiratory volume in I s) after the work shift was observed among tea packers sensitized to moulds. CONCLUSIONS: Although specific sensitization to black tea was not observed in our study groups, cough and skin symptoms were significantly more frequently among the tea packers than in office workers. The irritant impact on the airways and the skin of tea dust and/or sensitization to moulds contaminating tea leaves are being suspected.

[Employees with mental illness - possibilities and barriers in professional activity]. / Pracownik z choroba psychiczna - mozliwosci i bariery w pracy zawodowej.

In Poland patients with psychiatric problems form a large group; in 2010 there were almost 1.5 million people for whom outpatient psychiatric care was provided, whereas approximately 200 thousand ill individuals were treated in 24-h psychiatric wards. Only 17% of the mentally disabled are professionally active. The results of many researches show that despite the detrimental influence of mental disorders on the employment (e.g., lower productivity, absenteeism, presenteism, increased risk of accidents at the workplace), professional activity can play a key role in the7stabilization of the mental state, it can also help in disease recovery. People with mental disorders are a social group that is at the higher risk of exclusion from the job market. The opinion prevailing among employers is that mentally ill individuals have decreased ability to conduct professional activity, and social attitudes towards them tend to be based on marking and stigmatizing. This review tackles the advantages of working during the illness, barriers which people with mental disorders face on the job market when they want to either start or continue work, and professional functioning of people with diagnosed depression (e.g., affective disorders) and schizophrenia (representing psychotic disorders). The analysis of existing data show that to improve the situation of mentally ill people present on the job market close cooperation between the representatives of various medical specializations is necessary, as well as their active participation in the process of social and professional rehabilitation of people affected by mental disorders.