Occupational Exposure to Solar Radiation and the Eye: A Call to Implement Health Surveillance of Outdoor Workers.

Globally, hundreds of millions of outdoor workers are exposed to solar radiation (SR) for the majority of their working life. Such occupational exposure is known to induce various adverse health effects to the eyes, mainly related to its ultraviolet (UV) component. The present work is a call-to-action aimed at raising the awareness on the need of health surveillance for the prevention of the chronic ocular diseases in outdoor workers. Photo-chemical chronic damage can induce pterygium at the outer layer of the eye and cataract in the lens. Considering carcinogenic effects, rare squamous-cells tumors of the cornea and/or of the conjunctiva and the ocular melanomas are associated with UV radiation exposure. Solar UV-related eye diseases should be considered as "occupational diseases" when there is sufficient exposure in workers, but they are often not recognized, and/or frequently not reported to the national compensation authorities. Therefore, to prevent the burden of these work-related eye pathologies, an adequate risk assessment with identification of appropriate preventive measures, and a provision of periodic health surveillance to the exposed workers, in particular considering those at higher risk of exposure or with individual susceptibility, should be urgently implemented.

Digitally measuring solar ultraviolet radiation in outdoor workers: A study protocol for establishing the use of electronic personal dosimeters in Portugal.

Introduction: The rising incidence of skin cancer over the years has made it a significant public and occupational health issue. However, skin cancer is highly preventable, mainly through reduced exposure to solar ultraviolet radiation (UVR), which can be achieved by a variety of individual and collective protective measures and interventions. The relative risk associated with different patterns of exposure to solar UVR differs for the subtypes of keratinocyte cancers (KC). Specifically, whether the exposure is intermittent or continuous, and occurs in an occupational or leisure/recreational setting. The main aim of the study using this protocol is to contribute to raising public and policy awareness on solar UVR-inflicted occupational skin cancers in Lisbon. This will be achieved by performing direct measurements of the solar UVR dose received by outdoor workers using a digital platform. Results will likely contribute to further understanding the risk estimates for keratinocyte cancer estimations in this population. Methods: A prospective observational study will be conducted in Lisbon, Portugal. Personal electronic dosimeters (GENESIS-UV system) integrated with a digital platform will be used to assess occupational solar UVR doses of gardeners, masons, and gravediggers of the municipality of Lisbon. Two hundred and ten outdoor workers will be selected to wear the dosimeter for 1 month each, between April and October during their daily working hours. A digital web-based platform that offers private access to information through dashboard visualization will provide information for the outdoor workers and facilitate communication with the participants. Discussion: The expected results of the overall proposal comprise the occupational solar UVR doses, expressed in standard erythemal dose (SEDs) per day of outdoor work for 7 months. Study data will provide outdoor workers with information on their personal solar UVR exposure during their working hours and an estimate of their risk of developing skin cancer. It is expected that the occupational solar UVR doses of the outdoor workers in Portugal will be above the threshold of 1 to 1.33 SED/day, due to the latitude of Lisbon and the nature of the occupations. The results prospectively should flow into the design of adequate prevention campaigns for skin cancer in outdoor workers.

Barriers and Facilitators in the Creation of a Surveillance System for Solar Radiation-Induced Skin Cancers.

Outdoor workers are exposed to many hazards, including solar ultraviolet radiation (UVR). Identifying, reporting, analyzing and tracking the exposures or health outcomes of outdoor workers have not generally been formally considered. This article aims to summarize the best practices/strategies for creating an occupational sun exposure or skin cancer surveillance system for outdoor workers and to understand the key barriers and facilitators to the development of such a system. For the design of a successful occupational safety and health (OSH) surveillance system five occupational surveillance strategies are summarized: exposure registry, disease registry, disease screening/medical surveillance, sentinel event surveillance, and disease surveillance via data linkage. Ten key considerations are identified, including identifying a clear goal, a defined target population and stakeholder involvement, five critical barriers are highlighted including underreporting and funding, and five vital facilitators are recognized including communication/collaboration and a simple reporting process.

Risk of cutaneous squamous cell carcinoma due to occupational exposure to solar ultraviolet radiation: Protocol for a systematic review and meta-analysis.

Solar ultraviolet radiation (UVR) is the most significant occupational carcinogenic exposure in terms of the number of workers exposed (i.e., outdoor workers). Consequently, solar UVR-induced skin cancers are among the most common forms of occupational malignancies that are potentially expected globally. This systematic review is registered in PROSPERO (CRD42021295221) and aims to assess the risk of cutaneous squamous cell carcinoma (cSCC) associated to occupational solar UVR exposure. Systematic searches will be performed in three electronic literature databases (PubMed/Medline, EMBASE, and Scopus). Further references will be retrieved by a manual search (e.g., in grey literature databases, internet search engines, and organizational websites). We will include cohort studies and case-control studies. Risk of Bias assessment will be conducted separately for case-control and cohort studies. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) will be used for the certainty of assessment. In case quantitative pooling is not feasible, a narrative synthesis of results will be performed.

Tailored Sun Safety Messages for Outdoor Workers.

Background: Messaging surrounding skin cancer prevention has previously focused on the general public and emphasized how or when activities should be undertaken to reduce solar ultraviolet radiation (UVR) exposure. Generic messages may not be applicable to all settings, and should be tailored to protect unique and/or highly susceptible subpopulations, such as outdoor workers. The primary objective of this study was to develop a set of tailored, practical, harm-reducing sun safety messages that will better support outdoor workers and their employers in reducing the risk of solar UVR exposure and UVR-related occupational illnesses. Methods: We adapted a core set of sun safety messages previously developed for the general population to be more applicable and actionable by outdoor workers and their employers. This study used an integrated knowledge translation approach and a modified Delphi method (which uses a survey-based consensus process) to tailor the established set of sun safety messages for use for outdoor worker populations. Results: The tailored messages were created with a consideration for what is feasible for outdoor workers, and provide users with key facts, recommendations, and tips related to preventing skin cancer, eye damage, and heat stress, specifically when working outdoors. Conclusion: The resulting tailored messages are a set of evidence-based, expert- approved, and stakeholder-workshopped messages that can be used in a variety of work settings as part of an exposure control plan for employers with outdoor workers.

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.

Assessor burden, inter-rater agreement and user experience of the RoB-SPEO tool for assessing risk of bias in studies estimating prevalence of exposure to occupational risk factors: An analysis from the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury.

BACKGROUND: As part of the development of the World Health Organization (WHO)/International Labour Organization (ILO) Joint Estimates of the Work-related Burden of Disease and Injury, WHO and ILO carried out several systematic reviews to determine the prevalence of exposure to selected occupational risk factors. Risk of bias assessment for individual studies is a critical step of a systematic review. No tool existed for assessing the risk of bias in prevalence studies of exposure to occupational risk factors, so WHO and ILO developed and pilot tested the RoB-SPEO tool for this purpose. Here, we investigate the assessor burden, inter-rater agreement, and user experience of this new instrument, based on the abovementioned WHO/ILO systematic reviews. METHODS: Twenty-seven individual experts applied RoB-SPEO to assess risk of bias. Four systematic reviews provided a total of 283 individual assessments, carried out for 137 studies. For each study, two or more assessors independently assessed risk of bias across the eight RoB-SPEO domains selecting one of RoB-SPEO's six ratings (i.e., "low", "probably low", "probably high", "high", "unclear" or "cannot be determined"). Assessors were asked to report time taken (i.e. indicator of assessor burden) to complete each assessment and describe their user experience. To gauge assessor burden, we calculated the median and inter-quartile range of times taken per individual risk of bias assessment. To assess inter-rater reliability, we calculated a raw measure of inter-rater agreement (Pi) for each RoB-SPEO domain, between Pi = 0.00, indicating no agreement and Pi = 1.00, indicating perfect agreement. As subgroup analyses, Pi was also disaggregated by systematic review, assessor experience with RoB-SPEO (≤10 assessments versus > 10 assessments), and assessment time (tertiles: ≤25 min versus 26-66 min versus ≥ 67 min). To describe user experience, we synthesised the assessors' comments and recommendations. RESULTS: Assessors reported a median of 40 min to complete one assessment (interquartile range 21-120 min). For all domains, raw inter-rater agreement ranged from 0.54 to 0.82. Agreement varied by systematic review and assessor experience with RoB-SPEO between domains, and increased with increasing assessment time. A small number of users recommended further development of instructions for selected RoB-SPEO domains, especially bias in selection of participants into the study (domain 1) and bias due to differences in numerator and denominator (domain 7). DISCUSSION: Overall, our results indicated good agreement across the eight domains of the RoB-SPEO tool. The median assessment time was comparable to that of other risk of bias tools, indicating comparable assessor burden. However, there was considerable variation in time taken to complete assessments. Additional time spent on assessments may improve inter-rater agreement. Further development of the RoB-SPEO tool could focus on refining instructions for selected RoB-SPEO domains and additional testing to assess agreement for different topic areas and with a wider range of assessors from different research backgrounds.

Diesel Engine Exhaust Exposure in the Ontario Civil Infrastructure Construction Industry.

OBJECTIVES: Diesel engine exhaust (DEE) is a known lung carcinogen and a common occupational exposure in Canada. The use of diesel-powered equipment in the construction industry is particularly widespread, but little is known about DEE exposures in this work setting. The objective of this study was to determine exposure levels and identify and characterize key determinants of DEE exposure at construction sites in Ontario. METHODS: Elemental carbon (EC, a surrogate of DEE exposure) measurements were collected at seven civil infrastructure construction worksites and one trades training facility in Ontario using NIOSH method 5040. Full-shift personal air samples were collected using a constant-flow pump and SKC aluminium cyclone with quartz fibre filters in a 37-mm cassette. Exposures were compared with published health-based limits, including the Dutch Expert Committee on Occupational Safety (DECOS) limit (1.03 µg m-3 respirable EC) and the Finnish Institute of Occupational Health (FIOH) recommendation (5 µg m-3 respirable EC). Mixed-effects linear regression was used to identify determinants of EC exposure. RESULTS: In total, 149 EC samples were collected, ranging from <0.25 to 52.58 µg m-3 with a geometric mean (GM) of 3.71 µg m-3 [geometric standard deviation (GSD) = 3.32]. Overall, 41.6% of samples exceeded the FIOH limit, mostly within underground worksites (93.5%), and 90.6% exceeded the DECOS limit. Underground workers (GM = 13.20 µg m-3, GSD = 1.83) had exposures approximately four times higher than below grade workers (GM = 3.56 µg m-3, GSD = 1.94) and nine times higher than above ground workers (GM = 1.49 µg m-3, GSD = 1.75). Training facility exposures were similar to above ground workers (GM = 1.86 µg m-3, GSD = 4.12); however, exposures were highly variable. Work setting and enclosed cabins were identified as the key determinants of exposure in the final model (adjusted R2 = 0.72, P < 0.001). The highest DEE exposures were observed in underground workplaces and when using unenclosed cabins. CONCLUSIONS: This study provides data on current DEE exposure in Canadian construction workers. Most exposures were above recommended health-based limits, albeit in other jurisdictions, signifying a need to further reduce DEE levels in construction. These results can inform a hazard reduction strategy including targeted intervention/control measures to reduce DEE exposure and the burden of occupational lung cancer.

Break-even Analysis of Respirable Crystalline Silica (RCS) Exposure Interventions in the Construction Sector.

OBJECTIVE: We investigated long-term economic impacts of respirable crystalline silica (RCS) removal interventions in the construction at the societal level. METHODS: We estimated costs and benefits of two RCS exposure interventions, use of "respirators" and "wet method," over a 30-year time period. We identified economic impacts of the interventions under four different scenarios. RESULTS: Under current practices, we estimated that approximately 125 lung cancer cases attributable to RCS exposure would arise in 2060. Under the full exposure removal scenario, we estimated there would be 53 new cases. Over the 30-year time period, the estimated cumulative averted cases are 787 and 482 for respirators and wet method, respectively, which amount to net benefits of $422.13 and $394.92 million. CONCLUSIONS: Findings provide important information for policymakers seeking to reduce the economic burden of occupational lung cancer in society.

Setting priorities: Testing a tool to assess and prioritize workplace chemical hazards.

BACKGROUND: Workplace Hazardous Materials Information System (WHMIS) training is obligatory for Ontario workplaces. The purpose of this training is to help workers understand the health and safety issues associated with using chemicals, including how to understand the information contained in the Safety Data Sheets (SDSs) that come with all chemicals. However, many workers still do not know how hazardous workplace chemicals can be and they find it difficult to objectively determine the level of hazard posed by the chemicals they use. OBJECTIVE: A team of researchers, unions, and health and safety associations created a tool for Joint Health and Safety Committees (JHSC) of small and medium-sized businesses to help them identify, assess and prioritize the health hazards posed by workplace chemicals using SDSs as the primary source of information. METHODS: The team recruited the JHSCs of six workplaces to pilot the usefulness of the Chemical Hazard Assessment and Prioritization (CHAP) tool. The CHAP tool helps workplaces rank their chemicals within one of five hazard levels using information contained in SDSs. RESULTS: Despite a difficult recruitment process, the participating JHSCs thought the CHAP process of assessing and prioritizing their workplace chemicals was useful. It raised their awareness of chemical hazards, increased their understanding of SDSs, and helped them prioritize their chemicals for improved control measures. CONCLUSIONS: Small and medium-sized businesses found the tool to be useful, but suggested that an electronic version would be easier to use.

Economic evaluation of interventions to reduce solar ultraviolet radiation (UVR) exposure among construction workers.

Solar ultraviolet radiation is one of the most common occupational carcinogens in Canada and is responsible for approximately 5,556 non-melanoma skin cancers per year. A large part of these cases are preventable by reducing solar ultraviolet radiation exposure. In this study, investigators estimated the potential economic impacts of different solar ultraviolet radiation reduction interventions among construction workers, as they are one of the largest at-risk occupational groups. Investigators performed an economic evaluation from a societal perspective, by comparing incremental costs in relation to incremental benefits achieved by two interventions-use of personal protective equipment by all exposed individuals and use of shade structure wherever and whenever feasible. Interventions costs were estimated for 2020-2050, and benefits with a 10-year delay, i.e., for the period 2030-2060. Economic evaluation estimates were reported by intervention costs, total costs of non-melanoma skin cancers cases averted, incremental cost per avert case, return on investment, and the break-even point. Various sensitivity analyses were undertaken with key parameters. Our findings indicate that if the rising trend of incidence continues, cases will be double in 2060, whereas by using personal protective equipment or shade structure, with the best-case scenario of full ultraviolet radiation removal, would result in 6,034 and 2,945 cases averted over 30 years, respectively. This translates into a total of $38.0 and $20.5 million of averted costs (all monetary values represented in 2017 Canadian dollars). Under this scenario investigators expect that by 2060, for every dollar invested in personal protective equipment and shade structures, $0.49 and $0.35 will be returned, respectively. Findings also suggested that under a conservative scenario, prevention of non-melanoma skin cancer cases by personal protective equipment and shade structures resulted in $5,812 and $7,355 incremental costs, respectively, over the 30-year period. This study provides important insights for decision makers about the potential impacts of solar ultraviolet radiation reduction interventions in the construction sector and other sectors with substantial outdoor work. Our estimates also can raise awareness of the importance of solar ultraviolet radiation reduction interventions.

Sun Protection Use at Work and Leisure by Outdoor Workers in Alberta, Canada.

OBJECTIVE: To assess the prevalence and determinants of sun protection behaviours among outdoors workers at work and leisure in Alberta, Canada. METHODS: We collected outdoor workers' demographics, skin cancer risk factors, job information, and sun habits at work and leisure using self-completed questionnaires. For both settings, we compared use of specific behaviours and modelled determinants of sun protection behaviour scores. RESULTS: At work, wearing a sleeved shirt (81% often/always) and hat (73%) were most prevalent, while seeking shade (12%) and applying sunscreen (36%) were least prevalent. Workers had higher sun protection scores at work than leisure. Hours spent outdoors was a strong determinant for both models. Additional leisure model predictors were eye colour, sex, skin type, and job group. CONCLUSIONS: Differences in behaviours across settings were observed and should be considered when developing solar UVR exposure reduction initiatives.

Solar ultraviolet radiation exposure among outdoor workers in Alberta, Canada.

BACKGROUND: Outdoor workers are at risk of prolonged and high solar ultraviolet radiation (UVR) exposure, which is known to cause skin cancer. The objectives of this study were to characterize the UVR exposure levels of outdoor workers in Alberta, Canada, and to investigate what factors may contribute to their exposure. METHODS: This study collected objective solar UVR measurements from outdoor workers primarily in Alberta during the summer of 2019. Workers were recruited via the management or health and safety teams from building trade unions and employers. Calibrated, electronic UVR dosimeters were worn by workers on their hardhats, wrists, or lapels for five working days. Data on workers' demographics, jobs, sun protection behaviors, and personal risk factors were collected using questionnaires, and meteorological data for each sampling day were noted. Mean daily exposure measured as the standard erythemal dose (SED) was calculated and compared to the international occupational exposure limit guideline (1.3 SED). Marginal models were developed to evaluate potential determinants of occupational solar UVR exposure. RESULTS: In total, 883 measurements were collected from 179 workers. On average, workerswere exposed to 1.93 SED (range: 0.03-16.63 SED) per day. Just under half of workers (45%) were exposed to levels exceeding the international exposure limit guideline. In the bivariate analyses, landscape and maintenance workers, as well as trade and recreation workers, had the highest levels of exposure (average: 2.64 and 1.84 SED, respectively). Regional variations were observed, with the "other" cities/regions (outside of Edmonton and Calgary) experiencing the highest average levels (2.60 SED). Workers who placed the dosimeters on their hardhats experienced higher levels compared to the other groups. Exposure was highest on sunny and mixed days. Education, trade, city, dosimeter placement, forecast, hair colour, and number of hours outside were included in the final exposure model, of which trade, dosimeter placement, forecast, and number of hours outside at work were statistically significant. CONCLUSIONS: Exposure to elevated solar UVR levels is common among outdoor workers in Alberta. The study findings can help inform future monitoring studies and exposure reduction initiatives aimed at protecting workers.

Strategic Task and Break Timing to Reduce Ultraviolet Radiation Exposure in Outdoor Workers.

Objectives: Public health messaging about sun avoidance strategies is often not practical for outdoor workers. The objective of this study was to use personal monitoring data to determine when peak UVR exposure occurs for outdoor workers, estimate how much UVR could be reduced by altering the timing of shady tasks or breaks during peak exposure times, and descriptively compare these to peak periods of ambient UVR. Ultimately, we aim to provide evidence-based sun avoidance recommendations for outdoor workers in British Columbia, Canada. Methods: UVR exposure data [standard erythemal dose (SED)] were collected during the 2013 summer months in Vancouver, using personal electronic dosimeters that sampled once per minute for an average of 4.4 working days (range: 1-7 days). Mixed-effect models were used to estimate the 60-, 30-, and 15-min time intervals at which maximum exposure occurred for the months of July and August. Using these time intervals, UVR exposure during peak periods was summarized as SED and as a percentage of the total daily exposure. Ambient UVR was also collected using data from the nearest Brewer spectrophotometer station and parallel analyses were conducted. Results: There were 73 workers and 321 participant-days available for analysis. Models indicated that periods of maximum exposure for 15-, 30-, and 60-min intervals began at 12:28, 12:17 pm, and 11:52 am, respectively, for sunny days in July. These periods were similar in August. The median exposure during these time periods and the potential for reducing UVR was 0.03 SED (2.8% potential daily exposure reduction), 0.09 SED (7.1%), and 0.18 SED (15.9%), respectively. However, there was a large range in exposure estimates as some workers experienced up to 84.8% of their exposure in the peak 60-min interval. Conclusion: Skin cancer prevention messaging does not include practical messages for outdoor workers and providing times of peak UVR help to identify times when the greatest reductions in exposure can occur. Prevention measures including shady breaks, increased sun protection, and task reorganization during these peak times are recommended during these peak times to reduce UVR exposure among those at highest risk.

RoB-SPEO: A tool for assessing risk of bias in studies estimating the prevalence of exposure to occupational risk factors 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). For this, systematic reviews of studies estimating the prevalence of exposure to selected occupational risk factors will be conducted to provide input data for estimations of the number of exposed workers. A critical part of systematic review methods is to assess risk of bias (RoB) of individual studies. In this article, we present and describe the development of such a tool, called the Risk of Bias in Studies estimating Prevalence of Exposure to Occupational risk factors (RoB-SPEO) tool; report results from RoB-SPEO's pilot testing; note RoB-SPEO's limitations; and suggest how the tool might be tested and developed further. METHODS: Selected existing RoB tools used in environmental and occupational health systematic reviews were reviewed and analysed. From existing tools, we identified domains for the new tool and, if necessary, added new domains. For each domain, we then identified and integrated components from the existing tools (i.e. instructions, domains, guiding questions, considerations, ratings and rating criteria), and, if necessary, we developed new components. Finally, we elicited feedback from other systematic review methodologists and exposure scientists and agreed upon RoB-SPEO. Nine experts pilot tested RoB-SPEO, and we calculated a raw measure of inter-rater agreement (Pi) for each of its domain, rating Pi < 0.4 as poor, 0.4 ≤ Pi ≥ 0.8 as substantial and Pi > 0.80 as almost perfect agreement. RESULTS: Our review found no standard tool for assessing RoB in prevalence studies of exposure to occupational risk factors. We identified six existing tools for environmental and occupational health systematic reviews and found that their components for assessing RoB differ considerably. With the new RoB-SPEO tool, assessors judge RoB for each of eight domains: (1) bias in selection of participants into the study; (2) bias due to a lack of blinding of study personnel; (3) bias due to exposure misclassification; (4) bias due to incomplete exposure data; (5) bias due to conflict of interest; (6) bias due to selective reporting of exposures; (7) bias due to difference in numerator and denominator; and (8) other bias. The RoB-SPEO's ratings are low, probably low, probably high, high or no information. Pilot testing of the RoB-SPEO tool found substantial inter-rater agreement for six domains (range of Pi for these domains: 0.51-0.80), but poor agreement for two domains (i.e. Pi of 0.31 and 0.33 for biases due to incomplete exposure data and in selection of participants into the study, respectively). Limitations of RoB-SPEO include that it has not yet been fully performance-tested. CONCLUSIONS: We developed the RoB-SPEO tool for assessing RoB in prevalence studies of exposure to occupational risk factors. The tool will be applied and its performance tested in the ongoing systematic reviews for the WHO/ILO Joint Estimates.

Solar Ultraviolet Radiation Exposure among Outdoor Workers in Three Canadian Provinces.

INTRODUCTION: Solar ultraviolet radiation (UVR) exposure places outdoor workers at risk of skin cancer and exposure is difficult to control. In response, the Sun Safety at Work Canada (SSAWC) project was undertaken (2014-2016). The purpose of this substudy was to characterize the UVR exposure levels of outdoor workers in the SSAWC project. METHODS: Thirteen workplaces in the provinces of British Columbia, Ontario, and Nova Scotia participated in an exposure monitoring campaign (late summer/early fall 2016). Study participants were workers from power utilities and municipalities. Participants wore a UVR measurement badge (light-sensitive polysulfone plastic) on their wrist, shoulder, or hardhat. Badge calibration and absorbance measurements were performed in the AusSun Research Lab. Personal UVR doses are presented as standard erythemal doses (SED) and compared with the internationally recommended exposure limit (1.3 SED), as well as to the total available UVR by date. Generalized linear models were used to examine determinants of solar UVR for personal UVR dose (for both SED and percent of ambient UVR). Models considered badge placement, date, province, industry, main job task, and the hours spent outdoors. RESULTS: Mean personal UVR dose of participating workers was 6.1 SED (nearly 5× the recommended limit). Just 14% of workers experienced 'acceptable' levels of solar radiation; 10% were exposed at >10 times the limit. In univariate analyses, workers in Ontario had the highest levels (mean 7.3 SED), but even in the lowest exposed province (British Columbia), the mean personal UVR dose was 4.5 SED. Utility workers had double the exposure of municipal workers (10.4 and 5.5 SED, respectively). In the determinants of exposure models, the differences by province were muted, but utility line workers and those in general maintenance had higher predicted exposures. Those who wore their badge on their hardhat also had higher values of SED in the fully adjusted determinants models. CONCLUSIONS: Solar ultraviolet overexposure among outdoor workers is a concern, even in a country like Canada with relatively low ambient UVR. Implementation of sun safety programs should be supported in an effort to reduce exposure in this vulnerable group of workers.

A Process Evaluation of the Skin Cancer Prevention Act (Tanning Beds): A Survey of Ontario Public Health Units.

Evidence of the dangers of indoor tanning and its popularity, including among youth, led the Government of Ontario to pass the Skin Cancer Prevention Act (Tanning Beds) (SCPA) in 2014. This legislation includes prohibiting the sale of indoor tanning services to individuals under 18, requiring warning signs be posted, and other safety regulations. We collected information from Ontario Public Health Units to conduct a process evaluation of the SCPA to: understand legislation implementation; assess available evidence about compliance, inspection, and enforcement; and, note barriers and facilitators related to inspection and enforcement. Data was collected March-April 2018. All 36 Ontario Public Health Units were invited to participate in an online questionnaire about the SCPA. Questions covered complaints, inspection, and enforcement, and used both close- and open-ended questions. Participants from 20 Public Health Units responded to the questionnaire; a response rate of 56%. These agencies reported 485 facilities offer indoor tanning. Since 2014, there have been 242 infractions by tanning facility owner/operators related to the SCPA, with most being uncovered during non-mandatory routine inspections (n = 234, 97%), rather than mandatory complaint-based inspections (n = 8, 3%). Most infractions were related to warning signs (n = 201, 83%). No charges were issued for any infractions. Instead, providing education (n = 90, 62%) and issuing warnings (n = 33, 23%) were the most common enforcement strategies. SCPA amendments are needed, including mandatory, routinely scheduled inspections. In addition to providing education, fines may improve compliance. More resources are required for inspection and enforcement of the SCPA.

With a little help from our friends: Collaborative research partnerships in three workplace-based occupational disease research projects.

BACKGROUND: Research conducted in collaboration between academic and non-academic partners (known as integrated knowledge translation [iKT]) in the field of occupational health and safety needs to be evaluated. OBJECTIVE: This study examined three collaborative workplace-based intervention projects that focused on reducing exposure to occupational carcinogens. Practice, policy and advocacy intermediary organizations partnered with multidisciplinary groups of researchers. This evaluation study sought to understand the characteristics of successful and unsuccessful iKT partnerships from the perspective of the intermediaries. METHODS: Researchers conducted face-to-face interviews with 21 intermediaries and used a thematic-driven "framework analysis" method to analyze the interviews, based upon an evolving conceptual framework. RESULTS: Seven enablers and barriers of collaboration were identified. Enablers included having: adequate capacity; defined project roles; the right partners; an inclusive project leader; mutual respect; good communication; and shared values and priorities. Lacking these was considered a barrier. Seven outcomes were identified as: improved relevance and quality of the research; learning about each others' "world"; building contacts; improved use of research in practice and policy; dissemination of the research; development of trust and goodwill; and continued collaborations. CONCLUSIONS: Recommendations for future collaborative studies include: spend time defining roles, responsibilities, and expectations; ensure practitioners have the time and resources, and the commitment to the project; and choose representatives from the organizations with the necessary skills or decision-making mandate.

WHO/ILO work-related burden of disease and injury: Protocol for systematic reviews of occupational exposure to solar ultraviolet radiation and of the effect of occupational exposure to solar ultraviolet radiation on melanoma and non-melanoma skin cancer.

BACKGROUND: The World Health Organization (WHO) and the International Labour Organization (ILO) are developing a joint methodology for estimating the national and global work-related burden of disease and injury (WHO/ILO joint methodology), with contributions from a large network of experts. In this paper, we present the protocol for two systematic reviews of parameters for estimating the number of deaths and disability-adjusted life years from melanoma and non-melanoma skin cancer (or keratinocyte carcinoma) from occupational exposure to solar ultraviolet radiation, to inform the development of the WHO/ILO joint methodology. OBJECTIVES: We aim to systematically review studies on occupational exposure to solar ultraviolet radiation (Systematic Review 1) and systematically review and meta-analyse estimates of the effect of occupational exposure to solar ultraviolet radiation on melanoma and non-melanoma skin cancer (Systematic Review 2), applying the Navigation Guide systematic review methodology as an organizing framework and conducting both systematic reviews in tandem and in a harmonized way. DATA SOURCES: Separately for Systematic Reviews 1 and 2, we will search electronic academic databases for potentially relevant records from published and unpublished studies, including Ovid Medline, PubMed, EMBASE, and Web of Science. We will also search electronic grey literature databases, Internet search engines and organizational websites; hand-search reference list of previous systematic reviews and included study records and consult additional experts. STUDY ELIGIBILITY AND CRITERIA: We will include working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State, but exclude children (<15 years) and unpaid domestic workers. For Systematic Review 1, we will include quantitative studies on the prevalence of relevant levels of occupational exposure to solar ultraviolet radiation (i.e. <0.33 SED/d and ≥0.33 SED/d) and of the total working time spent outdoors, stratified by country, sex, age and industrial sector or occupation, in the years 1960 to 2018. For Systematic Review 2, we will include randomized controlled trials, cohort studies, case-control studies and other non-randomized intervention studies with an estimate of the effect of any occupational exposure to solar ultraviolet radiation (i.e., ≥0.33 SED/d) on the prevalence of, incidence of or mortality due to melanoma and non-melanoma skin cancer, compared with the theoretical minimum risk exposure level (i.e. <0.33 SED/d). STUDY APPRAISAL AND SYNTHESIS METHODS: At least two review authors will independently screen titles and abstracts against the eligibility criteria at a first stage and full texts of potentially eligible records at a second stage, followed by extraction of data from qualifying studies. At least two review authors will assess the risk of bias and the quality of evidence, using the most suited tools currently available. For Systematic Review 2, if feasible, we will combine relative risks using meta-analysis. We will report results using the guidelines for accurate and transparent health estimates reporting (GATHER) for Systematic Review 1 and the preferred reporting items for systematic reviews and meta-analyses guidelines (PRISMA) for Systematic Review 2. PROSPERO REGISTRATION NUMBER: CRD42018094817.

WHO/ILO work-related burden of disease and injury: Protocol for systematic reviews of occupational exposure to solar ultraviolet radiation and of the effect of occupational exposure to solar ultraviolet radiation on cataract.

BACKGROUND: The World Health Organization (WHO) and the International Labour Organization (ILO) are developing a joint methodology for estimating the national and global work-related burden of disease and injury (WHO/ILO joint methodology), with contributions from a large network of experts. Here, we present the protocol for two systematic reviews of parameters for estimating the number of disability-adjusted life years of cataracts from occupational exposure to solar ultraviolet radiation, to inform the development of the WHO/ILO joint methodology. OBJECTIVES: We aim to systematically review studies on occupational exposure to solar ultraviolet radiation (Systematic Review 1) and systematically review and meta-analyse estimates of the effect of occupational exposure to solar ultraviolet radiation on the development of cataract (Systematic Review 2), applying the Navigation Guide systematic review methodology as an organizing framework and conducting both systematic reviews in tandem and in a harmonized way. DATA SOURCES: Separately for Systematic Reviews 1 and 2, we will search electronic academic databases for potentially relevant records from published and unpublished studies, including Ovid Medline, PubMed, EMBASE, and Web of Sciences. We will also search electronic grey literature databases, Internet search engines and organizational websites; hand search reference list of previous systematic reviews and included study records; and consult additional experts. STUDY ELIGIBILITY AND CRITERIA: We will include working-age (≥15 years) workers in WHO and/or ILO Member States, but exclude children (<15 years) and unpaid domestic workers. For Systematic Review 1, we will include quantitative studies on the prevalence of relevant levels of occupational exposure to solar ultraviolet radiation and of the total working time spent outdoors from 1960 to 2018, stratified by sex, age, country and industrial sector or occupation. For Systematic Review 2, we will include randomized controlled trials, cohort studies, case-control studies and other non-randomized intervention studies with an estimate of the effect of any occupational exposure to solar ultraviolet radiation (i.e. ≥30 Jm-2/day of occupational solar UV exposure at the surface of the eye) on the prevalence or incidence of cataract, compared with the theoretical minimum risk exposure level (i.e. <30 Jm-2/day of occupational solar UV exposure at the surface of the eye). STUDY APPRAISAL AND SYNTHESIS METHODS: At least two review authors will independently screen titles and abstracts against the eligibility criteria at a first stage and full texts of potentially eligible records at a second stage, followed by extraction of data from qualifying studies. At least two review authors will assess risk of bias and the quality of evidence, using the most suited tools currently available. For Systematic Review 2, if feasible, we will combine relative risks using meta-analysis. We will report results using the guidelines for accurate and transparent health estimates reporting (GATHER) for Systematic Review 1 and the preferred reporting items for systematic reviews and meta-analyses guidelines (PRISMA) for Systematic Review 2. PROSPERO registration: CRD42018098897.