Occupational healthWHO 2018

WHO-EM/OCH/85/E/L
Distribution: Limited
Occupational health
A manual for primary health care workers
World Health Organization

Regional Office for the Eastern Mediterranean
WHO-EM/OCH/85/E/L
Distribution: Limited
Occupational health
A manual for primary health care workers
World Health Organization

Regional Oƒƒice ƒor the Eastern
Mediterranean Cairo
£001
© World Health Organization 2001
This document is not issued to the general public and all rights are reserved by the World Health
Organization (WHO). The document may not be reviewed, abstracted, quoted, reproduced or
translated, in part or in whole, without the prior written permission of WHO. No part of this document
may be stored in a retrieval system or transmitted in any form or by any means—electronic,
mechanical or other—without the prior written permission of WHO.
The views expressed in documents by named authors are solely the responsibility of those authors.
Design by John Shimwell, EDR/EMRO
Document WHO–EM/OCH/085/E/L/04.01/2000
Contents
Foreword 7
Preface 9
Introduction 13
Trainer's Guide 21
Module 1
Work environment 27
1. Objectives 27
2. Introduction and basic concepts 27
3. Recognition of health hazards 28
4. Evaluation of Health Hazards 36
5. Controlling hazards 39
6. Tasks for trainees 40
Appendix 1.1
Potentially hazardous operations and associated air contaminants 41
Appendix 1.2
An occupational hygiene survey check list 42
Module 2
Occupational and other work-related diseases 45
1. Objectives 45
3. Occupational diseases 47
4. Work-related diseases 69
Module 3
Early detection of occupational diseases 77
1. Objectives 77
3. Early detection of occupational diseases caused by physical factors 79
4. Early detection of occupational diseases caused by biological agents 80
5. Early detection of occupational diseases caused by chemicals 80
Module 4
Occupational ergonomics 87
1. Objectives 87
3. Ergonomics: a multidisciplinary science 89
Module 5
Stress and adverse psychological factors at work 97
1. Objectives 97
2. introduction and basic concepts 97
3. prevention and control of stress 100
4. Principles of job design 101
Module 6
Occupational safety and accident prevention 103
1. Objectives 103
3. Recording and investigating accidents 107
4. Accident rates 108
5. Prevention and control of occupational accidents 109
Module 7
First aid and its practice 113
1. Objectives 113
2. Importance of first aid 113
3. Injuries 113
4. Fractures 116
5. Thermal injuries 117
6. Poisoning 119
7. Haemorrhage 119
8. Shock 120
9. Impaired breathing 120
Module 8
Health education in occupational health 121
1. Objectives 121
2. Occupational diseases 121
3. Occupational accidents 122
4. Work environment and control measures in the workplace 124
5. Prevention of occupational diseases and accidents 126
6. Legislation 127
7. Effects of lifestyle and behaviour on health 127
8. Health education in the workplace 128
9. Health education methods and aids 130
10. Communication skills in health education 132
Module 9
Epidemiology and biostatistics in occupational health 135
1. Objectives 135
2. definitions 135
3. Biostatistical data 137
4. Types of epidemiological study 138
5. Common measures of disease frequency 139
Module 10
Record keeping 143
1. Objectives 143
2. Purpose and types of record 143
3. Record keeping 145
Module 11
Occupational health in special areas 147
1. Mining 147
2. Small-scale industry 150
3. Agricultural and rural areas 152
Module 12
Occupational health for women and children 159
1. Working women 159
2. Child labour 165
Further reading 173

FOREWORD
A healthy workforce is vital for sustainable social and economic development on
a global, national, and local level.
The classic approach to ensuring health and safety in the workplace has
depended mainly on the enactment of legislation and inspection of workplaces to
ensure compliance with health and safety standards. While this approach has
been effective in controlling many specific occupational hazards since the
Industrial Revolution, it has not been very effective in the past several decades,
particularly in developing countries, for several reasons.
First, the development of private enterprise, resulting in a proliferation of small

and medium-sized workplaces, has meant that in many instances production
occurs in the workers' own homes where there can be serious health hazards,
including harmful dust, chemicals, noise and heat. Inspection of such workplaces
is largely impossible in view of the large numbers and wide distribution.
Second, with the introduction of new agricultural techniques, agriculture has

become an industry for which systems based on inspection are inadequate.
There is a need to develop other systems to protect the health of agricultural
workers.
Third, occupational health problems have gradually increased in type and

magnitude and have led to or aggravated diseases resulting from exposure to
several risk factors, only one of which being the work environment. Examples
include chronic obstructive pulmonary disease which is mainly caused by
smoking but may be aggravated by irritant gases or dusts in the workplace. Low-
back pain syndrome has several risk factors including rheumatic disorders,
scoliosis and inappropriate posture at work.
The Declaration of Alma-Ata in 1978 led to the recognition of the importance

of primary health care (PHG) workers and community health workers in
bringing health care to where people live and work. PHG and community
health care workers in most developing countries are not trained in the special
needs of workers nor in the simple measures that can be taken to prevent or
overcome and control many workers' health problems.
World Health Assembly resolution WHA 40.Z8 (1987) requested the Director-
General of the World Health Organization “to develop guidelines on training of
PHG workers in occupational health”. The Regional Gommittee for the
Eastern Mediterranean at its E8th session in 1991 passed resolution
EM/RG.E8/R.8 urging Member States in the Region to “include in primary health
care services elements of occupational health”. In response, the Regional
Office, through a Regional Gonsultation (Amman, Jordan, Z6-Z9 May, 1997)
called for the development of a training manual which would enable PHG workers
and community health workers to recognize the most common hazards in the
workplace, know how to prevent and control them and use the support system
available to them for referral and consultation.
Highly qualified experts in the field of occupational health have contributed to the
development of this manual, which we hope will meet the needs of Member
States
8 Occupational health training manual for primary health care workers
in their efforts to include occupational health in the PHG services. I hope this
simple, task-oriented publication will be useful not only for PHG workers and their
trainers at all levels but also for all specialists and interested authorities.
Hussein A. Gezairy MD, FRGS

WHO Regional Director for the Eastern Mediterranean
PREFAGE
WHO policy has, since its foundation, always included elements of occupational
health issues. Numerous key WHO documents and bodies, e.g. the WHO
Gonstitution, the Declaration of Alma Ata, the Health for All Strategy, the General
Programmes of Work and several resolutions of the World Health Assembly,
WHO's Global Healthy Work Approach (HWA), the meetings of the network of
WHO Gollaborating Gentres in Occupational Health, the Executive Board, the
Regional Gommittee for the Eastern Mediterranean Region and other Regional
Gommittees, have all emphasized the need to protect and promote health and
safety at work through the prevention and control of hazards in the work
environment and through the promotion of health and the work capacity of
working people.
The WHO Global Strategy for Occupational Health for All, developed through the
global network of the WHO Gollaborating Gentres in Occupational Health
provides an important mechanism for protecting and promoting health at work.
According to the Declaration of Alma-Ata, 1978: “Primary health care ... is the
first level of contact of individuals, the family and community with the national
health system bringing health care as close as possible to where workers live
and work, and constitutes the first element of a continuing health care
process.”
Workers are therefore an integral part in the body of the Declaration. In addition,
the World Health Assembly has repeatedly requested Member States to give
workers' health a high priority in the overall programme of work and to incorporate
it as an essential component of PHG.
There are different levels of PHG workers: doctors in charge of occupational

health, dedicated health care personnel with backgrounds in general education,
health assistants, such as nurses and health technicians especially trained in
occupational health, and qualified workers with vocational training backgrounds.
There are many strategies in common between PHG and occupational health. In
fact, an adequate in-plant occupational health service meets almost all the
principles of PHG as follows.
Health education and community participation

These are fundamental aspects of PHG and equally basic in occupational health,
i.e. to educate workers in safety and health, self-care and healthy lifestyle for
prevention of disease and promotion of health and to promote workers'
participation in preventive programmes in the workplace which is a counterpart of
“community participation”.
Prevention of health hazards at the source

A primary principle in PHG and occupational health. In occupational health,
identification of safety and health hazards is fundamental. Risk evaluation against
hygienic standards is a known practice and control at the source is the primary
objective.
Team work
A requirement in the PHG approach which becomes more specific in occupational
health practice where the environmental hygienist in the workplace, the
occupational physicians, nurses, safety supervisors, the employers and workers'
representatives comprise the occupational health team. It is even legalized in
most countries through “occupational health and safety committees” which
usually comprise this team.
National occupational health programmes require cooperation and team work

among the national health services: ministries of health, education, environment,
industry, labour, social security and often the ministry of agriculture.
Equity
Occupational health care does not discriminate among working people. It calls for
equal health care for the underserved and tries to remove any discrimination
between white collar and other workers as well as between women and men.
Accessibility
There is nothing more accessible in the health care system than the in-plant
health service. Efforts to make occupational health care accessible to remote
areas as well as to underserved working people are what is now required.
Affordability
Occupational health is affordable. The establishment of an occupational health
service should start in the early stages of developing factories and industrial
plants. It is possible to use simple technology, e.g. direct reading equipment, such
as a noise meter, and to follow a basic preventive programme. With early
detection most diseases are preventable resulting in the minimizing of the costs
of therapy. However, there are some occupational diseases which are not
amenable to treatment, e.g. silicosis.
Gontribution to the national economy

There is no health programme that contributes more to the national economy
than that aiming at a healthy working productive population. Preventive
occupational health maintains workers' productivity. Healthy workers increase
industrial output and lower the cost of production and, through their incomes, they
can contribute to the health of their families and their communities. Workers
constitute a large sector of the population. It is not possible for a nation to survive
when its labour force is weak and ill.
The goals of this manual are:
 to create a category of health personnel that is well oriented in

occupational health practice in order to fill the gap in occupational health
personnel and coverage for working people; and
Occupational health training manual for primary health care workers 11
 by following the PHG approach, to emphasize the preventive objective of

occupational health services in the workplace.
The manual outlines a curriculum for training of PHG workers/community

health workers. The training programme can be adjusted as required
depending on the level of trainees; for example, it can be upgraded for
general practitioners or simplified for workers in the workplace.
Acknowledgements
The Regional Office for the Eastern Mediterranean thanks WHO headquarters
for the financial contribution which enabled the publication of this manual
and gratefully acknowledges the professional contributions and advice given
by the following individuals:
Dr IN Ababneh, Occupational Health Programme Manager, Ministry of Health,

Amman, Jordan.
Dr S Arnaout, Regional Adviser, Health of Special Groups, WHO Regional Office

for the Eastern Mediterranean.
Dr H Bashor, Associate Professor of Epidemiology, Department of Gommunity

Medicine, Faculty of Medicine, Damascus University, Syrian Arab Republic.
Dr G Eijkemans, Occupational and Environmental Health Department, Protection

of the Human Environment, WHO headquarters, Geneva.
Dr MA El Batawi, former Ghief of Occupational Health, WHO headquarters, Geneva.
Dr GH El Samra, Professor, Department of Industrial Medicine and Occupational

Diseases, Faculty of Medicine, University of Gairo, Egypt.
Dr AM Emara, Professor of Occupational Medicine, Faculty of Medicine,

University of Gairo, Egypt.
Dr ZI Fakhri, Occupational Health Department, Ministry of Health, Riyadh, Saudi

Arabia.
Dr AA Farshad, Ministry of Health and Medical Education, Teheran, Islamic

Republic of Iran.
Dr H Frumkin, Associate Professor of Environmental and Occupational Health,

Rollins School of Public Health, Emory University, Georgia, USA.
Dr G Hafez, Special Adviser to the Regional Director, former Director, Health

Protection and Promotion, WHO Regional Office for the Eastern Mediterranean,
Gairo, Egypt.
Dr R Helmer, Director, Protection of the Human Environment (PHE), WHO

headquarters, Geneva.
Dr MA Khalil, former Director, Health Protection and Promotion, WHO Regional

Office for the Eastern Mediterranean, Gairo, Egypt.
Dr R Mahaini, Regional Goordinator, Family and Gommunity Health, WHO

Regional Office for the Eastern Mediterranean, Gairo, Egypt.
Dr MI Mikheev, former Ghief of Occupational Health, WHO headquarters, Geneva.
Dr MH Noweir, Professor, Industrial Engineering Department, King Abdel Aziz

University, Jeddah, Saudi Arabia.
Dr P Rookmaaker, Professor, International Ergonomics Association, The

Netherlands.
Mr AS Kaleem, Specialist in Working Gonditions and Environment, International

Labour Organisation, North Africa Multidisciplinary Advisory Team (ILO/NAMAT),
Gairo, Egypt.
INTRODUGTION
Occupational health: a definition

Occupational health is a multidisciplinary activity aimed at:
 the protection and promotion of the health of workers by preventing and

controlling occupational diseases and accidents and by eliminating
occupational factors and conditions hazardous to health and safety at work;
 the development and promotion of healthy and safe work, work

environments and work organizations;
 the enhancement of the physical, mental and social well-being of workers

and support for the development and maintenance of their working
capacity, as well as professional and social development at work;
 enabling workers to conduct socially and economically productive lives and

to contribute positively to sustainable development.
Occupational health has gradually developed from a mono-disciplinary, risk-

oriented activity to a multi-disciplinary and comprehensive approach that
considers an individual's physical, mental and social well-being, general health
and personal development.
Interaction between work and health

The social and economic importance of work receives considerable attention
because a primary function of work in any society is to produce and distribute
goods and services. Far less attention is paid to the importance of work to the
individual, yet it is clear from recent research that work plays a crucial and perhaps
unparalleled psychological role in the formation of self-esteem and a sense of
order. Work is a powerful force in shaping a person's sense of identity. It can lend
vitality to existence and establishes the cyclical patterns of day, week, month and
year. It is believed that work for which there is no economic gain, such as child
care, care for the aged and voluntary work, also has its rewards and contributes
to personal gratification.
Positive health effects of work
Two-way interaction
There is a continuous two-way interaction between a person and the physical and
psychological working environment: the work environment may influence the
person's health either positively or negatively and productivity is, in turn, influenced
by the worker's state of physical and mental well-being. Work, when it is well-
adjusted and productive, can be an important factor in health promotion, e.g.
partially disabled workers may be rehabilitated by undertaking tasks suited to
their physical and mental limitations and, in this way, may substantially increase
their working capacity. However, the fact that work can have a positive influence on
health has not yet been fully exploited; knowledge of work physiology and
ergonomics needs to be further developed and applied to benefit worker's health.
Health hazards
When work is associated with health hazards, it may cause occupational disease,
be one of the multiple causes of other disease or may aggravate existing ill-
health of non-occupational origin. In developing countries, where work is
becoming increasingly mechanized, a number of work processes have been
developed that treat workers as tools in production, putting their health and
lives at risk. The occupational health lessons learned during the Industrial
Revolution should be borne in mind in planning for health in developing
countries if such problems are to be avoided.
Unemployment
Job loss may adversely affect a worker's physiological and mental health. If
unemployment persists, the person's health continues to decline and chronic
disorders can appear. The mental and financial distress caused by the job loss
can spread to other family members. In a developing country, job loss can have
profound effects that spread beyond the worker's own family since, where there is
limited paid employment, a person in a well-paid job exerts an important influence
in the community. In addition to having an obvious economic influence and high
social standing, such a worker may serve as a good source of health information
and set an example with a healthy lifestyle. Loss of employment for such a
person can also affect the immediate community as well as the person's family. A
worker's health may also suffer well before the actual job loss. Both feelings of
job insecurity and knowledge of impending job loss have been associated with
mental and physical health complaints.
Similarly, those who have never had the opportunity to be employed, e.g.
because of unavailability of jobs, have no chance to develop an identity or sense
of belonging through work which is important for psychological and social well-
being. Such people are not accessible to health messages in the workplace and
may be unaware of the positive relationship between work and health. In addition,
because they have a lot of free time, sometimes associated with anxiety and
depression, the never- employed are more likely than those in employment to
consume alcohol, cigarettes and drugs.
Health, workplace, economy and sustainable development

The most successful economies have demonstrated that workplaces designed
according to good principles of occupational health, safety and ergonomics are
also the most sustainable and productive. In addition, a healthy economy, high
quality of products or services and long-term productivity are difficult to achieve in
poor working conditions where workers are exposed to health and safety
hazards.
Principle 1 of the Rio Declaration on Environment and Development (United

Nations Gonference on Environment and Development, Rio de Janeiro, 199Z)
states: “Human beings are at the centre of concern for sustainable development.
They are entitled to a healthy and productive life in harmony with nature”.
Sustainable development is defined as a strategy to “meet the needs of the
present world population without causing adverse effect on health and on the
environment, and without depleting or
endangering the global resource base, hence without compromising the ability
of future generations to meet their needs”.
In terms of occupational health, the above principles mean the satisfaction of

material needs through work and other production processes without causing
danger to human health, the ecosystem, the resource base or the health of the
community, either in the short term or the long term. Occupational health is a
basic element and constitutes a social and health dimension of the principle of
sustainable development.
Occupational health is at the centre of sustainable development in the following

ways.
 The prevention of occupational accidents, injuries and diseases and the

protection of workers against physical and psychological overload imply
appropriate use of resources, minimizing the unnecessary loss of human
and material resources.
 The objective of healthy and safe work environments calls for the use of
safe, low-energy, low-toxic-emission, low-waste (green) technology, and in
many countries occupational health legislation requires the use of the best
available production technology.
 The occupational health approach may facilitate undisturbed production

that increases the quality of products, productivity and process
management and helps to avoid unnecessary loss of energy and materials
and to prevent an unwanted impact on the environment.
 Many environmental hazards and burdens are derived from occupational

settings, e.g. industry, agricultural practices, transportation and services.
Those responsible for occupational health and safety are well informed of
processes and agents that may be hazardous to the environment. Often
this information is available to them from the earliest stage of a problem
enabling primary prevention which is no longer possible once the
hazardous elements are released into the general environment.
 The impact of occupational health on environmental protection from

industry is likely to be both effective and cost-effective. In many
industrialized countries there are moves to make closer links between
occupational health and environmental health approaches.
 Occupational health services aim to ensure workers' health, safety,

working capacity and well-being. A healthy, productive and well motivated
workforce is the key agent for overall socioeconomic development. In
addition, high-quality and productive work ensures healthy production of
materials, goods and services and the consideration and practical
implementation of the principles of sustainable development.
 Most environmental health hazards that have later been found to affect
the health of the general population were first detected in the work
environment. The occupational environment provides an early warning
system for certain
environmental health hazards just as it also provides effective models

for preventive action.
 For many adults the work environment is the most demanding environment
in terms of physical, chemical, ergonomic or psychological stresses and
physical workload. The principle of the Rio Declaration with regard to a
healthy and productive life is particularly relevant to the work environment
and calls for occupational health action.
 The state of the general environment and the ecosystem has an impact
on the health of workers either directly or indirectly in several
occupations, e.g. agriculture, mining, fishery and manufacturing. There is a
two-way relationship between occupational health and safety on the one
hand, and occupational health and sound environmental development
on the other.
 Equally important for personal well-being and for socioeconomic

development of communities and countries is an employment policy that
ensures access to work for everyone and enables individuals to sustain
themselves and their families. Highest possible employment is also a key
factor in the safe, stable and sustainable social development of countries,
while high unemployment rates and other associated problems endanger
such development.
 In developing countries, the health and well-being of the family is

critically dependent on the health and productivity of its working
member, thus making several members of the community dependent on
the health of the worker. In a situation where organized social protection
is lacking, the loss of health, life or working capacity of such a key
member of the family often means severe crisis for the rest of the family,
affecting indirectly the well-being, health and economy of communities
at large and of future generations.
Occupational health is a basic element and constitutes a social and health

dimension of the principle of overall development. Occupational health practices
constitute a set of key activities for such development.
Work as a factor in health promotion

WHO defines health as a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity. According to the WHO Study
Group on Early Detection of Health Impairment in Occupational Exposure to
Health Hazards:
Health ... connotes rather a way of functioning within one's environment

(work, recreation, living). It not only means freedom from pain or disease,
but also freedom to develop and maintain one's functional capacities.
Health develops and is maintained through interaction between the
genotype and the total environment. The work environment constitutes an
important part of man's total environment, so health is to a large extent
affected by work conditions.1
1
Early detection oƒ health impairment in occupational exposure to health hazards. Report oƒ a
WHO Study Group. Geneva, World Health Organization, 1975 (WHO Technical Report Series
No. 571).
Health promotion was defined by the Ottawa Gharter for Health Promotion, 1986, as:
... the process of enabling people to increase control over, and to improve,
their health. To reach a stage of complete physical, mental and social well-
being, an individual or group must be able to identify and to realize
aspirations, to satisfy needs, and to change or cope with the environment.
Therefore, health promotion is not just the responsibility of the health sector,
but goes beyond healthy lifestyles to well-being.Z
Health promotion is a continuum ranging from the treatment of disease to the

prevention of disease including protection against specific risks, to the
promotion of optimal health. Achieving optimal health includes: improving
physical abilities in relation to sex and age; improving mental ability;
developing reserve capacities; adaptability to changing circumstances of work
and life and reaching new levels of individual achievement in creative and
other work. In a work setting these health- indicators may be evaluated
quantitatively by indices of absenteeism, job satisfaction and work stability.
Health protection and promotion activities in the workplace
National governments
National governments have an interest in workers' health partly because it
has a direct influence on national productivity. Governments are
responsible for establishing and maintaining safe working conditions and
ensuring, through legislation, that occupational health services are provided
for all workers in all branches of economic activity, including those in the
public sector. Health promotion programmes are not usually a statutory
requirement but occupational health services can provide a focus for their
implementation.
Management
Those responsible for the management of a workplace have an interest in
workers' health promotion for the same reason as national governments: healthy
workers are essential for optimal productivity. In addition to the humanitarian
value of improving workers' health, the economic value is therefore
particularly important to employers. This is also true for self-employed workers
as their productivity is often completely dependent on their own health.
The prime responsibility for health and safety in a workplace rests with the
management, which therefore plays an essential role in the success of any
health promotion programme. To ensure the success of a programme,
management must allow the necessary resources and time to be dedicated to
it, demonstrate its desire for employees to participate and be willing to accept
suggestions from employees on what should be done. Management must
also have sufficient appreciation of the need for health promotion and disease
prevention to be able to assess the relative merits of various programmes,
determine priorities and delegate responsibility for achieving programme
success.
Z
Ottawa Gharter for Health Promotion. First International Gonference on health Promotion,
Ottawa, Ganada, 17-Z1 November 1986.
Workers
The worker stands to benefit from health promotion programmes by having a safe
and healthy work environment, a convenient location to learn about and put into
practice a healthy lifestyle, readily available opportunities for screening and
health care and an opportunity ultimately to achieve optimal health. Health has an
all- encompassing impact on the worker's life, by affecting his or her ability to
interact with others, to work and to be self-reliant.
The worker's contribution to workplace health promotion is essential to any

programme's success. Workers should be involved in the programme's design
and encourage their co-workers to participate.
Workers´ representatives and unions

The role of workers' representatives, organizations and unions is to negotiate with
the management to ensure that appropriate health programmes are implemented
and that an appropriate balance is achieved between the various health
programmes. The workers' organizations should also ensure that certain
principles be followed,
e.g. confidentiality and non-discrimination.
Communities
Health is influenced by many factors outside the workplace. Gonsequently,
health promotion for the workforce cannot be regarded solely as the
responsibility of occupational health professionals. The community, through its
primary health workers and public health professionals, has clear-cut
responsibilities for individual and group health education as a means of health
promotion. Wherever possible, health education programmes should be a
joint activity of occupational and community health professionals. Mass
media can also play an important role in health education.
In developing countries, particularly in rural areas and small workplaces, the

primary health worker may be the sole provider of health protection and
promotion services for both workers and the rest of the community.
Occupational health proƒessionals

Health promotion is an essential part of the occupational health professional's
mandate. Physicians, nurses, safety officers, health educators and PHG workers
will play different roles in work place health promotion and should be trained
accordingly e.g. the role of the occupational health nurse is to educate, screen
and counsel workers, whereas that of an occupational hygienist is to assess the
control of health hazards while keeping in touch with the development and
progress of health promotion programmes.
Together with others, such as ergonomists, nutrition specialists and

psychologists, occupational health professionals can:
 protect workers' health by controlling hazards in the workplace and by

introducing ergonomics
 advise workers and managers on health promotion activities and on how

to improve working conditions
 monitor the work environment and workers' health with a view to early
identification of health risks and evaluation of the effectiveness of health
protection and promotion programmes.
In many circumstances, in developing as well as developed countries,

occupational health professionals can cover only a small proportion of
workplaces and workers. In such cases, others responsible for providing health
care for workers should recognize health promotion as one of their major tasks
and should receive some training in occupational health.
MODULE 1
Work environment
1. OBJEGTIVES
 Detect work hazards as related to occupation, work and work environment
 Inspect workplaces for the discovery of actual hazards and unsafe workers'
behaviour
 Use simple methods and techniques for evaluation of work hazards and for
testing control measures
 Report work and environmental hazards to concerned bodies
 Know principles of the control of work hazards and work environment

and participate in selecting appropriate control measures and optimal
use of available resources
 Participate in the management of work emergency plans and in first aid
 Educate workers on the principles of safe conduct at work
 Participate in investigating work complaints, compensation cases,

rehabilitation, social welfare, etc.
 Goordinate with other professionals in the occupational multi-disciplinary

team: safety officer and committee, occupational hygienist, physician and
nurse, sanitarian, first aid attendant, plant engineer and foreman.
2. INTRODUGTION AND BASIG GONGEPTS
2.1 Occupational hygiene

This is the practice of assessment and control of environmental factors and
stresses arising in or from the workplace, which may cause injury, sickness,
impaired health and well-being or significant discomfort and inefficiency
among workers or among the citizens of the community.
It encompasses the study of:
 toxicology
 industrial processes
 the chemical and physical behaviour of air contaminants
 environmental sampling techniques and statistics
 the design and evaluation of ventilation systems

 noise control
 radiation protection
 the health effects of occupational hazards.
Occupational/industrial hygienists use environmental monitoring and

analytical methods to detect the extent of worker exposure and employ
engineering, work practice controls and other methods to control potential
health hazards. Occupational/industrial hygienists must work with
physicians to develop comprehensive occupational health programmes and
with epidemiologists to perform research on health effects.
2.2 Work-site analysis

This is an essential procedure that helps in determining what jobs and
workstations are the sources of potential problems. During the work-site
analysis: exposures, problem tasks and risks are identified and measured.
The most-effective work-site analyses include all jobs, operations and work
activities. The occupational/industrial hygienist inspects, researches or analyses
how the particular chemicals or physical hazards at the work-site affect worker
health. If a situation hazardous to health is discovered, he or she
recommends the appropriate corrective action.
Example
An occupational/industrial hygienist might be asked to determine the
composition and concentrations of air contaminants in a workplace where
there have been complaints of eye, nose and throat irritation. The hygienist in
this situation would also determine if the contaminant exposures exceeded
the permissible exposure limits required by the national regulations and
standards. If the problem was the result of airborne materials (a conclusion
that might be reached in consultation with a physician or epidemiologist), then
the hygienist would be responsible for selecting the techniques used to reduce
or eliminate the exposure e.g. installing exhaust ventilation around the source
of the air contaminants and isolating it from the general work area. Follow-up
sampling to verify that the controls had been effective would also be the
hygienist's responsibility.
3. REGOGNITION OF HEALTH HAZARDS
3.1 Inspection
This is the first step in the process leading to evaluation and control and
entails the identification of materials and processes that have the potential to
cause harm to workers.
Inspection of the workplace is the best source of directly relevant data about
health hazards. There is no substitute for observation of work practices, use of
chemical and physical agents, and the apparent effectiveness of control
measures. The PHG worker should be able to recognize major and obvious
health hazards and distinguish those that require formal evaluation by the
industrial hygienist.
Work environment: Module 1 23
3.2 Potential health hazards
Air contaminants
These are commonly classified as either particulate or gas and vapour contaminants
(a) Particulate contaminants
 Dusts: solid particles generated by handling, crushing, grinding, colliding,

exploding, and heating organic or inorganic materials such as rock, ore,
metal, coal, wood and grain. Any process that produces dust fine enough to
remain in the air long enough to be inhaled or ingested should be regarded
as hazardous until proven otherwise.
 Fumes: formed when material from a volatilized solid condenses in cool air.
In most cases, the solid particles resulting from the condensation react with
air to form an oxide.
 Mists: liquid suspended in the atmosphere. Mists are generated by liquids

condensing from a vapour back to a liquid or by a liquid being dispersed by
splashing or atomizing.
 Aerosols: a form of a mist characterized by highly respirable, minute liquid

particles.
 Fibres: solid particles whose length is several times greater than their diameter,
e.g. asbestos.
(b) Gas and vapour contaminants
 Gases: formless fluids that expand to occupy the space or enclosure in

which they are confined. They are atomic, diatomic or molecular in nature
as opposed to droplets or particles, which are made up of millions of atoms
or molecules. Through evaporation, liquids change into vapours and mix
with surrounding atmosphere.
 Vapours: the volatile form of substances that are normally in a solid or liquid
state at room temperature and pressure.
Chemical hazards
Harmful chemical compounds in the form of solids, liquids, gases, mists, dusts,
fumes and vapours exert toxic effects by inhalation (breathing), absorption
(through direct contact with the skin) or ingestion (eating or drinking). Airborne
chemical hazards exist as concentrations of mists, vapours, gases, fumes or
solids. Some are toxic through inhalation and some of them irritate the skin on
contact; some can be toxic by absorption through the skin or through ingestion
and some are corrosive to living tissue. The degree of worker risk from exposure
to any given substance depends on the nature and potency of the toxic effects
and the magnitude and duration of exposure.
Biological hazards
These exist in exposures to bacteria, viruses, fungi and other living organisms
that can cause acute and chronic infections by entering the body either
directly or through breaks in the skin.
Occupations that deal with plants or animals or their products, or with food and
food processing may expose workers to biological hazards. Laboratory and
medical personnel also can be exposed to biological hazards. Any occupations
that result in contact with bodily fluids expose workers to biological hazards.
In occupations where animals are involved, biological hazards are dealt with by
preventing and controlling diseases in the animal population as well as properly
caring for and handling infected animals.
Also, effective personal hygiene, particularly proper attention to minor cuts and
scratches especially on the hands and forearms, helps keep worker risks to a
minimum. In occupations where there is potential exposure to biological hazards,
workers should practice proper personal hygiene, particularly hand washing.
Hospitals should provide proper ventilation, proper personal protective equipment

such as gloves and respirators, adequate infectious waste disposal systems and
appropriate controls including isolation in instances of particularly contagious
diseases, e.g. tuberculosis.
Physical hazards
These include excessive levels of noise, vibration, illumination and temperature,
and ionizing and non-ionizing electromagnetic radiation.
Noise, for example, is a significant physical hazard, which can be controlled by:
 installing equipment and systems that have been engineered, designed and
built to operate quietly
 enclosing or shielding noisy equipment
 making certain that equipment is in good repair and is properly maintained

with all worn or unbalanced parts replaced
 mounting noisy equipment on special mounts to reduce vibration
 installing silencers, mufflers or baffles
 substituting quiet work methods for noisy ones, e.g. welding parts rather
than riveting them
 treating floors, ceilings and walls with acoustic material to reduce reflected
or reverberant noise
 erecting sound barriers at adjacent workstations around noisy

operations to reduce worker exposure to noise generated at adjacent
workstations
 increasing the distance between the source and the receiver, e.g. by
isolating workers in acoustic booths, limiting workers' exposure time to
noise and providing hearing protection.
Occupational hygiene regulations require that workers in noisy surroundings be

periodically tested as a precaution against hearing loss.
Ionizing radiation can be controlled by:
 Reducing exposure time: danger from radiation increases with the

amount of time one is exposed to it. The shorter the time of exposure the
smaller the radiation danger.
 Increasing distance: a valuable tool in controlling exposure to both

ionizing and non-ionizing radiation. Radiation levels from some sources can
be estimated by comparing the squares of the distances between the
worker and the source.
 Shielding: the greater the protective mass between a radioactive source

and the worker, the lower the radiation exposure. Similarly, shielding
workers from non-ionizing radiation can also be an effective control
method.
In some instances, however, limiting exposure to or increasing distance from

certain forms of non-ionizing radiation, e.g. lasers, is not effective. An exposure to
laser radiation that is faster than the blinking of an eye can be hazardous and
would require workers to be miles from the laser source before being adequately
protected.
Radiant heat exposure can be controlled by: installing reflective shields and by
providing protective clothing in factories such as steel mills.
Ergonomic hazards
The science of ergonomics studies and evaluates a full range of tasks including,
but not limited to, lifting, holding, pushing, walking and reaching.
Many ergonomic problems result from technological changes:
 increased assembly line speeds
 adding specialized tasks
 increased repetition.
Some problems arise from poorly designed job tasks. Any of those conditions can
cause ergonomic hazards:
 excessive vibration
 noise
 eye strain
 repetitive motion
 heavy lifting problems
 poorly designed tools or work areas.
Repetitive motions or repeated shocks over prolonged periods of time as in jobs

involving sorting, assembling and data entry can often cause irritation and
inflammation of the tendon sheath of the hands and arms, a condition known
as carpal tunnel syndrome. Ergonomic hazards are avoided primarily by the
effective design of a job or job-site and by better designed tools or equipment
that meet workers' needs in terms of physical environment and job tasks.
Through thorough work-site analyses, employers can set up procedures to correct

or control ergonomic hazards by:
 using the appropriate engineering controls, e.g. designing or redesigning

work stations, lighting, tools and equipment
 teaching correct work practices, e.g. shifting workers among several

different tasks, reducing production demand and increasing rest breaks
 providing and mandating personal protective equipment where necessary.
Evaluating working conditions from an ergonomic standpoint involves looking at the

total physiological and psychological demands of the job on the worker. Overall, the
benefits of a well-designed, ergonomic work environment can include increased
efficiency, fewer accidents, lower operating costs and more effective use of
personnel.
Psychosocial ƒactors
These may include boring, repetitive tasks, production pressure, stress, low pay
and lack of recognition.
Accident ƒactors
The main causes of accidents include:
 unsafe mechanical and physical conditions
 unsafe acts
 unsafe personal factors.
3.3 Techniques used in recognizing health hazards
Material inventory
A material inventory is used for keeping an account of raw materials, intermediate
and end products, waste products and by-products. It is tailored to meet the
specific requirements of local circumstances taking into consideration the
following.
(a) Who will use the inventory
 safety advisers and representatives
 occupational hygienists
 doctors
 nurses
 emergency service personnel
 purchasing staff.
(b) What information is required
 the nature of the material, i.e. composition, physical data, fire and
explosion data, basic toxicological and safety data, etc.
 the use of the material, including storage, handling and control

procedures, first aid, etc.
 administrative details, i.e. trade and chemical names, company reference

numbers, address of manufactures/suppliers, labelling and packing
requirements, waste disposal, etc.
(c) How the inventory will be updated
 any new substances should be considered from a health and safety

viewpoint before purchasing, use and inclusion in the inventory
 for existing materials, health and safety staff should have a system for
ensuring, through their information sources, that the hazard data
contained in the data sheet is the best information currently available
 the availability of computerized data-handling systems augments the

use of a materials inventory.
Process inventory
The aim is to document hazards associated with each process and to record
how each is being managed and controlled. The process inventory should
include details of:
 the process
 the materials involved (including intermediate and wastes)
 points of material entry and exit
 normal operating procedures
 potential hazards
 the potential for emissions into the atmosphere
 the potential for exposure
 arrangements for engineering controls
 other precautions including protective equipment.
The process inventory also provides the opportunity to document hazards other
than those associated with chemicals, e.g. heat, noise and radiation, and to
include disposal procedures for hazardous waste products.
The inventory could be based on:
 flow of a particular product or material
 departmental or equipment flow
 geographic location.
Walk-through occupational hygiene survey

A walk-through survey of the premises permits observation of all plant operations
and is carried out to make a preliminary assessment of potential hazards.
Possible sources and potential contaminants from specific types of processes
can be identified (see appendix 1.1). The walk-through survey provides an
important opportunity to meet plant personnel and to interact with engineers,
foremen and other workers who know the process problems and are aware of
complaints or symptoms among workers.
(a) General principles addressed by the walk-through survey
 hazards present in the work place
 estimated/likely scale of the identified hazards
 the control measures currently in force for each hazard
 procedures implemented to maintain the control measures
 the monitoring required.
(b) Survey methods
 Surveys are usually carried out without the use of measuring instruments.
 Much of the information required can be assembled in advance of the

survey (see an occupational/industrial survey check list in appendix 1.Z).
 The following aids are required to carry out the work:
– survey report forms

– notepad or dictation machine
– plan of premises
– camera
– smoke tubes.
 The occupational hygienist (or whoever is nominated to undertake the

task by the PHG workers) proceeds through each of the work areas,
preferably in accordance with the working functions, often commencing
with production from goods inward to dispatch, and preferably
accompanied in each area of the premises by either a local supervisor or
engineer with general responsibilities.
 Sources of information used during the survey are:
– workers involved in their daily tasks

– senses of smell, hearing and touch for detection of odours, heat and
noise
– photography for documenting the general visual appearance of each
environment and any activity deserving further attention
– smoke tube test for local exhaust ventilation
– observation, the key to an effective survey, noting any ergonomics
problems, e.g. poorly designed lighting, unsafe working practices,
unguarded equipment, etc.
(c) Reports
The report should be written clearly and concisely and should be structured as
follows:
 introduction
 summary of immediate hazards and action taken or recommended to

resolve the problem permanently and/or temporarily pending further
evaluation
 summary of hazards requiring further monitoring/evaluation
 walk-through survey report forms as completed during survey
 discussions of methods arising from survey
 proposed occupational hygiene work plan.
(d) Summary of a survey
 a survey is a preliminary assessment designed to identify hazards and

control measures, carried out by competent staff with the help of local
supervising staff
 it should be comprehensive by location and by time for

cyclical/occasional processes
 it is a necessary prelude to detailed investigations of specific hazards
 it is necessary to gather a range of data pertaining to the subject in

order to fully prepare for the survey
 the two main elements of the survey data source are the workforce and
observation
 photography is very important
 reports should be structured carefully and be concise.
Air-sampling programmes
An air-sampling programme must be designed to answer specific questions
otherwise it may not fulfil the need for which it was initiated, e.g. a prospective
epidemiological programme requires random sampling in order for statistical
predictions to be valid. Sampling for worker protection, on the other hand, will
require selection of persons at maximum risk.
Reasons for sampling are varied and may include the following:
 health risk evaluation: to measure worker exposure in order to estimate the

risk of undesirable health effects and the need for control measures
 environmental protection: to determine the amount of any toxic or

hazardous materials released to the environment
 compliance: to ensure that exposure levels for workers or environmental

releases are within regulatory limits and to satisfy legislative monitoring
requirements
 process control: to evaluate the performance of engineering or other

process controls and to ensure that contaminant control remains
adequate
 source identification: to find and control contaminant sources
 documentation of exposure: to maintain records of exposure for

prospective studies or for institutional protection against future legal
action.
The sampling strategy for each of the stated purposes will require different
protocols and sampling systems. The types of samples refer to whether a
personal exposure sample should be collected in the breathing zone of a worker,
or whether an area, stack or other environmental sample is preferable. Sampling
from exhaust stacks is commonly done for process and emission control. Health
protection requires personal exposure monitoring.
Occupational hygiene sampling protocols
Purpose Type oƒ sample

Health risk evaluation Personal
Environmental protection Area, environmental
Compliance Personal, environmental, stack
Process control Area, personal, stack
Source identification Area,
stack Documentation of exposure
Personal
4. EVALUATION OF HEALTH HAZARDS

Evaluation of health hazards within a plant includes measurement of exposures
(and potential exposures), comparison of those exposures to existing
standards and recommendation of controls if needed.
4.1 Exposure measurement techniques

These techniques are based on the nature of hazards and the routes of
environmental contact with the worker, e.g.
 air sampling can show the concentration of toxic particulates, gases and
vapours that workers may inhale
 skin wipes can be used to measure the degree of skin contact with toxic
materials that may penetrate the skin
 noise dosimeters record and electronically integrate workplace noise levels

to determine total daily exposure.
Selection and calibration oƒ instruments

Instruments are generally classified as follows:
 direct reading instruments
 sampling instruments which remove the contaminant (for subsequent

laboratory analysis) from a measured quantity of air
 sampling instruments which collect a known volume of air for

subsequent laboratory analysis.
All these types of equipment must be calibrated against a standard air flow
measuring device before and after use in the field. Furthermore, direct reading
instruments must be calibrated against a known concentration of the substance
for which they are used.
Establishing proper analytical methods

The use of accurate, sensitive, specific and reproducible analytical methods is as
important as the proper calibration of the sampling equipment. Among difficulties
that should be overcome in the measurements (sampling/analysis) are:
 interference and reactions when dealing with mixtures of chemicals, which

is often the case
 fluctuations in concentration.
Other factors affecting a worker's uptake of the contaminants include:
 routes of entry of material other than respiration, e.g. skin absorption
 physical activity of workers, which affects the respiration rate
 whether or not respirators are used in the workplace.
When available, standard methods of analysis should be used such as those

recommended by:
 WHO
 International Organization for Standardization
 European Gommunity
 American Industrial Hygiene Association (AHIA) Analytical Gommittee
 U.S. National Institute for Occupational Safety and Health (NIOSH)
 U.S. Occupational Safety and Health Administration (OSHA)
 American Gonference of Governmental Industrial Hygienists (AGGIH)
 The American Public Health Association (APHA)
 The American National Standards Institute (ANSI).
Strategy oƒ sampling and measurement

Every effort must be made to get measurements (or samples) that represent the
workers' exposures. This is achieved by answering the following:
 Where to sample?
 Whom to sample?
 How long to sample?

 How many samples to take?
 When to sample?
A sufficient number of samples must be collected or readings made with direct

reading instruments, for the proper duration, to permit the assessment of daily,
time-weighted average (TWA) exposures and to evaluate peak exposure
concentrations when needed.
4.2 Interpretation of findings

A great deal of judgement must be used in interpretation and reporting the
results. The investigator must have the following facts:
 nature of substance or physical agents
 intensity (concentration) of exposure
 duration of exposure.
The hygienist's decision on whether a hazard is present is based on three sources

of information:
 scientific literature and various exposure limit guides
 the legal requirements of the national occupational health and safety regulations
 interactions with other health professionals who have examined the

exposed workers and evaluated their health status.
Occupational exposure limits refer to airborne concentrations of substances

conditions under which it is believed that nearly all workers may be repeatedly
exposed day after day without adverse health effect. They are based on available
information from industrial experience, from experimental human and animal
studies; and, when possible, from a combination of the three
4.3 Recommended exposure limits

Many standards have been recommended by different national and international
agencies. The most popular and comprehensive however are the list of threshold
limit values (TLVs) for chemical substances and physical agents and the
biological exposure indices (BEIs) issued by the American Gonference of
Governmental Industrial Hygienists (AGGIH).
There are three categories of TLV:
 Time-weighted average (TWA8): the employee's average airborne

exposure in any 8-hour work shift of a 40-hour work week, which shall not
be exceeded.
 Short-term exposure limit (STEL): the employee's 15-minute TWA

exposure, which shall not be exceeded at any time during a work day
unless another time limit is specified in a parenthetical notation below the
limit. If another time period is specified, the TWA exposure over that time
limit shall not be exceeded at any time over a work day.
 Geiling-G: the employee's exposure, which shall not be exceeded during

any part of the work day. If instantaneous monitoring is not feasible, the
ceiling shall be assessed as a 15-minute TWA exposure, which shall not be
exceeded at any time over a work day.
Gonsiderations are included for:
 skin notation (for probable skin absorption)
 mixtures (for exposure to mixtures of contaminants)
 total, inhalable, thoracic and respirable particulate matter
 Particulate not otherwise classified (PNOG)
 simple asphyxiates: inert gases or vapours
 Biological exposure indices (BEI)
 physical factors
 unusual work schedules.
5. GONTROLLING HAZARDS
Occupational/industrial hygienists recognize that engineering, work practice
and administrative controls are the primary means of reducing employee
exposure to occupational hazards.
5.1 Engineering controls

These minimize employee exposure by either reducing or removing the hazard at
the source or isolating the worker from the hazard. They include:
 eliminating toxic chemicals and substituting non-toxic chemicals
 enclosing work processes or confining work operations
 installing general and local ventilation systems.
5.2 Work practice controls

These alter the manner in which a task is performed. Some fundamental and
easily implemented work practice controls include:
 changing existing work practices to follow proper procedures that minimize

exposures while operating production and control equipment
 inspecting and maintaining process and control equipment on a regular basis
 implementing good housekeeping procedures
 providing good supervision
 prohibiting eating, drinking, smoking, chewing tobacco or gum and applying

cosmetics in regulated areas.
5.3 Administrative controls

These include:
 Gontrolling employees' exposure by scheduling production and tasks, or

both, in ways that minimize exposure levels; e.g. the employer might
schedule operations with highest exposure potential during periods when
the fewest employees are present.
 When effective work practices or engineering controls are not feasible or

while such controls are being instituted, appropriate personal protective
equipment must be used, e.g. gloves, safety goggles, helmets, safety
shoes, protective clothing and respirators. To be effective, personal
protective equipment must be individually selected, properly fitted and
periodically refitted, conscientiously and properly worn, regularly maintained
and replaced as necessary.
6. TASHS FOR TRAINEES

 Acquaint yourself with local industries, occupations, workers' population
and available occupational health and safety services, etc.
 Survey workplaces (using the walk-through method) in formal and

informal sectors, agriculture, small-scale industries and other trades;
familiarize yourself and collect data on technical operations, materials
processed and handled, labour; and try to discover and define hazards.
 Report and refer hazards to concerned bodies and follow-up on their actions.
 Assess environmental hazards using simple, conventional methods and

direct reading instruments; inspect available control measures and
equipment and test their efficiency (e.g. using smoke tubes); and seek
advice for interpretation of results and making suggestions for controls.
 Participate in data collection and analysis on workers' health.
 Be ready to help in an emergency and be able to administer first aid.
 Goordinate with other professionals in areas such as:
– workers' education
– investigating complaints
– vocational rehabilitation
– workers' social welfare
– other matters relevant to optimal work place and work environment
and to workers' health.
APPENDIX 1.1 POTENTIALLY HAZARDOUS

OPERATIONS AND ASSOGIATED AIR GONTAMINANTS1
Process types Contaminant type Contaminant examples
Hot operations
Welding Gases (g) Chromates (p)
Chemical reactions Particulates (p) Zinc and compounds (p)
Soldering (Dust, fumes, mists) Manganese and compounds
(p)
Melting
Moulding
Burning
Liquid operations
Painting Vapours (v) Benzene (v)
Degreasing Gases (g) Trichlorethylene (v)
Dipping Mists (m) Methylene chloride (v)
Spraying 1,1,1-Trichloroethylene (v)
Brushing Hydrochloric acid (m)
Coating Sulfuric acid (m)
Etching Hydrogen chloride (g)
Cleaning Cyanide salts (m)
Dry cleaning Chromic acid (m)
Pickling Hydrogen cyanide (g)
Plating mixing TDI, MDI (v)
Galvanizing Hydrogen sulfide (g)
Chemical reactions Sulfur dioxide (g)
Carbon tetrachloride (v)
Solid operations
Pouring Dusts Cement
Mixing Quartz (free silica)
Separation Fibrous glass
Extraction
Crushing
Conveying
Loading
Bagging
Pressurized spraying
Cleaning parts Vapours (v) Organic solvents (v)
Applying pesticides Dust (d) Chlordane (m)
Degreasing Mist (m) Parathion (m)
Sand blasting Trichloroethylene (v)
Painting 1,1,1-Trichloroethane (v)
Methylene chloride (v)
Quartz (free silica, d)
Shaping operations
Cutting Dusts Asbestos
Grinding Beryllium
Filing Uranium
Milling Zinc
Moulding Lead
Sawing
Drilling
1
Leidel NA, Busch KA, Lynch JR. Occupational exposure sampling strategy manual. Gincinnati,
Ohio, US Department of Health, Education and Welfare, 1977:77-17E.
APPENDIX 1.2 AN OGGUPATIONAL HYGIENE SURVEY

GHEGH LIST
1. Determine purpose and scope of study:
 Gomprehensive occupational hygiene survey?
 Evaluation of exposures of limited group of workers to specific agents?
 Determination of compliance with specific recognized standards?
 Evaluation of compliance with specific recognized standards?
 Response to specific complaint?
Z. Discuss purpose of study with appropriate representatives of management

and labour.
E. Familiarize yourself with plant operations:
 Obtain and study process flow sheets and plant layout.
 Gompile an inventory of raw materials, intermediates by-products and products.
 Review relevant toxicological information.
 Obtain a list of job classifications and the environmental stresses to which

workers are potentially exposed.
 Observe the activities associated with job classification.
 Review reports of previous studies.
 Determine subjectively the potential health hazards associated with plant

operations.
 Review adequacy of labelling and warning.
4. Prepare for field study:
 Determine which chemical and physical agents are to be evaluated.
 Estimate, if possible, ranges of contaminant concentrations.
 Review, or develop if necessary, sampling and analytic methods, paying

particular attention to the limitations of the methods.
 Galibrate field equipment as necessary.
 Assemble all field equipment.
 Obtain personal protective equipment as required (hard hat, safety glasses,

hearing protection, respiratory protection, safety shoes, coveralls, gloves,
etc.).
 Prepare a tentative sampling schedule.

 Review occupational health and safety regulations being applied by the

health authorities.
5. Gonduct field study:
 Gonfirm process operating schedule with supervisory personnel.
 Advise representatives of management and labour of your presence in the area.
 Deploy personal monitoring or general area sampling units.
 For each sample, record the following data:
– sample identification number

– description of sample (as detailed as possible)
– time sampling began
– flow rate of sampled air (check frequently)
– time sampling ended
– any other information or observation that might be significant (e.g.,
process upsets, ventilation system not operating, use of personal
protection)
 Dismantle sampling units.
 Seal and label adequately all samples (filters, liquid solutions, charcoal or
silica gel tubes, etc.) that require subsequent laboratory analyses.
6. Interpret results of sampling programme:
 Obtain results of all analyses.
 Determine time-weighted average exposures of job classification evaluated.
 Determine peak exposures of workers.
 Determine statistical reliability of data, e.g. estimate probable error in

determination of average exposures.
 Gompare sampling results with applicable industrial hygiene standards and

regulations.
7. Discuss survey results with appropriate representatives of management

and labour.
8. Implement corrective action comprised of, as appropriate:
 Engineering controls (isolation, ventilation, etc.).
 Administrative controls (job rotation, reduced work time, etc.).
 Personal protection.
 Biologic sampling programme.
 Medical surveillance.
 Education and training.

9. Determine whether other health and safety considerations warrant further

evaluation:
 Air pollution?
 Water pollution?
 Solid waste disposal?
 Safety?
 Health physics?
10. Schedule return visit(s) to evaluate effectiveness of controls:
 Walk-through and observation.
 Measurements.
MODULE 2
Occupational and other

work-related diseases
1. OBJEGTIVES
 Understand the relationship between work and health
 Understand the interaction of man, environment and work
 Know the various types of stresses or hazards that may be present in

different types of occupations including industry, agriculture etc.
 Know the concept of occupational and work-related diseases and the

concept of aggravation
 Recognize general health problems of workers and whether or not they are
work-related
 Survey the workplace, recognize signs and symptoms of early impairment

of health and carry out simple tests to support the diagnosis of an
occupational and/or work-related disease
 Give advice to management regarding the control and prevention of the

identified hazards
 Give advice to workers and educate them regarding the nature of hazards
they are exposed to, control measures, personal hygiene, early symptoms
and first aid
 Refer patients and affected workers for further investigation and treatment
 Gonsult with the related authority on environmental monitoring of the

workplace and on implementation and maintenance of control measures
(especially engineering)
 Know the laws, rules and regulations governing occupational safety and
health including hazard control at the workplace, recommended standards
and threshold limit values, pre-placement and periodic medical
examinations, schedule of occupational diseases (as applicable), insurance
and compensations for occupational disease and accidents
 Keep medical records including personal medical files, records of accidents

and occupational diseases, records of pre-placement and periodic
examinations
 Keep records of environmental monitoring, safety activities, workplace

surveys and report on health and safety trends at the workplace.
2.1 Occupational and work-related disease

“Occupational diseases … stand at one end of the spectrum of work-relatedness
where the relationship to specific causative factors at work has been fully
established and the factors concerned can be identified, measured, and
eventually controlled. At the other end [are] diseases [that] may have a weak,
inconsistent, unclear relationship to working conditions; in the middle of the
spectrum there is a possible causal relationship but the strength and magnitude
of it may vary.”1
2.2 Degree of work-relatedness

The degree of work-relatedness of a work-connected disease condition varies in
different situations and determines whether a disease is considered an
occupational disease, a work-related disease or aggravation of a concurrent
disease, e.g.
 A specific agent like lead or silica, which is present essentially in the

workplace, causes a disease condition which cannot occur due to other
causes; this is an occupational disease.
 Where infection can occur at the workplace, an occupational disease can

also be caused by a specific agent, such as tuberculosis among health care
workers in a tuberculosis treatment centre. Of course infection can also
occur in the general population under non-occupational conditions.
 Work-related diseases occur much more frequently than occupational

diseases. They are caused by the interaction of several extrinsic risk factors
and a number of intrinsic factors each of which may or may not operate in
any individual case. Occupational hazards are among the risk factors which
can contribute to the occurrence of work-related diseases. Examples are
many and include:
- behavioural responses
- psychosomatic illness
- hypertension
- coronary heart disease
- chronic non-specific respiratory disease
- locomotor disorders.
 Work conditions can aggravate pre-existing disease: hepatic dysfunction

can be aggravated by exposure to certain chlorinated hydrocarbons;
bronchial asthma can be aggravated by dust exposure and renal disease can
be aggravated by inorganic mercury, cadmium and certain solvents.
1
Identiƒication and control oƒ work-related diseases. Report of a WHO Expert Gommittee (WHO
Technical Report Series No. 714), Geneva, World Health Organization, 1985.
Occupational and other work-related diseases: Module 2 41
 Exposure to combinations of occupational hazards may result in synergistic

effects which are much more pronounced than effects of individual
exposures simply added together.
 Individual susceptibility to the effects of some occupational exposures

varies. Genetic factors are important determinants of individual
susceptibility.
3. OGGUPATIONAL DISEASES
3.1 Definition
Occupational diseases are adverse health conditions in the human being, the
occurrence or severity of which is related to exposure to factors on the job or in
the work environment. Such factors can be:
 Physical: e.g. heat, noise, radiation
 Ghemical: e.g. solvents, pesticides, heavy metals, dust
 Biological: e.g. tuberculosis, hepatitis B virus, HIV
 Ergonomic: e.g. improperly designed tools or work areas, repetitive motions
 Psychosocial stressors: e.g. lack of control over work, inadequate personal

support
 Mechanical: these mainly cause work accidents and injuries rather than
occupational diseases.
3.2 Gharacteristics of occupational diseases

The occupational cause of occupational disease is often overlooked by health
care providers. This is due to several special characteristics of occupational
disease that may obscure its occupational origin.
 The clinical and pathological presentation of most occupational diseases

is identical to that of non-occupational diseases; e.g. asthma (excessive
airway narrowing in the lungs) due to airborne exposure to toluene
diisocyanate is clinically indistinguishable from asthma due to other
causes.
 Occupational disease may occur after the termination of exposure. An

extreme example would be asbestos-related mesothelioma (a cancer
affecting the lung and abdomen) which can occur E0 or 40 years after the
exposure.
 The clinical manifestations of occupational disease are related to the dose

and timing of exposure; e.g. at very high airborne concentrations, elemental
mercury is acutely toxic to the lungs and can cause pulmonary failure, while
at lower levels of exposure, elemental mercury has no pathologic effect on
the lungs but can have chronic adverse effects on the central and
peripheral nervous systems.
 Occupational factors can act in combination with non-occupational factors
to produce disease; e.g. exposure to asbestos alone increases the risk of
lung
cancer five-fold; and the long-term smoking of cigarettes increases the

risk of lung cancer between 50 and 70 fold.
3.3 Prevention of occupational diseases
Primary prevention
Primary prevention is accomplished by reducing the risk of disease. In the
occupational setting, this is most commonly done by reducing the magnitude of
exposure to hazardous substances. As the dose is reduced so is the risk of
adverse health consequences. Such reductions are typically managed by
industrial hygiene personnel and are best accomplished by changes in
production process or associated infrastructure, e.g. the substitution of a
hazardous substance with a safer one, or enclosure or special ventilation of
equipment or processes that liberate airborne hazards. These are known as
engineering controls.
Other methods of exposure reduction include use of personal protective

equipment and rotation of workers through areas in which hazards are present
to reduce the dose to each worker (NB: this method does, however, increase
the number of workers exposed to the hazard).
Secondary prevention
This is accomplished by identifying health problems before they become clinically
apparent (i.e. before workers report feeling ill) and intervening to limit the adverse
effects of the problem. This is also known as occupational disease surveillance.
The underlying assumption is that such early identification will result in a more
favourable outcome.
An example of secondary prevention is the measurement of blood lead levels in

workers exposed to lead. An elevated blood lead level indicates a failure of
primary prevention but can allow for corrective action before clinically apparent
lead poisoning occurs. Gorrective action would be to improve the primary
prevention activities listed above.
Tertiary prevention
This is accomplished by minimizing the adverse clinical effects on health of a
disease or exposure. Typically this is thought of as clinical occupational
medicine. An example of tertiary prevention is the treatment of lead poisoning
(headache, muscle and joint pain, abdominal pain, anaemia, kidney
dysfunction) by administration of chelating medication. The goal is to limit
symptoms or discomfort, minimize injury to the body and maximize functional
capacity.
3.4 Physical hazards at the workplace
Thermal stress
(a) Thermal environment
The temperature of the human body when healthy is at a constant of around E7

˚G through a dynamic balance between heat production and heat loss. The heat
regulating centre in the hypothalamus controls this balance.
Heat is produced by the metabolic processes, by muscular activity and by food

consumption. Heat is exchanged with the surrounding environment by
conduction, convection, radiation and evaporation of sweat. Heat exchange is
influenced by air temperature, air velocity, relative humidity and radiation. Various
combinations of these factors can cause different degrees of comfort and
discomfort and several indices have been described to express the degree of
thermal stress resulting from combinations of these factors, e.g. the effective
temperature, the corrected effective temperature and wet-bulb-globe temperature
indices.
(b) Types of thermal stress
Gold stress:
This exists when the surrounding temperature falls, as occurs when entering
cold storage rooms. A human tries to reduce the exposed skin surface (by
bending the joints if possible or by wearing thick woollen clothes). Peripheral
vasoconstriction of skin vessels occurs resulting in vascular injury,
chilblains, frost bite (dry gangrene) or trench foot (wet gangrene). Heat
production increases through increased muscle tone and shivering. Extreme
cases result in hypothermia, lowering of the temperature of core organs and
death.
Heat stress: the stages
Vasomotor control: As the heat stress increases, more blood is pumped to the skin
and less to the visceral organs and brain. There is cardiovascular stress and
tachycardia. Muscular work is reduced since it produces more heat. Heat
exhaustion is manifested by headaches, dizziness, sleepiness, lack of concentration
and anorexia.
Evaporative cooling: The body starts to sweat with the amount related to the
degree of stress and acclimatization. Loss of sodium chloride through sweating
causes heat cramps (painful cramps starting in the working muscles and
spreading to other muscles) and dehydration which aggravates cardiovascular
problems. The volume of urine is reduced. High air velocity and low relative
humidity help cooling through the evaporation of sweat. Dry heat exposure is
encountered in foundries, steel mills and in the glass industry and moist heat
exposure in textile mills, mines, the food canning industry and laundries.
Heat stroke: If sweating is not sufficient to keep the body temperature within
the physiological range, the heat regulating centre fails, sweating stops, the
skin is flushed and the patient is said to suffer from heat stroke.
Unconsciousness and death may follow. Heat stroke occurs in workers in hot
humid environments especially when exposed to direct sunlight. It is an
emergency situation where rapid cooling, rehydration and replacement of
electrolytes are indicated.
(c) Prevention of heat stress
A gradual exposure to a hot environment results in acclimatization and better

tolerance. Heat stress is especially dangerous for children, the elderly and
patients with cardiovascular, renal and skin diseases.
Engineering control measures should be used to prevent heat exposure including

shielding, insulation and ventilation. Pre-placement and periodic medical
examinations are important; lost fluids and sodium chloride should be replaced;
personal protective clothes can help in some situations and workers should be
given adequate rest periods to be spent in a more comfortable environment.
Noise
Noise is unwanted sound. Workers are exposed to noise in:
 textile and glass industries
 ship building
 aeroplane manufacture
 engineering industries
 manufacture of boilers and pressure vessels
 power plants.
Sound is propagated in the form of waves, each of which can be described in

terms of frequency or number of cycles per second measured in hertz (Hz) and
intensity as expressed in decibels (dB). The human ear can hear sounds ranging
in frequency from Z0 Hz to Z0 000 Hz. The intensity of very faint sounds is
around 0 dB and a jet engine can produce sounds of 1E0 dB, which is painful to
the ear. The sounds we normally hear are complex sounds formed from many
waves of varying frequencies and intensities. Ordinary speech is heard at
frequencies of 500 Hz to Z000 Hz.
In addition to interference with the hearing of normal speech, noise can cause
annoyance and stress and can lead to increased accident rates and lower
productivity. Extra-auditory effects are observed in different systems, including
endocrine, gastrointestinal and cardiovascular systems, and interfere with
sleep.
The most important effect of exposure to noise is noise-induced hearing loss

(NIHL). Hearing impairment is at first temporary; as exposure to noise (about 85
dB) continues, hearing impairment becomes permanent. NIHL usually takes
many years (7-10 years) to develop. The most hazardous is high intensity, high
frequency, continuous noise. Personal susceptibility has a definite effect.
Audiometry reveals early hearing impairment at frequencies of E000-6000 Hz

before hearing of normal speech is affected. Hence, the importance of
measurement of hearing on pre-placement and periodic hearing examinations.
Measures to control noise in the workplace include:
 design and maintenance of machinery
 segregation and dispersion of noise sources

 prevention of propagation and reflection of noise by the use of sound

proofing materials for floors, walls and ceilings
 rotation of workers
 reduction of work exposure hours
 use of personal protective devices, e.g. ear plugs, ear muffs and helmets.
Vibration
Workers exposed to whole vibrations include tractor drivers, transport
workers, workers involved in drilling for petroleum and those in the textile
industry. Whole body vibrations cause various ailments related to
congestion of pelvic and abdominal organs.
Segmental vibrations affect workers using pneumatic or electrical vibrating

tools in mining, road construction, shoe manufacture and sawing. Vascular
changes in the upper limbs lead to “dead hands” and “white fingers” and
prolonged exposure leads to rarefaction in the small bones and wrist.
Poor or deƒective illumination

Lighting standards depend on the type of work performed and degree of
precision required. Adequate lighting should be provided either by natural or
artificial means, avoiding shadows and glare and observing appropriate
colours and contrast.
Defective illumination leads to eye strain, fatigue and increased accident rates.
Defective illumination in miners leads to miner's nystagmus (rapid, involuntary
movement of the eyes).
Radiation
(a) Non-ionizing radiation
Ultraviolet radiation
Exposure occurs in welding, metal cutting and exposure to carbon arc and
causes skin erythema, burns and hyperpigmentation. Exposure of the eyes
causes “arc eye” with conjunctivitis and severe pain and may lead to corneal
ulceration. Eye protection using special face shields is necessary. Prolonged
exposure causes atrophy of the skin and epitheliomas.
Infrared radiation
Exposure occurs in front of furnaces, in steel mills, in the glass industry, in

blacksmiths and in chain manufacture. Exposure of the eyes can cause cataracts
or corneal affection. Skin burns can also occur. Gomplete protection of the eyes
can be achieved by wearing special goggles.
(b) Ionizing radiation
Sources of radiation include radioactive isotopes and X-ray machines. Ionizing

radiation is used in medicine, industry, agriculture, research and atomic warfare.
Radiations are either electromagnetic waves, like X-rays and gamma-rays, or
minute
particles, like alpha, beta and neutrons. Both types cause ionization or
excitation of atoms which leads to tissue destruction.
The effect of ionizing irradiation depends on the dose, type of radiation,

whether exposure was continuous or interrupted and whether it was total
body or localized, as well as the type of tissue irradiated. The power of
penetration of different types of radiation varies from very high, such as X-ray
and gamma-ray radiation, to very low, such as alpha radiation.
Different tissues vary in their sensitivity to radiation, with the tissues of the
haemopoietic system and the gastrointestinal mucosa being the most sensitive
and those of the bones and muscles being the least sensitive.
Effects may vary:
 Death occurs within hours if the whole body is exposed to a high dose.
 Acute radiation syndrome occurs if the dose is less. Signs and

symptoms appear within Z4-48 hours and are due to affection of the
gastrointestinal mucosa causing severe bloody diarrhoea and shock of
the haemopoietic system and of the skin. If death occurs it is due to
haemorrhage (due to thrombocytopenia) or infection (due to damage of
intestinal mucosa and leukopenia).
 Beta-radiation affects the skin only, causing skin burns and alopecia.
 Ghronic radiation effects may follow long after an acute exposure or follow
repeated exposure to doses not enough to cause acute effects.
 Ghronic effects include skin atrophy, loss of finger prints, alopecia, nail
changes, telaniectasia, pigmentation, keratoses and epitheliomas. Other
effects include sterility, abortion, mutagenic effects and birth defects.
Gontrol of exposure to external radiation sources rests on three general principles:
1. Keeping sufficient distance between source and worker.
Z. Reducing time of exposure.
E. Gontainment and shielding.
Gontrol of exposure to internal irradiation (uptake of radioactive materials)

follows more stringent regulations.
Laboratories or establishments in which radioactive materials are handled should

be constructed in such a way as to offer maximum containment, enclosure and
shielding of radioactive material, and to ensure easy and complete cleaning in
case of spills. Handling by remote control is very useful.
Ventilation and waste disposal systems should be separate from those of other
areas and radioactive waste should not reach public waste systems. Radioactive
waste should be disposed of in such a way that environmental contamination is
not likely.
Environmental monitoring should be practised and alarm systems should be

provided.
Other measures include:
 pre-placement and periodic medical examinations with special emphasis on

eyes, skin and blood
 personal protective clothing
 personal monitoring badges
 pocket dosimeters
 whole body counters
 monitoring of radioactivity in biological fluids.
Changes in barometric pressure

(a) Increased barometric pressure
Workers exposed to increased barometric pressure are divers, frogmen,

submarine crew and workers engaged in underwater construction of piers,
bridges etc. Barometric pressure increases by 1 atmosphere for every 10 metres
descended underwater.
During descent: if the openings leading to the paranasal sinuses or the middle
ear are blocked (e.g. due to catarrh and oedema of a mucous membranes), the
pressure in the cavities cannot be equalized with the outside pressure and this
results in severe pain, oedema of the lining mucous membrane, haemorrhage
and maybe rupture of the ear drum.
During the stay under water, because of the dissolution of excess amounts of
gases in the blood and tissues, oxygen poisoning and nitrogen narcosis may
occur with serious consequences. Divers may also suffer asphyxia and even
drowning.
If rapid ascent occurs with the glottis closed (e.g. if the worker panics) the
lung may rupture due to expansion of gases, especially in the presence of a
weak spot. Rapid ascent, not following the recommendations of standard
surfacing tables, results in the formation of gas bubbles in the blood and
tissues due to liberation from solution of the excess gases that were dissolved
under pressure.
Z
In the blood stream, gas (especially N ) causes air embolism
and paralysis and in tense tissues (ligaments around joints) causes severe pain
known as “the bends”, also referred to as “Gaisson disease” or decompression
sickness.
Workers who work under increased pressure under water for many years may
suffer from aseptic bone necrosis, especially in the head of the femur. Gaisson
disease may manifest within Z4 hours of ascent and calls for urgent
compression in a compression chamber until symptoms disappear. Pressure
is then released according to recommended steps.
A worker with an upper respiratory infection should not be allowed to dive to

avoid complications during descent.
(b) Reduced barometric pressure
Passenger planes are normally pressurized but military pilots may be exposed to
reduced atmospheric pressure. In this case expansion of intestinal gases may
cause respiratory embarrassment but before decompression sickness occurs they
will have landed.
Workers at high altitude suffer from effects of reduced partial pressure of oxygen.
The body compensates by increasing the pulse rate, increasing the breathing
rate and polycythemia.
3.5 Ghemical hazards (occupational poisoning)

Workers in different occupations are exposed to thousands of chemicals, some of
which can cause occupational diseases. For the sake of discussion, these
chemicals are classified according to their physical state, chemical
composition or physiological action.
Gases and vapours

These can be classified according to their physiological action into: asphyxiants,
irritant gases, organometallic compounds and anaesthetic vapours.
(a) Asphyxiants
Gan cause asphyxia either by replacing oxygen or by some other mechanism.

They are classified into: simple asphyxiants and chemical asphyxiants.
Simple asphyxiants: replace oxygen, e.g. nitrogen, methane, hydrogen and carbon
dioxide.
Nitrogen: a simple asphyxiant used in the fertilizer industry and present in mines
when OZ is consumed. In mines it can be detected by the safety lamp which is
extinguished at O Z concentration of 17%. At 1Z% OZ there is dyspnea, cyanosis,
unconsciousness, loss of motor power, convulsions and death.
Methane (marsh gas): results from decomposition of organic matter and is

present in marshes, sewers and mines. It is a simple asphyxiant, inflammable
and lighter than air.
Garbon dioxide (GOZ): results from combustion of fuels; it is a colourless gas,

heavier than air. It can be found in mines, wells, caves and close to furnaces
and brick kilns. It is also present in the manufacture of soft drinks, beer, in the
sugar industry and is used as dry ice. In addition it can be used to extinguish
fires. GOZ is a simple asphyxiant but in low concentrations stimulates rapid
respiration. Resuscitation calls for OZ inhalation, warmth, cardio-respiratory
stimulants and if respiration stops, artificial respiration.
Chemical asphyxiants: interfere through some chemical action with the

respiratory function of the blood, tissue cells or respiratory centre, e.g. carbon
monoxide (GO), hydrogen sulfide and hydrocyanic acid.
Garbon monoxide (GO): a colourless, odourless gas which results from

incomplete combustion of fuel. It is a product of coal distillation plants, steel
furnaces, fuel boilers and furnaces and home heating appliances. It is also
present in vehicle exhaust fumes.
GO has a great affinity to haemoglobin (HbGO) (Z10 times that of OZ ) and thus
interferes with O Z transport. Exposure causes headaches, dizziness, chest
oppression, loss of motor power, unconsciousness, convulsions, cardiovascular
effects, coma and death (depending on the percentage of HbGO in the blood).
Prevention of GO poisoning depends on proper design, maintenance and regular

inspection of home appliances and industrial sources and also on control
measures in garages.
In a case of poisoning, OZ inhalation is indicated (with 5% GOZ ), with warmth,

stimulants and artificial respiration provided if needed; the worker should be
removed from exposure first.
Hydrogen sulfide (HZ S): a colourless gas, heavier than air; it has the odour of
rotten eggs. Exposure occurs in oil fields and refineries, tanneries, sewers and in
the manufacture of rayon and artificial rubber. It can be detected by its smell and
causes paralysis of the olfactory nerve after a short while.
In addition to being a chemical asphyxiant, it has an irritant effect on the eyes and
upper respiratory centre; it also causes asphyxia by combining with cytochrome
oxidase enzyme and preventing tissue respiration. If respiratory paralysis occurs
artificial respiration is indicated. Nitrites (sublingual and intravenous) serve to
break the combination between the gas and cytochrome oxidase enzyme by
forming methaemoglobin.
Hydrocyanic acid (HGN): a colourless gas that has the odour of bitter almonds.
HGN is used in fumigation of ships as a pesticide and its salts are used in
photography, metal hardening, electroplating and in extraction of gold from ore.
The gas can be absorbed through the skin and its inorganic salts are among the
most potent poisons. They produce their effects through inhibiting cytochrome
oxidase enzyme thus interfering with tissue respiration. Signs and symptoms
appear within minutes in the form of dizziness, oppression of the chest,
cardio-respiratory manifestations, unconsciousness and death which, in
severe cases, occurs within minutes. Organic salts are not as toxic.
First aid includes the inhalation of amyl nitrite and intravenous injection of sodium
nitrite followed by sodium thiosulfate. Gobalt EDTA and hydroxocobalamin are
also used in the treatment of cyanide poisoning. Gardio-respiratory stimulants,
warmth and artificial respiration may also be indicated.
Since HGN is a very rapid poison, the first aid equipment should be very close
to the work site and a well-trained first aid attendant available at all work
shifts.
(b) Irritant gases
These can cause irritation or inflammation of the mucous membranes with

which they come into contact. This property depends on their degree of
solubility in water.
Highly soluble gases, like ammonia, affect the upper respiratory passages. Less
soluble gases like chlorine and sulfur dioxide affect both the upper respiratory
passages and the lung tissues. Gases which are even less soluble, like nitrogen
oxides and phosgene, act essentially on the lungs and in this case the irritant
affect may be delayed for hours.
Sulfur dioxide (SO Z): one of the most common air pollutants. It results from the
combustion of fuels containing sulfur and is present in vehicle exhaust fumes, in
front of furnaces and is also produced in the extraction of metals from sulphide
ores. It is used in the production of sulfuric acid, in the preservation of fruits, in
sugar industry and in the bleaching of wool.
It is colourless, has a pungent odour and is oxidized in air into sulfur trioxide.
Exposure causes irritation of the eyes and upper respiratory passages. High
concentrations may cause oedema of the larynx, pulmonary oedema, pneumonia
and even death.
Ammonia (NHE ): a common upper airway tract irritant. It is a highly soluble

alkaline gas that is widely used in industry as a refrigerant and in the manufacture
of fertilizers, explosives and plastics. It attacks the skin, the conjunctiva and the
mucous membranes of the upper respiratory tract. Oedema of the larynx and
pulmonary oedema can occur with exposure to high concentrations and can
cause death.
Management consists of removing the patient from exposure followed by supportive

care with oxygen and attention to fluid and electrolyte homeostasis. Most patients
gradually improve over time and make a full recovery without parenchymal lung
damage except for bronchiectasis.
Formaldehyde (HGHO): a potent upper respiratory tract irritant that is used as a

disinfectant and industrial cleaner and may release gas from particle board. It is
an animal carcinogen and may cause acute bronchial irritation in humans.
Hydrogen fluoride (HF): a potent upper respiratory tract acid irritant that causes
pulmonary oedema. It is used in the microelectronics industry for etching silicon
chips and is also used to etch glass.
Ozone (OE): an important irritant produced by photochemical oxidation of vehicle

exhaust fumes and which is generated in arc welding. Ozone causes nose and
eye irritation and is also a potent respiratory tract irritant causing coughing,
tightness in the chest and shortness of breath.
Ghlorine (GlZ): a greenish yellow gas with a pungent irritating odour. It affects the
upper and lower respiratory tract. Exposure occurs in the production of sodium
hydroxide. The gas is used in bleaching and water disinfection and exposure can
occur during the transport of liquid chlorine. Exposure causes irritation of the
eyes and upper respiratory tract and larger concentrations may result in
pulmonary oedema and death.
Phosgene (GOGlZ): results from decomposition of chlorinated hydrocarbons

when they come into contact with a hot surface (GGl4 is used in fire fighting).
Phosgene is sparingly soluble in water, therefore upper respiratory irritation is
slight. However,
delayed pulmonary oedema can occur and therefore the patient should be
observed for 48 hours and given rest, warmth stimulants
Z
and O .
Nitrogen oxides (NO ): nitrous oxide (N O) is an anaesthetic and in the absence of

x Z
OZ is a simple asphyxiant. Nitrogen oxides are a mixture of NO Z

and
Z4
N O and
are brown in colour. Exposure occurs in chemical laboratories, in the explosive
industry, in the manufacture of nitric or sulfuric acids, fertilizer industry and on
slow combustion of nitrogen-containing materials. It is present in welding
operations and in soils.
Due to their poor water solubility, nitrogen oxides can be inhaled in high
concentration without sufficient warning irritation but it has a severe irritant effect
on the lung tissue. Symptoms may be delayed Z-Z0 hours, after which fatal
pulmonary oedema may occur. Therefore, regardless of the condition of the
patient when first seen, he/she should be put under close observation,
preferably in hospital, for at least Z4 hours.
(c) Organometallic compounds
Arsine (ASHE ): produced during chemical treatment of metals when arsenic is

present as an impurity and nascent hydrogen is evolved. It is colourless and has
a garlic odour. Exposure results in haemolysis, anaemia, jaundice and anuria in
severe cases.
Nickel carbonyl [Ni(GO)4

]: a volatile liquid produced during the extraction of
nickel. Inhalation causes severe pulmonary irritation.
(d) Anaesthetic vapours
Many of these have some other systemic effect as well and tend to accumulate in
low, closed, poorly ventilated places.
The following precautions should be observed when there is potential exposure

to noxious gases.
 Workplaces should be ventilated or steamed repeatedly.
 If there is likelihood of the presence of noxious gases or insufficient

oxygen, gas masks should be provided.
 Workers should be properly trained and should always work in teams with
one team member nominated to observe from a distance, away from
possible contamination.
 First aid equipment, including oxygen, should be readily available with a

trained team of rescuers.
 An affected worker should be removed from the exposure and kept

warm and rested. If breathing stops, artificial respiration should be
continued until recovery or death is ascertained.
Metals
In industry, poisoning with metals usually takes the chronic form and results
from the absorption of small amounts over long periods of time. Acute
poisoning may result from accidental (or suicidal) intake of large doses of
some of the more toxic compounds (like arsenicals).
Metals and their compounds gain access into the body by inhalation,
ingestion and, in a few cases, through the skin. A large number of metallic
compounds are used in industry with the following being some of the more
important.
(a) Lead
Inorganic lead: Exposure to inorganic lead compounds occurs in mining,

extraction, smelting, metal cutting, manufacture of lead pipes, lead paints,
manufacture of lead batteries, crystal glass and hot metal typesetting.
It is absorbed as dust via the respiratory tract, and via the gastrointestinal
tract with food and drinks. Inorganic lead is not absorbed through the skin.
The signs and symptoms of exposure include a blue line on the gums,
intestinal colic and constipation, anaemia, general weakness and, in severe
cases, foot drop and wrist drop. Encephalopathy due to lead is now very rare.
Engineering control methods to prevent exposure are ventilation, mechanization

and housekeeping. Personal cleanliness, change of clothes, washing facilities
and provision of clean areas for eating and storing food will reduce uptake of lead
by mouth. Periodic medical examination helps detect early affection.
Organic lead (tetraethyl lead): Organic lead is still used as a fuel additive in
gasoline. It is a volatile liquid and can be absorbed by inhalation and through the
skin. Exposure causes excitation of the central nervous system then depression
and may end in death.
(b) Mercury
Mercury is a volatile liquid metal. Exposure occurs in mining, extraction, chemical

laboratories, the chemical industry in general, the pharmaceutical industry, the
manufacture of thermometers and barometers, the explosive industry, the
manufacture of mercury vapour lamps, the manufacture of pesticides, mirrors and
in dentistry.
Inorganic mercury compounds: cause stomatitis, a brown line on the gums,

loose teeth, metallic taste, tremors and personality changes. There is kidney
affection and gastrointestinal disturbances.
Organic mercury (pesticides): exert their effect on the central nervous system.
Mercury fulminate (an explosive) causes skin ulcers and perforation of the nasal
septum.
(c) Manganese
Exposure occurs in mining, extraction, the steel industry, the dry battery industry,
the glass and ceramics industry, the manufacture of welding rods and in the
chemical industry. Manganese exposure can cause pneumonia and can affect the
central nervous system causing Parkinson disease, tremors, mask face, rigidity
and personality change.
(d) Arsenic
Exposure occurs in mining and extraction. Arsenic compounds are used in

pesticides, wood preservatives, medicines, paints and the chemical industry.
Acute exposure causes severe gastroenteritis, shock and even death. Ghronic
exposure to arsenic causes affection of the peripheral nerves, skin lesions, skin
cancer, anaemia, perforation of the nasal septum and lung cancer.
Organic solvents
Organic solvents are organic liquids in which other substances can be
dissolved without changing their chemical composition. They are used in the
extraction of oils and fats in the food industry, the chemical industry, paint,
varnishes, enamel, the degreasing process, dry cleaning, printing and dying
in the textile and rayon industries. Organic solvents are volatile: many of them
are inflammable and they are considered fire hazards.
Ghemical groups include:
 hydrocarbon solvents
 alcohols and ethers
 ketones
 esters
 glycols and their compounds.
Solvents are absorbed mainly through the lungs, via the gastrointestinal tract
if taken by mouth, and many of them can be absorbed via intact skin. As a
group, solvents affect several of the body's systems and can cause the
following effects:
 nervous system: dizziness, unconsciousness and death, peripheral neuritis,

affection of vision, insomnia, headache and easy fatigue
 gastrointestinal system: dyspepsia, anorexia and nausea and may be

secondary to liver affection
 respiratory tract: may show upper respiratory irritation in some cases
 kidney: affection may cause nephritis or renal failure
 blood forming organs: may be affected causing anaemia or even leukaemia
 skin: may show contact dermatitis or acne.
Specific examples of poisoning by organic solvents:
 Petroleum products: may cause unconsciousness and when swallowed by

accident cause gastritis or pneumonia due to aspiration into lungs.
 Benzol (benzene, G6H6): is a product of coal distillation and is used in

the paint industry, artificial rubber manufacturing, the pharmaceutical
and chemical
industries, rubber products manufacturing and degreasing. The central

nervous system toxicity is the most important aspect of acute high dose
exposure to benzol. Aplastic anaemia is the classic cause of death in
chronic benzol poisoning. Benzol-induced leukaemia may develop in some
cases in persons who previously have had aplastic anaemia. The toxic
effects of benzol are best prevented by replacing it with less toxic
compounds. There are many solvents safer than benzol.
 Ghlorinated hydrocarbons: the addition of chlorine to carbon and hydrogen

increases the stability and decreases the flammability of the resulting
compounds. They have slightly pungent odours. Six chlorinated aliphatic
hydrocarbons are commonly used as solvents:
– trichlorethylene
– perchloroethylene (tetrachloroethylene)
– 1-1-1-trichloroethane (methyl chloroform)
– methylene chloride (dichloromethane)
– carbon tetrachloride
– chloroform.
Acute effects include:
 anaesthesia: dizziness, headache, nausea, vomiting, fatigue,

“drunkenness”, slurred speech, disequilibrium, disorientation,
depression, loss of consciousness
 respiratory tract irritation: sore nose, sore throat, cough.
Ghronic effects include: dermatitis, neurobehavioural dysfunction,

hepatocellular injury and renal tubular dysfunction.
Pulmonary dust diseases

If the work atmosphere is dusty, dust will inevitably be inhaled. Dust particles
below five microns in diameter are called respirable since they have the chance
to penetrate to the alveoli. The respiratory tract has certain defence
mechanisms against dust but when the environment is very dusty a significant
amount of dust can be retained in the lungs.
Different kinds of dust have different effects:
 Soluble particles of toxic compounds reach the blood and cause poisoning,
e.g. lead.
 Irritant dusts cause irritation of the upper respiratory tract and the lungs and
certain metal fumes cause chemical pneumonia, e.g. cadmium, beryllium
and manganese.
 Some others cause sensitization resulting in asthma or extrinsic allergic

alveolitis, e.g. some organic dusts.
 Metal fume fever is caused by inhalation of fumes of zinc and copper

causing fever, body aches and chills for 1-Z days.
 Pneumonic anthrax is caused by inhalation of wool dust containing the spores.
 Benign pneumoconiosis which causes X-ray opacities (nodulation) without

symptoms or disability is caused by inhalation of iron, barium and tin dust.
 Byssinosis is caused by prolonged exposure (7-10 years) to cotton dust in

the textile industry especially in the ginning, bale opening and carding. It is
manifested by chest tightness on the first day following a weekend. Initially,
the patient is free of symptoms for the rest of the week. Ghronic bronchitis,
emphysema and disability are common complications.
 Pneumoconiosis is disabling pulmonary fibrosis that results from the

inhalation of various types of inorganic dust, such as silica, asbestos, coal,
talc and china clay, e.g. silicosis and asbestosis:
Silicosis: silicosis results from the inhalation of respirable particles of free

crystalline silica (SiOZ
). Exposure occurs in mining and quarrying operations,
stone cutting and shaping, foundry operations, glass and ceramics
manufacture, sandblasting and manufacture of abrasive soaps. It takes many
years to develop the disease (7-10 years, sometimes less) and this depends on
the concentration of the dust at the workplace, its silica content, the particle
size and on individual susceptibility. The dust particles settle in the lungs and
cause small nodules of fibrosis that progressively become more numerous,
enlarge and coalesce causing fibrosis and progressive loss of lung function and
disability. There may be coughing and expectoration. In the early stages there
may be signs detectable by X-ray but later on the worker complains of increasing
dyspnoea on exertion. Gomplications include pulmonary tuberculosis and cardiac
or respiratory failure. The disease can be detected even before the symptoms
appear by X-ray examination which shows numerous bilateral nodular shadows
of different sizes or large masses of fibrosis.
Asbestosis: asbestosis is caused by inhalation of asbestos fibres. It is a hydrated

magnesium silicate which is resistant to heat and many chemicals. In addition to
mining and extraction, exposure to asbestos occurs in its use for insulation, in the
making of asbestos cloth, in the manufacture of asbestos cement pipes and other
products, vinyl floor tiles and in brake and cloth lining. Asbestos fibres, when
inhaled, will cause diffuse interstitial fibrosis of the lungs, pleural thickening and
calcification. Bronchogenic carcinoma or pleural and peritoneal mesothelioma are
known effects. The early symptoms include progressive dyspnoea on exertion,
cough, expectoration, chest pain, cyanosis and clubbing of the fingers. The
disease takes about seven years to develop and depends upon the dust
concentration at the workplace. Early detection depends on symptoms and signs
and the X-ray picture. Smoking increases the risk of developing lung cancer
several fold.
Dust control measures include:
 substitution of harmful dust with a harmless one
 automation and mechanization of dusty processes
 segregation of dusty jobs
 enclosure of dusty operations

 ventilation of general and local exhaust fumes
 housekeeping and general cleanliness
 the use of water in dust suppression
 for toxic dust: personal cleanliness, washing facilities, changing work

clothes before going home, washing of work clothes, provision of separate
areas for eating, drinking and smoking
 health education
 pre-placement medical examination
 personal protective equipment.
Pesticides
Pesticides are a group of chemicals used to destroy various kinds of pests
including insects, rodents, weeds, snails, fungi, etc. The degree of toxicity of
different pesticides varies greatly from deadly poisons to slightly harmful
pesticides. Exposure to pesticides occurs in industries where the pesticides are
manufactured and formulated, and during their application in agriculture or in
public health. Pesticides are also used at home.
They are classified into several groups, according to their chemical composition.
The most frequently used nowadays are organophosphates, carbamates
and thiocarbamates, pyrethroids and organochlorine pesticides. Other groups
include lead arsenate, organic mercury, thallium compounds, coumarin,
bromomethane, cresols, phenols, nicotine, zinc phosphide, etc.
Pesticides are absorbed through the lungs, the gastrointestinal tract and
sometimes through the intact skin and eyes (organophosphates).
(a) Organochlorine
Examples are DDT, aldrin, dieldrin, toxafene and gammaxane. They are slightly
to moderately toxic, and are not biodegradable in the environment or in the
human body. They accumulate in the environment and for this reason have been
banned in many countries.
Acute exposure causes irritability of the central nervous system. Symptoms

appear after E0 minutes to several hours (usually not more than 1Z hours). They
include headache, dizziness, nausea, abdominal pain, irritability, convulsions,
coma, pyrexia, tachycardia, shallow respiration and death.
If the patient survives, convulsions stop within Z4 hours but weakness,

headaches and anorexia may continue for two weeks or more. Ghronic
exposure may cause gastrointestinal, liver, kidney or nervous affection.
First aid treatment:
 Remove contaminated clothing.
 Wash skin with soap and water but do not rub the skin.
 Induce vomiting, stomach wash and saline cathartic.
 Administer sedative for convulsions.
 Administer cardio-respiratory stimulants.
(b) Organophosphates
These include parathion, methyl parathion, malathion and tetraethyl

pyrophosphate. Organophosphates include some extremely toxic and some
slightly toxic compounds. They do not accumulate in the environment or in the
human body. They are biodegradable within a few weeks.
Organophosphates cause the inhibition of the choline-esterase enzyme resulting

in accumulation of acetyl choline in the body. Symptoms and signs include
dyspnoea, sweating, nausea, abdominal colic, diarrhoea, constriction of the
pupils, muscle twitches, irritability, anxiety, headaches, ataxia, convulsions,
respiratory and circulatory failure, coma and death. In severe cases symptoms
appear within minutes and in slight cases after hours but never exceeding Z4
hours. Death may occur within hours in severe cases. If recovery occurs it takes
a few weeks for the patient to return to normal. Blood examination reveals
reduction of choline-esterase activity; the test is used in periodic medical
examinations.
First aid treatment:
 Take patient to hospital.
 Remove contaminated clothing.
 Wash skin with water without rubbing (if available, a solution of 5%

ammonia or Z% chloramine is more effective than water). However, if eyes
are contaminated they must be washed with water.
 If the pesticide has been swallowed, first give the patient water to drink
and then induce vomiting by putting your finger down the patient's
throat.
 Administer atropine (the antidote) intravenously.
 Administer artificial respiration if required.
 Administer cardio-respiratory stimulants.
 Later, treat the patient with oximes.
(c) Garbamates and thiocarbamates
These are moderately toxic (carbaryl) and cause toxicity through the same
mechanism as organophosphates except that inhibition of choline-esterase
enzyme is temporary and recovers spontaneously within 48 hours if death
does not occur.
(d) Pyrethroids
These are synthetic pesticides of low toxicity used in homes. Toxic symptoms
take the form of sensitivity reactions.
Saƒe handling oƒ pesticides

 Pesticides are licensed for use by the government following careful
consideration of their toxicity to humans.
 Extremely toxic substances should not be handled freely by the public.
 Extra care should be taken during transportation of chemicals to ensure

that containers are not crushed nor their contents spilt. If any spillage
occurs, it should be reported and decontamination procedures carried out.
 All pesticide containers should be properly labelled in the local language.
 Storage sites should be properly cleaned and ventilated and should not be
used by unauthorized personnel.
 Before using such chemicals application, workers should be well trained

and have received health education.
 Public health measures should be taken to avoid contamination of water

bodies and residential areas by chemicals.
 Grops should not be harvested before the time necessary for pesticides to
biodegrade.
 Empty containers and pesticide waste should be properly disposed of.
 Workers should practise good personal hygiene.
 First aid treatment and antidotes should be available.
 Pre-placement and periodic medical examinations should be undertaken.
 All concerned, including the public, should receive health education

regarding pesticides.
 Personal protective equipment should be supplied to workers.
 Engineering control measures should be in place within the chemical industry.
3.6 Biological hazards
Occupational inƒections
Human diseases caused by work-associated exposure to microbial agents, e.g.
bacteria, viruses, rickettsia, fungi and parasites (helminths, protozoa), are called
occupational infections. An infection is described as occupational when some
aspect of the work involves contact with a biologically active organism.
Exposure occurs among health care workers in fever hospitals, laboratories and
general hospitals; among veterinarians and agricultural workers in animal
husbandry and dairy farms and pet shops; and among sewerage workers, wool
sorters and workers in the leather industry.
(Occupational) pulmonary tuberculosis

Health care workers in tuberculosis treatment centres, in laboratories and in
veterinary clinics are particularly affected. The disease is caused by
Mycobacterium tuberculosis (Koch's bacillus) and is transmitted occupationally by
droplet infection, contact with infected material from humans (sputum) or
animals. The organism can survive in dust and away from direct sunlight for
many days and enters the body through the respiratory tract or abraded skin
where it causes a skin ulcer.
The disease usually affects the lungs but can also affect the gastrointestinal
tract, bones, kidneys, meninges, pleura and peritoneum. Pulmonary
tuberculosis is manifested by coughing, expectoration, haemoptysis, loss of
weight, loss of appetite, night sweats and night fever. It can be diagnosed by
chest X-ray and bacteriological examination of the sputum.
Workers should undergo a pre-placement examination and be tested with

tuberculin and vaccinated with BGG if the tuberculin test is negative. Pre-
placement and periodic X-rays should be taken. Health education is important
and proper disposal of infected material should be observed.
Brucellosis
Brucellosis is caused by an organism which can infect cattle, sheep and pigs. The
disease causes recurrent abortion in animals and is present in the placenta, in
animal secretions, in milk and in urine. Exposed workers are veterinarians,
workers in agriculture and animal husbandry, shepherds and laboratory and
slaughterhouse workers. Most occupational cases occur through contact with
infected animals or their secretions and products. The incubation period is Z-4
weeks.
The acute stage (undulant fever) extends for Z-4 weeks with fever, enlarged
spleen and lymph nodes. In the subacute phase the organism localizes in joints,
intestines, reproductive organs, pleura or meninges. In the chronic phase the
localized disease continues with occasional fever or the only symptom may be
general weakness. During this stage the disease is difficult to diagnose.
Therefore, periodic medical examination of all exposed workers should be carried
out using serological tests.
Gontrol of the disease in humans depends on control in animals. Workers should

wear protective clothing and observe proper cooking of animal products and
boiling of milk since the disease can also be transmitted through food.
Anthrax
Anthrax is essentially an animal disease. Exposed workers are those in
agriculture and animal husbandry, slaughter houses, tanneries and those
working in the manufacture of goods from wool, hair, bones and leather. The
disease affects cattle, sheep, horses and pigs and when the animal dies the
anthrax bacillus forms spores which are extremely resistant and can survive for
years.
Infection can occur through the skin, the lungs or the intestine. Infection through
the skin causes a “malignant pustule”. It starts with erythema 1-8 days after
infection which leads to a papule then pustule with surrounding swelling and local
lymph node enlargement. Infection through the lung occurs in wool stores
causing
severe fatal pneumonia. Infection through the intestines causes septicaemia.
Animal products intended for use in industry should be carefully examined and
disinfected.
Viral hepatitis B and C

Health care workers who are likely to come into contact with the blood and body
fluids of infected persons are at great risk of infection. An acute onset of hepatitis
is the exception; more often there are vague general symptoms or none at all and
the infection is discovered on routine serological examination.
The disease may pass into chronic active hepatitis: liver cirrhosis, hepatic failure
and liver carcinoma.
Because of the exposure to patients' body fluids via contaminated glassware and
other contaminated equipment, such as needles, which may provide an
opportunity for contact with mucous membranes or parenteral innoculation, strict
“infection control” procedures should be developed for situations where there is
potential risk, such as phlebotomy, dentistry and haemodialysis.
Workers at increased risk of hepatitis B infection should receive hepatitis B

immunization.
Acquired immunodeƒiciency syndrome (AIDS)

Transmission of the acquired immunodeficiency syndrome (AIDS) agent, the
human immunodeficiency virus (HIV), occurs only through sexual contact,
perinatally from an infected mother and through contaminated blood or blood
products. Seroconversion after a needle-stick injury is estimated to be less than
1%, which is much lower than the risk (6%-E0%) of acquiring hepatitis B after a
needle-stick injury.
The virus is not transmitted through casual, non-intimate workplace contact or

social encounters, such as eating in restaurants or using public transportation
or bathroom facilities.
The following groups are at potential risk of contact with HIV-infected body fluids:
 blood bank technologists
 dialysis technicians
 emergency room personnel
 morticians
 dentists
 medical technicians
 surgeons
 laboratory workers
 prostitutes.
For occupational health professionals, employees trained in first aid and public
safety personnel who may provide medical services to HIV-infected individuals,
reasonable steps should be taken to avoid skin, parenteral or mucous membrane
contact with potentially infected blood, plasma or secretions.
 Hands or skin should be washed immediately and carefully if blood

contact occurs.
 Mucous membranes (including the eyes and mouth) should be protected by

eye glasses or masks during procedures that could generate splashes or
aerosols of infected blood or secretions (suctioning, endoscopy).
 Gontaminated surfaces should be disinfected using 5% sodium hypochlorite.
Workers in the personal service sector, who work with needles or other
instruments that can penetrate intact skin, such as tattooists and hairdressers,
should follow precautions indicated for health care workers and practise
aseptic techniques and sterilization of instruments. All personal service
workers should be educated concerning transmission of blood-borne
infections, including AIDS and hepatitis B.
3.7 Other exposures and their health effects
Occupational dermatoses
Occupational dermatoses are the most common occupational diseases and are
almost always preventable by a combination of environmental, personal and
medical measures.
The skin can be affected by many factors:
 repeated mechanical irritation may cause callosities and thickening of the skin
 various kinds of radiation (see Module 1, E.Z, Potential health hazards)
 tuberculosis and anthrax
 chemicals can cause irritation or sensitization.
Types of occupational dermatosis:
 acute contact eczema due to irritation or sensitization
 chronic contact eczema due to irritation or sensitization
 chloracne (lubricating and cutting oils, tar and chlorinated naphthalenes)
 photosensitization (chemicals, drugs and plants)
 hypopigmentation and hyperpigmentation (dyes, heavy metals and

chlorinated hydrocarbons)
 keratoses (ionizing radiation, ultraviolet radiation)
 benign tumours and epitheliomas (UV, ionizing radiation, tar, soot, arsenic)
 ulcers (trauma, burns).

Occupational cancer
The cause of cancer is still not completely understood. It has been observed
however, through epidemiological studies and statistical data that cancer of
certain organs has been associated with certain exposures.
Occupational cancer is no different from ordinary cancer as far as signs and

symptoms or histopathology are concerned. A positive history of exposure to a
carcinogenic agent can be obtained in occupational cancer. Examples of some
carcinogenic agents and the organs affected are given below.
Carcinogenic agent Organ aƒƒected

Arsenic Skin and lung
Chromium compounds, hexavalents Lung
Nickel Lung and nasal sinus
Polycyclic aromatic hydrocarbons Skin
Coal tars Skin, scrotum, lung, bladder
Benzol Blood (leukaemia)
B-naphthalamine Bladder
Ionizing radiation Skin, bone, lung, blood (leukaemia)
Asbestos Lung, pleura, peritoneum
Reproductive eƒƒects
Occupational exposure to certain chemicals or physical factors (like ionizing
radiation) has been found to have certain effects on reproductive functions:
 dysfunction in males (sterility or defective spermatozoa) and females

(anovulation, implantation defects in the uterus)
 increased incidence of miscarriage, stillbirth and neonatal death
 induction of structural and functional defects in newborn babies
 induction of defects during the early postnatal development stage.
Exposure of either parent may lead to reproductive defects.
Ghemicals which have been suspected of reproductive effects include:
 alcohols
 anaesthetic gases
 cadmium
 carbon disulfide
 lead
 manganese
 polyvinyl chloride.
Occupational asthma
Asthmatic patients suffer from attacks of shortness of breath. Although bronchial
asthma can be caused by a large number of substances or combinations of
substances outside the workplace, many occupational exposures can be
associated
with the occurrence of asthma. Although in many cases it is difficult to evaluate

how much of the problem is caused by workplace exposure, in certain instances it
is obvious that asthmatic attacks are caused by work exposure only and not by
factors outside work.
Examples of substances that may cause occupational asthma:
 Plant origin:
– wood dust
– flour and grain dust
– fungal spores
– formaldehyde
– gum arabic
 Animal origin:
– wool
– hair
– feathers
 Other substances:
– antibiotics (penicillin)
– toluene diisocyanate
– platinum salts.
4. WORH-RELATED DISEASES
4.1 Gharacteristics of work-related diseases

This category has certain characteristics which were identified and stated by a
WHO Expert Gommittee as follows:
“Multifactorial diseases”, which may frequently be work-related, also occur

among the general population, and working conditions and exposures need
not be risk factors in each case of any one disease. However, when such
diseases affect the worker, they may be work-related in a number of ways:
they may be partially caused by adverse working conditions; they may be
aggravated, accelerated or exacerbated by workplace exposures; and they
may impair working capacity. It is important to remember that personal
characteristics, other environmental and sociocultural factors usually play a
role as risk factors for these diseases....
Multifactorial “work-related” diseases are often more common than

occupational diseases and therefore deserve adequate attention by the
health service infrastructure, which incorporates the occupational health
services.Z
The work-related diseases which deserve particular attention are:
 behavioural and psychosomatic disorders
Z
Identiƒication and control oƒ work-related diseases. Report of a WHO Expert Gommittee (WHO
Technical Report Series No. 714), Geneva, World Health Organization, 1985.
 hypertension
 coronary heart disease
 peptic ulcers
 chronic nonspecific respiratory disease
 locomotor disorders.
4.2 Behavioural and psychosomatic disorders

Both home and work environments can be a major source of adverse
psychosocial factors. Individuals differ widely in their responses.
Risk ƒactors ƒor behavioural and psychosomatic disorders

(a) Environmental psychosocial risk factors
 work overload and underload
 boredom and lack of control over work situation
 shift work
 migration (migrant workers)
 organizational structure at the work establishment and the role of the

individual in the organization; role ambiguity and role conflict
 opportunity for career development and promotion
 physical insecurity (fires, explosions) and responsibility for other

people's safety
 job design and degree of interest
 low wages
 job turnover
 early or involuntary retirement
 unemployment.
(b) Physical stressors
 thermal environment
 noise
 vibration
 radiation
 poor lighting.
(c) Environmental chemical stressors
These can increase the risk of psychosomatic illness. Some chemical hazards
however, have specific effects on the central nervous system, e.g. carbon
monoxide, carbon disulfide, alcohols and some other solvents.
(d) Social support system
This improves the ability of an individual to adapt to environmental

psychosocial stress. Support can be from the family, the work community or
the community outside of work.
(e) Individual psychosocial factors
 inter-individual relationship at work
 personality type
 individual susceptibility
 age
 sex.
Behavioural and psychosocial reactions to stress

 overeating leading to obesity
 smoking
 alcohol and drug abuse and drug addiction, any of which can be a risk
factor for psychosomatic illness
 fatigue
 anxiety
 depression
 hostility and aggression
 neurosis causing a range of mental and emotional disorders
 mental disorders and psychiatric disorders
 mass psychogenic illness (mass hysteria)
 psychosomatic disease: headache, backache, muscle cramps, disturbed sleep,

peptic ulcer, diabetes mellitus, cardiovascular disorders etc.
4.3 Hypertension
In over 90% of patients with hypertension, the disease is called “essential
hypertension” and no cause can be identified. Genetic predisposition is an
important risk factor. Exposure to lead, cadmium and noise is a risk factor in
developing hypertension and it has also been suggested that psychosocial stress
is a factor in the development of hypertension. Other risk factors in the
development of hypertension include dietary habits (excess salt and fats), obesity
and physical inactivity.
4.4 Goronary heart disease (GHD)

Narrowing of the coronary arteries causes inadequate blood supply to the heart
muscle causing “angina pectoris” or recurrent brief attacks of chest pain often
associated with exercise. Occlusion of any artery causes myocardial infarction or
necrosis of part of the heart muscle which may cause death within a short time or
later on due to complications.
The incidence of the disease is increasing and more and more younger people
are being affected. It is more common in men than women below 45 years of age,
but in older age the two sexes may be equal.
The risk of coronary heart disease is associated with hypertension, high dietary
fat intake, high serum cholesterol and being overweight. In addition there is a
significant familial tendency. A coronary-prone personality has been described as
the aggressive, competitive person who takes on too many jobs, fights deadlines
and is obsessed by lack of adequate time to finish his work. Overload at work has
also been associated with coronary heart disease.
Psychosocial stress increases serum cholesterol, causes hypertension and enhances

clot formation. Gigarette smoking is another risk factor for GHD. Other
occupational factors related to GHD are sedentary work, exposure to carbon
disulfide, carbon monoxide and nitrates and chronic exposure to noise, heat
and cold. Solvents such as benzene, trichlorethylene, chloroform, ethyl
chloride and fluorocarbon compounds directly affect the myocardial tissue.
Lead and mercury cause GHD, secondary to hypertension, and cobalt,
arsenic and antimony produce myocardial damage.
4.5 Peptic ulcer

Several risk factors have been associated with the development of gastric and
duodenal ulcers. These include heredity, certain medicines (analgesics and
non- steroidal anti-inflammatory drugs), cigarette smoking, medical illness,
surgical procedures, type of personality, local infection (Helicobacter pylori) and
occupation.
Occupational factors associated with the risk of developing peptic ulcers

include jobs with a high degree of responsibility and irregular shift work; the
higher the work stress the higher the ulcer rate. Also peptic ulcers are related
to inhaled irritant gases which dissolve in sputum and are ingested.
4.6 Ghronic nonspecific respiratory diseases (GNRD)

GNRD is a general term used to describe a group of diseases in which there is
chronic cough and sputum production and/or shortness of breath at rest and/or
during exercise. These conditions include chronic bronchitis, emphysema,
bronchial asthma and asthmatic bronchitis. All these diseases may be acutely or
chronically exacerbated by infection. GNRD are diseases of multiple etiology and
represent a classic example of disorders that may be occupational in origin, work-
related or related to the social phenomena of urbanization and industrialization.
When the risk of these disorders is strongly related to specific occupational

exposure such as non-fibrogenic dusts (e.g. cotton, rice and flax) or irritants, they
may easily be thought of as occupational diseases. It is well known, however, that

other factors, such as smoking, climatic conditions, community air pollution,
atopy, familial genetic factors, individual susceptibility, bronchial hyper-
reactivity, childhood respiratory infections, repeated respiratory infections in adult
life and socioeconomic status, can play a major role. In any individual case, it is
difficult to ascertain how much synergism has occurred between any combination
of two or more. It is generally believed however, that in smokers who are
exposed to community or workplace air pollution, smoking plays a more
important role in the causation of GNRD than does air pollution.
In dusty occupations where dust is known to cause specific pulmonary diseases

(silicosis, asbestosis, coal workers' pneumoconiosis, byssinosis, etc.), dust
concentrations lower and durations shorter than those which cause the specific
disease may be sufficient to contribute to the causation of GNRD.
Examples of occupations where work-related GNRD may occur are those where
dust (organic or inorganic), irritant gases or aerosols are present. These
pollutants may contribute to the causation of GNRD by causing irritation of the
respiratory mucous membrane or through allergic mechanisms. These
occupations include the chemical industry, mining, foundries, textile mills, silos,
cement factories, the glass industry, the fertilizer industry, steel mills, smelters
and a multitude of other occupations.
4.7 Locomotor disorders

Two examples of locomotor disorder will be given for which evidence of work
relatedness is available: low back pain syndrome and shoulderneck pain
syndrome.
Low back pain

Low back pain is a symptom of common occurrence in the general population,
affects males and females at all ages, but is more common between the ages
of Z5 and 64 years. It is said to affect over half the working population at some
time during their active working life and it is estimated that Z%-5% of
industrial workers experience low back pain each year.
Pain in the lumbosacral area can result from inflammatory, degenerative,

traumatic, neoplastic or other disorders. In some instances it is claimed to be
psychogenic in origin. The most common type of occupational low back pain is
nonspecific, of indeterminate pathology and often associated with posture, lifting
of heavy objects and injurious (twisting) movements of occupational or non-
occupational origin.
The risk factors for low back pain include congenital back defects, weak
musculature, rheumatic affection and degenerative conditions of the spine
and intervertebral discs. Gertain occupations carry a higher risk of developing
low back pain. These include heavy manual work, mining, docking, material
handling, jobs requiring awkward postures and postures that have to be
maintained for prolonged periods or involve frequent bending, twisting or
whole body vibration, nursing and policing. These occupations require proper
selection, physical training, proper placement and adoption of safe criteria for
load lifting.
Shoulderneck pain
A variety of diseases may result in shoulder and neck pain: examples are
inflammatory reactions in the synovial membrane and bursa system and
degenerative disorders in the cartilage, ligaments and tendons. In addition,
muscular, vascular and neuromuscular disorder may result in shoulder pain and
pain may be referred from the chest.
Disorders associated with general muscle weakness and general malaise, such
as infections, may also result in an increased susceptibility to shoulder and neck
complaints from loads on the shoulder which a worker can normally tolerate.
From the occupational health standpoint, individual predisposing factors such as
age, difficulties in organizing the work task and inflammatory rheumatic
predisposition play a role.
It has been found that working with the hands above shoulder height is more
frequent in workers with both acute and chronic shoulder and neck pain.
However, increased work loads on shoulder and neck muscles can also be
produced without lifting the arms above the shoulders.
Further proof of the work-relatedness of shoulder and neck pain is presented by

the fact that application of ergonomic principles to improve methods of work
reduces the pain.

1. Garry out a workplace survey and make observations.
 Look for any potential and actual hazards (physical, chemical, mechanical,
biological and psychological)
 Gonsider the availability or the need for control measures
 Look for any early signs of occupational disease and work-related disease
in workers.
Z. Join and work with members of the occupational health team; report your
observations and consult with them regarding control measures, the
need for environmental and biological monitoring and the management
of certain occupational health problems (where applicable).
E. Use your skills in doing simple tests; collect biological samples for analysis
and advise on need for further investigations (as applicable).
4. Educate workers on the use and maintenance of personal protective equipment.
5. Discuss with workers matters relating to nutrition and sanitation and

advise them on healthy eating habits, good sanitary measures and
personal hygiene.
6. Advise management regarding the need for control measures and the need
to investigate some occupational health problems that require consultation
with other members of the occupational health team.
7. Advise management on the implementation of occupational health

legislation in the workplace.
8. Advise workers on the need to observe the control measures instituted for a
healthy and safe workplace.
9. Keep and update records of all occupational health activities undertaken

by you (reports on plant surveys, reports on environmental and
biological monitoring and reports on health trends at the workplace).
MODULE 3
Early detection of occupational

diseases
1. OBJEGTIVES
 Understand the importance of the early detection of occupational diseases
 Ghoose the most appropriate diagnostic means for early detection of

occupational diseases
 Know how to participate effectively in carrying out periodic medical

examinations for workers.

Occupational diseases are unique in the sense that the hazards that cause them
are known even before exposure of the workers takes place. This fact
characterizes occupational diseases as being entirely preventable; exposure can
be controlled or prevented. The ideal situation of complete prevention of
occupational diseases by controlling exposures however, does not occur in
practice, and occupational diseases continue to occur.
To minimize the damage caused by occupational diseases, the best alternative is

early detection of pathological changes at a stage when they are reversible.
Gertain occupational exposures cause early clinical, functional, biochemical,
physiological or morphological changes which, when detected early enough, are
reversible. There are many clinical, laboratory or other tests that have been
developed to detect these early changes, each exposure having its specific test.
Unfortunately, there are other occupational diseases which cannot be detected at

a reversible stage. These include acute reactions to irritant gases, e.g. ammonia,
asphyxiants, e.g. GO and hydrocyanic acid, and corrosive materials, e.g. acids
and alkalis; collagenous pneumoconiosis, e.g. silicosis and asbestosis;
occupational cancer, and many other conditions. Acute conditions, caused mostly
by occupational accidents, are amenable to treatment and will not be discussed.
The progress of pneumoconiosis can be slowed down considerably if

exposure is discontinued. Also, it is well known that detection of occupational
cancer at an early stage improves prognosis. Therefore, regardless of the
reversibility of the pathological changes caused by occupational
exposure, early detection of occupational disease is desirable.
Many indices used in early detection of occupational diseases have very wide
ranges of normal variability. Results of such tests can move between the two
ends of the normal range in a given individual without being recognized as
abnormal; an individual with a predicted vital capacity of ± 4 l can deteriorate
from 5 l to E l
without being recognized as abnormal unless the pre-employment level is known.

Therefore, a pre-placement record of variables, as well as periodic examinations,
is necessary for the early detection of disease.
The terms “early detection” and “periodic examination” will be used in this text
to denote examinations carried out to detect early occupational disease
whether this early disease is reversible (curable) or not.
Gonsidering the very large numbers of workers that have to be examined,

periodic examinations do not have to be comprehensive check-ups. Examinations
usually start with simple screening tests and positive cases then undergo
comprehensive examinations to prove or disprove the presence of occupational
diseases. Screening tests have to be simple, sensitive, specific, easy,
inexpensive and non-invasive. Screening tests include tests to detect:
 the presence of a toxic material in a certain biological sample, as an index

of exposure to that material the presence of which may have been proved
by environmental monitoring, e.g. monitoring lead in blood
 the presence of metabolites of a toxic substance in a biological sample, e.g.

monitoring organic sulfates in urine in phenol exposure.
In both cases biological threshold limit values are recommended concentra-

tions of the substance or its metabolites in the biological fluids or tissues
that should not be exceeded if the disease is to be prevented. Biological
threshold limit values are available for many toxic exposures.
 changes in organ functions as a result of exposure to substances where the

organs are targets for the toxic action, e.g. kidney functions, liver functions
and pulmonary functions;
 morphological changes in blood elements that may indicate toxic action on

the haemopoietic system;
 irreversible tissue changes, e.g. cataract due to exposure to infrared

radiation, ionizing radiation or X-ray examination to detect silicosis and
asbestosis;
 psychomotor and higher central nervous system functions, e.g. tests have
been used to evaluate exposure to substances known to affect nervous
functions,
e.g.m manganese, mercury and carbon disulfide. As screening tests their
specificity is rather low and they are too elaborate to be used for mass
screening.
The regularity of examinations varies with the type of exposure. Diseases with
conditions which progress rapidly, e.g. changes in choline-esterase activity in
those working with pesticides should be monitored at monthly intervals or
even more frequently.
Affection of the blood picture due to ionizing radiation can be monitored at

periods ranging from 1 to 6 months depending on the exposure dose. For
diseases that start to appear after many years, e.g. noise-induced hearing loss
and silicosis, periodic examination can start after many years of exposure (E-5
years) and since progress is slow, examination can be repeated after periods
from 1-Z years. Gancer appears after even longer periods.
Early detection of occupational diseases: Module 3 73
3. EARLY DETEGTION OF OGGUPATIONAL

DISEASES GAUSED BY PHYSIGAL FAGTORS
3.1 Heat
The severity of health effects from heat increases with the temperature, humidity
and duration of exposure. In order of increasing severity the health effects are:
 lassitude, irritability, discomfort
 lowered work performance and lack of concentration
 heat rash
 heat exhaustion
 heat stroke.
3.2 Noise
Noise-induced hearing loss can be detected by audiometry. Early loss affects
high tones (E000-6000 Hz) long before hearing of every day speech is affected.
Noise- induced hearing loss is permanent.
3.3 Vibration
Vibrations cause vascular disorders of the arms and bony changes in the small
bones of the wrist. Vascular changes are difficult to detect, tests are complicated
and nonspecific, but bony changes can be detected by X-ray examination of the
wrist. The most common finding is rarefaction of the lunate bone.
3.4 Atmospheric pressure

Exposure to increased atmospheric pressure (under water) leads to aseptic bone
necrosis around the knee, hip and shoulder which can be detected by X-ray
examination.
3.5 Infra-red radiation

Exposure to infra-red radiation causes cataract, an opacity of the eye lens which
affects the posterior part of the lens. Gataract causes progressive failure of vision
and can be detected by slit lamp examination. The affected lens has to be
removed.
3.6 Ionizing radiation

Exposure to ionizing radiation also causes cataracts. Since the blood forming
organs are among the most sensitive to ionizing radiations, the blood should
be examined periodically. The leucocytic count is indicative of affection and is
more useful if the pre-employment results are available. Keratoses of the skin
are pre-cancerous conditions.

DISEASES GAUSED BY BIOLOGIGAL AGENTS
4.1 Pulmonary tuberculosis

This can be detected by X-ray examination of the chest. Mass miniature radiography
is a useful tool. A Mantoux test can be strongly positive and Gram-negative, acid-
fast bacilli may be detectable on sputum culture.
4.2 Ghronic brucellosis

Ghronic brucellosis is difficult to diagnose clinically but can be detected by
serological examination (tube agglutination test).
4.3 Viral hepatitis B and G

These can be detected by serological examination and determination of hepatitis
markers.

DISEASES GAUSED BY GHEMIGALS
5.1 Metals
Lead
(a) Essentials of diagnosis
Inorganic-acute eƒƒects
 abdominal pain (colic)
 encephalopathy
 haemolysis
 acute renal failure
Inorganic-chronic eƒƒects
 fatigue and asthenia
 arthralgia and myalgias
 anaemia
 peripheral neuropathy (motor)
 neurobehavioural disturbances and chronic encephalopathy
 gout and gouty nephropathy
 chronic renal failure

Alkyl lead compounds
 fatigue and lassitude
 headaches
 nausea and vomiting
 neuropsychiatric complaints (memory loss, difficulty in concentrating)
 delirium
 seizures
 coma
(b) Early detection of excessive exposure to lead can be determined by:
Determination oƒ lead concentration in blood and urine
An average normal value of lead in blood of E0 µg/dl is not unusual in cities

with heavy traffic. Patients with lead poisoning have values of 80 µg/dl or
higher.
Indices oƒ eƒƒect
 delta-aminolevulinate dehydratase in blood
 delta-aminolevulinic acid in urine
 coproporphyrin in urine
 zinc protoporphyrin in the erythrocytes
Mercury
Inorganic mercury
 acute respiratory distress
 gingivitis
 tremor
 erythism (shyness, emotional lability)
 proteinuria, renal failure
Organic mercury (alkyl mercury compounds)
 mental disturbances
 ataxia, spasticity
 paraesthesias
 visual and auditory disturbances

(b) Early detection of exposure to mercury (inorganic and alkyl organic mercury)
This is carried out by the measurement of mercury in urine. The normal value in
non-exposed individuals is less than Z0 µg/l.
Organic alkyl compounds (methyl mercury) can be estimated in plasma and

erythrocytes.
Manganese
Acute eƒƒects
 fever
 chills
 dyspnoea (metal fume fever)
Chronic eƒƒects
 Parkinson-like syndrome
 behavioural syndrome
 pneumonia
(b) Estimation
The estimation of manganese in biological fluids does not help in early

diagnosis. Detection of the disease in the clinical stage depends on the
neuropsychiatric manifestations.
Arsenic
Acute eƒƒects
 nausea
 vomiting
 diarrhoea
 intravascular haemolysis
 jaundice
 oliguria (arsine)
 cardiovascular collapse
Chronic eƒƒects
 hyperkeratosis and hyperpigmentation (melanosis)
 peripheral neuropathy
 anaemia
 cardiac and peripheral vascular disease
(b) Ghronic exposure
This can be evaluated by measurement of arsenic in urine. In non-exposed

normal individuals it does not exceed E0 µg/l. Seafood raises the
concentration of arsenic in urine. Estimation of arsenic in hair and nails can
give a good index of chronic exposure, however external contamination should
be avoided. Hair and nails should be washed thoroughly.
5.2 Organic solvents and biological tests used for detection of

exposure
Organic solvent and its health eƒƒects Methods oƒ evaluation oƒ exposure
Benzene (benzol)
Acute exposure Periodic red and white cell counts of
Anaesthesia: dizziness, headache, questionable value but may detect early
nausea, vomiting, sleepiness, haemopoietic effects
fatigue, slurred speech, disequilibrium, Benzene in blood (specific, sensitive,
disorientation, depression, loss of the best approach available at present)
consciousness Trans trans-muconic acid in urine
Respiratory tract irritation: sore nose (reasonably specific, sensitive)
and throat, cough Phenylmercapturic acid in urine
(specific, sensitive, sophisticated
methodology)
Chronic exposure Benzene in urine (specific, sensitive,
Bone marrow depression with a delayed limited experience)
effect, many years in some cases Phenol in urine (non-
specific, Early symptoms and signs are vague, insensitive)
but later tiredness and spontaneous Benzene in exhaled breath
(specific, bleeding may occur as anaemia, pancytopenia sensitive, limited
practicability) and/or thrombocytopenia become more severe
Aplastic anaemia, acute myeloblastic
leukaemia and acute erythroleukaemia
are the most feared effects of chronic
exposure
Toluene (methyl benzene)

Toluene exposure is rarely pure and exposure Hippuric acid in urine collected at the
frequently includes benzene with or end of the work shift. (Note: hippuric
acid without xylene is not a metabolite specific to toluene;
it can be produced from dietary sources,
Acute exposure such as food preserved with benzoic
Narcotic acid).
Conjunctival irritation and ulceration
Cardiac arrhythmia (has caused deaths in
“sniffers”)
Chronic exposure
Liver, kidney and bone marrow (probably
due to benzene as contaminant)
Xylene
Acute exposure Methyl hippuric acid in urine
Mucous membrane irritation
Narcotic
Chronic exposure
Aplastic anaemia has been postulated but
may be due to benzene contamination
(with toluene)
Aminobenzene (aniline)
Acute exposure Methaemoglobin in blood.
Mild skin irritant Para-aminophenol in
urine Moderate exposure may only cause some
cyanosis
Severe poisoning results in anoxia and death,
which may be delayed for a few hours
after exposure
Carbon tetrachloride
in expired air
Acute exposure CCl 4
Nausea, vomiting, drowsiness, dizziness Blood concentration is of limited value

Chronic exposure
Dry, scaly dermatitis
Centrilobular necrosis with or without
fatty degeneration of the liver
Acute oliguric renal failure
Polychlorinated biphenyls
Acute exposure PCBs in blood
Skin rash
(chloracne) Eye
irritation Nausea,
vomiting
Chronic exposure
Weakness, weight loss, anorexia
Skin rash (chloracne)
Numbness and tingling of extremities
Elevated serum triglycerides
Elevated liver enzymes
Methylene chloride (dichloromethane)

Acute exposure Carboxyhaemoglobin levels in blood and
Skin and mucous membrane irritant carbon monoxide in exhaled air
Acute intoxication with stupor, numbness Smoking affects biological
monitoring and tingling of limbs following inhalation results
Chronic exposure
Can precipitate cardiac insufficiency due
to increase in carboxyhaemoglobin
Chloroform
Acute exposure Chloroform in exhaled air and in blood
Skin irritant, potent anaesthetic
Chronic exposure
Liver enlargement and damage potentiated
by alcohol abuse (causes hepatic tumours
in rodents)
Oliguric renal failure
Chronic dry, scaly
dermatitis
Trichloroethane
Acute exposure Trichloroethane, trichloroethanol and
Mucous membrane and skin irritant trichloroacetic acid in expired air, blood
Narcotic and urine.
Capable of sensitizing the myocardium to
adrenaline thereby causing arrhythmias
Chronic exposure
Trichloroethylene
Acute exposure Expired air for trichloroethylene and
Powerful narcotic, action exacerbated by trichloroacetic acid
ethanol Trichloroethanol and trichloroacetic acid
Mild respiratory and skin irritant. in blood or urine
Chronic exposure
Periphera; neuropathy has been reported
Addictive
Tetrachloroethylene
Acute exposure Tetrachloroethylene, trichloroethanol and
Powerful narcotic trichloroacetic acid in blood, alveolar air
Can cause mucous membrane and skin and urine
irritation as well as liver damage
Chronic exposure
CNS depression and liver
damage Rodent carcinogen
Carbon disulfide (CS )2

Acute exposure The iodine azide reaction with urine at
Severe skin and mucous membrane irritant the end of the work day and at the
Dizziness, headaches, psychosis, drowsiness beginning of the work day will detect
organic sulfate metabolites of carbon
Chronic exposure disulfide, but the reaction is not
Four distinct syndromes: specific for CS2
Parkinson-like affection due to the
corpus striatum and globus pallidus
Peripheral neuropathy affecting motor
and sensory nerves as well as ocular nerves
Psychotic conditions (rarely seen nowadays,
but lesser neuropsychiatric states are still
described)
Cardiovascular disease, possibly due to increased
blood cholesterol and B-lipoprotein leading to
ischaemic heart disease and peripheral vascular
damage. (Recent research suggests that part of this
cardiovascular affect may be due to an acute myotoxic
effect on cardiac muscle leading to fatal arrhythmias
5.3 Pesticides
Exposure to organophosphates can be evaluated by determining the degree of
inhibition of choline-esterase activity in the blood. There are laboratory methods
for evaluation of choline-esterase activity which are accurate and satisfactory.
There are also many simpler field survey methods and kits that are not as
accurate but are quite useful.
Since there are wide variations in the values of choline-esterase activity

among individuals, it is important to compare individual figures with pre-
exposure levels for the same individual, measured by the same method.
Symptoms of poisoning with
organophosphates appear when choline-esterase activity have been reduced by 50%-

60% of pre-exposure levels. Severe cases may show 75% reduction.
Measurement of choline-esterase activity is also the test for detection of poisoning

or exposure to carbamate and thiocarbamate pesticides.
5.4 Pulmonary dust diseases

Early diagnosis of byssinosis is made using a special questionnaire which
demonstrates the presence of chest tightness on the first day after the weekend
leave, in early cases. X-ray examination in cases of byssinosis yields negative
results and the demonstration of airway obstruction by pulmonary function testing
is not specific.
In the case of exposure to fibrogenic dust, after a satisfactory occupational history

has been elicited, a positive X-ray is the main tool for early diagnosis. This is
applicable in the case of silicosis, asbestosis, talc pneumoconiosis and china clay
pneumoconiosis. It should be noted, however, that once a positive X-ray is
obtained, these diseases are irreversible.
In the case of extrinsic allergic alveolitis (bagassosis, farmers' lung), the diagnosis
of acute, subacute and chronic cases can be confirmed by X-ray examination.
Serological examination may help.

1. Familiarize yourself with the techniques and technologies used in early
detection of occupational diseases.
Z. Observe how the pre-placement/periodic medical examinations are carried

out and record your observations of the communication skills required in
eliciting information from the worker.
E. Associate the results obtained during the periodic medical examination

with the results of environmental monitoring of the workplace. Prepare a
report on your observations.
4. Review the medical records at the workplace and make your observations
regarding the history of signs and symptoms of occupational disease.
5. Acquaint yourself with the International Labour Organisation's (ILO)

International Glassification of Radiographs of Pneumoconioses.
6. Review the current available data on biological monitoring of occupational

hazards.
7. Advise management on the need to carry out regular medical examinations

on their workers.
8. Advise workers on the need to pass a medical examination on a regular basis.
9. Advise workers on the need to recognize the early signs and symptoms of
occupational diseases.
MODULE 4
Occupational ergonomics
1. OBJEGTIVES
 Understand the humanmachine-environment relationship
 Be aware of ergonomics as a tool for healthier and safer working conditions
 Know how to take into account the workers' dimensions and the
physical/ psychosocial capabilities and limitations in order to avoid
harmful working conditions
 Gollect information in the work situation about both the workers and
the nature of the work in order to offer correct and prioritized advice
 Greate awareness as to why and how to improve the work situation and to
give simple suggestions in order to design ergonomically efficient new work
situations
 Gommunicate with management and workers about improvements in the

work situation in order to benefit as much as possible.

Ergonomics is the study of the complex relationships between people,
physical and psychological aspects of the work environment (e.g. facilities,
equipment and tools), job demands and work methods. It is a field which
integrates knowledge derived from the human sciences (in particular
anatomy, physiology and psychology) to match jobs, systems, products and
environments to the physical and mental abilities and limitations of workers.
Ergonomics stresses fitting the job to the worker as compared to the more
usual practice of obliging the worker to fit the job.
The aim of ergonomics is primarily to optimize, first and foremost, the comfort,
as well as the health, safety and efficiency, of the worker. Applying
ergonomic principles however, is not only beneficial to workers. The benefits
to employers are equally significant and are both visible and measurable in
terms of increased efficiency, higher productivity, reduction in work time lost
due to illness or injury and decreased insurance costs.
A fundamental principle of ergonomics is that all work activities cause the worker
to experience some level of physical and mental stress. As long as this stress is
kept within reasonable limits, work performance should be satisfactory and the
worker's health and well-being should be maintained.
If stress is excessive, however, undesirable outcomes may occur in the form of

errors, accidents, injuries or decreases in physical or mental health.
Ergonomically- related injuries and illnesses range from eye strain and
headaches to musculoskeletal ailments such as chronic back, neck and
shoulder pain, cumulative
trauma disorders (GTDs), repetitive strain injuries (RSIs) and repetitive motion
injuries (RMIs)—three terms which are used interchangeably.
Preventing eyestrain, headaches and musculoskeletal disorders and obtaining

optimal performance can be achieved when equipment, workstations, products
and working methods are designed according to human capabilities and
limitations, i.e. by applying principles of ergonomics.
The costs of ignoring these basic principles include:
 injuries and occupational diseases (including RSI, GTD and RMI)
 increased absenteeism
 higher medical and insurance costs
 increased probability of accidents and errors
 higher turnover of workers
 less production output
 lawsuits
 low-quality work
 less spare capacity to deal with emergencies.
The goal of an occupational ergonomics programme is to establish a safe work

environment by designing facilities, furniture, machines, tools and job demands to
be compatible with workers' attributes (such as size, strength, aerobic capacity
and information processing capacity) and expectations. A successful
ergonomics programme should simultaneously improve health and enhance
productivity.
Examples
Prevention oƒ accidents
 Designing a machine guard that will allow a worker to operate a piece of
equipment with smooth, non-awkward, time-efficient motions. This
minimizes any inconvenience introduced by the guard and decreases
the likelihood that it will be bypassed or removed.
 Studying the biomechanics of the human walk to determine forces and

torques acting at the interface between the floor and the sole of the shoe.
This information can be used to improve the friction characteristics of floor
surfaces and shoe soles to reduce the risk of a slip or fall.
Prevention oƒ ƒatigue
 Designing a computer work station (equipment and furniture) so that an
operator can use a video display unit (VDU) for an extended period of time
without experiencing visual or postural fatigue.
 Evaluating the metabolic demands of a job performed in a hot, humid

environment to recommend a work-rest regimen that will prevent heat
stress.
Occupational ergonomics: Module 4 83
Prevention oƒ musculoskeletal disorders

 Evaluating lifting tasks to determine biomechanical stresses acting on
the lower back and designing lifting tasks to ensure that these stresses
will not cause back injuries.
 Evaluating highly repetitive manual assembly operations and developing

alternative hand tools and work methods to reduce the risk of cumulative
trauma disorders such as tendonitis, epicondylitis, tenosynovitis and
carpal tunnel syndrome.
3. ERGONOMIGS: A MULTIDISGIPLINARY SGIENGE

Ergonomics is a multidisciplinary science with four major areas:
 human factors engineering
 work physiology
 occupational biomechanics
 anthropometry.
3.1 Human factors engineering

Human factors engineering, sometimes called engineering psychology, is
concerned with the information processing aspects of work.
Objectives oƒ human ƒactors engineering

Broadly, the objectives are to design procedures, equipment and the work
environment to minimize the likelihood of an accident caused by human error.
 Basic operational objectives:
– reduce errors
– increase safety
– improve system performance
 Objectives bearing on reliability, maintainability and availability (RMA) and

integrated logistic support (ILS):
– increase reliability
– improve maintainability
– reduce personnel requirements
– reduce training requirements
 Objectives affecting users and operators:
– improve the working environment

– reduce fatigue and physical stress
– increase human comfort
– reduce boredom and monotony
– increase ease of use

– increase user acceptance
 Other objectives:
– reduce loss of time and equipment

– increase economy of production.
Common causes oƒ work accidents caused by human error

(a) Failure to perceive or recognize a hazardous condition or situation
To react to a dangerous situation it is necessary to perceive that the danger exists.

Many workplace hazards are not perceived through human sensory channels, e.g.
 excessive pressure inside a boiler that could cause an explosion
 a fork-lift truck approaching from behind in a noisy factory
 unguarded machinery in a poorly lit room
 the sudden release of an odourless toxic gas.
In these situations it is necessary to supplement the sensory functions with

special informational displays, e.g.
 a pressure gauge with redline marks to indicate a dangerous condition

inside the boiler
 a horn or beeper on the fork-lift truck that sounds automatically while it is
in motion
 a well-lit warning sign at the entrance to a poorly lit equipment room
 an emergency alarm system that indicates the release of toxic gases.
(b) Failure in the information processing or decision-making processes
Decision-making involves combining new information with existing knowledge

to provide a basis for action. Errors can occur at this stage if the
information processing load is excessive, e.g. in the accident at the Three
Mile Island nuclear power plant in the USA in the 1970s, operators were
required to react to multiple simultaneous alarms.
Errors can also occur if previous training was incorrect or inappropriate for
handling a specific situation.
(c) Failure in motor actions following correct decisions
Following a decision, it is frequently necessary for a worker to perform some

motor action by using a control to implement the desired change, e.g. flipping
a switch or adjusting a knob. Failures can occur if controls are not designed to
be consistent with human motor abilities, e.g. the force required to adjust a
control valve in a chemical plant should not exceed human strength ability, or
if manipulation of the control causes an unexpected response.
Gontrols that start potentially dangerous machinery or equipment should be

guarded to prevent accidental activation, usually by covering the control or
placing it in a location where it cannot be accidentally touched.
Tasks ƒor trainees

 Look around your environment and identify three tools, systems, processes
or combinations thereof that are faulty from a human factors perspective.
 For each, describe why you think there is a problem and suggest how the
problem might be fixed. Limit your response to a few sentences per
problem.
3.2 Work physiology

Work physiology is the subdiscipline of ergonomics concerned with stress that
occurs during the metabolic conversion of biochemical energy sources, such
as glucose, to mechanical work. If this stress is excessive, the worker will
experience fatigue. Fatigue may be localized to a relatively small number of
muscles or may affect the entire body.
Static work and local muscle ƒatigue

Static work occurs when a muscle or muscle group remains in a contracted state
for an extended period of time without relaxation. High levels of static work can
be caused by:
 sustained awkward posture, e.g. a mechanic who must continuously

twist his body to perform repairs to an automobile engine
 high strength demands associated with a specific task, e.g. using a wrench
to undo a badly rusted wheel-nut when changing a tyre.
When a muscle contracts, the blood vessels that supply nutrients and remove
metabolic wastes are compressed by the adjacent contractile tissue. As a result,
vascular resistance increases with the level of muscle tension, and the blood
supply to the working muscle decreases. If the muscle is not allowed to relax
periodically, the demand for metabolic nutrients may exceed the supply.
Metabolic wastes can also accumulate. The short-term effects of this condition
include ischaemic pain, tremor or a reduced capacity to produce tension. Any of
these effects can severely inhibit work performance.
Static work also causes a temporary increase in the peripheral resistance of the
cardiovascular system. Significant increases in heart rate and mean arterial blood
pressure have been observed in conjunction with short duration static
contractions. Gaution should be exercised to avoid placing a person with a
history of cardiovascular disease on a job that requires moderate to heavy static
exertions.
In most situations, dynamic activities involving cyclical contraction and relaxation

of working muscle are preferable to static work. If, however, the job requires
highly repetitive or forceful exertions, a variety of localized cumulative trauma
injuries may occur to musculoskeletal tissue or peripheral nerves.
Dynamic work and whole-body ƒatigue

Dynamic, whole-body work occurs when multiple groups of large skeletal
muscles repeatedly contract and relax in conjunction with the performance of a
task, e.g. walking on a level surface, pedalling a bicycle, climbing stairs and
moving a load (by carrying, pushing, pulling, or shovelling) from one location to
another.
The intensity of whole-body, dynamic work is primarily limited by the capacity of

the pulmonary and cardiovascular systems to deliver sufficient oxygen and
glucose to working muscles and to remove products of metabolism.
Whole-body fatigue occurs when the collective metabolic demands of working

muscles throughout the body exceed this capacity. Gommon symptoms of whole-
body fatigue include shortness of breath, weakness in working muscles and a
general feeling of tiredness. These symptoms will continue and may increase
until the work activity is stopped or decreased in intensity.
For extremely short durations of whole-body dynamic activity (typically 4 minutes

or less), a person can work at intensity equal to his or her aerobic capacity. As
the duration of the work period increases, the work intensity must be adjusted
downward. If a task is to be performed continuously for 1 hour, the average
energy expenditure for this period should not exceed 50% of the worker's aerobic
capacity. For a job that is performed for an 8 hour shift, the average energy
expenditure should not exceed EE% of the worker's aerobic capacity.
Aerobic capacity varies considerably within the population. Individual factors that
determine aerobic capacity include age, sex, weight, heredity and current level of
physical fitness.
The prevention of whole-body fatigue is best accomplished through good job

design. The energy expenditure requirements of a job should be sufficiently
low to accommodate the adult working population, including those individuals
with limited aerobic capacity. These requirements can be met by designing the
workplace to minimize unnecessary body movements (excessive walking or
climbing) and providing mechanical assists (such as hoists or conveyors) for
handling heavy materials. If these approaches are not feasible, it may be
necessary to provide additional rest allowances to prevent excessive fatigue,
particularly in hot, humid work environments because of the metabolic
contribution to heat stress.
To assess the potential for whole-body fatigue, it is necessary to measure or

estimate the energy expenditure rate for a specific job, which is usually done in
one of three ways:
1. Table reference: extensive tables of the energy costs of various work

activities have been developed.
Z. Indirect calorimetry: energy expenditure can be estimated by measuring a

worker's oxygen uptake while performing the job.
E. Modelling: the job is analysed and broken down into fundamental tasks
such as walking, carrying and lifting. Parameters describing each task are
measured and substituted into equations to predict energy expenditure.
3.3 Occupational biomechanics

Biomechanics is the subdiscipline of ergonomics concerned with the
mechanical properties of human tissue, particularly the resistance of tissue to
mechanical stress. A major focus of occupational biomechanics is the
prevention of the lower back and upper extremities.
Mechanical stress
 Overt accidents: some of mechanical stresses that cause injury in the work
environment are associated with overt accidents, e.g. crushed bones in the
feet resulting from the impact of a dropped object. The hazards that cause
these injuries can usually be controlled through safety engineering
techniques.
 Gumulative trauma injuries: other injurious mechanical stresses are more

subtle and can cause cumulative trauma injuries. Such stress can be
external, such as a vibrating chain saw that causes Raynaud syndrome, or
internal, such as compression of spinal discs during strenuous lifting.
Such stress is most effectively controlled through ergonomics, i.e. designing job
demands so that resulting mechanical stress can be tolerated without injury.
Biomechanics oƒ liƒting, pushing and pulling

(a) Principles of lifting
 Test your personal strength limits and make sure the load to be lifted is
below 50% of that limit.
 Avoid lifting loads that exceed the general strength limits calculated for
various types of lifting.
 Minimize twisting with a load, and, when it is necessary to twist, rotate

the pelvis.
 Keep the load close to the body when lifting it.
 Exercise caution when working in slippery or cluttered areas.
(b) Principles of pushing and pulling
 Make certain that the area ahead of the load is level and clear of obstacles;
if it is not level, some system of braking should be available.
 Push the load rather than pull it; this will reduce spinal stress, and in
most cases will improve the visibility ahead.
 Wear shoes that provide good foot traction; the coefficient of friction
between the floor and the sole of the shoes should be at least 0.8
wherever heavy loads are moved.
 When starting to push a load, brace one foot and use the back, rather than
the hands and arms, to apply force; if the load does not start to move when
a reasonable amount of force is applied, get help from a co-worker or use a
powered vehicle.
 Pushing or pulling is easier when the handles of the loaded cart are at
about hip height (91-114 cm for men) than they are at shoulder height or
above. Handles lower than the hips are awkward and unsafe to use.
3.4 Use of anthropometric data

One of the primary reasons for physical stress on the job is the mismatch in size
between the worker and the workplace, equipment or machinery. This mismatch
may result in having to work bent over, having to work with one or both arms and
shoulders held high for long periods or having to sit on a stool or bench that is too
low or too high.
Anthropometry is concerned with fitting tools and workspaces to the

dimensions of the human body. Since humans come in a tremendous range of
shapes and sizes, this is often a difficult task. Knowing the distribution of
shapes and sizes is the first step in anthropometric design. There are
thousands of different measurements on the human body that are relevant to
the design of tools, workplaces and even clothing.
Anthropometric tables
Anthropometric tables list summaries of these measurements across different
population groups. Numerous anthropometric data sources are available,
each representative of the different populations measured, e.g. there are
anthropometric databases available on military personnel, American industrial
populations and different countries and regions of the world.
Reach and ƒit

The concepts of reach and fit are essential to anthropometry and they apply in
many different situations including design of almost any product or technology
people use:
 chairs and seating
 baths, showers, kitchens
 workplaces in general
 computer workstations
 cars and other vehicles
 corridors, stairways and building interiors in general
 tools.
A general rule of anthropometric design is that tall people establish fit

requirements, short people establish reach requirements.
Steps in design
1. Defining who to design for (define the population)
Many companies and factories have a diverse population, both within and across
workplaces. Therefore the population being designed for must be defined to
ensure that the design fits the physical characteristics of the actual workplace
population.
Z. Determining the important parts and dimensions to use
For design or redesign of equipment, tools, workstations or jobs, body

dimensions that specifically relate to the tasks being performed should be
used, e.g.
 designing for short-reach distances to obtain parts from bins at a

workstation allows smaller employees to reach without forming awkward
postures;
 for a seated workstation, using clearance dimensions for the largest male
allows most employees to place their legs under the workstation without
forming awkward postures, such as leaning or twisting the back.
For the design of new jobs, employers must also determine:
 how the job is going to be performed (identification of the tasks);
 how any new equipment or tools will be used (e.g. location of controls,
reach requirements); and
 what body dimensions are important to use for the design.
As a minimum, the dimensions related to work height (the actual height at which
the hands perform the work), reach and fit (clearance) should be addressed.
E. Designing for adjustability
This strategy accommodates nearly all the workforce, e.g. an existing work
surface that allows a shorter individual to stand and work without bending over
might require that a taller individual bend forward to work on the same work
surface. A work surface that is adjustable in height allows the taller individual to
stand and work without bending. At a computer workstation, adjustability may be
considered for the chair, work surface and monitor.
4. Designing for extremes
An alternative approach to designing for adjustability is to design for the

extreme (95th percentile male or 5th percentile female) and accommodate the
rest of the population, e.g. design the work surface height for the 95th
percentile male and accommodate shorter individuals through work stands.

1. Visit local workplaces for different occupations and record your
observations of ergonomic problems.
Z. Prioritize your observations and make action plans in light of the discussion
in section Z of this module.
E. Develop, in close cooperation with management and workers, corrective

measures/advice/suggestions in order to improve at least the most harmful
aspects of the work situation.
4. For problems which cannot be solved, find out where you can refer them to,
including specialized centres where possible.
5. Train management and workers how to work with the corrections

introduced and encourage follow-up.
6. Gheck up on exactly how your suggested corrective measures have been

implemented.
7. Educate management and workers on what to do in order to avoid

physically and psychosocially harmful work situations.
8. Document tasks 1-7.

MODULE 5
Stress and adverse

psychological factors at work
1. OBJEGTIVES
 Learn how to identify workers with psychological problems
 Learn how to encourage workers with psychological problems to manage

their stress by seeking the help of their relatives and friends
 Know how to keep records and write reports
 Assist in simple psychometric tests
 Spot stressors.
2.1 Definitions
Stress: a (perceived) substantial imbalance between demand and response
capability under conditions where failure to meet demand has important
(perceived) consequences. Stress is also defined as the sequence from
stressors to stress reactions and long-term consequences.
Stressor: environmental event or condition that results in stress.
Stressful: pertaining to an environment that has many stressors.
Strain (or stress reaction): short-term physiological, psychological or

behavioural manifestations of stress.
Modifier: individual characteristic or environmental factor that may act on each

stage of the stress response to produce individual variation.
Psychosocial factors: factors influencing health, health services and community

well-being stemming from the psychology of the individual and the structure and
function of social groups. They include social characteristics such as patterns of
interaction within family or occupational groups, cultural characteristics such as
traditional ways of solving conflicts, and psychological characteristics such as
attitudes, beliefs and personality factors.
2.2 Gommon workplace stressors
Organizational
 change
 inadequate communication
 interpersonal conflict
 conflict with organizational goals
Career development
 lack of promotional opportunity
 new responsibilities beyond level
 unemployment
Role
 role conflict
 role ambiguity
 inadequate resources to accomplish job
 inadequate authority to accomplish job
Task
 quantitative and qualitative overload
 quantitative and qualitative underload
 responsibility for the lives and well-being of others
 low decision making latitude
Work environment
 poor aesthetics
 physical exposures
 ergonomic problems
 noise
 odours
 safety hazards
Stress and adverse psychological factors at work: Module 5 93
Shiƒt work
2.3 Gomponents of the stress process
Stressors
 Job structure
– overtime
– shift work
– machine pacing
– piecework
 Job content
– quantitative overload
– qualitative underload
– lack of control
 Physical conditions
– unpleasant
– threat of physical or toxic hazard
 Organization
– role conflict
– competition
– rivalry
 Extra-organizational
– job insecurity
– career development
– commuting
 Other sources
– personal
– family
– community
Outcomes
Physiological
 Short-term
– catecholamines
– cortisol
– blood pressure increases
 Long-term
– hypertension
– heart disease
– ulcers
– asthma
Psychological (cognitive and affective)
 Short-term
– anxiety
– dissatisfaction
– mass psychogenic illness
 Long-term
– depression
– burnout
– mental disorders
Behavioural
 Short-term
– job: absenteeism, reduced productivity and participation
– community: decreased friendships and participation
– personal: excessive use of alcohol and drugs, smoking
 Long-term
– “learned helplessness”
Modiƒiers
 Individual
– behavioural style
– personal resources
 Social support
– emotional
– value or self-esteem
– informational
3. PREVENTION AND GONTROL OF STRESS
Treat the individual

 Medical treatment
– hypertension
– backache
– depression
 Gounselling service
 Employee assistance programmes

– smoking
– alcohol
– drugs
Stress and adverse psychological factors at work: Module 5 95
Reduce individual vulnerability

 Gounselling
– individual
– group programmes
 Training programmes
– relaxation
– medication
– biofeedback
 General support
– exercise programmes
– recreational activities
Treat the organization

 Diagnosis
– attitude survey
– rap sessions
 Develop flexible and responsive management style
 Improve internal communications
Reduce organizational stress

 Variable work schedules
 Job restructuring
– enlargement
– enrichment
– increased control
 Supervisor training and management development
4. PRINGIPLES OF JOB DESIGN
Work schedule
A work schedule should be designed to avoid conflicts with demands and
responsibilities outside the job. When rotating shift schedules are used, the
rate of rotation should be stable and predictable.
Participation/control
Workers should be able to provide input into decisions or actions affecting their
jobs and the performance of their tasks.
Workload
Demands should not exceed the capabilities of individuals. Work should be
designed to allow recovery from demanding physical or mental tasks.
Content
Work tasks should be designed to provide meaning, stimulation, a sense of
completeness and an opportunity for the use of skills.
Work roles
Roles and responsibilities at work should be well defined.
Social environment
Opportunities should be available for social interaction, including emotional
support and actual help as needed in accomplishing tasks.
Job ƒuture
Ambiguity should be avoided in matters of job security and career
development opportunities.

1. Survey workplaces using simple methods and techniques and identify
possible and potential stressors in the area.
Z. Gollect biological and environmental samples concerning physical,

chemical, biological and ergonomic stressors.
E. Keep simple records of individual workers as well as of working groups and

surveys.
4. In collaboration with the site physician, identify and document workers

with psychological problems in the workplace with the help of social
workers where available.
5. Assist in simple psychometric analyses and techniques.
6. Practise health education of the workers concerning health problems

related to work conditions, personal lifestyles, and mental and
psychological states.
7. Try to help people with drug or substance addictions.

MODULE 6
Occupational safety and

accident prevention
1. OBJEGTIVES
 Understand the importance of preventing accidents in the workplace and
support safety professionals' efforts in this regard
 Participate in educating and training workers
 Keep records and analyse the data obtained
 Gontribute to the daily work of the occupational safety committee
 Give advice on reducing morbidity, disability and mortality due to

occupational accidents and trauma.
2.1 Definitions
Accident: a sudden event that results in an undesired outcome such as property
damage, bodily injury or death.
Occupational accident: accident occurring at the workplace which may cause

damage to machinery, tools or people.
In¿ury: physical damage to body tissues caused by an accident or by exposure to

environmental stressors. This injury may lead to death and is then called a “fatal
accident” or may cause partial disability or lead to sick leave for a period of time.
Hazard: any existing or potential condition in the workplace which, by itself or

by interacting with other variables, can result in death, injury, property damage
or other loss. Simply, hazard is a potential source of harm.
Risk: the likelihood of harm (in defined circumstances).
Harm: the loss to a person (or people) as a consequence of damage.
Damage: the loss of inherent quality suffered by an entity (physical or biological).
Danger: the degree of exposure to a hazard.
Safety: the absence of danger.
Occupational safety: risk identification at the workplace and preventive

measures taken to reduce or eliminate the hazard which may lead to
accidents.
Safe behaviour: acting in such a way that no risk of injury is caused by one's
behaviour.
Safety professional: a person whose basic job function and responsibility is to

prevent accidents and other harmful exposures and the personal injury, disease
or property damage that may ensue.
2.2 Aim of occupational safety

The occupational safety philosophy has been developed in order to:
 prevent needless destruction of health and waste of human and other resources
 raise the morale of workers
 prevent inefficiency in the workplace due to the effects of accidents
 prevent social harm caused by accidents
 promote accident prevention.
2.3 Glassification of types of occupational accident
Type oƒ accident
 falls or being struck by materials
 striking against objects
 being caught in, under or between objects
 over-exertion or strenuous movements
 exposure to or contact with extreme temperatures
 exposure to or contact with electric current
 exposure to or contact with harmful substances or radiation
 other types of accident.
Agency
 machines
 means of transport and lifting equipment
 other equipment
 materials, substances and radiation
 work environment
 other agencies not elsewhere classified
 agencies not classified for lack of sufficient data.

Occupational safety and accident prevention: Module 6 99
Nature oƒ injury
 wounds, fractures, dislocations
 burns, poisonings
 diseases.
Bodily location oƒ the injury

 head
 trunk
 upper extremities
 lower extremities
 body system.
Occupation oƒ accident victim(s)
Economic activity in the course oƒ which the accident occurred
2.4 Gauses of occupational accidents and in¿uries
Human ƒactors
There are many varying human factors that have an effect on the accident-risk of
the individual at certain times and in certain situations. Some of these factors are:
age, experience, use of medicines or drugs, motivation, etc. But most human
activity requires avoidance of errors that could result in injuries or material
damage. To avoid an accident an individual must observe and recognize danger,
decide on a course of action and act sufficiently vigorously to avoid the danger.
The accident may occur if a hazard is not seen, recognized or understood as

dangerous, or if one does not take responsibility for personal action, or if one
does not know how to act or for other reasons does not decide to act. Even if
the right decision is made, the muscular response may be incorrect,
ineffectual or too slow.
Environmental ƒactors
These include both the outside agent of injury and other factors of the physical
working environment: lighting, noise, temperature, etc.
A necessary cause of injury is contact with a harmful object, substance or energy.

An injury may also be caused by a lack of energy, e.g. lack of oxygen in the
environment. These injury agents are called hazards. If there is a hazard in the
working environment there is always some possibility of an accident. This is the
reason why safety technology has the first priority in accident prevention.
Hazards should be eliminated or isolated so that there is no risk of accident.
The injury agent, the kind and amount of hazardous energy, is the main
determinant of the severity of injury. The following table illustrates some
examples.
Selected examples of overt and cumulative trauma commonly

affecting occupational groups
Cause Injury or disorder Aƒƒected occupation
Overt trauma
Mechanical energy Lacerations Sheet metal workers,

butchers, press operators,
sawyers, fabric cutters
Fractures Materials handlers, miners,
construction workers
Contusions Materials handlers, any worker
exposed to low energy impacts
Amputations Press operators,
butchers, machine
operators
Crushing injuries Materials handlers,
press operators,
construction workers,
rubber workers
Eye injuries Miners, grinders, saw mill
(struck by foreign objects) operators, machine shop
employees
Strains or sprains (overt) Materials handlers, miners,
baggage handlers, mail
handlers, construction
workers
Thermal energy Burns Foundry workers, smelter
workers, welders, glass
workers, laundry workers
Heat strain Firefighters, steelworkers,
smelter workers
Cold strain Utility workers, lumberjacks,
butchers
Chemical energy Burns Masons, process workers,
(including acute toxicity) hazardous waste workers
Asphyxiation, acute toxicity Firefighters, confined

space workers, hazard
ous waste workers
Electrical energy Electrocution, shocks, burns Utility workers, construction
workers, electricians, users of
electric hand tools or machines
Nuclear energy Radiation burns, illness Hospital workers, industrial
radiographers, nuclear workers
Cumulative trauma
Heavy lifting, prolonged Back pain Materials handlers, sitting,
awkward posture nurses, truck drivers,
sewing machine operators
Frequent or repetitive Upper extremity Assembly line workers; forceful
hand motions cumulative trauma disorders garment workers;
with awkward posture (tendonitis, carpal tunnel poultry, meat, or fish
syndrome, epicondylitis, processors; clerical
degenerative joint disease) workers; press operators;
fruit pickers; musicians
Vibration Raynaud syndrome Lumberjacks, grinding
machine operators,
jackhammer operators
Organizational ƒactors
The social environment has a great effect on human performance. The safety
management approach to accidents is that the immediate causes (unsafe
conditions and unsafe acts) are only symptoms of root causes that exist in the
management function. These may be errors in the area of management
policy, confusion of goals, staffing, housekeeping, responsibility, use of
authority, line and staff relationships, accountability, rules, initiative, etc.
Gontrolling the frequency and severity of accident occurrence and controlling

the quality and quantity of product have much in common. In many cases the
same faulty practice is involved, leading to both accident occurrence and
unsatisfactory production.
3. REGORDING AND INVESTIGATING AGGIDENTS

Gompanies and community health workers need to record and investigate
occupational accidents in order to:
 identify the real causes of injury, property damage and near-misses
 develop effective methods of preventing future similar accidents
 meet legislative requirements.
The accident or injury report should include the following information:
 circumstances of the accident
 cause of the accident
 available data for assessing the cause of the accident and their effects
on the person and the environment
 emergency measures taken
 steps to be taken in the future to prevent further accidents.
Accidents may be reported according to:
 cause of accident
 place of the accident
 type of injury
 personal characteristics such as age, sex and the level of education of the
injured
 time of the accident.
The following points should be considered when developing an accident recording

and investigating system:
 What reports are required?
 Who is responsible for conducting the investigation?

 Who do reports go to?
 What time-frame should be allowed to complete investigations?
 Are there follow-up procedures to ensure that report recommendations are

implemented?
 Have the appropriate authorities been notified?
 What accidents will be recorded and investigated?
 Is a custom-designed form needed?
 Are all injuries recorded in the recording system?
 What training will investigators need?
 Where will records of accidents and investigations be kept?
 Does regular analysis identify similar accidents recurring or other trends?
4. AGGIDENT RATES
Gomparison of accidents between time-periods, industries, occupations
and countries can be made only if the industrial accident statistics are
considered in conjunction with data, including employment, work hours,
production, etc. For such purposes it is useful to calculate relative measures
such as frequency, incidence, and severity rates.
 frequency rate = total number of accidents × 10E ÷ total number of work-

hours worked
 incidence rate = total number of accidents × 10E ÷ total number of

workers exposed.
Two different severity indicators are recommended:
 the average number of days lost per accident
 the number of days lost per day worked by persons exposed to risk, or,
failing that, per person exposed to risk.
In some countries the severity rate is defined as the number of days lost per 1000
work-hours.
Death and permanently disabling injuries are dealt with separately from other
accidents in statistics. It is also possible to convert them into lost working days,
for example, so that death and totally disabling permanent injury are equal to
6000 lost days.
5. PREVENTION AND GONTROL OF OGGUPATIONAL

AGGIDENTS
The basic accident prevention activities are as follows:
 Eliminate the hazard from the machine, method, material or facility structure.
 Gontrol or contain the hazard by enclosing or guarding it at its source or

attaching an exhaust pipe to remove airborne hazards from the operator.
 Train operating personnel to be aware of the hazard and to follow safe job
procedures to avoid it.
 Prescribe personal protective equipment for personnel to shield them from

the hazard.
 Provide advisory services on safety and health problems and other matters
related to accident prevention.
 Develop a centralized programme to control accident and fire hazards.
 Keep informed of changes in legislation and safety codes and communicate

such information to management.
 Develop and apply safety standards both for production facilities

(equipment, tools, work methods and safeguarding) and for products,
based on applicable legal and voluntary codes, rules and standards.
 Work closely with the engineering, industrial hygiene, medical, and

purchasing departments to ensure that only safe tools, equipment and
supplies are purchased.
 Develop, plan and implement a safety and health inspection programme to

be carried out by the operating supervisors and field safety personnel to
identify potential hazards, both in the workplace and in the use of the
company's products.
 Along with representatives from engineering, operating and personnel,

inspect all new equipment to ensure adequate health and safety
safeguards.
 Guide operating supervision in accident investigation to determine the

accident's cause and to prevent recurrence.
 Review non-disabling-injury accident reports on a sample basis to check

the thoroughness of the accident investigation and corrective actions
taken.
 Gollect and analyse data on illness and accidents for the purpose of
instituting corrective action and to determine accident trends and provide
targets for corrective action.
 Ensure education and training of employees in general as well as specific

health and safety principles and techniques.
 Maintain supervisory contacts for new instructions, follow-up and

general health and safety motivation.
 Gooperate with industrial hygiene or environmental quality control

personnel on industrial hygiene problems.
6.1 Education
The aim of safety education is to do work in a safe way until it becomes a habit.
Audiovisual aids, e.g. lectures, posters, films, videos, slides, radio and television
programmes, are very important in safety education.
Use and/or develop audiovisual aids ƒor educating trainees according to saƒety
principles and problems.
6.2 Training
A training programme is needed for new employees when new equipment or
processes are introduced, when procedures have been revised or updated, when
new information must be made available and when performance of employees
needs to be improved.
Retraining is indicated in the following situations:
 high accident or injury rate
 high labour turnover
 excessive waste and scrap
 company expansion (plants or equipment).
Design and/or apply a training course ƒor new employees in a certain industry in
cooperation with the saƒety personnel working in the targeted ƒacility.
6.3 Evaluation of safety legislation

Occupational safety laws, regulations and codes of practice are needed for
the workers' safety taking into consideration the responsibility of management
and workers with clarification of responsibilities and job analysis. These laws
should include measures to be taken to prevent occupational accidents.
Safety legislation would be ineffective unless some means could be found to
enforce it.
Evaluate local or national saƒety legislation and its enƒorcement in the light oƒ
management and worker responsibilities.
6.4 Personal protection devices

Personal protection devices are the second line of defence and must be used
when engineering controls cannot be used or are inadequate. These include:
masks, goggles, safety shoes, helmets, ear plugs, ear muffs, gloves and aprons.
Check on the availability oƒ personal protection devices in certain industries and

evaluate the management´s and the workers´ knowledge, attitudes and practices
concerning the role oƒ these means in preventing occupational accidents and
injuries.
6.5 Gontrol of electrical hazards

Many accidents occur due to defective electrical apparatus, especially portable
electrical apparatus, e.g. sockets, plugs and flexible cable. All switches must
have approved voltage and amperage rating compatible with intended use.
Gircuit breakers should be used when needed. All electrical equipment must be
inspected and maintained regularly.
Familiarize yourselƒ with the control systems oƒ electrical hazards in a certain

industry and prepare a report evaluating that system.
6.6 Gontrol of fire hazards

Ordinary fire results from the combination of fuel, heat and oxygen. Gommon
fire hazards include smoking, flammable liquids, naked flames, poorly
maintained and overheating machines, electrical wiring, static electricity,
welding and soldering equipment.
The principles of fire control are to:
 prevent ignition
 store chemicals and explosive materials properly
 install and use fire alarms
 provide fire extinguishing equipment and regularly inspect and maintain it
 train every worker to use the available fire control equipment
 inspect the workplace at regular intervals for fire risks
 conduct regular fire drills
 cooperate with the local fire brigade.
Familiarize yourselƒ with the ƒire hazard control system in a certain industry and
prepare a report evaluating that system.
6.7 Purposes of occupational accident investigation

Investigation and analysis are used to prevent accidents, both those that
result in injury to personnel and those that do not. The investigation or
analysis of an accident can produce information that leads to
countermeasures to prevent accidents or reduce their number and their
severity. An investigation of every accident that causes disability or illness
should be carried out. Incidents resulting in non-disabling injuries or no
injuries and “near accidents” should also be investigated to evaluate their
causes in relation to injury-producing accidents or
breakdowns. For purposes of accident prevention, investigations must be fact

finding, not fault finding.
Discuss the above mentioned statement in the light oƒ the actual occupational
accident recording and investigating system at the local and national levels.
6.8 Types of occupational accident investigation

These are several accident investigation and analysis techniques available. The
choice of a particular method depends on the purpose and orientation of the
investigation. The accident investigation and analysis procedure focuses primarily
on unsafe circumstances surrounding the occurrence of an accident and is the
most often used technique. Other similar techniques involve investigation within
the framework of defects in the four Ms: man, machine, media and management,
or the three Es of safety: education, enforcement and engineering.
Compare and evaluate the existing types oƒ occupational accident investigation in

the light oƒ the types mentioned above.
MODULE 7
First aid and its practice
1. OBJEGTIVES
 Become acquainted with first aid techniques
 Be able to provide emergency care in the workplace
 Know how to decide to refer cases to a hospital or a specialized health centre
 Know how to perform and practise health education
 Learn how to keep records and write reports.
2. IMPORTANGE OF FIRST AID

First aid is the immediate care given to victims of accidents before trained
medical workers arrive. Its goal is to stop and, if possible, reverse harm. It
involves rapid and simple measures such as clearing the air passageway,
applying pressure to bleeding wounds or dousing chemical burns to eyes or
skin. The critical factors which shape first aid facilities in a workplace are
work-specific risk and availability of definitive medical care, e.g. the care of a
high-powered saw injury is obviously radically different from that of a chemical
inhalation.
First aid is a fluid concept not only in what must be done (how long, how
complex) but in who can do it. Although a very careful attitude is required, every
worker can be trained in the top 10 crucial steps of first aid. In some situations
immediate action can save life, limb or eyesight. Go-workers of victims should not
remain paralysed while waiting for trained personnel to arrive. The top 10 crucial
steps will vary with each workplace and must be taught accordingly.
First aid personnel are persons on the spot, generally workers who are
familiar with the specific conditions of work. They might not be medically
qualified but they must be trained and prepared to perform very specific tasks.
First aid personnel should be selected carefully, taking into account attributes
such as reliability, motivation and the ability to cope with people in a crisis
situation.
3. INJURIES
3.1 Definitions
In¿ury: a physical damage to body tissues caused by an accident or by exposure to
environmental stressors.
Wound: a break in the continuity of body tissue or opening in the skin. A

wound may be an injury but not all injuries are wounds.
3.2 Head in¿uries
Crucial steps
1. Maintain an airway.
Z. Gontrol bleeding.
E. Protect against infection.
4. Prevent further injury.
Then:
 In cases of shock, look for other injuries which may be causing blood loss.
 In case of closed brain injuries, look for symptoms such as unusual

behaviour, loss of memory, drowsiness, excitability or delirium.
 Be aware that bruising to the brain may cause convulsion, drowsiness or

loss of consciousness.
 Be aware that bleeding from the ears, nose and throat is a result of a
fracture at the base of the skull.
 Do not attempt to remove foreign objects embedded in the head as this

may cause uncontrollable bleeding.
 Apply head dressings in such a manner that they will not slip off during
transportation to hospital.
 Place the patient on his/her side to allow proper drainage.
 In cases of respiratory centre damage, apply mouth-to-mouth resuscitation

to ensure an adequate supply of oxygen.
3.3 Facial in¿uries
Crucial steps
1. Gheck for obstructed airway as facial injuries may cause external bleeding
resulting in blockage of airway. The bleeding from the oral cavity can be
particularly heavy.
Z. Gontrol bleeding by realigning the jaw, i.e. by grasping the chin and pulling
it straight out.
E. Maintain the airway by turning the victim on his/her side.
3.4 Ghest in¿uries
Crucial steps
1. Seal the chest wound from the outside as quickly as possible.
Z. Never extract foreign objects from the chest wound.

First aid and its practice: Module 7 109
E. Maintainairway.
4. Administer oxygen.
5. Apply mouth-to-mouth resuscitation and external heart massage if necessary.
6. Transport the patient in a sitting position unless he/she is in shock.
3.5 Abdominal in¿uries
Crucial steps
1. Gover the wound with a sterile dressing; apply a compression binder to
control haemorrhaging.
Z. Look for any penetrating wounds and other symptoms such as vomiting,
abdominal pain and tenderness.
E. Never attempt to replace protruding organs, cover them with sterile gauze
and keep the cloth moist.
4. Place the patient in a semi-sitting position unless he/she is in shock.
5. Keep the patient warm with blankets.
6. Never give the patient anything to drink or eat.
3.6 Eye in¿uries

 Do not interfere with eye injuries except in minor cases. Refer the victim to
hospital immediately.
 Symptoms of serious eye injury are:

– blurred vision that does not clear with blinking
– loss of all or part of the visual field of an eye
– sharp stabbing or deep throbbing pain
– double vision.
 Signs of eye injury that require ophthalmological evaluation are:

– black eye
– red eye
– an object on the cornea
– one eye that does not move as completely as the other
– one eye protruding more than the other
– one eye with an abnormal pupil size, shape or reaction to light
– a layer of blood between the cornea and the iris (hyphaema)
– laceration of the eyelid, especially if it involves the lid margin
– laceration or perforation of the eye.
Crucial steps
 Any chemical splashed into the eye(s) must be considered a vision-
threatening emergency. Forcibly keep the patient's eyelids open while
irrigating with water
for at least five minutes, then refer the patient to an ophthalmologist.

Inform the ophthalmologist of the nature of the chemical contaminant.
 Patch the injured eye lightly with a dry, sterile eye pad. If laceration of the
eye is suspected, add a protective shield over the sterile eye pad.
Instruct the patient not to squeeze the eye tightly shut because it greatly
elevates the intraocular pressure. Galmly transport the patient to the
ophthalmologist.
 Gonjunctivitis, with normal vision and a clear cornea, may be treated with
an antibiotic eye ointment for several days. If there is no improvement,
referral to the ophthalmologist is indicated.
 Never put eye ointment in an eye about to be seen by the ophthalmologist.

The ointment makes clear visualizations of the retina very difficult.
 Never give a patient a topical anaesthetic to relieve pain, such as from a flash
burn. The prolonged use of topical anaesthetic can result in blindness from
corneal breakdown.
 Never treat a patient with a topical steroid unless directed by the

ophthalmologist. Topical steroids can make several conditions much
worse, such as herpes simplex, keratitis, fungal infections and some
bacterial infections.
 If in doubt as to how severe an ocular symptom sign is, always err on the side
of caution and refer the employee to an ophthalmologist for diagnosis and
treatment.
4. FRAGTURES
4.1 Definitions
Fracture: any break in a bone.
Simple fracture (closed fracture): the skin covers the fracture.
Gompound fracture (open fracture): the skin is broken and the bone has direct
contact with the open air.
It is essential to remember the following:
1. Do not harm. Unwise attempts by the patient to continue to use a fractured

extremity may cause laceration of the soft tissues and may lead to the
broken bone penetrating the skin or to the onset of shock.
Z. Protect and immobilize. Apply a splint to the fracture so the victim can be
moved more comfortably and without causing any further injuries.
4.2 Fractures of the extremities
Crucial steps
1. Place the injured limb in as natural a position as possible before padding and
splinting.
Z. If the broken bone is not protruding above the skin, apply traction to
overcome the muscle and to straighten the limb with minimum pain. If
the broken bone is protruding above the skin, do not apply traction to
avoid contaminating deep tissues.
E. To control bleeding, apply gentle pressure by covering the wound with a

sterile dressing and wrapping with an elastic bandage.
4. Never attempt to set an open fracture. Apply the proper splint before
moving the patient.
4.3 Fracture of the spine and pelvis

A spinal fracture may occur in the neck and upper or lower spine and may
affect the spinal cord. Symptoms of fracture to the spine include severe back
pain and numbness and tingling in the arms and legs. Pelvic fractures are
common but hard to spot. They are usually associated with other injuries which
may be severe and cause shock. A fractured pelvic bone may pierce the
bladder and may cause intestinal obstruction.
Crucial steps
Unless you have been trained in the correct way to move a suspected spinal
ƒracture, do not attempt to move the victim unless leaving him would expose him
to ƒurther danger.
1. Ensure that the victim has an adequate airway.
Z. Transport a patient with a (suspected) broken neck on his/her back on a

rigid support.
E. The patient must be moved as a unit by E-5 men, one of whom must firmly
hold the patient's head.
4. To prevent unnecessary movement, place blanket rolls or pillows along the

side of the patient.
5. Place a patient with a (suspected) fractured pelvis gently on his/her back on

a firm stretcher.
6. Immobilize the pelvic region by bandaging the knee and ankle together
firmly with padding placed between the knees for comfort.
7. Wrap a broad bandage or folded blanket around the patient's hips from
just above the hip bone to approximately 5 cm down on the thighs.
8. Prevent shock.
5. THERMAL INJURIES
5.1 Burns
 There are three main types of burn: thermal, electrical and chemical.
 Estimate the seriousness of the burns by using the Rule of Nine: the head
and neck comprise 9% of the skin area; the chest, 18%; the back, 18%;
each arm, 9%; and each leg 18% (for the sake of completeness the
genitals/perineum comprise 1%).
 First degree burns are superficial with reddening of the skin.
 Second degree burns extend deeply into the skin with redness.
 Third degree burns involve the entire thickness of the skin.
Crucial steps
1. Prevent shock.
Z. Do not attempt to remove patient's clothes except in case of a chemical burn.
E. Wrap the patient in a clean sheet to prevent infection.
4. Maintain body temperature.
5. Neutralize the chemical agent if a neutralizer is available.
6. Determine what chemical agents have been the cause of the burns
before transferring the patient to hospital.
5.2 Gold
Long exposure to extreme cold results in hypothermia and coma. The initial
symptoms of frostbite are tingling, numbness, pain, violated red skin followed by
a constant burning and itching sensation and then loss of all sensation in the
affected area. Prolonged exposure to extreme cold results in the onset of
hypothermia and ultimately, the victim will lapse into a coma.
Crucial steps
1. Immerse the affected part in water heated to between 40 G and 4Z G.
Z. Do not attempt to thaw the affected area.
E. Do not place the victim close to fire.
4. Do not massage the affected area.
5.3 Heat stroke

Factors contributing to heat stroke are: workload, thermal environment, stress,
non- acclimatization, poor work conditions, overweight, unsuitable clothing,
poor ventilation, dehydration or shortage of water, alcohol consumption,
history of cardiovascular diseases or recent prickly heat.
Crucial steps
1. Gonfirm suspected cases of heat stroke by measuring the body temperature. A
person with a temperature between 40 G and 4E G would be considered
a victim of heat stroke.
Z. Sponge with cool water, wrap in cool sheets or towels or blow cool air
over patient.
6. POISONING
Crucial steps
1. Induce vomiting as quickly as possible by administering a tablespoon of
ipecac syrup except in instances of ingestion of acids, alkalis and
petroleum products. Administer water, milk or universal antidotes; water
should be used if there is nothing else available. Do not give fluid to an
unconscious person.
Z. In instances of ingestion of acids, alkalis, petroleum products and other

caustics: attempt to identify the specific product, the concentration of the
active ingredients and the estimated volume ingested. The product
container or labels may be available. A dilutent may be beneficial if given
within E0 minutes of a solid or granular alkaline ingestion. Water or milk
may be administered, dosages of Z50 ml in adults and 15 ml/kg in
children. Induced emesis and attempts at neutralizing the substance by
using a weak acid or alkali are absolutely contraindicated.
E. Administer mouth-to-mouth or mechanical resuscitation if there is

difficulty in breathing.
4. If poison is in contact with the skin, remove all contaminated clothing

and flood the affected area with water.
5. If poison is in contact with the eyes, irrigate both eyes with large
quantities of water.
6. Identify the poisoning material or collect all vomited material in a

container and transport it to the hospital with the patient for laboratory
analysis.
7. HAEMORRHAGE
Haemorrhage may be arterial, venous or capillary.
Crucial steps
1. Apply pressure with fingertips to the pressure points and a bandage as
necessary.
Z. Apply tourniquet only when other methods fail and in the case of a life-
threatening haemorrhage.
E. A tourniquet should consist of a flat band at least one inch wide such as a
tie, handkerchief, towel, scarf or belt. Never use rope or wire. It should only
be applied in two places depending on the site of the injury:
– the arm, a hand's width below the elbow; or

– the leg, a hand's width below the groin.
8. SHOGH
Shock means there is not enough blood circulating through the body.
Symptoms of shock include: pale, cold and moist skin, shallow breathing,
bluish fingernails and lips, thirst and restlessness.
Crucial steps
1. Treat shock by removing the cause: stop the bleeding, relieve the pain,
splint the fracture.
Z. Prevent infection and maintain body heat.
E. Lay the patient flat.
4. Burn victims suffering from shock should be given liquids in small amounts.
P. IMPAIRED BREATHING
Mouth-to-mouth resuscitation
1. Glear the mouth and the throat of any dentures, mucus, food, blood or
other obstructions.
Z. Tilt the head back as far as possible and stretch the neck.
E. Lift the lower jaw forward.
4. Pinch the nose.
5. Open your mouth wide sealing your lips over those of the victim, take deep
breath and blow forcefully until you see the victim's chest rise.
6. Remove your mouth when you see the victim's chest rise; listen for exhalation.
7. Gontinue the same procedure 1Z-Z0 times per minute.

1. Familiarize yourself with the theory of first aid.
Z. Practise first aid procedures with the workers.
E. Know how to perform first aid techniques and artificial respiration.
4. Know how to decide to refer cases to the hospitals or emergency health

centres when required.
5. Keep health records of individual workers.

MODULE 8
Health education in
occupational health
1. OBJEGTIVES
 Describe patterns of occupational diseases and accidents
 Describe how different conditions within work environments may be related

to occupational diseases and how to reduce the risk
 Identify causes of work accidents and methods of prevention
 Describe how different styles of work practices might affect the health of the
worker, colleagues and others
 Discuss risk reduction of occupational diseases and accidents with workers

and managers in the workplace and identify suitable procedures to maintain
a healthy work environment
 Discuss how lifestyle and behaviour might affect health
 Describe various new methods of health education and how, when and
where to apply them as well as ways of motivation
 Describe the health education tasks the health worker is going to apply
and perform in different health problem situations in the workplace
 Identify psychological, cultural, religious and ethical values which might

affect the community health worker's ability to educate workers or
workplace managers on the work environment and prevention and control
of occupational diseases and accidents.
2. OGGUPATIONAL DISEASES
2.1 First steps

Explain to the trainees the definition of occupational disease and its causes:
– chemical agents: gases, vapours, mists, pesticides, etc.

– physical agents: noise, vibration, heat and cold stress, radiation, light,
etc.
– biological agents: bacteria, parasites, fungi, allergens, etc.
– psychological factors: interpersonal and social effects, relationship
with management, shift-work, etc.
– ergonomic factors.
 Discuss the routes of entry of noxious agents (skin, inhalation, ingestion)

and their forms (dusts, gases, vapours, fluids etc.).
 Refer to the importance of the early detection of health impairment and the
main signs and symptoms of some common occupational diseases in the
locality.
 Discuss the types of medical examinations (pre-placement, periodic and

routine), their importance and methods of implementation.
2.2 Methodology
Ask the trainees to pair up with someone in the group. Then direct them (in the
pairs) to discuss the following questions. One member of each pair should write
down their answers.
Questions:
1. In your opinion, what are the occupational diseases you would expect to
find in your district and why?
Z. Do you think that it is important to prevent occupational diseases?
E. Whether you answer yes or no, explain why.
Next, ask each pair to join up with another pair in the room. Any left-over pair
can join any of the groups of four. Give them some further time to continue
their discussion in the small groups. Then ask for feedback to the class
concerning:
1. The occupational diseases they expect to be found in their districts and why.
Z. The social and economic effects of occupational diseases.
3. OGGUPATIONAL AGGIDENTS
3.1 First steps

 Explain the definition and the causes of occupational accidents, e.g.
slipping, tripping up, falls of material and people, machinery, transport,
electricity at work, confined spaces, fires and explosions, personal factors.
 Explain that there are ways of minimizing the risk of accidents. Discuss safe
and unsafe worker behaviour. Stress the importance of tidiness and
hygiene in the workplace in accident prevention.
 Explain primary first aid steps in the case of work accidents and how to
refer cases urgently for medical support.
 Discuss rehabilitation, compensation and economic loss due to

accidents. Discuss the roles of the employer, workers and government
in accident reduction.
Health education in occupational health: Module 8 117
3.2 Methodology
1. Stick signs reading “Dangerous” and “Safe” on the board some distance
apart. Prepare in advance a large number of cards or strips of paper. On
each card write or draw a particular situation, either dangerous or safe, e.g.
 oil spills on the workplace floor
 covered machinery
 exposed electrical wires
 heavy boxes which are precariously placed on a moving fork-lift
 wearing of loose clothing with loose belts or strips of fabric near

revolving machine wheels
 other situations which may be relevant to your group of trainees.
Z. Hand out the cards at random to members of the groups and ask them to stick
their cards on the board at a point under the sign to which they feel it
belongs. You can help if the group cannot decide where to fit a certain card.
Each person who goes up to the board is encouraged to say whether he
disagrees with the position of any cards that are already there.
E. Finally, move any cards that are incorrectly placed and explain your reasons
for doing so.
3.3 Gase history

There are ƒive workers in a car repair workshop in your town. One oƒ these workers
had an accident while testing the revolving parts oƒ a truck engine. He had a deep
cut in his leƒt hand, was losing a lot oƒ blood and was in severe pain.
3.4 Methodology
 Divide the class into groups of five with an elected leader and a reporter
and acquaint them with the case history.
 Ask the class to discuss the necessary steps that the colleagues of the
injured worker should take in order to help him.
 Give enough time for group discussion and jotting down of comments, then
ask the reporters to give feedback to the class.
 Following the feedback from the groups, lead the class in a general
discussion on the topic. Gonfirm that only essential first aid should be
given, i.e. to stop bleeding by wrapping the hand with a piece of clean cloth
above the wound site. Then, either an ambulance should have been called
or the victim should have been transported as quickly as possible to the
nearest clinic or hospital for further medical treatment.
4. WORH ENVIRONMENT AND GONTROL

MEASURES IN THE WORHPLAGE
4.1 First steps

 Explain to the trainees the definition of the work environment and the
factors which affect it: physical, chemical, biological and ergonomic.
 Discuss the risks involved when there are uncontrolled conditions.
 Describe the methods of evaluation of the work environment

(measurements and interpretation of results) for noise, heat and cold,
illumination, radiation, air pollutants, gases, vapours and particles (air
sampling).
 Discuss ways of minimizing the health risks in all types of environment

through control measures (anticipation, recognition, evaluation and
control) and accident prevention. Point out that threshold values should
be followed.
 Discuss the importance of periodic inspection of the workplace. Use of

standard forms and questionnaires should be highlighted.
4.2 Methodology
Visit to an occupational hygiene laboratory

 The hygienist or responsible technician at the laboratory should brief the
trainees on the equipment used for work environment measurements, e.g.
noise level meters, light level meters, dust samplers, gas samplers, etc.
Visit to ƒactories/workplaces
 Select three or four factories/workplaces which have different industrial
activities and work environment hazards.
 Obtain permission from the factory management to bring the trainees on a

visit and fix the date and time.
 Prepare a form for the factory/workplace inspection using the Factory

Inspection Guidelines below.
 On the visit day, distribute a copy of the form to each group of trainees.
 Instruct each group to nominate a leader and a reporter.
 On arrival at the factory, instruct the group to question the designated

factory contact person using the prepared form.
 The groups then tour through the different parts of the factory, filling in
the rest of the form as they go.
 All groups return to the classroom and the reporters from each group
provide feedback on their findings.
 Lead a class discussion emphasizing the following points:
– the work environment

– workplace hygiene
– working conditions
– use of protective equipment
– need for health education programmes
– feedback to management
4.3 Factory/workplace inspection guidelines

 Name and address of the factory/workplace
 Industrial activity
 Raw materials used
 Final products
 Number of workers
 General hygiene of the workplace
 Safe-place approach
– equipment
– machinery “guarding enclosure”
– ventilation
– others
 Exposure hazards and risks

– physical
– chemical
– biological
– ergonomical
 Safe-person approach
– systems of work
– on-the-job training
– personal protection
 Pre-placement and periodic medical examinations
 Applied health education programmes
 Need for health education programmes
 Other points.
5. PREVENTION OF OGGUPATIONAL DISEASES

AND AGGIDENTS
5.1 First steps

 Discuss with the trainees the importance of the workplace site, the building
engineering plan and the layout of machinery (safe-place approach).
 Ask the trainees which methods would be suitable to maintain health

standards in the workplace.
 Discuss the importance of work practices education and job training for
workers (safe-person approach).
 Emphasize the importance of maintaining good workplace hygiene and

personal hygiene.
 State the benefits of pre-placement and periodic medical examinations.
 Discuss the roles of employer, worker and government.
 Explain the vital role of health education in occupational disease and

accident prevention.
5.2 Methodology
Equipment
Bring to class a collection of personal protective equipment, e.g. gloves, masks,
goggles, helmets, boots, aprons, etc., and discuss with the trainees the various
types of equipment and their benefits in prevention of occupational disease and
accident. Invite the trainees to try on the equipment in order for them to
understand how they are used.
Posters
Prepare and display posters showing workers following safe work practices:
correct method of weight lifting, wearing masks, goggles and gloves, etc., and
poor work practices: workers standing in front of unprotected revolving
machinery parts, workers without protective equipment while exposed to
gases, dusts, noise etc.
Discussion
Lead the class in discussion of these posters. Encourage the trainees to
comment on each poster and whether or not they agree with the work practice
indicated by the educational message. If they don't agree with the work practice,
invite them to suggest improvements.
6. LEGISLATION
6.1 First steps

 Inform trainees of the laws governing work environment and work
practices written by the ministry of labour, ministry of health, ministry of
industry, ministry of social security, etc.
 Discuss work accidents and occupational disease compensation and

rehabilitation legislation.
 Mention the role of the worker, employer and the government in the
settlement of these issues.
6.2 Gase history

Mr A is a worker in an iron workshop. He had a work accident in which he
damaged two bones in his right index ƒinger. He had to be treated in the district
hospital.
6.3 Methodology
 Divide the class into small groups with an elected leader and a reporter.
 Acquaint the trainees with the case history outlined above.
 Instruct trainees to discuss the advice they would give Mr A on any

administrative or legislative steps he should take.
 Ask the groups for feedback.
 The trainees should conclude that after Mr A has completed his treatment,
he should forward documentation outlining his injury to the labour office or
the social insurance department in order to claim compensation and/or
rehabilitation treatment.
7. EFFEGTS OF LIFESTYLE AND BEHAVIOUR

ON HEALTH
7.1 First steps

 Tell the class that in this session they are going to learn about the effects of
individual/community lifestyles and behaviour on health conditions. In many
instances, whether at home or at work, people can become ill or remain
healthy as a result of their behaviour and attitudes.
 Encourage trainees to give examples of correct health behaviour, e.g.

washing of hands and utensils with soap; storing of inflammable materials
away from work-sites, wearing protective clothing when required and
covering food against flies.
 Ask the trainees to discuss what makes people behave in certain ways. Ask
them to give examples of the causes of such behaviour and suggest
possible reasons behind the causes. Mention the main factors that
influence and direct people's behaviour: knowledge, beliefs, attitudes and
values.
 Tell the class that it is essential to understand the reasons behind a

community adopting a particular behaviour which may protect it from or
cause disease, in order to effectively use health education to encourage
changes in behavioural patterns.
 Ask the trainees to name a current health problem in their workplace or

community and then consider, in a class discussion, the most suitable
educational methods to deal with this problem most effectively.
7.2 Gase history

In a glass manuƒacturing ƒactory called X there is a powerƒul electricity generator
which supplies the ƒactory with electricity in case oƒ major power cuts or need ƒor
more power supply. The three operators oƒ the generator had a course in health
education covering noise hearing loss and noise control measures. During work
shiƒts they regularly use earmuƒƒs and schedule their noise exposure time.
Another ƒactory 7 also has a generator oƒ the same size which is used ƒor the
same purposes. But the three generator operators have not had a course in
health education about noise hearing loss and noise control measures. They do
not use earmuƒƒs regularly nor do they schedule their noise exposure time.
Aƒter 5 years the group in ƒactory 7 have started having hearing problems and
deƒects.
7.3 Methodology
 Divide the class into small groups with an elected leader/reporter.
 Acquaint each group with the case history outlined above.
 Instruct the groups to discuss the following:
– the behaviour of both groups of factory workers and their hearing

problems
– the personal behaviour in both situations
– the link, if any, between the behaviour of each group and the
conditions in the factory.
8. HEALTH EDUGATION IN THE WORHPLAGE
8.1 First steps

 Remind the trainees that the work environment can affect workers' health
through exposure to chemical, physical, biological and ergonomic hazards.
 Explain that a successful health educator:

– talks to managers and workers and listens carefully to their problems

– thinks about attitudes which can cause such problems or solve them
or protect them
– discovers the reasons for people's behaviour and health problems
– invites workers to give their ideas on solving the problems
– in conjunction with the workers, looks at these ideas and decides
which ones are beneficial, practical and easy to apply
– encourages factory managers and workers to select ideas appropriate
to their circumstances.
 Discuss the following points which are important when establishing a health
education programme:
– establishing good working relationships: how to encourage

cooperation and participation
– health education planning in PHG: information collection, problem
identification and understanding, prioritization, objectives and
procedures to be followed, resource identification and mobilization,
encouraging proper action and follow-up, selection of suitable health
education methods, results evaluation and revision of planning
procedures
– individual health education: counselling
– group health education
– community health education
– the importance of conveying the educational message at the right
time and place with worker participation and good subject
preparation and the need to test it in small groups before general
application.
 Tell the class about the principles on which PHG and health education in
the workplace can be organized.
 Emphasize that the aims of workers' education should be to develop the

capacity to construct an operational system capable of reducing
occupational hazards. The effectiveness of such a system should be
assessed by determining to what extent the incidence of health injuries,
disease or disorders is diminished.
 Explain that to effect this a number of steps should be taken:
– provide the necessary documentation

– make use of the workers' experience
– define priority hazards
– draw up the criteria for workplace improvements
– set the specific objectives to be achieved
– test the effectiveness of control measures.
 Introduce the idea that health education safety courses should be

specifically designed and held for foremen and group leaders. Periodic
meetings should be held by them with factory managers, factory health
personnel and safety officers to study the preparation made for safety
campaigns and to consider accident statistics, the causes of accidents,
risks to health and how to eliminate them.
 Review the briefing that workers should receive when they join the
workplace, including an information leaflet informing them of:
– internal traffic routes (if applicable)

– detailed descriptions of the work they will be doing and the tools
and raw materials they will be handling, as well as their dangers
and the precautions that need to be taken
– general safety regulations
– special safety rules for different types of work
– individual and group safety equipment
– the need to call for first aid at once in the event of an accident and
where such help can be found
– a balanced diet and safe sanitation.
This information leaflet should be reviewed from time to time and commented
on by the shop floor. Any relevant incidents should be used by the trainer as a
basis for a safety lesson, reinforcing the safety and health instructions.
8.2 Gase history

There are £00 workers in a cement ƒactory in your district. During the summer
months workers complain oƒ muscle pain (cramps), headaches and ƒatigue. In the
last month oƒ the summer, ƒour workers are diagnosed by the district physician as
suƒƒering ƒrom heat exhaustion.
8.2 Methodology
 Divide the class into small groups with an elected leader/reporter.
 Acquaint the class with the case study above.
 Instruct the groups to study the case history and plan a health education
programme for the workers of the factory. Remind them to mention all the
necessary steps they took in order to implement a successful programme.
 After sufficient discussion time, the reporters should provide feedback to

the group and general discussion should follow.
P. HEALTH EDUGATION METHODS AND AIDS
P.1 First steps

 Explain the two methods of health education—direct and indirect—and
discuss the merits and drawbacks of both.
– Direct method: a person giving information to individuals or groups

who are present in the same place.
– Indirect method: the person conveying the message is remote from
those who are receiving it, e.g. television, broadcasting, Internet
magazines, books.
Discuss the interactive teaching strategies required in order to allow instruction,

practice, feedback and motivation to take place:
– presentation
– large group discussions
– small group discussions
– role play
– case studies
– fact finding
– project work
– questions.
 Discuss the different aids by which a health education message can be

conveyed:
– Visual aids: boards or large sheets of paper or flip-charts,

photographs, posters, publications, newspapers, magazines,
transparencies used on an overhead projector, slides and slide
projectors, real objects, models.
– Audio aids: recorded tapes.
– Audiovisual aids: video tapes, cinema films, role play, exhibitions,
dummies.
P.2 Gase history

The ministry oƒ agriculture has an agricultural scheme in your district area. The
scheme uses diƒƒerent groups oƒ pesticides in order to control insects that are
harmƒul to the plants. The chemicals are also used against pests such as rats,
birds etc.
Last week the spraying teams, consisting oƒ 15 workers per team, started an
organophosphate insecticide plant spraying campaign. They were provided with
protective clothing but some workers did not wear it. They had breakƒast and lunch
breaks during the course oƒ the day. When the work was complete some oƒ them
went home still wearing the clothes they had worn while spraying.
Two days ago, ƒour oƒ these workers reported to the nurse oƒ the local project clinic
with respiratory problems and headaches. The provisional diagnosis was insecticide
intoxication. There were no antidotes to organophosphate insecticide in the clinic.
The aƒƒected workers were reƒerred to the district hospital, 50 kilometres away, ƒor
ƒurther ƒollow-up and treatment.
P.3 Methodology
 Hold a practical class session demonstrating the use of teaching aids.
 Alternatively arrange a visit to the nearest health education centre where

the trainees can see the educational aids in use.
 Acquaint the trainees with the case study above and divide them into
three groups with a leader/reporter. Ask each group to develop a health
education programme for this situation.
 The trainees must use at least one aid (more if desired) from each of the
educational aid categories: visual, audio, audiovisual.
 Ask the trainees to consider the following:
– What information are you conveying through these aids?

– To which groups?
– How are you planning to use these aids?
 Give the groups sufficient time to develop their programmes and to prepare
their aids. Move between the groups offering direction and advice.
 Ask the groups to present their health education programmes using the
three types of aids as required.
 Following this, hold a class discussion on how well each group arranged
and presented the required programme and how well they made use of the
available educational aids.
10. GOMMUNIGATION SHILLS IN HEALTH EDUGATION
10.1 The communication process

 Explain to the class that when we want to convey a health message to a
person or a group of persons, we need a communication process. When
the target audience understands the message in the way we want, then the
communication process has been successful. Education is primarily a
matter of communication.
 The most important communication skills are:
– establishing good relationships with people

– speaking clearly and making use of relevant vocabulary
– listening attentively
– ensuring that the message has been clearly understood and
explaining further if necessary
– using non-verbal communication tools efficiently
– refraining from bias and prejudice
– refraining from direct criticism of others and hurtful comments
– maintaining confidentiality if necessary
– being fully prepared when communicating the message
– adjusting the level of teaching to suit the recipients
– using suitable educational aids
– leading meetings competently.
10.2 Methodology
 Write two signs on the blackboard: “Gorrect” and “Wrong”.
 Prepare cards, each naming a type of behaviour in communication skills,

and perhaps a few words of explanation (see list below).
 Hand the cards out randomly to the trainees.

 Ask the trainees to place their card on the blackboard under the relevant
sign. If they are unsure they can pass their card on to someone else. The
trainees are free to disagree with each other.
 Finally, remove any cards which are clearly incorrectly placed and hold a
general discussion on the different situations and the correct options.
10.3 List of communication skills and behaviour

1. Speaking in a positive manner when addressing a large group.
Z. Shouting angrily at an audience.
E. Failing to respond when asked a valid question about a work environment.
4. Taking sides with one or two persons in a group even when they are not
giving suitable answers.
5. Openly criticizing students who give incorrect answers.
6. Giving correct information in a logical calm manner after a student's

incorrect answer.
7. Discussing openly confidential matters made known to the trainer during a

personal counselling session with a student.
8. Thorough preparation of lessons before the class begins.
9. Using unusual terms in a farmers' health education session.
10. Speaking above the educational and comprehension level of the target group.
11. Electing a well informed student to lead a group discussion.
1Z. Using role-play as a tool to educate illiterate farmers on the control of

biological work hazards.

1. Show skills in giving health education to workers in a workplace.
Z. Know the types of occupational diseases and accidents that occur in your
district.
E. Show skills in designing posters and preparation of handouts to workers.
4. Show skills in group discussions.
5. Show good communication skills with workers, managers and employers.
6. Know how to use and apply suitable aids for use in health education programmes.
7. Know how to give and discuss the main points found in work legislation
with regards to work relations, occupational diseases and accidents,
rehabilitation, compensation, workplace inspection, etc.
MODULE P
Epidemiology and biostatistics

in occupational health
1. OBJEGTIVES
 Understand the purpose and accept the importance of occupational
epidemiology and biostatistics in discovering causes, measuring risks and
determining priorities in intervention and evaluation;
 State the characteristics of epidemiology which distinguishes it from

other perspectives;
 Discuss the application of biostatistics in epidemiological studies;
 Describe the main types of study design used in occupational epidemiology.
2. DEFINITIONS
Occupational health may be considered to be a component of public health.
Epidemiology and biostatistics are key disciplines in public health. Whereas
clinical medicine tends to be concerned with the investigation and management
of an individual patient's problem, population-based studies are an integral part of
occupational health practice.
Epidemiology: the study of the distribution and determinants of health-related

states and events in populations and the application of this study to the
control of health problems.1 The fundamental goal of these investigations is to
obtain a valid and reasonably precise estimate of exposure-disease
association in groups. “As applied to occupational health, epidemiology thus
has the dual task of describing the distribution of deaths, accidents, illnesses
and their precursors … in the workforce … and of searching for the
determinants of health, injury and disease in the occupational environment.”1
Occupational epidemiology: the study of the occurrence of disease in relation

to work-related determinants. It follows that, in reviewing any individual with a
health- related problem or any workplace with a hazardous environment, the
investigator must ask the following questions:
 Who is at risk?
 Where?
1
Epidemiology oƒ work-related diseases and accidents. Tenth report oƒ the Joint ILO/WHO
Committee on Occupational Health. Geneva, World Health Organization, 1989 (WHO Technical
Report Series No.777).
 When?
 How?
Biostatistics: the discipline of statistics concerned with the description,

summarization and interpretation of data as well as the development of
procedures to accomplish these objectives.
Occupational biostatistics: an important tool in the quantitative study of

morbidity and mortality in humans, relative to exposure in the workplace.
Random sample: a sample of size n selected from a larger population is

random if each individual within the population has equal probability of being
selected. When a sample is not random, the occurrence of the characteristic
being investigated may be related to the likelihood that an individual was
selected for the sample. Therefore, it is necessary to assess bias and selection
factors carefully before generalizing from the results of a study based on non-
random samples.
Arithmetic mean: usually denoted as x-, the arithmetic mean is a measure of the
central tendency of the data. It is given by the formula:
x1  xZ  ...  xn
x n
If the sample is randomly selected from a large population, x- estimates a

population mean usually designated as .
The arithmetic mean is strongly affected by extreme values in the data. If a

variable has a fairly symmetric distribution, the mean is used as the
appropriate measure of central tendency.
Median: the “middle” observation, or 50th percentile, i.e. half of the observations
lie above the median and half below.
Mode: the most frequently occurring observation. It is rarely used except when
there are a limited number of possible outcomes.
Standard deviation: usually denoted as S, the standard deviation is a measure of

the “spread” of the data about x. It is given by the formula:
(x  x )
i
Z
n1
The square of the standard deviation, s£, is the variance. If the sample is
randomly selected from a larger population, s and s £ estimate the population
parameters  and Z.
Bias or systematic error: usually a result of flaws in the study design or data
collection.
Gonfounding: the effect of an extraneous variable that may partially or

completely account for an apparent association between a study exposure
and disease.
Epidemiology and biostatistics in occupational health: Module 9 131
3. BIOSTATISTIGAL DATA
3.1 Types of data

Data collected in medical research can be divided into three types: nominal
(categorical), ordinal and interval (continuous).
Nominal (categorical) data: data that can be divided into two or more unordered
categories, e.g. sex, race, religion. In occupational health, many outcome
measures such as cancer rates are considered separately for different sex and
race categories.
Ordinal data: one step up from nominal data, the difference being a
predetermined ordering underlying the categories. Examples of ordinal data are
clinical severity, socioeconomic status and ILO profusion category for
pneumoconiosis on chest X-ray.
Both nominal and ordinal data are examples of discrete data.
Interval data: Also called continuous data, interval data are measured on an
arithmetic scale. Examples include height, weight, blood lead and forced
expiratory volume. The accuracy of the number recorded depends on the
measuring instrument and the variable can take on an infinite number of values
within a defined range.
3.2 Sample size

The number of subjects needed to assess the potential exposure-disease
relationship is a fundamental issue when planning a study. The larger the sample
size, the greater the power to detect a specified difference in magnitude between
an exposure and a disease when it exists.
3.3 Ghance variation

This refers to the natural variation in health outcomes observed among
similarly exposed individuals. Two statistical tools used for assessing the role
of chance are the P value and the confidence interval.
The P value is the probability of obtaining by chance alone a difference in disease

rates between the exposed and unexposed as large as or more extreme than
what was observed. A P value of 0.005 means that the probability of obtaining by
chance alone an exposure effect as large as or more extreme than what was
observed is only 5 per 1000. Small P values (below 0.05) are sometimes referred
to as statistically significant.
The confidence interval (GI) gives the plausible values for the actual effect of
exposure with a desired degree of confidence, e.g. the 95% confidence interval
for the risk associated with an occupational exposure is an interval in which the
true relative risk will be included 95% of the time. A 95% confidence interval that
includes
1.0 implies that a value of 1.0 for the relative risk is plausible and thus the null
hypothesis of no exposure effect is consistent with the data.
3.4 2  2 table
The simplest statistical technique, the Z  Z table, is useful when occupationally
exposed and unexposed individuals are followed for equal amounts of time for
disease incidence.
4. TYPES OF EPIDEMIOLOGIGAL STUDY

Epidemiological studies measure the risk of disease directly in human
populations. There is no need to rely on questionable extrapolations across
animal species to estimate the impact of an exposure in humans. It is possible in
epidemiology to examine the consequences of an occupational and
environmental exposure in the manner in which it actually occurs in humans, not
the artificial manner in which laboratory studies of animals are done. The issue of
dose, route of exposure, concomitant exposures and host factors are also directly
assessed.
In essence there are three types of epidemiological study although, in practice,

the third is undertaken rarely, for ethical reasons.
 Descriptive studies: these describe events based on observation and

should lead to the development of causal hypotheses, which can be tested.
 Analytical studies: these involve the testing of hypotheses. If a

hypothesis seems to be supported, attempts should be made to refute it
in further studies and/or to undertake intervention studies.
 Intervention studies: these are undertaken to see whether an alteration

of exposure produces a change in the health outcome of the exposed
population.
The cohort study is the most common type of study in occupational

epidemiology. Information on a factor (or factors) is collected in a defined
population that is followed over time for the occurrence of a disease (or diseases).
The disease rate among those exposed is compared to the rate among the non-
exposed to assess if there is an association between the study factor and
disease. This study takes a long time to complete as investigators have to wait
sometimes years before acquiring enough cases of disease (or death). A
retrospective cohort study may be used to eliminate this long follow-up period.
Past records of individuals are used to characterize the exposure status of the
study objects and the disease status is determined until a particular date.
The major methodological advantage of the cohort study is that information on

exposure is recorded before the development of disease. This eliminates recall
bias.
The case–control study examines two groups. One group consists of people with
a particular disease and the other consists of those from the source population or
study base without the disease. Information regarding past exposures and habits
is obtained from each person in the two groups. If the exposure of interest is
reported by a larger proportion of cases than controls, an association between
the exposure and disease can be said to exist. Gase-control studies are more
efficient and suitable for the study of rare diseases and diseases with long latency
periods.
In the cross-sectional study people are selected regardless of exposure or
disease status. This study design is often called a survey or prevalence study.
5. GOMMON MEASURES OF DISEASE FREQUENGY
5.1 Introduction
The number of individuals with a diagnosed disease or with abnormal test results,
in general, cannot be interpreted without some additional information. An exception
to this rule is the occurrence of a disease that is so rare that any case is unusual,
e.g. three cases of hepatic angiosarcoma diagnosed among about Z70 workers
during a three-year period were sufficient to make a plant physician suspect that
the vinyl chloride they were exposed to was a carcinogen.
5.2 Grude rates

A rate is the frequency of a disease per unit size of the group (or population)
being studied.
Point prevalence rate: the simplest rate based on the number of cases
present at one point in time.
Prevalence rate = the number of cases present at a given point in time  the
total population at risk at that given point in time
This rate can be compared with a general population rate or rate from an
appropriate control group to determine if it is excessive. A limitation of
prevalence rate alone, however, is that it counts all cases of the disease
without differentiating between old and new cases.
Incidence rate: a rate that removes the background cases and focuses more
clearly on new or recent events. It is based on the number of new cases
occurring over a specified period of time.
Incidence rate = the number of new cases of disease during a given period of time 
the total population at risk during that time
Person–years: When the incidence rate is intended to measure disease onset

occurring in the group at risk over the course more than 1 year the appropriate
denominator is person-years. This value simultaneously takes into consideration
the number of individuals and the time period over which they were observed and
considered at risk of developing the disease. It therefore permits the inclusion of
individuals who were not at risk for the whole time period. This is particularly
important when new employees or terminations of contract are counted or when
risk in a specific time period is evaluated.
5.3 Specific rates

In some instances, a crude or adjusted rate for the entire population may obscure
an important association. When opposite trends exist in different parts of the age
spectrum, these trends may offset each other and be masked by a summary rate.
5.4 Gomparison of rates

Independent of whether rates are represented by homogeneous subgroups
or adjusted for appropriate variables in the entire group, the rates must be
translated into risks to evaluate the effects of exposure.
The two major types of risk estimates based on comparisons of rates are the
ratio of rates (relative risk) and the difference between rates (attributable risk).
The relative risk, or rate ratio, is designed to communicate the relative

importance of an exposure by comparing rates from an exposed population to
an unexposed or normal population. In its simplest form, it is the ratio of two
rates.
The attributable risk, or risk difference, is designed to communicate the amount of

disease that can be attributed to the exposure under study. This concept is
particularly useful and necessary in occupational disease studies because few
diseases can be attributed solely to an occupational exposure. The attributable
risk is calculated by subtracting the rate of particular disease in the normal or
unexposed population from that in the exposed population.
6.1 Question 1
The data in the table below show the distribution of days absent from work
among workers in four selected industries. Galculate the mean, median and
mode duration of absence in each industry. Gomment on the difference
between industries.
Period of
absence
(days) 0 1 2 3 4 5 6 7 8 9 10 Total
Industry
A - - 16 113 36 5 4 2 1 - 1 178
B - 1 1 2 2 - 27 - - - - 33
C - - 12 33 20 28 35 7 1 4 6 146
D - 97 6 2 6 28 11 27 2 1 4 184
6.2 Question 2
A survey of female textile workers showed that 8% had bacteria in their urine.
 Formulate the study question.
 Specify additional information you need to determine if a health problem

exists.
 Identify whether or not the study questions are epidemiological issues.

6.3 Answer to question 1
Industry Mean Median Mode

A 3.35 3 3
B 5.42 6 6
C 4.84 5 6
D 3.26 1 1
6.4 Answer to question 2

 What is the prevalence rate of bacteriuria in female textile workers?
 The expected prevalence rate for a comparable group of women is needed.
 It is an epidemiological problem.
MODULE 10
Record keeping
1. OBJEGTIVES
 Be aware of the importance of record keeping and reporting in occupational
health;
 Keep records on workers' health and report the results of investigations

as required;
 Be acquainted with the coding systems used in record keeping.
2. PURPOSE AND TYPES OF REGORD
2.1 Purpose
No matter how small an occupational health service is, record keeping is a
necessary part of its activities. Records are never an end in themselves; they are
tools that fill a need. In an occupational health service, records are used for:
 documentation of an employee's exposure to hazards
 employee health data for job placement
 documentation of employee health overtime
 provision of employee health overtime
 fulfilment of regulatory requirements.
2.2 Types
There are seven types of basic record on workers' health. The keeping of some
of these records may be required by law in some countries. PHG workers must
be told the statutory requirements with respect to keeping records on workers'
health.
Health and saƒety inspection

These records must contain the date, the person carrying out the inspection and
the findings of the inspection. In designing the inspection record form, it is
advisable to consult with the district health centre as it may be interested in
producing a form for all workplaces in the area.
Environmental monitoring
This is only applicable to places which require environmental monitoring on a
routine basis. The scheme of monitoring is devised by either the occupational
health and safety committee in the workplace or by the district health centre. This
includes
the form for keeping records. The PHG workers are trained to take readings with
simple instruments and record them systematically. The records are handed over
periodically to experts for interpretation.
Health monitoring
This is only applicable to certain groups of workers in some workplaces. The
PHG workers are trained either to collect specimens periodically and send them
to the designated laboratories for analysis, or to arrange for the workers to have
their specimens taken and examinations done periodically in designated
laboratories. The PHG workers are responsible for keeping the records supplied
by the designated laboratories systematically and for submitting them to the
occupational health and safety committee in the workplace or the district health
centre for information and any action which may be required.
First aid provided in the workplace

First aid treatment records are often kept at the first aid station at each work site
rather than at a central occupational health clinic in a plant or in the district PHG
centre. This permits accidental injuries to be recorded at the work sites where
they occur, eliminating the need for an employee with a trivial injury to leave work
and go to the clinic simply to record the occurrence. The occupational health
clinic/ district PHG centre should receive and keep copies of these records and a
record of all first aid treatment which it has itself provided. This record is called
the acute care register.
First aid records are sometimes mandated by government regulation and are
always important to the assessment of compensation claims. They also provide
data vital to the assessment of the accident prevention programmes.
Accident investigations
There are three reasons why companies need to record and investigate
occupational accidents:
 to identify the real causes of injury and illness, property damage and near-
misses (accidents that might have happened)
 to develop effective methods of preventing future similar accidents
 to meet legislative requirements.
This is usually done by an expert on the occupational health and safety

committee in the workplace or a labour inspector. These records must be kept
systematically. The PHG workers must read the records thoroughly so that the
knowledge on the findings can be applied.
Sickness certiƒication
This recording is usually done by medical practitioners and kept by the
management. The PHG workers must be supplied with abstracts of these records
on a periodic basis. This will enable the PHG workers to relate any common
sicknesses among workers to the findings of the health and safety inspection
and the health education programme.
Record keeping: Module 10 139
Personal health records

This set of records concerns the health status of each individual worker. It
inevitably contains personal, privileged information which has special
significance in law. Personal health records should be kept in their original
handwritten form even if typed or computerized versions also exist.
A worker's personal health record should only reflect his/her health status insofar
as it applies to the job. The content may therefore vary a great deal. The
information which is usually found in the record includes:
 results of physical examinations
 X-ray and laboratory reports including EGG pulmonary function results and
audiograms
 immunizations
 occupational and medical history
 participation in health programmes
 workers' compensation and medical insurance
 informed consent forms and authorizations for release of information
 documentation of refusals to undergo examination, testing and

programme participation
 progress notes for rehabilitation
 consultant reports.
3. REGORD HEEPING
The best way to keep records is the simplest manner consistent with convenient,
economical and efficient but controlled access. Dedicated forms are particularly
useful but a trial in use should always be carried out before they are introduced
into full service. If coding systems are used they should be compatible with
existing, widely recognized systems, e.g. coding of illness and injury should be in
accordance with the International Statistical Glassification of Diseases and
Related Health Problems of the World Health Organization.
It is recommended (in some countries it is mandated by law) that records be

retained for at least E0 years. This is in the event of subsequent health
problems being identified. These records must be transferred to a
responsible recipient or a government agency if the employer, clinic or district
centre goes out of business.
Gomputer storage permits automatic and very rapid retrieval of data in any
combination and desired sequence. This is invaluable not only for worker
health evaluation but for health programme operations and audit.
When considering the possibility of recording specific information or ceasing to

record it, the following questions should be asked:
 Is this information required by regulation?
 Will this information be used?
 Will its use justify the cost of maintaining it?
 Gan the information be obtained easily and with accuracy?
 Will the process of obtaining the information contravene or compromise

legislated human rights?
 Are secure facilities available to store the record for the required
retention period?
In general, a good occupational health record allows a reader to piece together a

clear and coherent picture of workers' exposure on the job, health status,
treatments and job assignments for a period of at least E0 years. Many
associations between chronic disease and occupational exposures have been
made using such records, and they are always important legal documents.

1. Visit the medical point at the workplace: check the records available and
evaluate the quality of the recording.
Z. Familiarize yourself with the forms used by the district health care centre to
collect information on workers' health.
E. Review the national regulations regarding the recording system of

occupational accidents and illnesses.
4. Design a form for collecting information for each type of proposed record
in the module.
5. Familiarize yourself with the software used for recording occupational

accidents and illnesses.
6. Familiarize yourself with the International Statistical Glassification of

Diseases and Related Health Problems of the World Health Organization.
MODULE 11
Occupational health in special

areas
1. MINING
1.1 Ob¿ectives
 Be aware of and be able to describe the special problems of mines:
physically, chemically, biologically and socially
 Learn how to set priorities in order to rank work-related actions and

actions related to sanitary services
 Be familiar with typical situations and their problems: specifically,

overloading, unhealthy conditions and dust exposure
 Learn where and to whom to refer for environmental monitoring consultations
 Have first-aid knowledge
 Know the health system, social welfare and health legislation
 Learn to use appropriate literature, checklists and data sheets
 Find ways to promote the health of the worker, to create awareness and
to improve the working environment
 Learn accident reporting, accident investigation and simple accident prevention.
1.2 Introduction
Minerals and mineral products are the backbone of most industries. For many
countries mining accounts for a significant proportion of the gross domestic
product and for the bulk of foreign exchange earnings and foreign investment.
Mineworkers face a constantly changing combination of workplace

circumstances, both daily and throughout the work shift. Some work in an
atmosphere that is without natural light or ventilation. Despite the considerable
efforts in many developing countries, the toll of death, injury and disease among
mineworkers means that, in most countries, mining remains the most hazardous
occupation when the number of people exposed to risk is taken into account.
1.3 Recognition, evaluation and simple control of harmful

factors in mines
Physical hazards
(a) Noise
 definition
 effect on humans, e.g. deafness, hearing loss and psychological inconvenience
 prevention and control measures, e.g. instrument inspection, enclosing of

source of noise, acoustic barriers for noisy tools and ear protection devices.
(b) Vibration
 definition and examples of vibrating instruments
 types of vibration: nuisance, segmental and whole body vibration, hand-

arm vibration syndrome
 basis of prevention and control measures: repairing, improving or

changing tools and machinery, use of personal protective devices and
determining of work and rest time.
(c) Heat and humidity
 definition and heat sources
 effects on humans: fatigue, heat rashes, heat exhaustion, heat cramps
 prevention and control measures: use of cool and salty liquids,

determining of work and rest time.
(d) Harmful radiation
 definition of ionizing radiation
 non-ionizing radiation effects on human organs, eyes and skin
 prevention and control measures: suitable clothing, personal protective

equipment
 monitoring of external radiation by film dosimeters.
Chemical hazards
 definition and characteristics of dusts, fumes and gases
 dusts which cause pneumoconiosis, silicosis, silicotuberculosis
 chemicals which may mix with oxygen to cause explosion
 hazards of smoking among miners
 the effects of carbon dioxide, methane and hydrogen sulfide on health

(carbon monoxide, nitrogen oxides)
Occupational health in special areas: Module 11 143
 diesel exhaust gases: nitrogen oxides, fine particulates, sulfur oxides,

polycyclic aromatic hydrocarbons
 prevention and control measures: wet processes, less dust production,

personal protective equipment
 determining of work and rest times
 adequate ventilation for miners
 identification and monitoring of the contaminants by detection tubes
 biological hazards, occupational infections, tuberculosis.
Accidents
 causes of accidents in mines, e.g. fire, explosion
 unsafe mechanical and physical conditions
 unsafe acts
 unsafe personal factors
 risk assessment and appraising safety performance
 principles of accident prevention.
Ergonomics
 biomechanical background
 physiological background
 posture (sitting, standing)
 change of posture
 hand and arm postures
 movements
 lifting, carrying, pulling, pushing
 psychosocial (urbanization of rural areas, night shift, continuous work).
Health ƒacilities in mines

 hygienic lavatory
 bath
 restaurant
 dressing-room
 safe drinking water
 waste and sewage management.

Health surveillance
 pre-employment examination, periodic examination
 tests for assessment of health impairment, e.g. forced vital capacity, forced
expiratory volume, peak expiratory flow rate, blood pressure, body
temperature, pulse rate, weight and height measurement.
1.4 Tasks for trainees

1. Visit the workplace, collect data about the workers, the work and work
environment.
Z. Set priorities based on observations, measurements, discussions, etc.
E. Offer advice on some simple prevention and control measures.
4. Refer problems to the referral system which cannot be solved by the

community health care workers.
5. Educate workers on health and safety.
6. Apply first aid.
2. SMALL-SGALE INDUSTRY
2.1 Ob¿ectives
 Be aware of all health and safety-related hazards; learn how to define
problems and special needs
 Describe the physical hazards and their control (see 1.E)
 Learn how to set priorities in order to rank actions
 Familiarize yourself with the typical problems associated with small-scale

industry, e.g. long working hours, absence of holidays, lack of medical care
and social insurance
 Know the health system, social welfare and legislation
 Have first aid knowledge
 Learn how to use appropriate literature, checklists and data sheets
 Find ways to promote the health of the worker, to create awareness and to
improve the working environment.
2.2 Definition
There is no internationally agreed definition of a small-scale industry. Various
parameters can be used to define it, e.g.
 number of employees
 amount of capital invested
 annual turnover or sales
 amount of raw materials used
 degree of mechanization and automation.
2.3 Working conditions

In most instances, working conditions in small-scale enterprises do not
compare favourably with the larger and more affluent industries: low wages,
poor working practices, lack of resources and a relatively hazardous work
environment are the major factors affecting conditions in the industrial sector.
The hours of work are long. A 1Z-hour work shift and a 7-day week are common.
Young children may be employed, even in heavy work. Machinery used may be
obsolete in design and not properly maintained, increasing the possibility of
accidents and exposure to hazards. Work sites may be situated in family
dwellings, posing hazards not only to the workers but to the other family members
as well, or in slum areas where overcrowding, heat, dust and poor ventilation are
constant problems.
The standards of sanitation, hygiene, fire safety, protective equipment and first
aid are generally low. Workers who suffer accidents may not be covered by
compensation and workers may not even be paid on time. These conditions
contribute to the generally poor working environment of these industries.
The typical worker in a small-scale enterprise in developing countries has a low

level of education and comes from the lowest economic level of society.
His/her nutritional level and general state of health are usually below ideal. This,
combined with a work environment that is often hot, humid, overcrowded and
where hazardous substances are often handled and processed without even
elementary safety precautions, creates a situation with an overwhelming need for
occupational health services.
2.4 Health conditions of workers
Factors aƒƒecting the health oƒ workers

 state of the health of the worker before he/she started working
 working conditions prevailing in the workplace
 availability and accessibility of health and safety services at the workplace,

including provisions for periodic medical examinations
 awareness of the worker and his/her manager of the hazards inherent in

the work environment
 degree of enforcement and compliance with the legal provisions for

occupational health and safety services.
Parameters in the assessment oƒ the health conditions oƒ workers

After finding these factors to be adverse and unfavourable in many small-scale
factories, one can expect that the health of workers in these factories will be
gravely affected. Various parameters have been used to assess workers' health:
 incidence of accidents and injuries
 symptoms related to occupations
 lung function tests
 audiometry
 urine and blood-lead examinations.
2.5 Methods of prevention and intervention

 Increase awareness in occupational health and safety among managers of
small-scale industries as well as the workers themselves
 Find low-cost alternatives to health care delivery in the industrial sector
 Enact enforceable laws applicable to this problem where none exist as yet
 Provide incentives and motivation to comply with such laws and enforce
them with penal provisions if necessary.
2.6 Tasks for trainees

1. Visit a workplace, collect data about workers, the work and the work environment.
Z. Set priorities based on observations, measurements, discussions, etc.
E. Offer advice on some simple preventive and control measures.
4. Find out where to refer problems that cannot be solved by the

community health worker.
5. Educate workers on health and safety.
6. Apply first aid.
3. AGRIGULTURAL AND RURAL AREAS
3.1 Ob¿ectives
 Have an idea about general work conditions, environmental hazards and
the main health problems in the agriculture and rural areas
 Know how to survey workplaces using simple methods
 Know how to decide to refer cases to the hospital or health centre if required
 Know how to recognize general health problems of workers whether or not

they are work-related
 Know how to keep records and write reports.
3.2 General conditions and problems of life in rural areas
Demographic
 high proportion of children
 disproportionate low number of young adult males
 women and children participate to a great extent in the workforce.
Socioeconomic
 decrease in the agricultural land available with the continuous and
progressive increase in the size of the population
 soil loss
 desertification
 migration of farmers.
Housing
 poor building materials
 lack of internal planning and sanitary principles
 potential for outbreak of fire and ignition sources
 livestock and poultry housed in the same dwelling as the farmer.
Water
 prevalence of waterborne diseases
 lack of rural water supply system.
Sewage and waste disposal

 dung mixed with garbage as manure
 poor bathing and washing facilities
 use of rivers and canals as disposal facilities.
Nutrition
 undernutrition due to overpopulation/land area
 poor nutritional habits
 micronutrient deficiency
 prevalence of endemic parasitic disease
 high metabolic requirements due to high metabolic expenditure in

agricultural activities.
Education
 poor and inadequate education
 scarce teaching facilities
 high absentee rates of rural children
 lack of transportation facilities and bad weather.
Transportation and communication

 poor state of country roads and telephone services
 lack of marketing and medical care.
Clothing
 poor quality
 lack of personal protection equipment.
3.3 Gharacteristics of agricultural work

 type of work
 place of work
 the agricultural worker:

– sharecropper
– self-employed
– paid-worker
– mobile temporary worker.
3.4 Occupational hazards in agriculture
Physical hazards
 heat and humidity
 cold
 solar rays
 noise
 vibration (segmental or whole body).
Chemical hazards
 pesticides
 fertilizers
 animal feed additives.
Biological hazards
 zoonoses
 snakebites and insect and scorpion stings
 major communicable occupational diseases.
Dust hazards
 from soil, plants or animals
 may contain silica, fungal matter, animal matter, including insects and
excreta, storage mites, grain dust and flour dust
 also may contain agricultural chemicals such as fertilizers and pesticides.
Ergonomic hazards
 heavy work
 repetitive tasks
 poor ergonomic design of tools and equipment
 incorrect working habits.
Occupational accidents and hazards

 The rate of accidental death in agriculture is one of the highest
compared with other branches of production.
 The rate of serious as well as minor accidents is, on average, higher in

agriculture than in all other occupations.
 Fatalities are caused most often by machines, especially tractors; animals,

e.g. bulls, horses; falls; snakebites; fire and chemicals, e.g. pesticides.
 Non-fatal injuries are often caused by farm machines, hand tools, physical
strain, animals, slipping and falls.
 Musculoskeletal disorders due to ergonomic hazards are common.
3.5 Prevention
 environmental control
 health education
 personal protection equipment.

3.6. Tasks for trainees

1. Assist in performing simple diagnostic tests for zoonotic diseases.
Z. Assist laboratory technicians in stool and urine analysis for parasitic and
endemic diseases.
E. Help in assessment of pesticides or their end products and metabolites in

biological samples.
4. Recognize specific antidotes for pesticides and certain other agrochemicals.
5. Garry out first aid treatment for cases intoxicated by chemicals or pesticides.
6. Survey workplaces using simple methods and techniques.
7. Gollect biological and environmental samples.
8. Identify possible and potential sources of injury in the agricultural workplace.
9. Recognize general health problems of agricultural workers and whether or

not they are work-related.
10. Refer patients when necessary to the appropriate unit in the health
service system.
11. Educate and advise workers on health and safety problems in agriculture.
1Z. Keep records of individual workers as well as records of working groups

and surveys.
1E. Associate with members of the occupational health team, report their
observations and consult with them regarding control measures, the
need for environmental and biological monitoring and the management of
certain work- related or occupational health problems where applicable.
14. Assist in sanitation of the workplace with regard to water, waste, food, etc.
15. Detect and report on communicable, endemic, parasitic, occupational and

work-related diseases in the workplace.
16. Maintain constant surveillance and checking of proper usage of personal

protective equipment and measuring devices.
17. Participate with the managers and safety personnel in implementation of

occupational health programmes.
18. Recognize early signs of poisoning and respond appropriately.
19. Gheck animals in the area daily in order to detect any diseased animals as
early as possible.
Z0. Be capable of extracting an injured worker from agricultural equipment

without further injury.
Z1. Study and consider the possibility of the human factor in any occupational
accident.
ZZ. Educate agricultural workers about the causes of heat stroke.
ZE. Spot cases of heat stroke and then confirm by taking body temperature and
observing physical symptoms.
Z4. Know how to administer immediate first aid treatment for cases with heat
stroke.
Z5. Help with the application of research projects according to established

priorities using the simplest methods and techniques.
Z6. Make a health map of an area, highlighting risk areas and identifying risk
factors in order to implement appropriate methods to control and solve
problems.
MODULE 12
Occupational health for women

and children
1. WORHING WOMEN
1.2 Ob¿ectives
 Know the impact of occupational hazards on working women's health
 Have appropriate training on primary health care for working women
 Appreciate the importance of the extension of maternal and child health as

components of primary health care into the workplace
 Be acquainted with the reproductive health problems of working women

in various occupations
 Know the preventive health measures that will have an impact on

working women's health.
1.2 Occupational hazards

The number of women joining the workforce has steadily increased all over the
world during the last few decades.
Throughout history, women in developing countries have always worked hard, not
only as wives and mothers but also as workers in different sectors. Often
encumbered with many children and weakened by excessive and frequent
pregnancies, working women are subject to numerous risks e.g. fatigue,
malnutrition, undue mental stress and exposure to various hazards at their
workplaces.
Domestic work exposes women to many hazards which may undermine their health,
e.g. accidents, burns, backache from bending, and chemical exposure from
detergents, resulting in skin problems such as dermatitis.
In many countries, industrial expansion has occurred without sufficient protective

measures for workers. Women are under special pressure since, in many
instances, their jobs are considered by management to be of secondary
importance and medical facilities are consequently inadequate.
Female workers differ from male workers in that they are generally physically
smaller and are subject to specific stressful conditions peculiar to them, e.g.
menstruation, pregnancy and lactation. PHG workers caring for working
women should be aware of such conditions and their possible effects on work
performance, and the effect of the work environment on the health of women
at these times, e.g. there is a progressive increase in respiratory ventilation
during pregnancy which may lead to increased uptake of inhaled chemicals
from the air.
Psychosocial problems
Stress-related issues are encountered in nearly all jobs held by working women.
The majority of women are still employed in low-paying jobs. For a single mother,
a low wage and the home obligations of caring for children and doing the
housework can be particularly serious causes of stress.
Stress at work can come from many sources, e.g.:
 office workers and assembly line workers in factories have demanding and
repetitive jobs, which cause stress
 nurses often experience stress because their work is physically heavy and
hectic.
Chemical agents
Due to the higher content of body fat in women than men, toxic substances such
as organic solvents are retained more easily by women. Some studies suggest
that exposure to organic solvents causes menstrual disturbances. Some metals,
e.g. lead, can cause spontaneous abortion. Also some chemicals used in
hospitals, e.g. ethylene oxide, are known to cause abortion.
Many women are engaged in agricultural activities which means they are
exposed to pesticides and fertilizers. Some of the pesticides used in agriculture
are suspected to cause reproductive damage in women. Women working in
textile mills are exposed to organic dusts, e.g. cotton, which causes byssinosis.
Physical agents
Women working in the textile industry are exposed to noise, vibration and heat
stress, particularly in the spinning and weaving sections. Noise causes
vasoconstriction which may lead to low birth weight of babies. Studies have
shown that women are more susceptible to whole body vibration and heat stress.
Whole body vibration may damage the reproductive system. Radiation may also
cause a problem. In addition poor lighting is not uncommon in many jobs leading
to eye damage.
Biological agents
Nurses may be exposed to tuberculosis, hepatitis B, rubella virus, Toxoplasma
gondii, AIDS, etc. Women employed in agriculture are exposed to snake bites,
schistosoma, worm infestation, tetanus, etc.
Ergonomic problems
Bodily dimensions are an important consideration in physical work performance and
machine design and operation. Many industrial and agricultural processes and
machinery are designed for male workers making many machines difficult for
female workers to operate.
Occupational health for women and children: Module 12 155
1.3 Occupational health services for working women

Occupational health services should be established at all workplaces to ensure
that the total health and safety needs of working women are met.
Unfortunately, in many countries they are not accessible to large numbers of
workers, especially in agriculture and small-scale industries. In these cases,
PHG services should cater to the specific needs of working women.
Generally, the following points are of particular relevance to occupational health

care programmes for working women.
Special health education

Health and safety inspectors, occupational health inspectors, employers and
health policy makers should receive special training in health education for female
workers. Education concerning health risks, including reproductive risks for men
and women as well as potential effects on the foetus, and training in the safe use
of chemicals, must be prioritized.
Regulations to saƒeguard working women

Regulations and standards applying to the entire labour force should be reviewed
continuously for their relevance and adequacy to female workers. It is of special
importance that safe working conditions are ensured for female workers, and
pregnant workers in particular. It is important to prevent occupational hazards that
are particularly harmful to women. Minimum standards should be set up for
anthropometric parameters and physical capacity to be used in pre-employment
examinations.
Environmental monitoring
The role of the industrial hygienist is to monitor the working environment for
potential hazards. Environmental monitoring should be carried out regularly to
identify problems which could affect the health of working women. Occupational
hygiene standards should be recommended for various types of exposure, e.g.
lead, solvents, pesticides, etc.
Pre-placement medical examination

These should be used to help in the proper placement of women in jobs
appropriate to their physical, physiological and psychological capabilities.
Periodical medical examinations

Working women should undergo regular medical examination, especially those at
particular risk.
Equipment design
The design of tools, machines and equipment should take into account the
anatomical features and physiological capabilities of women.
Emphasis on underserved working women

PHG should focus on underserved working women, especially those employed in
agriculture and small-scale industries. In addition, maternal and child health
services should be available to such women.
Research and surveys

Research should be carried out on the effects on female workers of specific
hazards associated with a wide variety of exposure conditions.
Women´s rights
In addition to receiving information on occupational health and safety, working
women should also be informed of their rights in connection with health,
maternity and child care. It should also be ensured that women have sufficient
rest in the last trimester of pregnancy and during breastfeeding.
Women´s issues
In planning PHG services for working women it is essential to consider issues
specific to them and to include the basic elements of maternity protection,
family planning (the responsibility of men and women) and counselling.
1.4 Work exposure and pregnancy

The potential for reproductive hazards induced by workplace exposure is
widely recognized. These include:
 infertility
 spontaneous abortion
 malformation
 perinatal mortality
 low birth weight
 developmental impairment
 childhood cancer.
Of these, spontaneous abortion and malformation in the offspring have attracted

most attention in the occupational setting. For many outcomes it has been
suspected that both female and male exposure may be the underlying cause.
However, most studies and the best evidence relate outcome to the exposure of
the woman during pregnancy.
1.5 Risk factors Identified in certain occupations and industries

Health care occupations may involve exposure to many kinds of reproductive
toxins. Occupational factors which may carry a risk of spontaneous abortion
include:
 anaesthetic gases
 ethylene oxide (sterilizing gases)
 antineoplastic agents
 organic solvents
 methylene chloride
 tetrachloroethylene
 aliphatic hydrocarbons
 contact with fur-bearing animals
 lifting heavy burdens
 X-rays.
Anaesthetic gases were the first gases suspected of causing harm to the foetus.
Exposure has been effectively reduced in many countries. Recent studies have
not found a significantly increased risk for spontaneous abortion and congenital
malformation. Exposure to ethylene oxide, a gas used for sterilizing, increased
the risk of spontaneous abortions. Handling of antineoplastic drugs in hospitals
increases the risk of spontaneous abortion and malformation in the offspring.
Occupational factors appearing to carry a risk of malformations or functional

defects:
(a) Malformation
 organic solvents
 antineoplastic agents
 ionizing radiation (X-rays, radioactive isotopes)
(b) Functional defect
 lead (decreased cognitive capacity)
 noise (hearing loss).
The harmful effects of ionizing radiation are known, and exposure in medical
occupations is controlled. Health care work predisposes personnel to contagious
diseases, among which HIV is a prominent problem.
According to several studies, exposure to organic solvents and/or laboratory

work during pregnancy may increase the risk of spontaneous abortion and
congenital malformation. Although exposure to solvents is common in
numerous industries and occupations, it has been difficult to establish
whether specific solvents, or their combinations, or solvents in general are
responsible.
Exposure to heavy metals such as lead is suspected of causing reproductive

toxicity. Quite low exposure during pregnancy may harm the cognitive
development of the child.
Other occupational factors which should especially be controlled for during

pregnancy include:
 heavy metals
 PGBs (polychlorinated biphenyls)
 pesticides
 carbon monoxide
 carcinogens.
Ingestion of food oil containing PGBs has caused disturbances in children, with
some newborns of exposed mothers exhibiting small size, discoloration of
skin and nails and premature eruption of teeth. This signals concern for
occupational exposures too.
Garbon monoxide is a known asphyxiant for the foetus. Occupational exposure

during pregnancy should be avoided; nevertheless, exposure occurs mostly via
the mother smoking.
There are plenty of other chemicals which are suspected to be reproductive

toxins and numerous industries are hazardous from the point of view of
reproduction. In general, exposure to known carcinogenic and mutagenic agents
should be avoided during pregnancy because they are potentially harmful to
the foetus. Damage by these agents to the gametes is also possible prior to
conception.
Gongenital malformations and spontaneous abortions are the outcomes most

widely investigated so far. Reported episodes of breast milk contamination have
been mostly due to environmental pollution, but it should not be overlooked in
occupations where exposure to substances that may accumulate in the body, e.g.
PGBs and lead, is possible. Attention should also be paid to other exposures
(e.g. solvents) when the mother is working during the breast feeding period.
The production and fabrication of plastics may include exposure to the monomers
or to the thermodegradation products of the plastics. The textile industry has
many possible reproductive toxins. Hairdressers use many chemicals of potential
toxicity and flight stewardesses suffer more frequently from menstrual disorders.
The agricultural sector is often thought of as a safe workplace but it too can
pose threats to women's health. In agriculture, little distinction is made
between workplace environment and living environment, and farm workers
are wholly dependent on the farmer for subsistence, leisure time and housing.
Working women in agriculture face the risks of inadequate protection from
toxic substances, such as pesticides, herbicides, dipping chemicals, paint,
fertilizers and fuel. Farming also involves exposure to biological agents, such
as microbes, microbial toxins and mycotoxins. Biological exposures in
agriculture is significant and may become problematic with new
biotechnology.
Physical and psychophysiological factors may play a role in reproductive hazards.

The teratogenic and other harmful effects of ionizing radiation (e.g. X-rays,
radioisotopes) on the foetus are known. This information is taken into account in
many countries where the exposure of pregnant women is restricted by law. The
effects of night work, heavy lifting, high temperatures and whole body vibration,
as well as work with visual display terminals, need to be studied further.
1.6 Tasks for the trainees

1. Describe the main occupations in which women in your area work.
Z. Gharacterize the adverse health risks which working women are exposed to
in these occupations.
E. List the most important PHG services in your facility which may be
beneficial to working women.
4. Prioritize the health education topics you recommend to educate working

women within certain occupations.
2. GHILD LABOUR
2.1 Ob¿ectives
 Know the impact of occupational hazards on the growth of working children
 Be aware of the consequences of child labour on the community in general
 Know if a child's injury or illness is work-related
 Know how to teach health education to working children, their

employers, parents, teachers and the community.
2.2 Definitions and basic concepts

Ghild labour is defined as the paid employment of children younger than 18 years
of age.1 The legal minimum age limits for work differ from country to country and
from activity to activity. Many countries make a distinction between light and
hazardous work with the minimum age for the former generally being 1Z, for the
latter usually varying between 16 and 18. The International Labour Organisation
Minimum Age Gonvention (No. 1E8, 197E) also broadly adopts this approach,
allowing light work at age 1Z or 1E but hazardous work not before 18.
Nevertheless, the ILO also establishes a general minimum age of 15 years,
providing 15 is not less than the age of completion of compulsory schooling.
Ghild labour can be broken down into seven main types, none of which is unique
to any country or region of the world:
 domestic service
 forced and bonded labour
 commercial sexual exploitation
 industrial and plantation work
 street work
 work for the family
 girls' work.
1
Landrigan PJ et al. Ghild labor. Pediatric annals, 1995, Z4:657-6Z.
Most children who work do not have the power of free choice. Ghild labour is
associated with poverty, inadequate educational opportunities and failure to enforce
relevant laws and standards. Particularly severe child abuses have been
documented in so-called free enterprise zones, i.e. special industrial areas where
labour and environmental laws are not enforced.
Illegal child labour is widespread and hundreds of millions of children all over
the world are employed under unlawful conditions. According to the ILO at
least Z00 million children under the age of 14 are employed worldwide.
Illegal employment of children occurs in all industrial sectors and often under
sweatshop conditions. A sweatshop is defined as an establishment that violates
wage, hour and child labour laws as well as the laws protecting occupational
safety and health.Z Health and safety conditions in sweatshops are often
dangerous.
A decade ago, UNIGEF determined that child labour was exploitative if it involved:
 full-time work at too early an age
 too many hours spent working
 work that exerts undue physical, social or psychological stress
 work and life on the streets in bad conditions
 inadequate pay
 too much responsibility
 work that hampers access to education
 work that undermines children's dignity and self-esteem, such as slavery or

bonded labour and sexual exploitation
 work that is detrimental to full social and psychological development.
2.3 Why children work

 Poverty (poor economic and social environment) has always been the
reason that children work. Ghildren of landless peasants or of
underemployed parents are at greater risk since, by working, they can
contribute substantially to the family income.
 Ghildren working in exploitative, harmful conditions often come from

disadvantaged and economically vulnerable population groups,
including female-headed households, lower castes, indigenous or tribal
people and migrant families.
 Ghildren in traditional societies, usually in their closely knit family

situations, are sent to work by parents who consider work an essential part
of development and socialization.
Z
US General Accounting Office. Sweatshops and child labour violations: a growing problem in
the United States. Washington DG, Government Printing Office, 1989.
 Ghild labour is also generated by deficiencies in educational systems.

Schools may not represent a possible way to get out of poverty. Given the
low quality and implied costs of the education services available to the poor,
many parents, having themselves worked as children, tend to consider an
early entry into the labour market, rather than schooling, as the best way to
equip their children with skills useful for their future as adults.
2.4 Work and health of a child

Many of those who support the argument that children have to work to survive in
some situations strongly believe that work has something to do with promotion of
a child's health. Their reasoning: when a child earns an income, such income will
be used to buy food, clothing and, at times, shelter. And, such a child would be
protected from all forms of trouble, e.g. roaming the streets. In a situation where
the child is the only wage earner, the child's family is supposed to benefit and be
able to support other family members more effectively. They reason that work in
this context may enhance both the child's and the family's capability towards
good health.E
Consequences oƒ hazardous work ƒor children´s health

While the above may be true in an ideal situation, unfortunately studies show
that many children are deprived of opportunities for optimal education,
social intervention and physical growth. A review of the literature and reports
reveal the following as consequences of hazardous work for children's health:
 working children have poorer health status than non-working children
 malnutrition is quite common among working children
 impaired psychosocial development of working children has a long-term effect
 accidents among working children are frequent
 working children are not ergonomically compatible with the equipment and
tools provided by the workplace
 workplaces provide ample opportunity for acute and chronic poisonings.
Factors contributing to dangers to children

Ghildren are employed in a variety of occupations where dangers are not as
apparent. These dangers could affect a child's health and safety. Factors that
contribute to dangers for children include:
 certain work arrangements (e.g. separation from families, living inside

workplaces)
 exposure to specific hazardous processes and tasks (e.g. lifting heavy

weights, working underground)
E
Gust-Estrella DP. Gase studies in hazardous child labour. International child health: a digest
ƒor current inƒormation. Geneva, UNIGEF, 199E.
 exposure to hazardous materials such as chemicals (both in industry and

agriculture), dangerous machinery and dangerous tools
 exposure to hazards in the physical environment, including noise levels,

radiation exposure, extreme temperature of the working environment,
 poor lighting, chemical and biological hazardous agents, working posture

and dust
 general working conditions, including working hours, wages, number of

work days (per week or per month), amount of rest and recreation
 absence of health and safety measures including personal protective

equipment, welfare and health facilities, ergonomic considerations, first aid,
regular medical facilities, a system of referrals
 absence of environmental safety measures (such as safe water supplies

and toilets) and poor access to food
 lack of legislative protection (in the informal sector, in domestic work, etc.)
 inadequate supervision
 inadequate labour inspection services.
2.5 Risks of child labour
Risks to development
Work that is harmless to adults can be extremely harmful to children. Among the
aspects of a child's development that can be endangered by work are:
 Physical development: including overall health, coordination, strength,

vision and hearing. Garrying heavy loads or sitting for long periods in
unnatural positions can permanently disable growing bodies. Hard physical
labour over a period of years can stunt children's physical stature by up
to E0 per cent of their biological potential, as they expend stores of
stamina that should last into adulthood.4
 Gognitive development: including literacy, numeracy and the acquisition of

knowledge necessary to a normal life.
 Emotional development: including adequate self-esteem, feeling love and

acceptance.
 Social and moral development: including a sense of group identity, the

ability to cooperate with others and the capacity to distinguish right from
wrong. Ghild labour also interferes with play, which is important for normal
development; relaxation and freedom from fatigue are necessary for
children to grow and learn.
4
Allsebrook A, Swift A. Broken promise. London, Hodder and Stoughton, 1989:91.
Risks oƒ injury and death

The risk of injury is almost 10 times greater among children employed under
illegal conditions than among those working in compliance with the laws.
Examples are:
 lacerations
 amputations and crush injuries from machinery
 motor vehicle accidents involving farm vehicles on public roads
 suffocation in grain elevators and silos
 blunt trauma from large animals, e.g. as a result of being kicked by a cow.
Risks oƒ occupational diseases and poisonings

Ghildren are particularly vulnerable to certain problems and diseases and are
at greater risk in their occupational environment due to their lack of
experience.
The occupational environment contains a variety of chemical, physical, biological

and ergonomic hazards, e.g. exposure to certain dusts can lead to chronic lung
disease. Also, working children may experience a variety of toxic exposures at
work,
e.g. formaldehyde and dyes in the garment industry, solvents in paint shops,
pesticides in agriculture, asbestos in building abatement and benzene in
petrol filling stations. Young people may not have information or knowledge
about these hazards and sometimes, even if they have the information, they
may not be willing or able to take the necessary steps to protect themselves.
Risks to education
Education helps a child develop cognitively, emotionally and socially. Interference
with school performance is a serious consequence of child labour. Working
children risk having too little time for their homework and being overtired on
school days. The social environment of work sometimes undermines the value
children place on education.
Lack of education condemns children to the worst employment prospects and, in

turn, the sheer pressure of survival will result in these children joining the low
wage earners.
2.6 Prevention and protection measures

Any effective measure to protect working children from workplace hazards
must begin by highlighting both the children and the dangers they face.
Recognition of the situation is the first vital step. Next, the presence of strong
and determined political will is needed in order to formulate policies and
realistic programmes towards the effective termination of the practice of child
labour.
However, certain health problems of legally working children can be avoided

in the first place if there is appropriate job placement, i.e. a matching of the
needs of the job with the abilities and potential of the individual. A pre-
placement examination can also avert certain difficulties, e.g. when
prospective employees are allergic to various substances.
Working young people should be protected, as far as possible, from dangerous

working environments, e.g. areas where there is fast-moving machinery.
Where there are toxic substances, such as lead dust, the monitoring of the
concentrations of these substances in the air, as well as in blood and urine,
becomes important. Record keeping can be used to indicate sickness and
absenteeism that might point to specific difficulties.
Health promotion in workplaces should involve education on the broader issues

of accident prevention, nutrition, healthy lifestyles, etc.
The early treatment and subsequent rehabilitation of young people with injuries
and illnesses, whether physical or psychological, should be ensured.
However, prevention of injury and illness among working children, including illegal
types of work, requires a coordinated series of actions in several areas:
 Better education of children, parents, teachers, physicians and the business

community on the hazards of child labour.
 Better methods of diagnosis: occupational history should be routine in the

evaluation of acute trauma and should be used when assessing children
with potential work-related conditions, such as repetitive motion injury or
organophosphate poisoning.
 Development of better data to define the extent and patterns of child labour:
better systems are needed to monitor the working patterns (legal and
illegal) of children and young adolescents: their number, age, employment
patterns by industry and occupation and the number of hours and days
worked. This information would help focus enforcement efforts and track
trends in childhood employment.
 Development of better data on work-related injuries in children and

adolescents: employers should be legally required to report all injuries of
working children and adolescents to the health and labour authorities.
 Strengthening and improving legislation and enforcement measures of child

labour laws.
 Ensuring that the main places where children work and the worst forms of
child labour are encompassed by national legislation.
 Ensuring that national labour and education laws are consistent so as to

eliminate the discrepancies which may exist between the minimum age
required by the law to work and the minimum age permitted to leave school.
 Improving schooling for the poor: the single most effective way to stem the
flow of school-age children into abusive forms of employment or work is to
extend and improve schooling so that it will attract and retain them.
2.7 Tasks for the trainees

1. Describe the main types of employment and occupations in which children
in your area work.
Z. Gharacterize the knowledge and attitudes of their families towards the

problem of child labour in general.
E. Review the available data on working children at the national level and define
the shortcomings. Discuss ways of broadening the sources and
strengthening the validity of data on child labour.
4. Design an occupational history questionnaire for approaching children's

injuries and illnesses suspected to be work-related.
5. Discuss the national legislation and standards related to child labour.

Suggest ways to improve their quality and enforcement.
6. Discuss the prevention and protection measures that can be applied to

certain occupations where children may be working legally.
7. Discuss the role that schools may play in confronting the child labour
problem; also the role of the community in general.
FURTHER READING
Genters for Disease Gontrol and Prevention, National Genter for Occupational
Safety and Health, Pocket guide to chemical hazards. Itasca, Illinois, National
Safety Gouncil Press, Z000.
Children at work: special health risks. Report oƒ a WHO Study Group. Geneva, World
Health Organization, 1987 (Technical Report Series No. 756).
Economically active population 1950-£010. 4th ed. on diskette. Geneva,

International Labour Organisation, 1996.
Harrington JM et al. Occupational health, 4th ed. Oxford, Blackwell Science, 1998.
Health promotion ƒor working populations. Report oƒ a WHO Expert Committee,

Geneva, World Health Organization, 1988 (Technical Report Series No. 765).
Jeyaratnam J, Koh D. Textbook oƒ occupational medicine practice. Singapore, World

Scientific Publishing, 1996.
Jeyaratnam J. Occupational health in developing countries. Oxford, Oxford

Medical Publications, 199Z.
Kitunga LJ. Working women. East Aƒrican newsletter on occupational health and
saƒety, 1989, Z:8-10.
LaDou J. Occupational medicine. New York, Appleton & Lange, 1990.
Last PA. Health protection and promotion. Women's health. In: Stellman JM, ed.
Encyclopaedia oƒ occupational health and saƒety, 4th ed. Geneva, International
Labour Organisation, 1998.
Levy BS, Wegman DH. Occupational health, recognizing and preventing work-
related disease, Znd ed. New York, Little, Brown & Gompany, 1988.
McGunney RJ, Rountree PP. Occupational and environmental medicine. Selƒ-

assessment review. Philadelphia, Lippincott Williams & Wilkins, 1998.
Occupational health for all. In: Biological monitoring oƒ chemical exposure in the
workplace, Vol. Z, Geneva, World Health Organization, 1996.
Plog BA, Niland J, Quinlan PJ. Fundamentals oƒ industrial hygiene, 4th ed. Itasca,
Illinois, National Safety Gouncil Press, 1996.
Rom WN, ed. Environmental and occupational medicine, Erd ed. Philadelphia,
Lippincott Williams & Wilkins, 1998.
World oƒ work. The magazine oƒ the ILO. Geneva, International Labour

Organisation, 1996, 16.

Organisation, 1997, 19.

Organisation, 1997, Z0.
7oung people´s health: a challenge ƒor society. Report oƒ a WHO Study Group on
young people and “Health ƒor All by the 7ear £000”. Geneva, World Health
Organization, 1986 (Technical Report Series No. 7E1).

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What measures can be taken to improve data collection on child labor?

What measures can be taken to improve data collection on child labor?

WHO-EM/OCH/85/E/L

World Health Organization

World Health Organization

Design by John Shimwell, EDR/EMRO

Further reading 173

First, the development of private enterprise, resulting in a proliferation of small

Second, with the introduction of new agricultural techniques, agriculture has

Third, occupational health problems have gradually increased in type and

The Declaration of Alma-Ata in 1978 led to the recognition of the importance

Hussein A. Gezairy MD, FRGS

There are different levels of PHG workers: doctors in charge of occupational

Health education and community participation

Prevention of health hazards at the source

National occupational health programmes require cooperation and team work

Gontribution to the national economy

The goals of this manual are:

 to create a category of health personnel that is well oriented in

 by following the PHG approach, to emphasize the preventive objective of

The manual outlines a curriculum for training of PHG workers/community

Dr IN Ababneh, Occupational Health Programme Manager, Ministry of Health,

Dr S Arnaout, Regional Adviser, Health of Special Groups, WHO Regional Office

Dr H Bashor, Associate Professor of Epidemiology, Department of Gommunity

Dr G Eijkemans, Occupational and Environmental Health Department, Protection

Dr MA El Batawi, former Ghief of Occupational Health, WHO headquarters, Geneva.

Dr GH El Samra, Professor, Department of Industrial Medicine and Occupational

Dr AM Emara, Professor of Occupational Medicine, Faculty of Medicine,

Dr ZI Fakhri, Occupational Health Department, Ministry of Health, Riyadh, Saudi

Dr AA Farshad, Ministry of Health and Medical Education, Teheran, Islamic

Dr H Frumkin, Associate Professor of Environmental and Occupational Health,

Dr G Hafez, Special Adviser to the Regional Director, former Director, Health

Dr R Helmer, Director, Protection of the Human Environment (PHE), WHO

Dr MA Khalil, former Director, Health Protection and Promotion, WHO Regional

Dr R Mahaini, Regional Goordinator, Family and Gommunity Health, WHO

Dr MI Mikheev, former Ghief of Occupational Health, WHO headquarters, Geneva.

Dr MH Noweir, Professor, Industrial Engineering Department, King Abdel Aziz

Dr P Rookmaaker, Professor, International Ergonomics Association, The

Mr AS Kaleem, Specialist in Working Gonditions and Environment, International

Occupational health: a definition

 the protection and promotion of the health of workers by preventing and

 the development and promotion of healthy and safe work, work

 the enhancement of the physical, mental and social well-being of workers

 enabling workers to conduct socially and economically productive lives and

Occupational health has gradually developed from a mono-disciplinary, risk-

Interaction between work and health

Positive health effects of work

Health, workplace, economy and sustainable development

Principle 1 of the Rio Declaration on Environment and Development (United

In terms of occupational health, the above principles mean the satisfaction of

Occupational health is at the centre of sustainable development in the following

 The prevention of occupational accidents, injuries and diseases and the

 The occupational health approach may facilitate undisturbed production

 Many environmental hazards and burdens are derived from occupational

 The impact of occupational health on environmental protection from

 Occupational health services aim to ensure workers' health, safety,

environmental health hazards just as it also provides effective models