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EPIDEMIOLOGICAL INVESTIGATION OF OCCUPATIONAL HEALTH AND SAFETY CONCERNS

Objectives
To understand the purpose and accept the importance of occupational epidemiology in determining causes, measuring risks and establishing priorities for intervention and evaluation To define Epidemiology and its application to Occupational Health and Safety (OHS) To discuss Epidemiologic Historical Perspectives in relation to OHS

by: Gallego, Misena and Rubayat OH 206: Workplace Surveys Master of Occupational Health College of Public Health University of the Philippines Manila

Objectives
To discuss the Stages of Occupational Epidemiologic Investigation To discuss the different phases of occupational epidemiologic investigation i ti ti To be able to describe the main types of study design used in occupational epidemiology To be able to illustrate the application of the above with examples

Objectives
To explain different sampling techniques to use in the studies To discuss methods in obtaining data in epidemiological studies To discuss the basic considerations in the design of epidemiological investigations To discuss various sources of occupational epidemiological data

Objectives
To institute control measures base on the result of the study To discuss occupational epidemiological monitoring and surveillance ill To identify the problems in Occupational Epidemiology To discuss the applications of Occupational Epidemiology Summary

Definition
Epidemiology study of the frequency, distribution and determinants of diseases and other health related conditions in human populations, and the application of this study to the promotion of health, and to the p , prevention and control of health problems. Occupational Epidemiology study of the effects of workplace exposures on the frequency and distribution of diseases and injuries in the population.

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Levels ofApplication
Surveillance todescribe theoccurrenceofillness and provide warningsignals ofunrecognized occupational hazards Generation andTesting ofHypothesis G ti d T ti fH th i todetermine harm caused byexposure and quantify its effect Evaluation ofIntervention Tomeasure changesinthehealth status ofa populationovertime

Historical Perspective
1700 : Bernardino Ramazzini Health is dependent on identifiable natural external factors. 1775 : Pott reported possible connection between cancer and occupation 1822 : A t P i surmised arsenic f Ayrton-Paris i d i fumes as causal agent for scrotal cancers 1874 : Von Volkmann reported skin tumors in paraffin workers 1876 : Bell suggested shale oil as responsible for cutaneous cancer.

Historical Perspective
1879 : Harting and Hesse observed lung cancer among Schneeberg miners 1952 : Doll lung cancer among gas workers 1954 : Case and Hosker studied bladder cancer in dye workers

STAGES OF OCCUPATIONAL EPIDEMIOLOGIC INVESTIGATION

PHASES
1. Diagnostic Phase presence of disease is confirmed 2 Inter-related Avenues of Diagnostic Phase: a) Intensive follow-up - a detailed, multifaceted study of all seemingly relevant aspects of a t d f ll i l l t t f disease even in a population unit. Example: Outbreak Investigation

PHASES
1. Diagnostic Phase presence of disease is confirmed 2 Inter-related Avenues of Diagnostic Phase: b) Surveillance - opposite of intensive follow-up; a disease accounting process i di ti i.e. a b d overall, broad, ll organized approach to the collection, collation analysis, expression and dissemination of data about diseases in populations. Examples: Death certificates, Cancer Registries, Hospital Records, Bureau of Labor Statistics, etc

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PHASES
Exposure Assessment critical step in identifying workplace hazards through epidemiological investigation. Important factors to consider:
a. b. c. d. e. f. Inventory of potentially toxic agents Presence and concentrations Routes of entry Time course of exposure and cumulative duration Engineering and personal controls Host and other considerations

PHASES
Summary Worklife Exposure Measures
Exposure measure Cumulative exposure index (CEI) Mean grade (MG) Highest grade ever (HG) Formula (grade x time exposed) Units grade and time

(grade x time exposed)/total grade time exposed highest grade to which exposed for days grade

Time-weighted average (grade x time exposed)/total grade (TWA) grade time employed Total time exposed (TTE) time exposed time

PHASES PHASES
2. Descriptive Phase - describes the population at risk and the distribution of the disease, both in time and space, within these populations; allows generation of a series of initial hypotheses. 3. Investigative Phase involves the implementation of a series of field studies to test the initial hypotheses.
Deaths, all causes

(hypothetical case)
10 12 5 3 100 5 10 persons

Newly diagnosed cases Previously diagnosed living cases

Deaths, disease of interest Persons in population Years observed Y b d Incidence Annual incidence rate Point prevalence (at end of year 5) Period prevalence (five-year period) Annual death rate Annual mortality rate

(10 + 12 - 3) = 19 persons (10 + 12) = 22 persons

PHASES
4. Experimental Phase performed under controlled conditions to test the hypotheses in more detail, should the result of phase 3 prove promising. 5. Analytical Phase - the results produced by the above investigations are analyzed.; often enables the epidemiologist to determine whether any vital bits of information about the disease process are missing.

PHASES
Biological markers assess target organ exposures, determining susceptibility and establish early disease. Its uses were: a. exposure assessment b. disentangle causative role of chemical b di t l ti l f h i l agent/substances in multiple exposures c. Estimation of burden of exposure d. Investigation of pathogenic mechanisms e. Study individual susceptibility f. Classify exposure/ disease accurately

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PHASES
6. Intervention Phase - appropriate methods for the control of the disease are examined either under experimental conditions or in the field. Interventions in the disease process are effected by manipulating existing determinants or introducing new ones.

PHASES
7. Decision-making Phase - a knowledge of the epidemiology of the disease is used to explore the various options available for its control; often involves the modeling of the effects. Cost benefit analysis of the control measures may be done in combination with other models, in terms of increased productivity.

PHASES
8. Monitoring Phase - takes place during the implementation of the control measures to ensure that these measures are being properly applied, are having the desired effect on reducing disease incidence, incidence and that developments that are likely to jeopardize the success of the control programs are quickly detected.

TYPES OF OCCUPATIONAL EPIDEMIOLOGICAL STUDIES

Case Control Studies

Figure1. Case Control Studies

TYPES OF OCCUPATIONAL EPIDEMIOLOGICAL STUDIES

Case Control Studies

TYPES OF OCCUPATIONAL EPIDEMIOLOGICAL STUDIES

Cross-Sectional Studies - prevalence of a particular disease or of a set of symptoms or other indication of ill-health is investigated in a single time-point (or over a relatively narrow period of time). Ex. Chest X-ray survey of quarry workers = Workers with high exposure to quartz have higher prevalence of pneumoconiosis than those with little or no such exposure

Figure2. Case of Occupational Cancer in Hardwood industry

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TYPES OF OCCUPATIONAL EPIDEMIOLOGICAL STUDIES

Cohort Studies

TYPES OF OCCUPATIONAL EPIDEMIOLOGICAL STUDIES

Cohort Studies

Figure4. Retrospective Cohort Figure3. Prospective Cohort

TYPES OF OCCUPATIONAL EPIDEMIOLOGICAL STUDIES

Cohort Studies Example: Time trends in cancer risk and pesticide exposure, a long-term follow-up of Danish long term follow up Gardeners (Hansen, E., et.al, 2007) Findings: There is a substantial pesticide exposure during the late 1940s and 1950s. Among gardeners born in 1915 or later, no excess cancer risk was found.

SAMPLING TECHNIQUES
Random Sampling - every unit in the population being sampled has exactly the same probability of being selected for the sample Multi-Stage Sampling - involves sampling a g p g p g population in different stages, with the sample unit being different at each stage Systematic Sampling - involves sampling a population systematically i.e. if a 1/n sample is required, every nth unit in that population is sampled. Ex. If a 10%(1/10) sample is required, every 10th unit in the population is sampled.

SAMPLING TECHNIQUES
Purposive Selection - involves the deliberate selection of certain sample units for some reason or other. The reason may often be that they are regarded as being "typical" of the population being sampled. Stratification - involves treating the population to be sampled as a series of defined subpopulations or strata.

SAMPLING TECHNIQUES
Paired Samples - variations in the sample groups due to host and management characteristics can sometimes be overcome by pairing individuals in the different sample groups according to common characteristics (age, sex, location) and then analyzing the paired samples; often greatly increases the precision of the study Sampling with and without replacement

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SAMPLE SIZES
Sample sizes for estimating disease prevalence in large populations - To what degree of accuracy do we require the results? - What sampling method have we used? - What is the size of the smallest subgroup in the population for which we require accurate answers? - What is the actual variability in the population surveyed of the variable we wish to measure?

SAMPLE SIZES
Sample sizes needed to detect the presence of a disease in a population concerns with the minimum sample size required to find at least one worker with the disease

Methods of Obtaining Data

Interviews and Questionnaires Questionnaire Functions: 1. Provides data on individuals which may not be available from any other source including p workplace records or environmental measurements 2. Permits targeted studies of specific workplace problems

Methods of Obtaining Data

Interviews and Questionnaires Questionnaire Functions: 3. Provides information about participant characteristics that are necessary for proper y p p analysis and interpretation of exposure-outcome relationships, especially possibly confounding variables like age and education, and other lifestyle variables that may affect disease risk like smoking and diet

Methods of Obtaining Data

Interviews and Questionnaires Types of Questionnaires: Mailed Questionnaire Telephone Questionnaire Face to face interviews Face-to-face Hybrid study design combination of the 3 types

Methods of Obtaining Data

Interviews and Questionnaires Stages of Survey Design Stage 1 Survey Design and Preliminary Planning Stage 2 Pretesting Stage 3 Final Survey Design and Planning Stage 4 Data collection Stage 5 Data reduction, data file construction, analysis and final report

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Methods of Obtaining Data

Interviews and Questionnaires Measurement Aspect of Questionnaire Design Validity degree to which a questionnairederived number approaches its true, but possibly unknown, value. Reliability measures the likelihood that a given measurement will yield the same result on repetition, whether that result is close to the truth or not.

Methods of Obtaining Data

Interviews and Questionnaires Questionnaires Content, Quality and Length 1. Wording 2. Question sequence and structure 3. 3 Type of questions 4. Length 5. Language 6. Clarity and leading questions 7. Questionnaire layout

Basic Considerations in the design of Epidemiological Investigations

Objectives and Hypothesis

Basic Considerations in the design of Epidemiological Investigations

Hypothesis Four Methods involved: 1. Method of Difference if the frequency of a y p disease is markedly different under two separate circumstances; cause of disease may be the factor absent in one circumstance and present in the other. 2. Agreement if a factor is common to a number of different circumstances that are associated with the presence of the disease = may be a cause of the disease

Figure5. Schematic Diagram in the formulation of Objective/Hypothesis (FAO)

Basic Considerations in the design of Epidemiological Investigations

Hypothesis Four Methods involved: 3. Concomitant variation involves the search for q y g a factor whose frequency or strength varies with the frequency of the disease 4. Analogy uses the process of deductive reasoning, whereby epidemiological principles already established are applied to other situations.

Basic Considerations in the design of Epidemiological Investigations

Hypothesis Consideration in the Formation of Hypothesis: 1. New hypotheses are commonly formed by g relating observations from several different fields 2. The stronger a statistical association, the more likely it is to suggest a causal hypothesis = Relative risk 3. Observations of change in frequency of disease over time have been very productive i.e., particularly of changes that have occurred over relatively short period of time.

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Basic Considerations in the design of Epidemiological Investigations

Hypothesis Consideration in the Formation of Hypothesis: 4. An isolated or unusual case should receive p particular attention in the formation of hypothesis yp 5. Observations that appear to be in conflict or to create a paradox are particularly worthy of consideration

Basic Considerations in the design of Epidemiological Investigations

Hypothesis How to state a hypothesis: 1. The characteristics of the persons to whom the yp pp hypothesis applies 2. The cause of being considered usually an environmental exposure 3. The expected effect the disease

Basic Considerations in the design of Epidemiological Investigations

Hypothesis How to state a hypothesis: 4. The exposure-response relationship the amount of cause needed to lead to a stated risk of the effect 5. The time-response relationship the time period that will elapse between exposure to the cause and the appearance of effect

Sources of Occupational Epidemiological data

Employee interviews Employer personnel and production records (these include work records, job descriptions, facility and process histories and chemical histories, inventories) Expert judgement

Sources of Occupational Epidemiological data

Biomonitoring data Industrial hygiene records (area, personnel, and compliance monitoring, and surface wipe samples, samples together with health hazard or comprehensive survey reports)

Sources of Occupational Epidemiological data

The use of existing data: Advantages: cheaper time efficient able to monitor progress of a disease through different worker population and able to establish linkages between disease events reduced chance of bias

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Sources of Occupational Epidemiological data

The use of existing data: Disadvantages: data sets are often incomplete data sources may have been collected for purposes other than the study objective

Instituting Control Measures

Engineering control Administrative control include recommendations and guideline to prevent recurrence PPE control
Note: Ensure that all control measures are well communicated to the workers at a level of their understanding

Monitoring and Surveillance

Surveillance continuous observation of disease or other safety- and health-related problems in general in a number of different working populations Monitoring continuous observation of a specific disease in a particular working population

Monitoring and Surveillance

Surveillance Provide a means of detecting significant developments in existing disease situations Provide a comprehensive and readily accessible d t b ibl data base on di disease, i j injury or other th health and safety-related problems in working populations for research and planning purposes.

Monitoring and Surveillance

Monitoring If control measures are being employed, provides a means to ascertain whether these measures are being carried out promptly and efficiently as specified i th program d i ffi i tl ifi d in the design It provides a means to ascertain whether the control measures being applied are having the desired and predicted effect on disease incidence ~ prompt and comprehensive disease-reporting system.

Monitoring and Surveillance

Monitoring It provides a means for a rapid detection of developments which might jeopardize the control program, or, in instances where no control measures are b i being i l implemented, which might t d hi h i ht warrant the introduction of control activities.

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Problems in Occupational Epidemiology

Internal Validity: Selection bias Self-selection bias Diagnostic bias Bias resulting from refusal to participate in a study Information bias Differential outcome assessment in prospective follow-up (cohort) studies Differential losses in retrospective cohort studies Differential assessment of exposure in casecontrol studies

Problems in Occupational Epidemiology

Internal Validity: Confounding Interaction or effect modification External Validity: can be addressed only after ensuring that internal validity is secured.

Applications of Occupational Epidemiology

Benefit for the workers Benefit for the community at large Reducing risks through reducing exposures

Summary
Epidemiological investigation of occupational health and safety concerns is a vital aspect of clinical epidemiology and occupational hygiene s ce p o des esse a a d p ac ca since it provides essential and practical information o a o to be aware of the causes and determinants of work-related ill health and injury, which thereby help in establishing necessary control measures or actions to take to reduce those risks and to evaluate the interventions for the benefit of the workers and of the community at large.

References
Agius, Raymond. (2006). Occupational Epidemiology. Retrieved December 20, 2012, from http://www.agius.com/hew/resource/occepi.htm. College of Veterinary Medicine, Nursing and Allied Health. (n.d). Epidemiology. USA: Tusekgee University. Retrieved December 30, 2012, from http://www.onemedicine.tuskegee.edu/Epidemiology/chap5_3.htm. Food and Agriculture Organizations of the United Nations (n d) The Nations. (n.d). epidemiological approach in investigating disease problems. Veterinary Epidemiology and Economics in Africa. Retrieved December 20, 2012, from http://www.fao.org/wairdocs/ILRI/x5436E /x5436e06.htm. Hansen, Eva S., et.al. (2007), Time trends in cancer risk and pesticide exposure, a long-term follow-up of Danish gardeners. Scandinavian Journal of Work, Environment & Health, Vol. 33, No. 6. Denmark: Proquest Central, pages 465-469.

References
ILO. (n.d). Epidemiology. Encyclopedia of Occupational Health and Safety, 3rd ed. Retrieved November 24, 2012, from http://www.ilo.org /safework_bookshelf/english?d&nd=170000102&nh=0. MacMahon, B. and Trichopoulos, D. (1996). Strategies of Epidemiology. Epidemiology Principles and Methods, 2nd ed. Boston: Little Brown, pages 65-84. Thomsen, Catherine, MPH, et.al. (2007). Indicators for Occupational Health Surveillance. CDC: MMWR Recommendations and Reports. Retrieved December 12, 2012, from http://www.cdc.gov/mmwr/ preview/mmwrhtml/rr5601a1.htm. Wikipedia. (n.d). Case control study diagram. Wikipedia: The Free Encyclopedia. Retrieved December 29, 2012, from http://en.wikipedia.org/wiki/Case-control_study.

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Thank you for your attention! Happy 2013!

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