The surveillance of occupational diseases in Italy: the MALPROF system.

BACKGROUND: Occupational diseases data can guide efforts to improve worker's health and safety. AIMS: To describe MALPROF, the Italian system for surveillance of work-related diseases collected by the subregional Department of Prevention. METHODS: The MALPROF system started in 1999 with contributions from Lombardy and Tuscany and spread in the following years to collect contributions from 14 out of the 20 Italian regions. MALPROF data were explored to follow-up work-related diseases and to detect emerging occupational health risks by calculating proportional reporting ratio (PRR), as in pharmacosurveillance. It classified work-related diseases according to economic sector and job activity in which the exposure occurred. Occupational physicians of the Italian National Health Service evaluate the possible causal relationship with occupational exposures and store the data in a centralized database. RESULTS: From 1999 to 2012, the MALPROF system collected about 112000 cases of workers' diseases. In 2010, more than 13000 cases of occupational diseases were reported. The most frequently reported diseases were hearing loss (n = 4378, 32%), spine disorders (n = 2394, 17%) and carpal tunnel syndrome (n = 1560, 11%). The PRR calculated for cervical disc herniation, a disease whose occupational origin has to be studied, in 1999-2010 was 2.47 [95% confidence interval (CI) 1.76-3.47] for drivers and 36.64 (95% CI 22.03-60.93) for air transport workers. CONCLUSIONS: MALPROF is a sensitive system for identifying possible associations between occupational risks and diseases, it can contribute to the development of preventive measures, to evaluate the effectiveness of preventive interventions and to stimulate research on new occupational risks and diseases.

[Manual lifting and manual transport: risk assessment and prevalence of work-related diseases in construction companies in Basilicata]. / Movimentazione manuale dei carichi e trasporto manuale: valutazione del rischio e prevalenza di patologie correlate nelle imprese edili lucane.

BACKGROUND: The Basilicata Regional Headquarters of the Italian Institute for Insurance against Occupational Accidents and Disease (INAIL) and the Basilicata association of small building enterprises (Edilcassa di Basilicata) promoted a research project to assess the risk of manual lifting and manual transport in construction enterprises in the Basilicata Region and estimate the prevalence of related diseases. METHODS: Manual lifting risk assessment was performed by calculating the VLI of 204 working days in as many building workers. Manual transport risk assessment was carried out comparing the weights transported (on the 204 days tested) with the reference values of the "Snoock and Ciriello" tables. RESULTS: Manual Ifting risk was present on 195 of the 204 days, with an average value of VLI equal to 2.1 (min 0.4, max 8.5), with higher values in the restructuring sector (VLI average of 2.3, min 0.4, max 8.5), and no significant differences between the different tasks. Manual transport risk was present on 129 of the 204 days, with average values of 1.2 (min 0.2, max 3.3), with no significant differences between the different tasks analyzed For both risks additional factors were present that were not analyzed by the methods of assessment used (for manual lifting: 8.8% of the geometries in the critical area; for manual transport: 39% of transport on shoulders, 42.5% on a route with uneven surface and 31.9% on a sloping route), so it is likely that the actual risk is greater than that indicated by the synthetic indices of exposure. The medical questionnaire showed from the case histories that 148 out of 546 subjects were positive for the threshold forpain or discomfort in the lumbosacral spine area and 99 out of 546 subjects reported suffering from an already diagnosed herniated spinal disk. Only 18% of osteoarticular diseases was reported to the Insurance Institute, al though there was widespread awareness that the diseases in question might be related to work. Diseases of the spine were responsible for 1.9% of absenteeism, equal to 30-40% of total absenteeism ofworkers enrolled in "Edilcassa di Basilicata". CONCLUSIONS: The method used provides a solid basis for evaluating the two risks in the construction industry, where employment is subject to extreme organizational, environmental and structural (machines, tools, operators involved) variability. Employment in the construction industry involves significant exposure to the two risks, counting for 30-40% of total absenteeism in this sector.

A simple tool for preliminary hazard identification and quick assessment in craftwork and small/medium enterprises (SME).

During the last Congress of the International Ergonomics Association (IEA), Beijing, August 2009, an international group was founded aimed at developing a "toolkit for MSD prevention" within IEA and in collaboration with World Health Organization (WHO). Possible users of toolkits are: members of health and safety committees, health and safety representatives, line supervisors; labor inspectors; health workers implementing basic occupational health services; occupational health and safety specialists.According to ISO standard 11228 series and the new Draft CD ISO 12259-2009: Application document guides for the potential user, a computer software ( in Excel®) was create dealing with hazard "mapping" in handicraft The proposed methodology, using specific key enters and quick assessment criteria, allows a simple ergonomics hazard identification and risk estimation. Thus it makes possible to decide for which professional hazards a more exhaustive risk assessment will be necessary and which professional consultant should be involved (occupational physician, safety engineer, industrial hygienist, etc.).

[Quality of work of occupational health physicians and of National Health Services physicians: are there common goals?]. / Qualità del lavoro del MC e dei medici dei Servizi: ci sono obiettivi comuni?

Starting from different institutional tasks, occupational health physicians and National Health Services physicians have a common goal represented by workers' health protection. The comparison between these professionals should not be limited to the moment of surveillance but should seek opportunities for dialogue aimed at improving their quality of performance. The points of contact may be sought on issues such risk assessment, health protocol, occupational diseases, occupational epidemiology, information/training and health promotion.

[A preliminary mapping methodology for occupational hazards and biomechanical risk evaluation: presentation of a simple, computerized tool kit for ergonomic hazards identification and risk assessment]. / La pre-mappatura dei disagi e dei pericoli professionali e la valutazione e gestione del rischio da sovraccarico biomeccanico: presentazione di uno strumento di analisi semplice e informatizzato (toolkit) e delle sue modalità di utilizzo.

BACKGROUND AND OBJECTIVES: During the last Congress of the International Ergonomics Association (IEA), Beijing, August 2009, an international group was founded with the task of developing a "toolkit for MSD prevention" under the IEA and in collaboration with the World Health Organization. The possible users of toolkits are: members of health and safety committees; health and safety representatives; line supervisors; foremen; workers; government representatives; health workers providing basic occupational health services; occupational health and safety specialists. METHODS: According to the ISO standard 11228 series and the new Draft CD ISO 12259-2009: Application document guides for the potential user, our group developed a preliminary "mapping" methodology of occupational hazards in the craft industry, supported by software (Excel). RESULTS AND CONCLUSION: The proposed methodology, using specific key enters and quick assessment criteria, allows a simple ergonomics hazards identification and risk estimation to be made. It is thus possible to decide for which occupational hazards a more exhaustive risk assessment will be necessary and which occupational consultant should be involved (occupational physician, safety engineer, industrial hygienist, etc.).

[Use of premapping of risks data sheet in artistic ceramics industries]. / Utilizzo della scheda di premappatura dei pericoli nel comparto delle ceramiche artistiche.

BACKGROUND: In 2006 there were more than 10,000 people working in artistic ceramics industries in Italy. The jobs in these industries that attracted most attention were work at the potter's wheel and decorating. OBJECTIVES: To test the premapping of risks data sheet in these enterprises. METHODS: We tested the data sheet in 3 craft industries: one was mainly artistic, one had a semi-industrial setting and in the third jobs were non-specific. RESULTS: In the semi-industrial craft industry the risks for potter's wheel workers were higher due to the repetitive movements required and to work organization aimed at achieving maximum productivity. CONCLUSIONS: The premapping of risks data sheet is a very sensitive tool. It can sometimes overestimate the risks, but in this way identifies situations that call for more in-depth analysis using tools that comply with international standards.

[The surveillance of occupational risks. Problems and perspectives of the recent legislative framework after the national preliminary survey]. / I dati sanitari aggregati e di rischio dei lavoratori sottoposti a sorveglianza sanitaria. Risultati preliminari dello studio pilota nazionale sulle comunicazioni ex art. 40. D.lgs 81/2008.

BACKGROUND: Legislation in Italy concerning health, safety and prevention at the workplace recently established a new data communication standard OBJECTIVES: The findings are reported of a specific survey on 18 Local Health Units (ASL) over the entire Italian territory, aimed at identifying the critical points in data management and analyze the available information. METHODS: The occupational health physician for each company must collect and transmit information on the number of workers submitted to health surveillance protocols to the Local Health Unit. Information must be divided by risk factor and gender Local health Units then transmit the data to the Regions and finally to the Italian National Institute for Occupational Safety and Prevention (ISPESL). RESULTS: A sample of 22.977 companies was studied, providing information on about 410,009 workers undergoing health surveillance protocols. Carrying or moving heavy loads, exposure to noise, VDU and chemical substances were the most frequent risk factors. The difference between genders was significant in risk allocation, with exposures to VDU and biological agents prevalently among females. CONCLUSIONS: The information thus collected suffered from a lack of data organization and completeness in the sample under study, but nevertheless provides preliminary evidence of a map of occupational risks on a national basis, confirming the potential for the new law (D.Lgs 81/2008) to investigate health safety and prevention at the workplace.

[L.D. n. 81/08: the role of National Health Service Occupational Health and Safety Units]. / Il D.Lgs. n. 81/08: ruolo dei Servizi di Prevenzione e Sicurezza negli Ambienti di Lavoro delle ASL.

The new legislative decree n. 81/2008 restates the national health service occupational health and safety units primary role on the workplaces safeguard. Comparing with the previous law, the need of co-operation and co-ordination between these units and the other public agencies with the same institutional aim is now emphasized; moreover, the health promotion in workplaces and the risk communication are required to be enforced as necessary needs complementary to the traditional controls about workplaces' safety rules abidance. These activities must be carried out together with all the interested local institutions and organizations, among which the occupational physicians can play a main role, as the projects realized in different Italian regions have already proved. The start up of the new central institutional system that have to decide the national health and safety policies in the workplaces should provide the technical and political directions for the health promotion, completing the local aims that have--usefully--been driving till now this kind of projects.

[Premapping of risks: guide to inspection by occupational physician]. / Premappatura dei rischi: guida al sopralluogo del medico competente.

Art. 25 of Law Decree 81/08 sets obligation for occupational physician to collaborate with employer for risk assessment (also in view of health surveillance planning) and to inspect "workplaces at least once a year or at different times according to risk assessment". Hence, collaboration to risk assessment, periodical inspection at workplace and definition of health surveillance protocols are extremely important in occupational physician's activity also in view of preventive effectiveness. An easily readable information technology tool is developed, in the frame of the most recent WHO activities: a toolkit for rapid and complete identification of the presence of possible risk inductors. This tool, already tested in several crafts, can be easily used also by occupational physician during periodical inspection.

[Working hypothesis of simplified techniques for the first mapping of occupational hazards in handicraft. First part: ergonomics hazards]. / Ipotesi di tecniche semplificate per la prima mappatura dei rischi professionali nel settore artigiano. Prima parte: rischi legati all'ergonomia.

During the last Congress of the International Ergonomics Association (IEA), Beijing - China August 2009, in collaboration with World Health Organization an international group for developing a "toolkit for MSD prevention" was founded. Possible users of toolkits are: members of a health and safety committee; health and safety representatives; line supervisors; foremen; workers; government representatives; health workers implementing basic occupational health services; occupational health and safety specialists. According with ISO standard 11228 series and their ISO Application document for the Key enters and Quick Assessment (green/red conditions), our group developed a first mapping methodology of occupational hazards in handicraft, working with the support of the information technology (Excel). This methodology, utilizing specific key enters and quick evaluation, allows a simple risk estimation. So it is possible to decide for which occupational hazards will be necessary an exhaustive assessment and to which professional consultant it is better to direct them to (worker's doctor, engineer, chemical, etc.).

[Working hypothesis of simplified techniques for the first mapping of occupational hazards in handicrafts. Part two: physical and chemical risks]. / Ipotesi di tecniche semplificate per la prima mappatura dei rischi professionali nel settore artigiano. Seconda parte: rischi fisici e chimici.

Craft features a strong link with tradition which preserves and perpetuates techniques created and consolidated over time, in a particular historical, cultural and geographical situation. Italy is home to excellent craftsmanship: fashion, furniture, giftware, design. The framework law for the craft n. 433/1985 defines the craft business carried on by the craftsman for a predominant objective of producing goods, including semi-finished or services. The D.L.gs 81/2008 defines the manner in which the employer must conduct risk assessment in the workplace and process the risk assessment document. The aim of the study is to provide employers with a simple methodology that allows the drafting of the first mapping of hazards/dangers identificating risk sources in the working process. The developed methodology is expressed as a model of information gathering, which brings to a first overview of all major risk indicators that may arise in the craftsmanship.

[Risk assessment of work-related upper limb musculoskeletal disorders in thirty factories in the upholstered furniture industry]. / Valutazione del rischio da movimenti e sforzi ripetuti degli arti superiori in trenta aziende del comparto del mobile imbottito.

BACKGROUND: One of the most common procedures for risk assessment of upper limb work-related musculoskeletal disorders (UL-WMSDs) in Italy is the OCRA synthetic index, which is recommended as the preferred method in the ISO standard 11228-3. OBJECTIVE: The aim of the survey was to assess the risk of UL-WMSDs due to repetitive strain and movements in thirty factories of the sofa industry located in a large geographic area of southern Italy. METHODS: The most characteristic working tasks of the manufacturing process were studied: filling preparation workers, leather-cutting operators, sewing and upholstery-assembly workers. The single tasks were carried out almost exclusively manually, with features of a handicraft approach. Data were collected through questionnaires and video tape recordings in each factory. The mean value of the OCRA index of every group of factories was calculated by weighting the values of the index of each single task group with the number of the workers. RESULTS: Figures obtained in the different factories showed values of the OCRA index ranging between 4 and 15. A 2,9 OCRA value was attributed to a low exposure group. CONCLUSIONS: Even though the work tasks analyzed were characterized by long duration of the manufacturing cycle (between 5 and 60 min), a particular but rigorous application of the OCRA procedures made it possible for a detailed risk assessment to be made for each of the working groups analysed.

[Manufacture of upholstered furniture and work-related upper limb musculoskeletal disorders: an industrial sector prevention project]. / Produzione del mobile imbottito: un progetto di ricerca finalizzato alla prevenzione delle patologie da sovraccarico biomeccanico degli arti superiori. Presentazione delle caratteristiche del comparto.

BACKGROUND: In cooperation with the IRCCS Fondazione Maugeri and the IRCCS Fondazione Ospedale Maggiore Policlinico - EPM-CEMOC, of Milan, the Local Health Unit in Bari, Italy carried out a research project, sponsored partly by the Italian Ministry of Health, on upper limb work-related musculoskeletal disorders (UL-WMSDs) in a specific manufacturing sector, the upholstered furniture industry. This "sofa district" is widely represented with approximately 14,000 workers and 500 factories over a wide geographic area of southern Italy. Advanced technology in the manufacturing process is combined with workers performing intensive arm-hand tasks. OBJECTIVES: The aim of the study included: a) assessment of exposure to repetitive strain and movements of the upper limb in a representative sample of the factories using the OCRA method, b) analysis of the annual prevalence and incidence rates, c) definition of possible improvement via ergonomic solutions in the various factories. METHODS: Via a network of occupational physicians a total of more than 6000 subjects were examined over a 5-year period. Case-definition was assessed through standardized procedures. RESULTS: A detailed description of the manufacturing process of the upholstered furniture industry and of the characteristics of the working population is provided Exposed groups at risk were:filling preparation workers, leather-cutting operators, sewing and upholstery-assembly workers. CONCLUSIONS: Data collected in private companies of different size in this extensive industrial "sofa area" emphasize the importance of prevention through adequate ergonomic solutions and the need to improve training programmes covering the whole area.

[Upper limb work-related musculoskeletal disorders (UL-WMSDs): a retrospective cohort study in three large factories of the upholstered furniture industry]. / Patologia da sovraccarico biomeccanico degli arti superiori: studio retrospettivo di coorte in tre grandi aziende del mobile imbottito.

BACKGROUND: The epidemiological evidence of work-related musculoskeletal disorders (UL-WMSDs) due to repetitive strain and movements in the various industries has been collected in the literature mainly through cross-sectional surveys. In particular there are no contributions so far regarding the upholstered furniture industry with a longitudinal design. OBJECTIVES: The aim of the study was to evaluate the incidence rate of WMSDs such as hand-wrist and shoulder tendonitis, carpal tunnel syndrome, and epicondylitis in exposed workers of three large companies of the upholstered furniture industry in a large geographic area of southern Italy. METHODS: The OCRA method, recommended by international standard ISO 11228-3 and EN 1005-5, was used for risk assessment. The following work tasks were considered:.filling preparation workers, leather-cutting operators, sewing and upholstery-assembly workers. A total population of 5,278 subjects (exposed n=2927, controls n=2351) was investigated. The person/year at risk parameters were calculated from 1 January 2000, or from the date of engagement if later, until the first diagnosis of WMSD or, in absence of disorders, until the end of the study, i.e. 31 December 2004. Disorders occurring after the first were not considered. A multiple regression analysis was used to evaluate relationships between rates. RESULTS AND CONCLUSIONS: Incidence rates correlated with risk classes of the OCRA index. An incidence rate of WMSDs higher than 1.2 cases per 100 person/year may be considered as a threshold value to suspect an occupational exposure to repetitive strain and movements warranting further investigation. The analysis of single factors did not show a greater predisposition of the female gender, with the single exception of the carpal tunnel syndrome (RR 2.92; 95% CI 1.57-5.43). Shoulder disorders affected mainly male leather-cutting operators (RR 4.97; 95% CI 2.03-12.16) and among all the factors influencing risk (frequency, force, posture, additional risk factors, pauses) posture seems to play a significant role.

[Prevalence of upper limb work-related musculoskeletal disorders (UL-WMSDs) in workers of the upholstered furniture industry]. / Prevalenza delle patologie da sovraccarico biomeccanico degli arti superiori negli addetti del comparto del mobile imbottito.

BACKGROUND: The upholstered furniture industry, the so-called "triangle of the sofa industry", is a geographic area of national and strategic economic importance in southern Italy. The single tasks are carried out mostly manually, with the characteristics of a handicraft approach. OBJECTIVES: The aim of the survey was to assess the prevalence of upper limb work-related musculoskeletal disorders (UL-WMSDs) in 30 factories of the sofa industry located in a large geographic area of the Puglia and Basilicata Regions. METHODS: In the period 1 January-31 December 2003 a network of occupational physicians investigated a population of 5.477 subjects (exposed n=3481, controls n=1996, M=3865, F=1612) in 30 different factories of the area. More than 60 percent of the total workforce studied was employed in large-sized companies (>500 employees). The following work tasks were considered: filling preparation workers, leather-cutting operators, sewing and upholstery-assembly workers. Case-definition was assessed through standardized procedures: symptoms by questionnaire plus physical and laboratory/imaging findings. RESULTS: Cumulative prevalence rates of UL-WMSDs as at 31 December 2003 reached values of up to 30% in high risk groups. Prevalence rates showed good correlation with the concise OCRA index used for assessment of exposure to repetitive strain and movements of the upper limb. The most frequently occurring disorders were tendon-related cysts and wrist tendonitis. Shoulder disorders were more frequent in male and female leather-cutting operators. CONCLUSIONS: This survey showed a significantly high prevalence of UL-WMSDs in sofa industry workers. It did not seem to be confirmed in this study that there was a greater female susceptibility to UL-WMSDs with the exception of carpal tunnel syndrome: gender difference seems to be less relevant at increasing levels of occupational exposure to repetitive movements and exertion of the upper limbs.

[From mandatory to participatory prevention: a model applied to the upholstered furniture industry]. / Dalla prevenzione imposta alla prevenzione partecipata: un modello applicativo nel comparto del mobile imbottito.

BACKGROUND: The Italian 2006-2008 National Health Plan emphasizes synergy and cooperation between the agencies formally involved in the prevention of occupational risks, in agreement with social partners. The so-called 'triangle of the sofa industry' is an interregional geographic area south-west of Bari, Italy. In 2003 this area produced 16% of the world-wide upholstered furniture output, with more than 500 plants of varying size. OBJECTIVE: The aim was to set up a network of communication and cooperation between the competent Agencies and Regions in order to address the rising trend of upper limb work-related musculoskeletal disorders. METHODS: The first step of the National Health Service Unit in Bari was to assess risk via a Ministerial research project and implement various information campaigns involving institutions, occupational physicians, private companies and public opinion. In a subsequent phase a synergy between the local Departmenst ofPrevention of the different Regions, the Italian Institute for Insurance Occupational Accidents and Disease (INAIL), the trade unions and the upholstered furniture industry Association was established. RESULTS AND CONCLUSIONS: New joint experimental projects (cutting tools, ergonomic table for assemblers, instruments for isokinetic evaluation) were launched together with training programmes for management, safety technicians and workers. This kind of 'participatory prevention' is more appropriate for the goal of a collaborative effort in order to assist the companies, which is a modern interpretation of the mission of public health prevention operators.

Cervical intraepithelial neoplasia: risk factors for persistence and recurrence in adolescents.

One of the most common sexually transmitted infections in adolescents is human papillomavirus. These infections can occur in one or multiple areas of the female genitalia but the vulva is usually the initial site of implantation for HPV. We carried out a long-term follow-up study of adolescents to evaluate the incidence of single or multiple lesions in the lower genital tract, the correlation between sexual behaviour and their localisation and behavioural risk factors for persistence and recurrence of HPV lesions and cervical intraepithelial lesion (CIN). We interviewed 268 women aged 12-21 years who had previously had cytology and/or physical examination suspicious for HPV infection. We asked them information about their lifestyle, sexual behaviour, work, personal or family history of genital warts and school attendance. Those who smoked more than five cigarettes a day were considered "smokers". We have no specific data about oral contraception although we know that none of the patients had used oral contraceptives for more than two years. Two hundred and thirty-four young women between the ages of 12 and 21 years were included in the study. The diagnostic schedule for a complete evaluation included exo- and endocervical cytology, colposcopy and directed biopsy. We found that in 126 out of 234 (53.8%) adolescents using contraceptives, only 85 (36.3%) had used a condom. The sites most frequently affected by lesions were the vulva, perianus and perineum (194/234; 82.9%), and the cervix (125/234; 53.4%). Vaginal lesions were detected in only 29/234 patients (12.3%). In 161 patients, sexual habits, age at first intercourse (p = 0.68), frequency of intercourse (p = 0.49) and number of lifetime partners (p = 0.27) as well as age (p = 0.26) played a role in transmission and incidence of HPV infection but not in the location of the lesions. This could be due to coexistent clinical and subclinical multiple infections as well as transmission via intercourse or from other sources, including tampons. HPV infection is detected by abnormal pap test, but the low correlation with colposcopic and histological findings in this study justify the support of other examinations such as colposcopy and punch biopsy for diagnosis. Moreover more attention should be paid to the psychological aspect of diagnoses and treatment of adolescents compared to older women as there was a high rate of patients lost in our study: 75/234 (32.05%) before LASER surgery and 55/159 (34.59%) during follow-up. Only 12-45% of sexually active adolescent girls had obtained Pap smear screening. In our study we found no correlation between treatment failure and cigarette smoking or between the use of oral contraceptives and persistence/recurrence after LASER surgery.

[Predisposition and evaluation of sanitary procedures in occupational medicine]. / Predisposizione e valutazione dei protocolli sanitari.

"Sanitary procedures" are used to perform preventive and periodic clinical examinations of workers. Their main purpose is to evaluate health status and function of target organs. Periodic medical procedures are used to evaluate the possible onset of precocious and reversible modifications of the health status induced by exposure to specific risk factors during working activities. Moreover, they must be considered an essential step of a correct management of the quality.

[Occupational health physician and risk assessment in workplaces]. / Il ruolo del medico competente nella valutazione del rischio.

The aim of this report is to analyse and discuss about professional duties of occupational health physicians dealing with risk assessment and health surveillance in workplaces. There are specific regulatory standards today regarding safety and health surveillance and protection of workers in occupational settings; on the other hand no clear recommendation exist, from the regulatory and practical point of view, in defining the specific tasks of a company doctor in risk assessment and management. Generally speaking safety professionals more often required by employers in risk assessment are industrial hygienists or safety and security technicians or engineers. The role of occupational physicians is almost confined to the practice of health surveillance. The paper highlights some specific circumstances in which occupational company doctors must be involved in risk assessment and management, it also describes their unique role in chemical and carcinogen hazard and risk assessment and management. Interactions between occupational health physician, workforce and employers are also underlined, because of their relevance from educational and social point of view, mainly in small and medium enterprises. In these particular workplaces the company doctor is often the unique safety professional directly implied in a good relationship with workforce and may have some opportunity in promoting safe behaviour related to job risks. Methods and occupational settings are described in order to promote and enhance the occupational health physician duties in workplaces, other than the health surveillance alone.