NJALA UNIVERSITY

Lecture Notes
on
SANITARY ENGINEERING AND

OCCUPATIONAL HEALTH AND SAFETY (OHS)

(EVHT 4114)

FOR

[Link]. PUBLIC HEALTH HONOURS – YEAR FOUR (4)

Compiled and presented by:

Alfred Y. Kargbou (MSc,MPH)
Public Health Epidemiologist
2024/2025 Academic Year

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 OCCUPATIONAL HEALTH AND SAFETY
1.0 BASICS
1.1 Definition
Occupational health and safety (OHS) is a cross-disciplinary area concerned with protecting
• Safety
• Health
• Welfare
of people engaged in work or employment. As a secondary effect, OHS may also protect co-workers,
family members, employers, customers, suppliers, nearby communities, and other members of the public
who are impacted by the workplace environment. Cross-disciplinarity describes a method that crosses
disciplinary boundaries but does so from a foreign angle and with no cooperation. Basically, cross-
disciplinary approaches attempt to explain a subject in the terms of a foreign method. Some good examples
of such interaction would be describing the physics of music or the politics of literature.

Occupational safety and health may involve interaction among many cognate disciplines, including:
• Occupational medicine,
• Occupational (or industrial) hygiene,
• Public health,
• Safety engineering,
• Health physics,
• Ergonomics,
• Toxicology,
• Epidemiology,
• Industrial relations,
• Public policy,
• Sociology,
• Psychology.

Since 1950, the International Labour Organizations (ILO) and the World Health Organization (WHO)
have shared a common definition of occupational health (See Appendix for websites of these
organisations). It was adopted by the Joint ILO/WHO Committee on Occupational Health at its first

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session in 1950 and revised at its twelfth session in 1995. The definition reads: "Occupational health
should aim at: the promotion
and maintenance of the highest degree of physical, mental and social well-being of workers in all
occupations; the prevention amongst workers of departures from health caused by their working
conditions; the protection of workers in their employment from risks resulting from factors adverse to
health; the placing and maintenance of the worker in an occupational environment adapted to his
physiological and psychological capabilities; and, to summarize, the adaptation of work to man and of
each man to his job."

The reasons for establishing good occupational safety and health standards are frequently identified as:

• Moral: an employee should not have to risk injury at work, nor should others have associated with
the work environment.
• Economic: many governments realize that poor occupational safety and health performance results
in cost to the State (e.g. through social security payments to the incapacitated, costs for medical
treatment, and the loss of the "employability" of the worker). Employing organisations also sustain
costs in the event of an incident at work (such as legal fees, fines, compensatory damages,
investigation time, lost production, lost goodwill from the workforce, from customers and from
the wider community).
• Legal: occupational safety and health requirements may be reinforced in civil law and/or criminal
law; it is accepted that without the extra "encouragement" of potential regulatory action or
litigation, many organisations would not act upon their implied moral obligations.

1.2 The Main Dilemma

The struggle to eliminate or reduce the accidents that can and do occur and the injuries and damages that
result were and have been predicated chiefly on two mutually opposing aspects:
• Costs of accident prevention;
• Moral regard for human life and well-being.

The moral aspect has come about because of massive numbers of accidental deaths and injuries. It was
felt by influential persons who knew of the effects of accidents. There were calls for corrective actions
and new laws to safeguard workers and the public. Gradually compromises have come about between the

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costs of accident prevention and those imposed for moral and legal aspects. Many of the larger
corporations have found the mutual consideration and compromise beneficial and workers are safer to a
higher degree than if no safeguards were provided. The result was fewer walkouts, strikes, and inefficient
operations because workers were slowed by their need to prevent and protect themselves against hazards.
The companies also benefited because of less costly litigation and lower insurance premium costs.

Unfortunately, many small companies still believe erroneously that safety programs are nonproductive
and unprofitable. Their safety efforts are minimal and accident and injury rates are higher than those of
large companies. The chief complaint when any new law or mandatory standard concerning safety is being
considered or has been enacted is that the increased costs will put them out of business. To such
organizations, it therefore appears that monetary aspects are more important than the moral considerations.

1.3 Concept on Health and Safety at Work (Occupational Health and Safety)

The right to life and health protection is a fundamental human right. The right of employees to just and
satisfactory working conditions is incorporated among the economic, social and culture rights. Therefore
constitutional policy that guarantees the right to health and safety at work for the employees should be put
in place.

The concept on Health and Safety at Work is in consonance with respecting conventions of the
International Labor Organization (the “ILO”), the European Social Charter, and others such as the laws
of the European Union and the strategy of the European Commission “Improvement of Work Quality and
Productivity: Community Strategy 2007 – 2012 on Health and Safety at Work” (the “Community Strategy
for OHS”).

2.0 SIGNIFICANCE OF OCCUPATIONAL HEALTH AND SAFETY (OHS)

The quality and level of protection of the “occupational” life and health of employees presents the cultural,
social and economic development of employers and the state within a wider context. Improving OHS can
be ensured by implementing preventative measures and specific programs and measures by employers
which will improve working conditions and eliminate risks and factors determining the incidence of
occupational accidents and diseases or other occupational health damage. The continual improvement of
OHS can be supported by the social policy of the government and the active participation of both social
partners in solving OHS issues individually and in mutual cooperation. The interest in OHS is determined

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by social and economic aspects which are mutually equal and influential upon each other. That is why it
is necessary to ensure the harmony of economic and social aspects also in connection with the human
factor, which constitutes the determining element of almost every job. Society as a whole and individual
employer, must implement economic and other activities with distinctive consideration for the creation
and maintenance of suitable legal labor relations, working conditions and requirements for ensuring OHS
in particular. This also relates to natural persons who are businessmen but not employers (“self employed
natural person”). Optimizing working conditions allows for the long-term maintenance of the health and
working ability of self employed natural persons. Developing care for the life and health of employees
and self employed natural persons and optimizing working conditions constitute a humanizing instrument
for the workplace and for enhancing the quality of life. They subsequently create the conditions for the
development of the entire society and individual employers, since correct relationships between the
employer and employee, which constitute one of the basic preconditions of an employer's economic
development, also arise from the application of OHS.

3.0 OCCUPATIONAL HEALTH AND SAFETY (OHS) AND COMPETITIVENESS

A good level of OHS may prevent and minimize the loss of human life and health due to occupational
accidents, occupational diseases and other occupational health damage. These health problems constitute
material loss in addition to human loss. The positive economic influence on improving the working
conditions and OHS in particular is expressed through higher productivity, effectiveness and the quality
of work and provided services. Thus, attention to safe and healthy working conditions assists in enhancing
competitiveness determined by quality products, quality services for customers, new products and services
and profits which are only created by healthy and motivated employees. Thus, it creates the precondition
for the competitiveness of products and services of Slovak employers and self-employed natural persons
at home and abroad.

4.0 RESPONSIBILITY FOR OCCUPATIONAL HEALTH AND SAFETY (OHS)

The employer is responsible for OHS. It is obliged to create and maintain the conditions for ensuring that
OHS, at least on the level of standards established by the legal regulations and other regulations for
ensuring OHS. It’s best if these standards are voluntarily improved according to the actual conditions of
individual workplaces. The self-employed natural persons are responsible for their own OHS.

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The promotion of OHS constitutes one of the activities of state bodies and representative organizations
for employers and employees. The state implements its OHS policy through legislative measures, and
through the system of inspection and supervisory bodies it controls the adherence to and implementation
of measures for ensuring OHS for employers and self employed natural persons. It also ensures the
fulfillment of other significant tasks, such as foreign cooperation, research, development, upbringing and
education, adult education, promotion, counseling, insurance, taxation and fund contribution policy.

The current status of OHS and the need for continuous development of care for OHS by employers
emphasize the requirement that the representative organizations of employers more actively support their
members through expert activities assisting the OHS activities of employers. The activities of the
representative organizations of employers lie especially in the field of education, enforcement of interests
of employees and the control of the OHS status at the workplace. The improvement of the overall OHS
situation could be achieved if the representative organizations of employers and employees would
influence the attitudes of employers, employees and self employed natural persons towards a healthy form
of “working” life, increasing the labour culture, strengthening responsibility for one’s own economic
activities in connection to health and safety protection and the consequent implementation of the
instruments for prevention.

5.0 OCCUPATIONAL HEALTH AND SAFETY (OHS) POLICY

Pursuant to the Policy Statement of the Government of the Safety Regulation, the re-evaluation of
pertinent legal norms and the improvement of their consequent adherence to the legal OHS regulations by
employers by strengthening the performance of labour inspection constitute part of Government of the
Safety Regulation intentions. Improving conditions to ensure OHS, i.e. improving working conditions
even in connection with the need to decrease the number of occupational accidents and occupational
diseases constitutes the purpose.

6.0 INTERNATIONAL ASPECTS OF OCCUPATIONAL HEALTH AND SAFETY (OHS)

Occupational Health and Safety (OHS) issues have a significant international dimension and all area of
OHS policy is bound by the ILO international agreements and conventions. The laws of the Federal
Republic on Nigeria regulating OHS (FMEnvr., NESREA, SEPAs) are significant in particular for OHS
practice.

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Occupational Health and Safety (OHS) in the international context is preferred, but not only in terms of
accident prevention and the creation and maintenance of conditions for ensuring OHS. In the wider context
it includes conditions for satisfactory work, wellbeing at work and social and legal protection of employees
and other persons at workplaces with the employers’ awareness. This has a distinctive positive impact on
public health and environmental protection. It contains elements of safety and health protection with a
consideration of all aspects of work, directly or indirectly related to work including social and psycho-
social factors, such as employment, stress, violence and harassment at the workplace and gender equality.
This is also in compliance with the philosophy of the World Health Organization, according to which
health is a condition of physical, mental and social wellbeing. Good working conditions, including the
ensuring of OHS constitute the necessary conditions for dignified or good work required from its members
by the Community and the ILO.
(a) International Labor Organization

The ILO regulates the conditions for ensuring OHS through a complex of conventions and
recommendations, all of which are mandatory and binding on member countries. Some of which include
ILO Convention No. 13 of 1921 on the Use of White Lead in Painting Work, ILO Convention No. 115 of
1960 on the Protection of Employees from Ionizing Radiation, ILO Convention No. 155 of 1981 on the
Safety and Health of Workers and the Working Environment and ILO Convention No. 184 of 2001 on
Safety and Health in Agriculture and many others, although some member states are yet to apply and ratify
all, especially the basic ILO standards on labor inspection.

(b) The European Union

The basic OHS framework in the Community is regulated through an extensive set of 26 Regulations; the
key aspects are contained in the Council Regulation of June 12, 1989 on the Introduction of Measures for
the Promotion of the Improvement of the Health and Safety of Workers at Work (89/391/EEC). Their
purpose is to establish equal minimum OHS standards for all EU Member States. This complex of
Regulations is supplemented by other acts of EU bodies, such as Regulations and Decisions. The health
and safety of workers at work constitutes one of the most developed aspects of the Community policy in
the area of employment and social affairs and represents a contribution to the implementation of basic
rights. It represents the precondition for applying the basic principle of the Community – the right to free
movement of workers within the common EU space.

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The Community equally prefers the social dimension to economic aspects and it is based on the principle
that the health and safety of employees at work constitutes a phenomenon in which it is impossible to see
only the economic aspect of the matter. The non-acceptance of this approach by employers is perceived
by the EU as the illegal economic preferential treatment of one subject over others and disturbing the
equality necessary for free economic competition.

The satisfactory working conditions and especially the safe and non-threatening health factors of work at
workplaces are significant for the Community in two cardinal policies i.e. the solution of situations arising
from demographic developments (the aging of the economically active population) by employing “more
mature” persons in connection with the prolonging of the old age pension age and the significant of
implementing the growth and employment strategy of the revised Lisbon Strategy in connection with the
creation of more and better jobs. The basic OHS intentions of the Community are contained in the
Community Strategy for OHS. Its purpose is to revive the policy of health and safety at work and to
improve its implementation within the Community space.

(c) Present Status of Occupational Health and Safety (OHS) OHS in Nigeria

The practice of OHS is low, as lip service is often paid to legislation resulting in ineffective monitoring
and evaluation. Many companies especially the multinational have taken advantage of corruption to cut
expense where needed for effective implementation of the OHS policy as entrenched in national law and
the ILO agreements and conventions. Thus employees are exposed to dangers which frequently pose threat
to their health when fulfilling their work duties. Dangers or their effects on employees are eliminated or
limited through suitable preventative or protective measures for ensuring OHS.

7.0 CREATING AND MAINTAINING THE CONDITIONS FOR ENSURING OHS

Monitoring and evaluation activities have revealed that the care for OHS by employers is frequently
minimal or formal. The creation of suitable working conditions for employees and the protection of their
life and health at the workplace in particular do not constitute a priority or natural need for a number of
employers. Frequently, the lack of interest of employers in ensuring satisfactory working conditions and
their greater concern for economic and business intentions prevail. These statements are valid especially
in the case of SMEs - production enterprise subjects as a rule, and especially self employed natural
persons. Especially dangerous working procedures, the organization of work, dangerous equipment and

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risky jobs are often found in the production and service sectors. These factors represent a constant potential
threat and the cause of health damage.

The outcome of such approach is the lack of a systematic and unified approach to the issues; care for OHS
is usually formal. Insufficient attention is paid to risk assessment, the cooperation between managing
employees and employees is too frequently unsatisfactory, and the quality of notifying the employees of
OHS issues is unsatisfactory. The OHS activities of employees and representatives of employees in
requiring and enforcing satisfactory working conditions, including the conditions for ensuring OHS at
employers’ workplaces is also limited by their fear of losing their jobs. The direct proof of the low level
of care for OHS are insufficiently secured and equipped operation buildings, working spaces and working
environments, not to mention unsuitable machinery and technical equipment.

8.0 STATUS OF OCCUPATIONAL ACCIDENTS AND OCCUPATIONAL DISEASES

In the case of the occupational accidents, the long term positive development of the decrease in their
number continues. Records are inadequate but unverified report showed that the number of occupational
accidents has increased. A long-term unfavorable development may be reflected in the increasing average
time (days) of sick leave due to occupational accidents. From the statistics on occupational accidents it
arises that the largest number of accidents occurred in relation to the manipulation with objects and loads,
in falls, the effect of sharp edges, etc. Means of transportation have constituted the most frequent source
of fatal and severe or serious occupational accidents over the past. Dangerous procedures or methods of
work, acting without authorization and lack of personal preconditions for work constitute the most
frequent causes of the occurrence of serious occupational accidents. The largest number of fatal and severe
or serious occupational accidents occurs in industrial production. The trend in the incidence of
occupational diseases is clear; however a number of new occupational diseases have been reported. The
following are the most significant factors of the working environment from the aspect of the number of
exposed employees. Physical factors include excessive noise, vibrations and ionizing radiation; chemical
factors include dust and chemical substances and agents with toxic effects. Recently, one of the major
positive factors determining the decrease of health damage at work is constituted by the introduction of
new technologies in which a higher level of unconditioned technical safety is integrated.

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9.0 ECONOMIC MOTIVATION

The present economic instruments are not sufficiently effective in encouraging employers to create and
apply satisfactory working conditions, including conditions for ensuring OHS. The basic economic
instruments which significantly lead to increases in the level of care for OHS, such as ensuring
preventative activities in the field of OHS through accident insurance policies and the allocation of a
certain amount of financial resources earmarked for accident insurance for guaranteeing this prevention,
are not legislatively regulated and used. The absence of these economic instruments is significant
especially in the financial coverage of implementing preventative measures by Small and Medium
Enterprises (SMEs).

10.0 EDUCATION AND PROMOTION

In general, legal awareness in relation to OHS among employers, their statutory bodies and other
managing employees, self employed natural persons and employees is low. The unawareness or
unreasonable underestimation of the risks of health damage, the effort and willingness to solve working
tasks even at the expense of one’s health and the unwillingness to prevent health damage through
preventative measures continue. It is difficult to enforce the philosophy of personal responsibility for the
protection of one’s own safety and health in the working process with employees. The sensitivity of the
population, employers and employees towards these issues is insufficient. This status also arises from the
fact that an adequate system of school education of pupils, students and teachers in the area of OHS is
insufficient or lacking.

11.0 THE RELATION OF THE CONCEPT OF OHS-TO-OHS LEGISLATION

OHS legislation is in compliance with the pertinent laws of the Community. The legal regulations and
other regulations for ensuring OHS establish a wide circle of tasks directly or indirectly related to
implementing the right to life and health protection of employees at work. This includes organizational,
technical, healthcare, upbringing-educational, social and other measures targeted on the management,
implementation and control of technical, organizational and personal aspects, for the creation of working
conditions that will ensure OHS and preserve the health and working capacity of employees. The
application of legal regulations and other regulations for ensuring OHS in the practice of employers, self
employed natural persons and employees is problematic. That is why the measures of the OHS Concept

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are targeted on the support of employers in the more conscientious performance of obligations established
by the legal regulations for ensuring OHS; they are also designed to support related aspects determining
or developing the performance of these obligations.

12.0 OHS CONCEPT OBJECTIVE

Optimizing the working conditions of employees, including the conditions for ensuring OHS constitute
the means for implementing the basic axiom in the field of OHS according to which the “occupational”
health of employees constitutes a valuable national resource. It represents the expression of accepting the
essence and value of human life. The significance of this approach is growing. This objective is in
compliance with the Community Strategy on OHS. The anticipated OHS Concept is created with the
consideration of the present status of OHS and current social conditions. It proposes a complex package
of measures whose implementation will significantly promote the application of life and health protection
at work for employees and self employed natural persons in the implementing of their business activities.
The primary objective of the OHS Concept is to gradually decrease the number of occupational accidents.
The support of employers and self employed natural persons in the conscientious application of legal
regulations and other regulations for ensuring OHS and related legislation is also an instrument that will
help to achieve this objective. The bodies of state administration in the field of labour inspection and state
supervision and the strengthening of their activities in enforcing the protection of employees at work in
compliance with the Community standards and the ILO make up another important instrument for
enforcing the established objective.

13.0 OHS CONCEPT PRIORITIES

In the interest of the successful and gradual achieving of the OHS Concept objective, it is necessary to
decrease the value of the monitored indicator of the number of occupational accidents. In order to achieve
this in the interest of improving the status of working conditions, including OHS in Nigeria and to decrease
the number of occupational accidents in general, all employers must show increased effort and adopt more
effective measures. This refers to employers performing work with a higher incidence of health injury
cases, especially those whose monitored indicators exceed its average value in the pertinent division
according to the statistical classification of economic activities. Small and middle-sized enterprises in
particular must equally concentrate on ensuring these activities. Self employed natural persons must also
take more distinctive care of their safety and health by themselves.

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From the aspect of the number of occupational accidents, high risk areas include the construction industry,
agriculture and forest management, the extraction of raw materials and industrial production, especially
in processing timber and wood products, metal production and the production of metal products, the
production of machinery and transportation means. In terms of the seriousness of occupational accidents
and the number of fatal accidents per 100 employees, the construction industry, agriculture, hunting and
forest management, transportation, storing and communications and industrial production, especially the
production of pulp, paper and paper products, the production of non-metal mineral products, the
processing of timber and wood products, chemical products and chemical fibers are especially risky.
Increased risks can also be found in working activities in which extremely tragic events have recently
occurred, for example in mining.

Employers and self-employed natural persons involved in the performance of these activities must more
thoroughly implement suitable protective and especially preventative measures in the interest of
decreasing the amount of health damage at work and achieving the OHS Concept objective. In the interest
of monitoring the fulfillment of the overall objective, the recommended year on year values for decreases
in the monitored indicator will be established after receiving the consent of the representatives of
employers on the OHS Coordination Committee. Increased attention must also be focused on specific
groups of employees which may be excessively exposed to risks connected with the performance of their
occupation or to the special and specific risks, for example juvenile employees (up t0 20 years of age),
employees performing their job for a short period of time, employees with insufficient knowledge and
experience, distinctively older employees (over 60 years of age), migrating persons and pregnant women.
Greater attention must also be devoted to improving OHS care in the performance of working activities
by persons with disabilities, with an emphasis on protected workplaces, protected workshops and social
enterprises.

The supervisory, advisory and informational attention of all involved, especially inspection bodies and
supervisory authorities, must be targeted on these activities, sectors and groups of employees. The
following priorities of the OHS Concept define the basic circles of measures which in the interest of the
further development of the attention of employers for OHS and decreasing the number of occupational
accidents and occupational diseases promote OHS activities of employers.

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14.0 ENFORCEMENT OF THE APPLICATION OF THE OHS CONCEPT

In the interest of the effective implementing of the tasks and measures of the OHS Concept, it is necessary
to universally promote its dissemination, explain its importance and promote its benefits. This is especially
important in relation to the expert public, employers, self employed natural persons, and SMEs. It is
suitable to use the media, seminars, etc. for this purpose.

15.0 MONITORING OF THE IMPLEMENTATION OF THE OHS CONCEPT OBJECTIVE

Implementing the OHS Concept objective and fulfilling its priorities including individual measures and
tasks should be monitored and evaluated on a semi-annual basis by the OHS Coordination Committee,
which constituted the Counseling Body established for the purpose of creating and assessing the state
OHS policy. For this purpose, the administrators and cooperating institutions submit information on the
fulfillment OHS concepts which will then be forwarded to the Coordination Committee. The members of
the Coordination Committee are continuously informed of the fulfillment of the Concept tasks.

It has been proposed that the report on implementing the OHS Concept be submitted to the session of the
Government as stipulated e.g. Quarterly Air quality Assessment Report, biannual Environmental Audit
Report, Annual Impact Statement report etc.

16.0 GOOD HOUSEKEEPING AND EQUIPMENT MAINTENANCE

16.1 Housekeeping

Good housekeeping can eliminate some workplace hazards and help get a job done safely and properly.
Poor housekeeping can frequently contribute to accidents by hiding hazards that cause injuries. If the sight
of paper, debris, clutter and spills is accepted as normal, then other more serious health and safety hazards
may be taken for granted.

Housekeeping is not just about cleanliness, it includes keeping work areas neat and orderly; maintaining
halls and floors free of slip and trip hazards; and removing of waste materials (e.g., paper, cardboard) and
other fire hazards from work areas. It also requires paying attention to important details such as the layout
of the whole workplace, aisle marking, safety signage, adequacy of storage facilities, and maintenance.
Good housekeeping is also a basic part of accident and fire prevention.

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Effective housekeeping is an ongoing operation: it is not a hit-and-miss cleanup done occasionally.
Periodic "panic" cleanups are costly and ineffective in reducing accidents.
• Purpose of workplace housekeeping
Poor housekeeping can be a cause of accidents, such as: tripping over loose objects on floors, stairs and
platforms, being hit by falling objects, slipping on greasy, wet or dirty surfaces, striking against projecting,
poorly stacked items or misplaced material, cutting, puncturing, or tearing the skin of hands or other parts
of the body on projecting nails, wire or steel strapping etc. To avoid these hazards, a workplace must
"maintain" order throughout a workday. Although this effort requires a great deal of management and
planning, the benefits are many.

• Benefits of good housekeeping practices

Effective housekeeping results in: reduced handling to ease the flow of materials, fewer tripping and
slipping accidents in clutter-free and spill-free work areas, decreased fire hazards, lower worker exposures
to hazardous substances (e.g. dusts, vapours), better control of tools and materials, including inventory
and supplies, more efficient equipment cleanup and maintenance, better hygienic conditions leading to
improved health, more effective use of space, reduced property damage by improving preventive
maintenance, less janitorial work, improved morale and improved productivity (tools and materials will
be easy to find)

• Good housekeeping program

A good housekeeping program plans and manages the orderly storage and movement of materials from
point of entry to exit. It includes a material flow plan to ensure minimal handling. The plan also ensures
that work areas are not used as storage areas by having workers move materials to and from work areas
as needed. Part of the plan could include investing in extra bins and more frequent disposal.

The costs of this investment could be offset by the elimination of repeated handling of the same material
and more effective use of the workers' time. Often, ineffective or insufficient storage planning results in
materials being handled and stored in hazardous ways. Knowing the plant layout and the movement of
materials throughout the workplace can help plan work procedures.

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Worker training is an essential part of any good housekeeping program. Workers need to know how to
work safely with the products they use. They also need to know how to protect other workers such as by
posting signs (e.g., "Wet - Slippery Floor") and reporting any unusual conditions.

Housekeeping order is "maintained" not "achieved." Cleaning and organization must be done regularly,
not just at the end of the shift. Integrating housekeeping into jobs can help ensure this is done. A good
housekeeping program identifies and assigns responsibilities for the following: clean up during the shift,
day-to-day cleanup, waste disposal, removal of unused materials, and inspection to ensure cleanup is
complete

It is important not to forget out of the way places such as shelves, basements, sheds, and boiler rooms that
would otherwise be overlooked. The orderly arrangement of operations, tools, equipment and supplies is
an important part of a good housekeeping program. The final addition to any housekeeping program is
inspection. It is the only way to check for deficiencies in the program so that changes can be made. The
documents on workplace inspection checklists provide a general guide.
• Elements of effective housekeeping program
o Dust and Dirt Removal
In some jobs, enclosures and exhaust ventilation systems may fail to collect dust, dirt and chips adequately.
Vacuum cleaners are suitable for removing light dust and dirt. Industrial models have special fittings for
cleaning walls, ceilings, ledges, machinery, and other hard-to-reach places where dust and dirt may
accumulate.

Special-purpose vacuums are useful for removing hazardous substances. For example, vacuum cleaners
fitted with high efficiency particulate air (HEPA) filters may be used to capture fine particles of asbestos
or fibreglass. Dampening (wetting) floors or using sweeping compounds before sweeping reduces the
amount of airborne dust. The dust and grime that collect in places like shelves, piping, conduits, light
fixtures, reflectors, windows, cupboards and lockers may require manual cleaning. Note that Compressed
air should not be used for removing dust, dirt or chips from equipment or work surfaces.

o Employee Facilities
Employee facilities need to be adequate, clean and well maintained. Lockers are necessary for storing
employees' personal belongings. Washroom facilities require cleaning once or more each shift. They also
need to have a good supply of soap, towels plus disinfectants, if needed. If workers are using hazardous

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materials, employee facilities should provide special precautions such as showers, washing facilities and
change rooms. Some facilities may require two locker rooms with showers between. Using such double
locker rooms allows workers to shower off workplace contaminants and prevents them from
contaminating their "street clothes" by keeping their work clothes separated from the clothing that they
wear home. Smoking, eating or drinking in the work area should be prohibited where toxic materials are
handled. The eating area should be separate from the work area and should be cleaned properly each shift.

o Surfaces
Floors: Poor floor conditions are a leading cause of accidents so cleaning up spilled oil and other liquids
at once is important. Allowing chips, shavings and dust to accumulate can also cause accidents. Trapping
chips, shavings and dust before they reach the floor or cleaning them up regularly can prevent their
accumulation. Areas that cannot be cleaned continuously, such as entrance ways, should have anti-slip
flooring. Keeping floors in good order also means replacing any worn, ripped, or damaged flooring that
poses a tripping hazard.

Walls: Light-coloured walls reflect light while dirty or dark-coloured walls absorb light. Contrasting
colours warn of physical hazards and mark obstructions such as pillars. Paint can highlight railings, guards
and other safety equipment, but should never be used as a substitute for guarding. The program should
outline the regulations and standards for colours.

• Maintain Light Fixtures

Dirty light fixtures reduce essential light levels. Clean light fixtures can improve lighting efficiency
significantly.

• Aisles and Stairways

Aisles should be wide enough to accommodate people and vehicles comfortably and safely. Aisle space
allows for the movement of people, products and materials. Warning signs and mirrors can improve sight-
lines in blind corners. Arranging aisles properly encourages people to use them so that they do not take
shortcuts through hazardous areas.

Keeping aisles and stairways clear is important. They should not be used for temporary "overflow" or
"bottleneck" storage. Stairways and aisles also require adequate lighting.

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 • Spill Control
The best way to control spills is to stop them before they happen. Regularly cleaning and maintaining
machines and equipment is one way. Another is to use drip pans and guards where possible spills might
occur. When spills do occur, it is important to clean them up immediately. Absorbent materials are useful
for wiping up greasy, oily or other liquid spills. Used absorbents must be disposed of properly and safely.

• Tools and Equipment

Tool housekeeping is very important, whether in the tool room, on the rack, in the yard, or on the bench.
Tools require suitable fixtures with marked locations to provide orderly arrangement, both in the tool room
and near the work bench. Returning them promptly after use, reduces the chance of being misplaced or
lost. Workers should regularly inspect, clean and repair all tools and take any damaged or worn tools out
of service.

• Maintenance
The maintenance of buildings and equipment may be the most important element of good housekeeping.
Maintenance involves keeping buildings, equipment and machinery in safe, efficient working order and
in good repair. This includes maintaining sanitary facilities and regularly painting and cleaning walls.
Broken windows, damaged doors, defective plumbing and broken floor surfaces can make a workplace
look neglected; these conditions can cause accidents and affect work practices. So it is important to replace
or fix broken or damaged items as quickly as possible. A good maintenance program provides for the
inspection, maintenance, upkeep and repair of tools, equipment, machines and processes.

• Waste Disposal
The regular collection, grading and sorting of scrap contribute to good housekeeping practices. It also
makes it possible to separate materials that can be recycled from those going to waste disposal facilities.
Allowing material to build up on the floor wastes time and energy since additional time is required for
cleaning it up. Placing scrap containers near where the waste is produced encourages orderly waste
disposal and makes collection easier. All waste receptacles should be clearly labeled (e.g., recyclable
glass, plastic, scrap metal, etc.).

• Storage
Good organization of stored materials is essential for overcoming material storage problems whether on
a temporary or permanent basis. There will also be fewer strain injuries if the amount of handling is

17
reduced, especially if less manual materials handling is required. The location of the stockpiles should not
interfere with work but they should still be readily available when required. Stored materials should allow
at least one metre (or about three feet) of clear space under sprinkler heads.

Stacking cartons and drums on a firm foundation and cross tying them where necessary, reduces the
chance of their movement. Stored materials should not obstruct aisles, stairs, exits, fire equipment,
emergency eyewash fountains, emergency showers, or first aid stations. All storage areas should be clearly
marked.

Flammable, combustible, toxic and other hazardous materials should be stored in approved containers in
designated areas that are appropriate for the different hazards that they pose. Storage of materials should
meet all requirements specified in the fire codes and the regulations of environmental and occupational
health and safety agencies in your jurisdiction.

• Equipment Maintenance Management

Equipment Maintenance is a risk management practice used to maximize production and minimize loss
and waste. Selecting a successful maintenance strategy requires a good knowledge of equipment failure
behaviour and maintenance management practices. Once you appreciate why equipment fails, how
equipment fails and when equipment fails you can select the right mix of maintenance strategies to extend
and maximize its service and performance. To master a thing, there must be a thorough understanding of
its operation. Hence, expertise is a clear and intimate knowledge absorbed with specialty of equipment.
When an equipment operation is understood, its behaviour is known under all circumstance; hence when
there is a change its impact and effect can be anticipated.

Maintenance is therefore a strategy for performance enhancement. Strategic maintenance decision making
involves selecting the right care and repair methodologies that maximize equipment life and performance
for the least cost to the user. But to be able to make successful maintenance management strategy choices
you must understand how equipment fails. When you know the equipment’s weaknesses and strengths
you can care for it properly and get maximum service from it at least cost.

• Equipment Failure
Today’s equipment technologies can be broadly grouped as mechanical or electrical. Equipment in both
groups has physical presence because they are made of solid matter which can break or deteriorate.

18
However, equipment fails because its physical substance and structure cannot support the last duty
required of it. In some cases the end of an equipment’s life is instantaneous and without warning. Many
times there is a gradual worsening of performance that can be detected. Equipment can therefore fail
because some part of it can be broken or deteriorated. The question is “what could be the cause of
equipment part breakdown or deterioration?” There are usually hundreds of combinations of causes that
can make a piece of equipment fail which can be categorized into:

o Over-stressed Components
Physical matter can only survive within a limited range of imposed stresses and environments. Once matter
is stressed beyond its endurance it will suddenly fail. Some common examples are overloading, becoming
too hot and placing an item under fluctuating forces leading to fatigue situations.

o Physical Attack
This is the case where the environment around the equipment actually damages the equipment. When
environmental attack gets too severe the equipment is compromised and fails, as it no longer has the
strength or capacity to handle its duty. Common examples are rusting, chemical corrosion, wear, erosion
and cavitations.

o Error or Mistake
Equipment can fail due to the wrong thing being done to it, or a wrong choice being made in ignorance.
Failure by error can start on the drawing board at the design stage. It can be due to an operator or
maintainer making a mistake. It can be due to incompetent management decision. Some examples include
starting equipment when not fully rebuilt, forgetting to put oil in a gearbox, introducing incompatible
chemicals and doing the wrong instruction sequence. Poor Design Choices and-or Poor Manufacturing /
Assembly Quality

There are times when equipment part is made incorrectly, built incorrectly or its design was unable to
withstand the imposed service duty. Such design errors include selecting undersized equipment, wrongly
specified components which introduces safety risks.

Manufacturing errors like poor welding, poor casting, incorrectly positioned holes and out of tolerance
machining are real possibilities. Similarly, assembly errors, such as under-torque on bolts, poorly fitted
electrical connections and short-cut assembly quality practices will eventually lead to equipment failure.

19
 o Lack of Maintenance and Care
When equipment is designed the designer makes the assumption that it will be treated with reasonable
care and it will undergo a minimum amount of required maintenance. When care and maintenance is
withheld from equipment for an extended period of time, accumulated problems develop which eventually
cause failure. This can include not changing lubricating oil, leaving electrical equipment open to dust and
dirt ingress, starting machines under full load, not checking remaining service life and not cleaning
equipment down.

o Unimagined Incidents and Knock-on Effects

Occasionally an unexpected disastrous event occurs that destroys equipment. These include sabotage, acts
of God, such as lightning and terrorism. Included in this category are unforseen preventable events that
are a consequence of planned events. An example is where a bolt falls into a machine during a repair and
is not noticed. On start-up the bolt is jammed into the working parts and causes a breakdown. Another
example is negligent behaviour, such as backing forklifts into operating plant or out-of-control vehicles
running into machinery.

Consequently, equipment failure is defined as the point when the equipment no longer delivers the
minimum duty required of it. It may not yet be broken, but it is not able to deliver the needed service. The
actual time of failure depends on when the cause of the failure coincides with the item’s ability to
accommodate the failure mechanism. This means that the failure happens at the time the item can no
longer operate as required. This point in time can be controlled by the selection of the right maintenance
strategies. However, equipment failure can even be totally prevented with appropriate maintenance
strategy.

• Equipment Maintenance Strategies

There are several maintenance strategies available, which range from pre-emptive methods that remove
the need for maintenance. There are those that cover the ways to maintain well and on to failure analysis
methods for removing existing failures. These include:

o Pre-emptive Detection and Elimination which is a strategic maintenance planning and

starts on the drawing board. Once an item of plant is built you are stuck with it. A statement
of equipment maintenance requirement is needs is made to maintain its performance. There

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 is no escaping the fact that the design specifies the maintenance requirements. Unless the
necessary maintenance is done it will fail.

o Quality Control and Assurance is a strategy originated in the manufacturing industries

and applies equally to maintenance work. It is simply the proper and correct control of
manufacture and assembly so that equipment is built precisely as it was designed, with
correct and accurate components. It involves substantiating and proving that each
equipment item meets its design requirements and that it is assembled into the equipment
correctly. When equipment is accurately and properly assembled using the right parts, it
lasts longer between repairs and so has a longer mean time between failures (MTBF). It
also runs sweeter and produces more consistent output. This translates into better running
equipment with longer mean times between failures.

o Preventative Maintenance (PM) strategy was one of the very first and it is still very
effective. It comes in two forms – 1) inspection and observation and 2) intervention and
replacement. The first Preventative Maintenance form is the usual response used for
equipment and parts that show signs of age and wear-out, which involves inspecting and
noting the condition of equipment and its parts and servicing it on a regular basis, such as
changing old lubricant so that servicing is done it is an ideal time to look for evidence of
impending failures in critical and working parts. If failure evidence is found, the part is
changed for new immediately or at the earliest convenient time before breakage.

o Shutdown Overhaul Maintenance is the second PM form which involves automatic

replacement of parts known to experience age and use related degradation on a set
frequency shorter than the mean time between failures. Doing this should prevent an
unexpected failure and give maximum production time. Such work is typically done as an
overhaul where the whole of the equipment is removed from operation during a shutdown
and taken to the workshop to be stripped down to its component parts and rebuilt as new.

o Predictive Maintenance (PdM) is a very powerful maintenance strategy. It involves

monitoring for evidence of changed conditions within the equipment. The amount of
change and the rate of change are tracked and used to predict the time of failure. PdM is
based on the recognition that many failures take time to happen. Typically there is a start

21
 point, a gradual worsening, and eventually a point where the item cannot perform its duty.
Finally there is a point in time when it breaks and totally fails. Hence if it is possible to
detect early onset of the failure then there is often time to manage the equipment carefully
and continue operation until a replacement is actually needed. When predictive
maintenance management strategy is used problems can be immediately and can act on
them before a failure occurs that shuts the operation down.

o Intentional Over-Design Selection: there are times when it is useful to select more robust
equipment than superficially appears necessary. This is a strategic maintenance choice that
is intended to produce longer periods of equipment operation between failures. It involves
specifying equipment with stronger, harder, more resistant parts, using longer lasting
components, applying improved protection against ingress of the external environment and
the like.

o Improved Technologies: new inventions and innovative designs usually occur in response
to existing problems. It is a wise and valid maintenance strategy to be constantly looking
for new technologies that reduce equipment operating problems. When there is a change
to a new technology that solves a maintenance problem, there is immediately gain in the
benefit of improved production output.

o Root Cause Elimination and Design-Out: is a maintenance strategy that solves problems
and continually improves plant and equipment performance. This is a strategic
maintenance step that if not done, results in long-term deterioration in production plant
performance. If operating problems are not removed by designing them out, then the
problems will accumulate to the point where production falls because equipment
continually fails.

o Proactive Education and Training: people can only change their behaviour and thoughts
when they find better ways to behave and think. Once a person knows what is right to do,
they will most likely do it. Ignorance is hugely expensive. One of the best maintenance
strategies is to teach the engineering design requirements of the equipment to the operators
and maintainers who will run and care for it. This is a sound strategic step because it means

22
 key knowledge is transferred to the users of the machinery. Knowledgeable users will make
wise choices and take correct actions.

o Maintenance Planning and Scheduling is a key strategic maintenance planning move. It

is based on the principle that prior planning and preparation will improve the actual
performance and execution. Here operations and maintenance must be thoroughly planned
and organized before being done.

NOTE: It should be noted that there is no one maintenance strategy for all situations and all
companies. Rather you require a blend of maintenance management strategies that are right for your
operation and for the age of the equipment. This will always require an amount of preventative
maintenance, as well as an amount of predictive maintenance when equipment ages, along with root
cause analysis to eliminate non-random failures. To this is added appropriate training, occasional
overhaul shutdowns, replacement of old technologies with new, and so on.

17.0 STRATEGIES FOR PROTECTING WORKERS IN WORK PLACES

In view of the attendant associated risk involved in both operational and practice procedures in work
places, there is need for developing proactive and pragmatic approaches to limit employees exposure to
peculiar hazards in industries and the Small and Medium scale Enterprises (SMEs). There are a few simple
strategies that can be used to protect your workers work hazards. These strategies can be documented in
employee’s protection policy. These include:

• Provide training

All employees should receive training and education to raise their awareness and knowledge about
lifestyle factors including work practices that contribute work and industrial hazards peculiar to their work
environment and their attendant exposure risk. This should include emergency response procedure and
what to do (first aid practice) in case of accident.

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 • Provide protective clothing

Employees should be provided with protective clothing, the use of which must be enforced even when
working in shade. Employees still need suitable clothing to protect them from exposure industrial fumes,
UV radiation etc which is scattered in the atmosphere or reflected off water, sand, snow, cement or grass.
Both the design and the type of fabric used in the garment are important in maximizing the protection it
offers.

o Design: get employees to wear loose-fitting clothing that covers as much skin as possible
- shirts with long sleeves and collars (turned up), trousers, or skirts or shorts that are at least
knee-length.

o Fabric: the more closely woven the fabric the less UV radiation or noxious gases will
penetrate through to the skin. Purpose-made protective work clothing will be most
effective.

• Provide hats and headgear

A well-designed hat can substantially reduce risk to head injury which can reach the face, neck, ears and
head. Common sites of head damage are the neck, ears, temples, lips, face and nose.

When choosing hats for your employees, remember: hats should shade the face, neck and ears, and be
made of tightly woven material; broad-brimmed hats (8-10cm), and caps with neck flaps (legionnaire
caps) offer good protection; use brims and neck flaps to attach to hard hats or helmets; and baseball caps
don't cover the face, ears and back of the neck adequately.
• Use of eye protection device
o Sunglasses
Sunglasses are vital in the outdoor workplace. Repeated exposure of the eyes to high intensity optical
radiation, UV radiation, thermal energy, flying objects etc can cause short-term eye complaints and
permanent eye damage. When choosing sunglasses, remember: close-fitting, wrap-around styles are best
and stop high intensity optical/UV/ thermal radiation coming in at the sides as well as from in front;
sunglasses should meet the look for category 2, 3 or 4 and a lens description that states “good optical and

24
UV protection”; sunglasses with an eye protection factor that offer the most effective protection; and UV
radiation protective eyewear and safety glasses used in laboratories, industry and medicine.

o Provision of shade
Try using available shade, such as trees and other plants, buildings or temporary shade structures, such as
umbrellas, canopies and wanings, to reduce thermal, radiation and sun exposure. Always provide a shaded
or indoor area for tea breaks and lunch.

18.0 INDUSTRIAL POLLUTANT AFFECTING COMMUNITIES (dust, effluents, fire, etc)

Industrial Pollution sources could be from Point and Nonpoint sources. The pollution could result air,
water and soil pollution which all have different adverse effect on the environment. Pollutant could range
from one or a combination of the following:

Heavy metals from industrial processes can accumulate in terrestrial areas or in nearby lakes and rivers.
These are toxic to marine life such as fish and shellfish, and can affect the rest of the food chain. This
means that entire animal communities can be badly affected by this type of pollutant.
Industrial waste often contains many toxic compounds that damage the health of aquatic animals and
those who eat them. Some toxins affect the reproductive success of marine life and can therefore disrupt
the community structure of an aquatic environment.
Microbial pollutants from sewage often result in infectious diseases that infect aquatic life and terrestrial
life through drinking water. This often increases the number of mortalities seen within an environment.
Organic matter and nutrients causes an increase in aerobic algae and depletes oxygen from the water
column. This is called eutrophication and causes the suffocation of fish and other aquatic organisms.
Sulfate particles from acid rain change the pH of water making it more acidic, this damages the health
of marine life in the rivers and lakes it contaminates, and often increases the number of mortalities within
an environment.

Suspended particles can often reduce the amount of sunlight penetrating the water, disrupting the growth
of photosynthetic plants and micro-organisms. This has subsequent effects on the rest of the aquatic
community that depend on these organisms to survive.

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 OCCUPATIONAL DISEASE SURVEILLANCE AND REPORTING SYSTEMS

1.0 INTRODUCTION
Occupational disease and injury surveillance entails the systematic monitoring of health events in
working populations in order to prevent and control occupational hazards and their associated diseases
and injuries. Occupational disease and injury surveillance has four essential components (Baker, Melius
and Millar 1988; Baker 1986).

1. Gather information on cases of occupational diseases and injuries.

2. Distil and analyse the data.
3. Disseminate organized data to necessary parties, including workers, unions, employers, governmental
agencies and the public.
4. Intervene on the basis of data to alter the factors that produced these health events.

Surveillance in occupational health has been more concisely described as counting, evaluating and acting
(Landrigan 1989).

Surveillance commonly refers to two broad sets of activities in occupational health. Public health
surveillance refers to activities undertaken by federal, state or local governments within their respective
jurisdictions to monitor and to follow up on occupational diseases and injuries. This type of surveillance
is based on a population, that is, the working public. The recorded events are suspected or established
diagnoses of occupational illness and injury. This article will examine these activities.

Medical surveillance refers to the application of medical tests and procedures to individual workers who
may be at risk for occupational morbidity, to determine whether an occupational disorder may be present.
Medical surveillance is generally broad in scope and represents the first step in ascertaining the presence
of a work-related problem. If an individual or a population is exposed to a toxin with known effects, and
if the tests and procedures are highly targeted to detect the likely presence of one or more effects in these
persons, then this surveillance activity is more aptly described as medical screening (Halperin and Frazier
1985). A medical surveillance programme applies tests and procedures on a group of workers with
common exposures for the purpose of identifying individuals who may have occupational illnesses and
for the purpose of detecting patterns of illness which may be produced by occupational exposures among

26
the programme participants. Such a programme is usually undertaken under the auspices of the
individual’s employer or union.
2.0 FUNCTIONS OF OCCUPATIONAL HEALTH SURVEILLANCE
Foremost among the purposes of occupational health surveillance is to identify the incidence and
prevalence of known occupational diseases and injuries. Gathering descriptive epidemiological data on
the incidence and prevalence of these diseases on an accurate and comprehensive basis is an essential
prerequisite for establishing a rational approach to the control of occupational disease and injury.
Assessment of the nature, magnitude and distribution of occupational disease and injury in any geographic
area requires a sound epidemiological database. It is only through an epidemiological assessment of the
dimensions of occupational disease that its importance relative to other public health problems, its claim
for resources and the urgency of legal standard setting can be reasonably evaluated. Second, the collection
of incidence and prevalence data allows analysis of trends of occupational disease and injury among
different groups, at different places and during different time periods. Detecting such trends is useful for
determining control and research priorities and strategies, and for evaluating the effectiveness of any
interventions undertaken (Baker, Melius and Millar 1988).

A second broad function of occupational health surveillance is to identify individual cases of occupational
disease and injury in order to find and evaluate other individuals from the same workplaces who may be
at risk for similar disease and injury. Also, this process permits the initiation of control activities to
ameliorate the hazardous conditions associated with causation of the index case (Baker, Melius and Millar
1988; Baker, Honchar and Fine 1989).An index case of occupational disease or injury is defined as the
first ill or injured individual from a given workplace to receive medical care and thereby to draw attention
to the existence of a workplace hazard and an additional workplace population at risk. A further purpose
of case identification may be to assure that the affected individual receives appropriate clinical follow-up,
an important consideration in view of the scarcity of clinical occupational medicine specialists (Markowitz
et al. 1989; Castorino and Rosenstock 1992).

Finally, occupational health surveillance is an important means of discovering new associations between
occupational agents and accompanying diseases, since the potential toxicity of most chemicals used in the
workplace is not known. Discovery of rare diseases, patterns of common diseases or suspicious exposure-
disease associations through surveillance activities in the workplace can provide vital leads for a more
conclusive scientific evaluation of the problem and possible verification of new occupational diseases.

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3.0 OBSTACLES TO THE RECOGNITION OF OCCUPATIONAL DISEASES

Several important factors undermine the ability of occupational disease surveillance and reporting systems
to fulfil the functions cited above. First, recognition of the underlying cause or causes of any illness is the
sine qua non for recording and reporting occupational diseases. However, in a traditional medical model
that emphasizes symptomatic and curative care, identifying and eliminating the underlying cause of illness
may not be a priority. Furthermore, health care providers are often not adequately trained to suspect work
as a cause of disease (Rosenstock 1981) and do not routinely obtain histories of occupational exposure
from their patients (Institute of Medicine 1988). This should not be surprising, given that in the United
States, the average medical student receives only six hours of training in occupational medicine during
the four years of medical school (Burstein and Levy 1994).

Certain features characteristic of occupational disease exacerbate the difficulty of recognizing

occupational diseases. With few exceptions-most notably, angiosarcoma of the liver, malignant
mesothelioma and the pneumoconioses-most diseases that can be caused by occupational exposures also
have non-occupational causes. This non-specificity renders difficult the determination of the occupational
contribution to disease occurrence. Indeed, the interaction of occupational exposures with other risk
factors may greatly increase the risk of disease, as occurs with asbestos exposure and cigarette smoking.
For chronic occupational diseases such as cancer and chronic respiratory disease, there usually exists a
long period of latency between onset of occupational exposure and presentation of clinical disease. For
example, malignant mesothelioma typically has a latency of 35 years or more. A worker so affected may
well have retired, further diminishing a physician’s suspicion of possible occupational aetiologies.

Another cause of the widespread under-recognition of occupational disease is that the majority of
chemicals in commerce have never been evaluated with regard to their potential toxicity. A study by the
National Research Council in the United States in the 1980s found no information available on the toxicity
of approximately 80% of the 60,000 chemical substances in commercial use. Even for those groups of
substances that are most closely regulated and about which the most information is available-drugs and
food additives-reasonably complete information on possibly untoward effects is available for only a
minority of agents (NRC 1984).

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Workers may have a limited ability to provide an accurate report of their toxic exposures. Despite some
improvement in countries such as the United States in the 1980s, many workers are not informed of the
hazardous nature of the materials with which they work. Even when such information is provided,
recalling the extent of exposure to multiple agents in a variety of jobs over a working career may be
difficult. As a result, even health care providers who are motivated to obtain occupational information
from their patients may not be able to do so.

Employers may be an excellent source of information regarding occupational exposures and the
occurrence of work-related diseases. However, many employers do not have the expertise to assess the
extent of exposure in the workplace or to determine whether an illness is work related. In addition,
financial disincentives to finding that a disease is occupational in origin may discourage employers from
using such information appropriately. The potential conflict of interest between the financial health of the
employer and the physical and mental health of the worker represents a major obstacle to improving
surveillance of occupational disease.

4.0 REGISTRIES AND OTHER DATA SOURCES SPECIFIC FOR OCCUPATIONAL

DISEASES

International registries
International registries for occupational diseases are an exciting development in occupational health. The
obvious benefit of these registries is the ability to conduct large studies, which would allow determination
of the risk of rare diseases. Two such registries for occupational diseases were initiated during the 1980s.

The International Agency for Research on Cancer (IARC) established the International Register of Persons
Exposed to Phenoxy Herbicides and Contaminants in 1984 (IARC 1990). As of 1990, it had enrolled
18,972 workers from 19 cohorts in ten countries. By definition all enrolees worked in industries involving
phenoxy herbicides and/or chlorophenols, principally in manufacturing/formulating industries or as
applicators. Exposure estimates have been made for participating cohorts (Kauppinen et al. 1993), but
analyses of cancer incidence and mortality have not yet been published.

An international registry of cases of angiosarcoma of the liver (ASL) is being coordinated by Bennett of
ICI Chemicals and Polymers Limited in England. Occupational exposure to vinyl chloride is the only
known cause of angiosarcoma of the liver. Cases are reported by a voluntary group of scientists from

29
companies producing vinyl chloride, governmental agencies and universities. As of 1990, 157 cases of
ASL with dates of diagnosis between 1951 and 1990 were reported to the registry from 11 countries or
regions. Table 1 also shows that most of the recorded cases were reported from countries where facilities
started polyvinyl chloride manufacture before 1950. The registry has recorded six clusters of ten or more
cases of ASL at facilities in North America and Europe (Bennett 1990).

Table 1. Number of cases of angiosarcoma of the liver in the world register by country and year of first
production of vinyl chloride
Country/Region Number of PVC Year PVC Number of cases
Producing production of angiosarcoma
facilities initiated of the liver
USA 50 (1939?) 39
Canada 5 (1943) 13
West Germany 10 (1931) 37
France 8 (1939) 28
United Kingdom 7 (1940) 16
Other Western Europe 28 (1938) 15
Eastern Europe 23 (pre-1939) 6
Japan 36 (1950) 3
Central and South 22 (1953) 0
America
Australia 3 (1950s) 0
Middle East 1 (1987) 0
Total 193 157
Source: Bennett, B. World Register of Cases of Angiosarcoma of the Liver (ASL) due to Vinyl Chloride
Monomer, January 1, 1990.

Governmental surveys
Employers are sometimes legally required to record occupational injuries and illnesses that occur in their
facilities. Like other workplace-based information, such as numbers of employees, wages and overtime,
injury and illness data may be systematically collected by governmental agencies for the purpose of
surveillance of work-related health outcomes.

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In the United States, the Bureau of Labor Statistics (BLS) of the US Department of Labor has conducted
the Annual Survey of Occupational Injuries and Illnesses (BLS Annual Survey) since 1972 as required by
the Occupational Safety and Health Act (BLS 1993b). The goal of the survey is to obtain the numbers and
the rates of illnesses and injuries recorded by private employers as being occupational in origin (BLS
1986). The BLS Annual Survey excludes employees of farms with fewer than 11 employees, the self-
employed and employees of the federal, state and local governments. For the most recent year available,
1992, the survey reflects questionnaire data obtained from a stratified random sample of approximately
250,000 establishments in the private sector in the United States (BLS 1994).

The BLS survey questionnaire completed by the employer is derived from a written record of occupational
injuries and illnesses which employers are required to maintain by the Occupational Safety and Health
Administration (OSHA 200 Log). Although OSHA mandates that the employer keep the 200 Log for
examination by an OSHA inspector upon request, it does not require that employers routinely report the
log’s contents to OSHA, except for the sample of employers included in the BLS Annual Survey (BLS
1986).

Some well-recognized weaknesses severely limit the ability of the BLS survey to provide a full and
accurate count of occupational illnesses in the United States (Pollack and Keimig 1987). Data are
employer derived. Any illness that the employee does not report to the employer as being work related
will not be reported by the employer on the annual survey. Among active workers, such a failure to report
may be due to fear of consequences to the employee. Another major obstacle to reporting is the failure of
the employee’s physician to diagnose illness as being work related, especially for chronic diseases.
Occupational diseases occurring among retired workers are not subject to the BLS reporting requirement.
Indeed, it is unlikely that the employer would be aware of the onset of a work-related illness in a retiree.
Since many cases of chronic occupational illnesses with long latency, including cancer and lung disease,
are likely to have their onset following retirement, a large proportion of such cases would not be included
in the data collected by the BLS. These limitations were recognized by BLS in a recent report on its annual
survey (BLS 1993a). In response to recommendations by the National Academy of Sciences, the BLS re-
designed and implemented a new annual survey in 1992.

According to the 1992 BLS Annual Survey, there were 457,400 occupational illnesses in private industry
in the United States (BLS 1994). This represented a 24% increase, or 89,100 cases, over the 368,300

31
illnesses recorded in the 1991 BLS Annual Survey. The incidence of new occupational illnesses was 60.0
per 10,000 workers in 1992.

Disorders associated with repeated trauma, such as carpal tunnel syndrome, tendonitis of the wrist and
elbow and hearing loss, dominate the occupational illnesses recorded in the BLS Annual survey and have
done so since 1987 (table 2). In 1992, they accounted for 62% of all illness cases recorded on the annual
survey. Other important categories of disease were skin disorders, pulmonary diseases and disorders
associated with physical trauma.

Although disorders associated with repeated trauma clearly account for the largest proportion of the
increase in cases of occupational illness, there was also a 50% increase in the recorded incidence in
occupational illnesses other than those due to repeated trauma in the six years between 1986 and 1992,
during which employment in the United States rose by just 8.7%.

These increases in the numbers and rates of occupational diseases recorded by employers and reported to
the BLS in recent years in the United States are remarkable. The rapid change in the recording of
occupational illnesses in the United States is due to a change in the underlying occurrence of disease and
to a change in the recognition and reporting of these conditions. By comparison, during the same time
period, 1986 to 1991, the rate of occupational injuries per 100 full-time workers recorded by the BLS went
from 7.7 in 1986 to 7.9 in 1991, a mere 2.6% increase. The number of recorded fatalities in the workplace
has likewise not increased dramatically in the first half of the 1990s.

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Table 2. Number of new cases of occupational illness by category of illness-US Bureau of Labor Statistics
Annual Survey, 1986 versus 1992.
Category of Illness 1986 1992 % Change 1986-
1992
Skin diseases 41,900 62,900 + 50.1%
Dust diseases of the lungs 3,200 2,800 - 12.5%
Respiratory conditions due to toxic agents 12,300 23,500 + 91.1%
Poisonings 4,300 7,000 + 62.8%
Disorders due to physical agents 9,200 22,200 +141.3%
Disorders associated with repeated trauma 45,500 281,800 +519.3%
All other occupational illnesses 20,400 57,300 +180.9%
Total 136,900 457,400 +234.4%
Total excluding repeated trauma 91,300 175,600 + 92.3%
Average annual employment in the private sector, 83,291,200 90,459,600 + 8.7%
United States
Sources: Occupational Injuries and Illnesses in the United States by Industry, 1991. US Department of
Labor, Bureau of Labor Statistics, May 1993. Unpublished data,
US Department of Labor, Bureau of Labor Statistics, December, 1994.

Employer-based surveillance
Apart from the BLS survey, many US employers conduct medical surveillance of their workforces and
thereby generate a vast amount of medical information that is relevant to the surveillance of occupational
diseases. These surveillance programmes are undertaken for numerous purposes: to comply with OSHA
regulations; to maintain a healthy workforce through the detection and treatment of non-occupational
disorders; to ensure that the employee is fit to perform the tasks of the job, including the need to wear a
respirator; and to conduct epidemiological surveillance to uncover patterns of exposure and disease. These
activities utilize considerable resources and could potentially make a major contribution to the public
health surveillance of occupational diseases. However, since these data are non-uniform, of uncertain
quality and largely inaccessible outside the companies in which they are collected, their exploitation in
occupational health surveillance has been realized on only a limited basis (Baker, Melius and Millar 1988).

33
OSHA also requires that employers perform selected medical surveillance tests for workers exposed to a
limited number of toxic agents. Additionally, for fourteen well-recognized bladder and lung carcinogens,
OSHA requires a physical examination and occupational and medical histories. The data collected under
these OSHA provisions are not routinely reported to governmental agencies or other centralized data banks
and are not accessible for the purposes of occupational disease reporting systems.

Surveillance of public employees

Occupational disease reporting systems may differ for public versus private employees. For example, in
the United States, the annual survey of occupational illnesses and injuries conducted by the federal
Department of Labor (BLS Annual Survey) excludes public employees. Such workers are, however, an
important part of the workforce, representing approximately 17% (18.4 million workers) of the total
workforce in 1991. Over three-fourths of these workers are employed by state and local governments.

In the United States, data on occupational illnesses among federal employees are collected by the Federal
Occupational Workers’ Compensation Program. In 1993, there were 15,500 occupational disease awards
to federal workers, yielding a rate of 51.7 cases of occupational illnesses per 10,000 full-time workers
(Slighter 1994). At the state and local levels, the rates and numbers of illnesses due to occupation are
available for selected states. A recent study of state and local employees in New Jersey, a sizeable
industrial state, documented 1,700 occupational illnesses among state and local employees in 1990,
yielding an incidence of 50 per 10,000 public-sector workers (Roche 1993). Notably, the rates of
occupational disease among federal and non-federal public workers are remarkably congruent with the
rates of such illness among private sector workers as recorded in the BLS Annual Survey. The distribution
of illness by type differs for public versus private workers, a consequence of the different type of work
that each sector performs.

Workers’ compensation reports

Workers’ compensation systems provide an intuitively appealing surveillance tool in occupational health,
because the determination of work-relatedness of disease in such cases has presumably undergone expert
review. Health conditions that are acute and easily recognized in origin are frequently recorded by
workers’ compensation systems. Examples include poisonings, acute inhalation of respiratory toxins and
dermatitis.

34
Unfortunately, the use of workers’ compensation records as a credible source for surveillance data is
subject to severe limitations, including lack of standardization of eligibility requirements, deficiency of
standard case definitions, disincentives to workers and employers to file claims, the lack of physician
recognition of chronic occupational diseases with long latent periods and the usual gap of several years
between initial filing and resolution of a claim. The net effect of these limitations is that there is significant
under-recording of occupational disease by workers’ compensation systems.

Thus, in a study by Selikoff in the early 1980s, less than one-third of US insulators who were disabled by
asbestos-related diseases, including asbestosis and cancer, had even filed for workers’ compensation
benefits, and many fewer were successful in their claims (Selikoff 1982). Similarly, a US Department of
Labor study of workers who reported disability from occupational disease found that less than 5% of these
workers received workers’ compensation benefits (USDOL 1980). A more recent study in the state of
New York found that the number of people admitted to hospitals for pneumoconioses vastly outnumbered
the people who were newly awarded workers’ compensation benefits during a similar time period
(Markowitz et al. 1989). Since workers’ compensation systems record simple health events such as
dermatitis and musculoskeletal injuries much more readily than complex diseases of long latency, use of
such data leads to a skewed picture of the true incidence and distribution of occupational diseases.

Laboratory reports
Clinical laboratories can be an excellent source of information on excessive levels of selected toxins in
body fluids. Advantages of this source are timely reporting, quality-control programmes already in place
and the leverage for compliance provided by the licensing of such laboratories by governmental agencies.
In the United States, numerous states require that clinical laboratories report the results of selected
categories of specimens to the state health departments. Occupational agents subject to this reporting
requirement are lead, arsenic, cadmium and mercury as well as substances reflecting pesticide exposure
(Markowitz 1992).

In the United States, the National Institute for Occupational Safety and Health (NIOSH) began to assemble
the results of adult blood lead testing into the Adult Blood Lead Epidemiology and Surveillance
programme in 1992 (Chowdhury, Fowler and Mycroft 1994). By the end of 1993, 20 states, representing
60% of the US population, were reporting elevated blood lead levels to NIOSH, and an additional 10 states
were developing the capacity to collect and report blood lead data. In 1993, there were 11,240 adults with
blood lead levels that equalled or exceeded 25 micrograms per decilitre of blood in the 20 reporting states.

35
The vast majority of these individuals with elevated blood lead levels (over 90%) were exposed to lead at
the workplace. Over one-quarter (3,199) of these individuals had blood leads greater than or equal to 40
ug/dl, the threshold at which the US Occupational Safety and Health Administration requires actions to
protect workers from occupational lead exposure.

Reporting of elevated levels of toxins to the state health department may be followed by a public health
investigation. Confidential follow-up interviews with affected individuals allows timely identification of
the workplaces where exposure occurred, categorization of the case by occupation and industry, estimation
of the number of other workers at the workplace potentially exposed to lead and assurance of medical
follow-up (Baser and Marion 1990). Worksite visits are followed by recommendations for voluntary
actions to reduce exposure or may lead to reporting to authorities with legal enforcement powers.

Physicians’ reports
In an attempt to replicate the strategy successfully utilized for the monitoring and control of infectious
diseases, an increasing number of states in the United States require physicians to report one or more
occupational diseases (Freund, Seligman and Chorba 1989). As of 1988, 32 states required reporting of
occupational diseases, though these included ten states where only one occupational disease is reportable,
usually lead or pesticide poisoning. In other states, such as Alaska and Maryland, all occupational diseases
are reportable. In most states, reported cases are used only to count the number of people in the state
affected by the disease. In only one-third of the states with reportable disease requirements does a report
of a case of occupational disease lead to follow-up activities, such as workplace inspection (Muldoon,
Wintermeyer and Eure 1987).

Despite the evidence of increased recent interest, physician reporting of occupational diseases to
appropriate state governmental authorities is widely acknowledged to be inadequate (Pollack and Keimig
1987; Wegman and Froines 1985). Even in California, where a system for physician reporting has been
in place for a number of years (Doctor’s First Report of Occupational Illness and Injury) and recorded
nearly 50,000 occupational illnesses in 1988, physician compliance with reporting is regarded as
incomplete (BLS 1989).

A promising innovation in occupational health surveillance in the United States is the emergence of the
concept of the sentinel provider, part of an initiative undertaken by NIOSH called Sentinel Event
Notification System for Occupational Risks (SENSOR). A sentinel provider is a physician or other health

36
care provider or facility that is likely to provide care for workers with occupational disorders due to the
provider’s specialty or geographic location.

Since sentinel providers represent a small subset of all health care providers, health departments can
feasibly organize an active occupational disease reporting system by performing outreach, offering
education and providing timely feedback to sentinel providers. In a recent report from three states
participating in the SENSOR programme, physician reports of occupational asthma increased sharply after
the state health departments developed concerted educational and outreach programmes to identify and
recruit sentinel providers (Matte, Hoffman and Rosenman 1990).

Specialized occupational health clinical facilities

A newly emergent resource for occupational health surveillance has been the development of occupational
health clinical centres that are independent of the workplace and that specialize in the diagnosis and
treatment of occupational disease. Several dozen such facilities currently exist in the United States. These
clinical centres can play several roles in enhancing occupational health surveillance (Welch 1989). First,
the clinics can play a primary role in case-finding-that is, identifying occupational sentinel health events-
since they represent a unique organizational source of expertise in clinical occupational medicine. Second,
the occupational health clinical centres can serve as a laboratory for the development and refinement of
surveillance case definitions for occupational disease. Third, the occupational health clinics can serve as
a primary clinical referral resource for the diagnosis and evaluation of workers who are employed at a
worksite where an index case of occupational disease has been identified.

Occupational health clinics have become organized into a national association in the United States (the
Association of Occupational and Environmental Clinics) to enhance their visibility and to collaborate on
research and clinical investigations (Welch 1989). In some states, such as New York, a statewide network
of clinical centres has been organized by the state health department and receives stable funding from a
surcharge on workers’ compensation premiums (Markowitz et al. 1989). The clinical centres in New York
State have collaborated in the development of information systems, clinical protocols and professional
education and are beginning to generate substantial data on the numbers of cases of occupational disease
in the state.

37
5.0 USE OF VITAL STATISTICS AND OTHER GENERAL HEALTH DATA

Death certificates
The death certificate is a potentially very useful instrument for occupational disease surveillance in many
countries in the world. Most countries have death registries. Uniformity and comparability is promoted by
the common use of the International Classification of Diseases to identify cause of death. Furthermore,
many jurisdictions include information on death certificates concerning the occupation and industry of the
deceased. A major limitation in the use of death certificates for occupational disease surveillance is the
lack of unique relationships between occupational exposures and specific causes of death.

The use of mortality data for occupational disease surveillance is most salient for diseases that are uniquely
caused by occupational exposures. These include the pneumoconioses and one type of cancer, malignant
mesothelioma of the pleura. Table 3 shows the numbers of deaths attributed to these diagnoses as the
underlying cause of death and as one of multiple causes of death listed on the death certificate in the
United States. The underlying cause of death is considered the principal cause for death, while the listing
of multiple causes includes all conditions considered important in contributing to death.

Table 3. Deaths due to pneumoconiosis and malignant mesothelioma of the pleura. Underlying cause and
multiple causes, United States, 1990 and 1991.
ICD-9 Code Cause of death Numbers of deaths
Underlying cause Multiple causes
1991 1990
500 Coal workers’ pneumoconiosis 693 1,990
501 Asbestosis 269 948
502 Silicosis 153 308
503-505 Other pneumoconioses 122 450
Sub-total 1,237 3,696
163.0, 163.1, and Malignant mesothelioma pleura 452 553
163.9
Total 1,689 4,249
Source: United States National Center for Health Statistics.

38
In 1991, there were 1,237 deaths due to the dust diseases of the lung as the underlying cause, including
693 deaths due to coal workers pneumoconioses and 269 deaths due to asbestosis. For malignant
mesothelioma, there was a total of 452 deaths due to pleural mesothelioma. It is not possible to identify
the number of deaths due to malignant mesothelioma of the peritoneum, also caused by occupational
exposure to asbestos, since International Classification of Disease codes are not specific for malignant
mesothelioma of this site.

Table 3 also shows the numbers of deaths in the United States in 1990 due to pneumoconioses and
malignant mesothelioma of the pleura when they appear as one of multiple causes of death on the death
certificate. For the pneumoconioses, the total where they appear as one of multiple causes is important,
since the pneumoconioses often co-exist with other chronic lung diseases.

An important issue is the extent to which pneumoconioses may be under-diagnosed and, therefore, missing
from death certificates. The most extensive analysis of the under-diagnosis of a pneumoconiosis has been
performed among insulators in the United States and Canada by Selikoff and colleagues (Selikoff,
Hammond and Seidman 1979; Selikoff and Seidman 1991). Between 1977 and 1986, there were 123
insulator deaths ascribed to asbestosis on the death certificates. When investigators reviewed medical
records, chest radiographs and tissue pathology where available, they ascribed 259 of insulator deaths
occurring in these years to asbestosis. Over one-half of pneumoconiosis deaths were, thus, missed in this
group well-known to have heavy asbestos exposure. Unfortunately, there are not a sufficient number of
other studies of the under-diagnosis of pneumoconioses on death certificates to allow a reliable correction
of mortality statistics.

Deaths due to causes that are not specific to occupational exposures have also been used as part of
occupational disease surveillance when occupation or industry of decedents is recorded on the death
certificates. Analysis of these data in a specified geographical area during a selected time period can yield
rates and ratios of disease by cause for different occupations and industries. The role of non-occupational
factors in the deaths examined cannot be defined by this approach. However, differences in rates of disease
in different occupations and industries suggest that occupational factors may be important and provide
leads for more detailed studies. Other advantages of this approach include the ability to study occupations
that are usually distributed among many workplaces (e.g., cooks or dry cleaner workers), the use of
routinely collected data, a large sample size, relatively low expense and an important health outcome
(Baker, Melius and Millar 1988; Dubrow, Sestito and Lalich 1987; Melius, Sestito and Seligman 1989).

39
Such occupational mortality studies have been published over the past several decades in Canada
(Gallagher et al. 1989), Great Britain (Registrar General 1986), and the United States (Guralnick 1962,
1963a and 1963b). In recent years, Milham utilized this approach to examine the occupational distribution
of all men who died between 1950 and 1979 in the state of Washington in the United States. He compared
the proportion of all deaths due to any specific cause for one occupational group with the relevant
proportion for all occupations. Proportional mortality ratios are thereby obtained (Milham 1983). As an
example of the yield of this approach, Milham noted that 10 of 11 occupations with probable exposure to
electrical and magnetic fields showed an elevation in the proportional mortality ratio for leukaemia
(Milham 1982). This was one of the first studies of the relationship between occupational exposure to
electro-magnetic radiation and cancer and has been followed by numerous studies that have corroborated
the original finding (Pearce et al. 1985; McDowell 1983; Linet, Malker and McLaughlin 1988).

As a result of a cooperative effort between NIOSH, the National Cancer Institute, and the National Center
for Health Statistics during the 1980s, analyses of the mortality patterns by occupation and industry
between 1984 and 1988 in 24 states in the United States have recently been published (Robinson et al.
1995). These studies evaluated 1.7 million deaths. They confirmed several well-known exposure-disease
relationships and reported new associations between selected occupations and specific causes of death.
The authors emphasize that occupational mortality studies may be useful to develop new leads for further
study, to evaluate results of other studies and to identify opportunities for health promotion.

More recently, Figgs and colleagues at the US National Cancer Institute used this 24-state occupational
mortality database to examine occupational associations with non-Hodgkin’s lymphoma (NHL) (Figgs,
Dosemeci and Blair 1995). A case-control analysis involving approximately 24,000 NHL deaths occurring
between 1984 and 1989 confirmed previously demonstrated excess risks of NHL among farmers,
mechanics, welders, repairmen, machine operators and a number of white-collar occupations.

Hospital discharge data

Diagnoses of hospitalized patients represent an excellent source of data for the surveillance of
occupational diseases. Recent studies in several states in the United States show that hospital discharge
data can be more sensitive than workers’ compensation records and vital statistics data in detecting cases
of diseases that are specific to occupational settings, such as the pneumoconioses (Markowitz et al. 1989;
Rosenman 1988). In New York State, for example, an annual average of 1,049 people were hospitalized

40
for pneumoconioses in the mid-1980s, compared to 193 newly awarded workers’ compensation cases and
95 recorded deaths from these diseases each year during a similar time interval (Markowitz et al. 1989).

In addition to providing a more accurate count of the number of people ill with selected serious
occupational diseases, hospital discharge data can be usefully followed up to detect and to alter workplace
conditions that caused the disease. Thus, Rosenman evaluated workplaces in New Jersey where
individuals who were hospitalized for silicosis had previously worked and found that the majority of these
workplaces had never performed air sampling for silica, had never been inspected by the federal regulatory
authority (OSHA) and did not perform medical surveillance for the detection of silicosis (Rosenman
1988).

Advantages of using hospital discharge data for the surveillance of occupational disease are their
availability, low cost, relative sensitivity to serious illness and reasonable accuracy. Important
disadvantages include the lack of information on occupation and industry and uncertain quality control
(Melius, Sestito and Seligman 1989; Rosenman 1988). In addition, only individuals with disease
sufficiently severe to require hospitalization will be included in the database and, therefore, cannot reflect
the full spectrum of morbidity associated with occupational diseases. Nonetheless, it is likely that hospital
discharge data will be increasingly used in occupational health surveillance in future years.

National surveys
Special surveillance surveys undertaken on a national or regional basis can be the source of information
more detailed than can be obtained through use of routine vital records. In the United States, the National
Center for Health Statistics (NCHS) conducts two periodic national health surveys relevant to
occupational health surveillance: the National Health Interview Survey (NHIS) and the National Health
and Nutrition Examination Survey (NHANES). The National Health Interview Survey is a national
household survey designed to obtain estimates of the prevalence of health conditions from a representative
sample of households reflecting the civilian non-institutionalized population of the United States
(USDHHS 1980). A chief limitation of this survey is its reliance on self-reporting of health conditions.
Occupational and industrial data on participating individuals have been used in the past decade for
evaluating rates of disability by occupation and industry (USDHHS 1980), assessing the prevalence of
cigarette smoking by occupation (Brackbill, Frazier and Shilling 1988) and recording workers’ views
about the occupational risks that they face (Shilling and Brackbill 1987).

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With the assistance of NIOSH, an Occupational Health Supplement (NHIS-OHS) was included in 1988
in order to obtain population-based estimates of the prevalence of selected conditions that may be
associated with work (USDHHS 1993). Approximately 50,000 households were sampled in 1988, and
27,408 currently employed individuals were interviewed. Among the health conditions addressed by the
NHIS-OHS are work-related injuries, dermatologic conditions, cumulative trauma disorders, eye, nose
and throat irritation, hearing loss and low-back pain.

In the first completed analysis from the NHIS-OHS, Tanaka and colleagues from NIOSH estimated that
the national prevalence of work-related carpal tunnel syndrome in 1988 was 356,000 cases (Tanaka et al.
1995). Of the estimated 675,000 people with prolonged hand pain and medically diagnosed carpal tunnel
syndrome, over 50% reported that their health care provider had stated that their wrist condition was
caused by workplace activities. This estimate does not include workers who had not worked in the 12
months prior to the survey and who may have been disabled due to work-related carpal tunnel syndrome.

In contrast to the NHIS, the NHANES directly assesses the health of a probability sample of 30,000 to
40,000 individuals in the United States by performing physical examinations and laboratory tests in
addition to collecting questionnaire information. The NHANES was conducted twice in the 1970s and
most recently in 1988. The NHANES II, which was conducted in the late 1970s, collected limited
information on indicators of exposure to lead and selected pesticides. Initiated in 1988, the NHANES III
collected additional data on occupational exposures and disease, especially concerning respiratory and
neurologic disease of occupational origin (USDHHS 1994).

6.0 SUMMARY
Occupational disease surveillance and reporting systems have significantly improved since the mid-1980s.
Recording of illnesses is best for diseases unique or virtually unique to occupational causes, such as the
pneumoconioses and malignant mesothelioma. Identification and reporting of other occupational diseases
depends upon the ability to match occupational exposures with health outcomes. Many data sources enable
occupational disease surveillance, though all have important shortcomings with regard to quality,
comprehensiveness and accuracy. Important obstacles to improving occupational disease reporting
include the lack of interest in prevention in health care, the inadequate training of health care practitioners
in occupational health and the inherent conflicts between employers and workers in the recognition of
work-related disease. Despite these factors, gains in occupational disease reporting and surveillance are
likely to continue in the future.

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 MANDATORY REPORTING OF OCCUPATIONAL DISEASES BY CLINICIANS

Occupational disease surveillance is a critical step in the prevention of work-related injury and illness.
Case reporting by health care providers to public health authorities is one way of identifying sources of
exposure toward which control measures can be directed. Most health care providers are familiar with the
existence of reporting requirements for infectious diseases such as tuberculosis and the sexually
transmitted diseases; however, less attention has been paid by the medical community to recognizing and
reporting occupationally related conditions.

The Department of Labor estimated that in 1978 approximately 1.9 million people were severely or
partially disabled from occupationally related diseases, at an annual cost of $11.4 billion in lost wages
alone. The Bureau of Labor Statistics reported an incidence of occupational injury and illness for 1984 of
8.0 cases and 63.4 lost workdays per 100 full-time workers. This is most likely an underestimate,
especially for occupational illnesses. Even for traumatic occupational fatalities, a rather discrete
occurrence and ostensibly one easy to count, there is significant underreporting to the Bureau of Labor
Statistics.

Table 4. Examples of illness and injury reporting code structure, US Bureau of Labor Statistics

Nature of injury or illness code-Examples

0* Traumatic Injuries and Disorders
08* Multiple traumatic injuries and disorders
080 Multiple traumatic injuries and disorders, unspecified
081 Cuts, abrasions, bruises
082 Sprains and bruises
083 Fractures and burns
084 Fractures and other injuries
085 Burns and other injuries
086 Intracranial injuries and injuries to internal organs
089 Other combinations of traumatic injuries and disorders, n.e.c.
Event or exposure code-Examples
1* Falls

43
 11* Fall to lower level
113 Fall from ladder
114 Fall from piled or stacked material
115* Fall from roof
1150 Fall from roof, unspecified
1151 Fall through existing roof opening
1152 Fall through roof surface
1153 Fall through skylight
1154 Fall from roof edge
1159 Fall from roof, n.e.c.
116 Fall from scaffold, staging
117 Fall from building girders or other structural steel
118 Fall from nonmoving vehicle
119 Fall to lower level, n.e.c.
Source of injury or illness code-Examples
7* Tools, instruments and equipment
72* Handtools-powered
722* Cutting handtools, powered
7220 Cutting handtools, powered, unspecified
7221 Chainsaws, powered
7222 Chisels, powered
7223 Knives, powered
7224 Saws, powered, except chainsaws
7229 Cutting handtools, powered, n.e.c.
723* Striking and nailing handtools, powered
7230 Striking handtools, powered, unspecified
7231 Hammers, powered
7232 Jackhammers, powered
7233 Punches, powered
Part of body affected code-Examples
2* Trunk
23* Back, including spine, spinal cord

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 230 Back, including spine, spinal cord, unspecified
231 Lumbar region
232 Thoracic region
233 Sacral region
234 Coccygeal region
238 Multiple back regions
239 Back, including spine, spinal cord, n.e.c.

* = division, major group, or group titles; n.e.c. = not elsewhere classified.

Occupational safety and health is one of 15 priority areas targeted in the US Public Health Service's 1990
Objectives for the Nation. State reporting requirements for occupational diseases are less uniform than
those for infectious diseases and, in practice, have elicited varying degrees of participation. Nonetheless,
the role of these reporting requirements in identifying and preventing occupational disease merits
examination.

The assistance of every state and territorial epidemiologist and numerous other state health department
staff enabled us to assemble this report. Written statements from each state health department listing the
reportable diseases were reviewed, and telephone contacts were made to states where discrepancies
existed between current and known previous reporting requirements. In most of these situations, previous
requirements had been supplanted by newer regulations or statutes. No further systematic attempts to
verify the data were made. Although some infectious diseases, such as anthrax, brucellosis, and
erysipeloid, are commonly associated with workplace exposure, they are not included in this summary, as
they have been listed in the corresponding document for infectious diseases. In addition, laws specifying
that certain classes of disease be notifiable, such as "outbreaks" or "occurrences of unusual disease," which
may pertain to occupational diseases in some situations, are presented in that document. A list of infectious
diseases related to work can be found elsewhere.

45
Table 5. List of reportable occupational diseases and occupational disease-related conditions.

Aniline poisoning Industrial dermatitis

Anthrax Lead poisoning

Arsenical poisoning Liver angiosarcoma

Asbestosis Manganese poisoning

Barotrauma Mercurial poisoning

Beryllium poisoning Mesothelioma

Byssinosis Noise-induced deafness

Cadmium poisoning Occupational asthma

Carbon disulphide poisoning Phosphorous poisoning

Chrome ulceration Silicosis

Chronic benzene poisoning Toxic anaemia

Compressed air illness Toxic hepatitis

The list of reportable occupational diseases and occupational disease-related conditions, as of September
1, 1988, for all US jurisdictions is given in Table 5. One term was used to describe each disease. Where
appropriate, eponyms have been changed to an internationally accepted format. States that are not listed
did not identify reportable occupational diseases. Additional information regarding time frames for
reporting, agencies to which reports are required, persons required to report, and specific conditions under
which reports are required is contained in the statutes and health department regulations of the respective
states. A list of the state epidemiologists, with addresses and commercial telephone numbers, is presented
elsewhere.

Recognition of the influence of occupation on health dates back to Ramazzini in the 16th century. In the
United States, it was not until Alice Hamilton's pioneering work early in this century that the impact of
occupation on health gained prominence as a public health concern. Federal efforts to document and limit
the burden of occupational injury and illness were catalyzed in 1970 by the establishment of the
Occupational Safety and Health Administration (OSHA) and the National Institute for Occupational

46
Safety and Health (NIOSH). Despite the creation of these two agencies, surveillance efforts to document
the magnitude and foci of occupational illnesses and hazards still lag far behind the successes achieved in
the area of communicable diseases.

In the United States, notification of diseases began in 1874 when the State Board of Health of
Massachussets initiated weekly voluntary reporting of prevalent diseases. None of these were occupational
diseases. In 1883, Michigan was the first state to pass a law mandating reporting of communicable
diseases. By 1913, 15 states had adopted some occupational disease reporting requirements, and the US
Public Health Service model state law for morbidity reports included a group of occupational diseases.
This model law required the reporting of arsenic, brass, carbon monoxide, lead, mercury, natural gas,
phosphorous, wood alcohol, naphtha, bisulphide of carbon, and dinitrobenzine poisoning; caisson disease;
and "any other disease or disability contracted as a result of the nature of the person's employment."

Surveillance--the collection, analysis, and dissemination of information on cases of occupational disease,

disability, and death--is the cornerstone of efforts to prevent work-related injuries and illnesses. Case
reporting by physicians and other health care providers is an important surveillance activity that facilitates
the identification of work sites with potentially hazardous exposures. Awareness of occupational hazards
and their consequences can influence the choice of effective control measures (eg, the use of product
substitution, ventilation, engineering, and personal protective equipment and the establishment of medical
screening appropriate to the types of workplace exposures). An ideal report-based surveillance system
would begin with a health care provider recognizing a reportable condition, followed by notification of
appropriate public health officials. Depending on the condition and the circumstances, various
intervention strategies might be instituted, frequently culminating in an on-site evaluation of the
workplace. At the same time, data from the report would be systematically recorded for the monitoring of
trends and early identification of emerging problems. Finally, information about control activities and
trends would be fed back to the reporting health care provider in a form that increases awareness and
reinforces the importance of participating in a meaningful public health activity.

Reporting of occupational disease is hindered by deficiencies in recognition of occupational diseases,

compliance, control, and dissemination efforts. Long latency periods can obscure the association between
an occupational exposure and a resulting illness. An occupational exposure may be one component among
many factors in the etiology of a diagnosed condition. Finally, once an occupational disease is recognized,

47
there are disincentives to report it, including health care professionals' concerns about becoming involved
in litigation and about preserving employee confidentiality.

There is little information on the yield of existing state reporting systems for occupational disease. A 1985
study identified 32 states with either voluntary or mandatory reporting requirements for occupational
diseases. Of these, 18 states gathered additional information on reported cases. Ten of the 32 used case
reports for intervention activities; seven had published summaries of case reports, and none had evaluated
its program to determine the frequency of reporting. There were, and continue to be, substantial differences
among the states as to the specific lists of diseases for which reporting is required.

Traditionally, surveillance of occupational illness and injury has relied mainly on data sources, such as
death certificates, that do not depend on provider-initiated reporting. Many of these sources, however,
ultimately rely on a physician's diagnosis of a given condition, but often they do not depend on the
physician's recognition of the condition as being occupationally related.

One effort to improve both the recognition of occupational disease and the focus of surveillance activities
has been the production of a list of Sentinel Health Events (Occupational), or SHE(O). These are
conditions that are occupationally related and may indicate a need for improvement in preventive and/or
therapeutic efforts. The list can be used both as a heuristic aid to the clinician and to assist in the design
of various surveillance systems. Since all SHE(O)s are linked to a specific code in the International
Classification of Diseases Adapted for Use in the United States, Ninth Revision (1975), this list is
particularly useful in the analysis of previously assembled medical data sets.

For some disorders, there are good surrogates for provider reporting: laboratory reports can be used for
those conditions diagnosed primarily by laboratory methods. New York's Heavy Metals Registry, for
example, relies exclusively on laboratory reports for case identification. In 1986, a total of 2247 reports
representing 1002 adults with lead levels greater than 1.20 umol/L of whole blood were sent to this
registry. A similar, laboratory-based registry in California received 2643 reports of lead levels greater than
1.20 umol/L of whole blood for the last 9 months of 1987. Colorado, Maryland, New Jersey, Texas, and
Wisconsin also have laboratory-based reporting systems for lead poisoning. All of these programs use
surveillance data to target site visits and other interventions such as worker education.

48
Worker's compensation records are another potential source of surveillance data for those conditions for
which a claim is likely to be filed. Compensation claims have the advantage of a physician diagnosis
accompanying the claim and the underlying assertion that the illness or injury was work related. Recent
work in Ohio has shown that surveillance of worker's compensation claims is a useful means of identifying
excessive lead exposures. In one case, this surveillance prompted a NIOSH Health Hazard Evaluation and
the identification of potential exposures to the neighborhood surrounding the plant.

Ten states are currently engaged with NIOSH in the Sentinel Event Notification System for Occupational
Risks (SENSOR). SENSOR is designed to establish reporting mechanisms for a list of occupational
conditions selected by NIOSH staff as being particularly amenable to provider reporting: carpal tunnel
syndrome, lead poisoning, noise-induced hearing loss, occupational asthma, pesticide poisoning, and
silicosis (Table
5). One approach to report-based surveillance in these SENSOR states involves the identification and use
of sentinel providers: health care professionals who are particularly likely to treat these selected conditions
and who have an interest in reporting. A key element of these case-reporting mechanisms is follow-up at
the work site.

Industry is another source of occupational disease surveillance. Currently, the primary data source for
occupational injuries and illnesses is the Bureau of Labor Statistics' Annual Survey. This survey uses the
information employers record on the OSHA 200 logs and is useful for estimating the trends and overall
burden of injuries. There has, however, been much concern about the completeness and accuracy of these
records. Occupational diseases are particularly susceptible to underreporting.

Although many states publish epidemiology bulletins to provide summary reports of the state's
surveillance activities, there is no national system to assemble these state reports of occupational diseases
as is done for infectious diseases in the Morbidity and Mortality Weekly Report from the Centers for
Disease Control. Although such a report would serve to publicize and emphasize work-related conditions
of national public health importance, this effort must await more widespread and uniform reporting within
states.

Even when case finding is via more efficient methods such as laboratory reporting, mandatory reporting
requirements are nonetheless useful. Targeted or routine follow-up may involve contacting involved

49
providers for further information. In the absence of a mandatory reporting requirement, concerns about
confidentiality may inhibit a provider's willingness to provide that information.

Although state reporting requirements for occupational disease may be disjointed systems that are
currently plagued by underreporting and a lack of follow-up and control efforts, they exist because there
is need for case identification of illnesses that require control and prevention efforts. Uniform and
streamlined requirements; coherent systems for data gathering, intervention, analysis, and dissemination;
and innovative programs such as SENSOR are essential to meet effectively this important need.

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