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Competency 1 – Good Clinical Care: Appreciate the relevance of certain symptoms and their potential link to occupation

Objective:to be competent in the assessment and management of a case which has a significant occupational health component.

AREA OF COMPETENCE:

APPRECIATE THE RELEVANCE OF CERTAIN SYMPTOMS AND THEIR POTENTIAL LINK TO OCCUPATION

This is considered by looking at each system in turn:

  • Skin
  • Respiratory system
  • Musculoskeletal system
  • Hand Arm Vibration Syndrome
  • Mental Health Disorders
  • Symptoms of Poisoning
  • Hearing
  • Cancer

and providing the following information.

  • common ‘conditions’
  • ‘agents’ that might cause that condition
  • ‘Occupations at risk’ from acquiring the described condition.

Skin

Resources

1. ABC of Work Related Disorders: Occupational Dermatitis (BMJ 1996; 313:487-489)

2.University of Iowa College of Medicine Dermatologic Image Database

Condition: Irritant contact dermatitis (ICD)

This is caused by direct chemical or physical damage to the skin. Everyone is vulnerable to developing an irritant contact dermatitis if exposure is high enough.

The dermatitis may be acute or chronic in nature. The chronic form occurs after repeated exposure. People with atopic eczema are particularly at risk of developing chronic irritant contact dermatitis.

Agents which may cause ICD: Wet cement, vegetable juices, soluble coolants, detergents.
Occupations at risk of ICD: Hairdressers, construction industry, mechanics, cooks.

Condition: Allergic contact dermatitis (ACD)

This form of dermatitis can be due to a type IV hypersensitivity reaction. The dermatitis develops where the allergen comes in to direct contact with the skin. Contact allergens tend to be of low molecular weight. It is not possible as yet to determine an individual’s susceptibility to developing a contact allergy.

Type I immediate hypersensitivity responses may also occur giving ACD. An example is a reaction to proteins present in gloves made from natural rubber (latex). Here a local urticarial reaction may occur at the site of skin contact or it may present as respiratory symptoms e.g.: a wheeze when starched gloves have been used. This is important to consider as sensitisation can lead to anaphylaxis. It is a problem which health care workers need to be aware of although now non powdered or latexfreegloves are now routinely provided. There is an increased incidence of ACD in atopic individuals.

Agents which may cause ACD : latex, hairdressing chemicals, chromate, plant allergens
Occupations at risk of ACD: Hairdressers, health care workers, laboratory workers.

Condition: Folliculitis

This occurs due to irritation of the hair follicle. It is not a common condition but when seen can look like acne.

Agents which cause folliculitis: Cutting oils used to cool metal
Occupations at risk of folliculitis : Engineers, machine operators.

Respiratory System

Resources

Wheezing; shortness of breath; haemoptysis; flu-like illnesses; weight loss and cough can all be associated with respiratory pathology.

The potential link to occupation can be divided into the following subgroups.

  • Pneumoconiosis
  • Asbestos related disorders
  • Occupational Asthma
  • Extrinsic Allergic Alveolitis
  • Malignant Disorders.

Condition: Pneumoconiosis

Pneumoconiosis is a general term for conditions relating to the inhalation of dusts such as coal and silica. Coal miners with X ray changes often showed no symptoms or physical signs of disease. However, some cases go on to develop ‘progressive massive fibrosis, a disabling condition which presents with severe shortness of breath and in some heart failure (cor pulmonale). With the closing of the mines this condition is now uncommon in the UK.

Chronic silicosis still occurs in the UK and is related to inhaling silica dust, usually where working with slate or granite. An acute form of this disease is also seen in which individuals become acutely short of breath following exposure, with death in some cases in months. This type of exposure is associated with sandblasting.

Agents which may cause pneumoconiosis: Coal dust, Silica, Beryllium
Occupations at risk: Mining, sandblasting, iron and slate industry, electronic industry, dental alloy preparation.

Asbestos related disorders:

Asbestos exposure can lead to a number of different disorders broadly categorised as:

  • Non malignant Disorders
  • Malignant Disorders
  • Mesothelioma

Condition: Non Malignant Disorders

The non malignant disorders include asbestosis, pleural plaques, diffuse thickening of the pleura, benign pleural effusions and asbestos corns.

Asbestosis produces a diffuse interstitial pulmonary fibrosis. The diagnosis is obtained from the history and evidence of other pathology related to asbestos exposure. Asbestos corns can present as tender calluses on the hands.

Condition: Malignant Disorders

Malignant disorders related to asbestos exposure are bronchial cancer and mesothelioma of the pleura and peritoneum. It is essential in any individual presenting with a bronchial cancer to exclude exposure to asbestos as these people are eligible to state compensation. Other occupational causes of lung cancer include radiation and chromium exposure.

Condition: Mesothelioma

Most cases of mesothelioma are due to pleural disease. The disease usually occurs 20 – 40 years after exposure. The incidence of death due to this disease in the UK is still rising. The onset of the disease is often insidious with patients complaining of increasing shortness of breath and chest pain. Examination often reveals a pleural effusion. Death usually occurs within a year of diagnosis, so treatment is usually palliative. All cases of mesothelioma related to occupational exposure are eligible for industrial injuries benefits which is compensation obtained from the Department for Work and Pensions.

Agents: there are 2 types of fibrous mineral silicates that cause asbestos disease.

  • Serpentines: Chrysolite known as white asbestos
  • Amphiboles: Crocidolite is blue asbestos and amosite, brown asbestos

Occupations at risk: Demolition workers, ship yard workers, insulation workers, builders, gas fitters, roofers, carpenters, electricians, asbestos workers.

Condition: Occupational Asthma

Occupational asthma is caused by exposure to specific sensitising substances that are inhaled whilst at work. Such substances are called respiratory sensitisers. This does not include other irritants such as cold or exercise that an individual might encounter in work that can cause bronchoconstriction. There are increasing numbers of sensitisers recognised as likely causes of occupational asthma.

Taking a detailed history of the timing of symptoms along with an occupational history is very important in making the diagnosis of occupational asthma. Here symptoms are initially better whilst on holiday and on rest days. There are often related symptoms of a runny nose. The treatment for occupational asthma is no different to asthma in general, although it is important to avoid further exposure to the sensitiser, as once the lungs become hypersensitive, further exposure to the substance, even at quite low levels, may trigger an attack.

It has been estimated that 1 in 10 people diagnosed with asthma have an occupational origin.

Agents: Isocynates, flour, laboratory animals, enzymes, glutaraldehyde, soldering flux, wood dust, resins
Occupations at risk: Coach and other paint sprayers, laboratory technicians and assistants, baking and milling, joinery, welders, electronic assembly, nursing, manufacturing of plastics.

Condition: Extrinsic Allergic Alveolitis

Extrinsic allergic alveolitis is a granulomatous inflammatory reaction caused by an immunological response to inhaled organic dust or chemicals ‘Farmers Lung’ and ‘Bird Fancier’s lung’ are the most commonly seen of these conditions. Here patients complain of flu like illness and shortness of breath. This usually resolves after 48 hours. More severe disease is associated with weight loss and fatigue. The diagnosis is made from the occupational history, the examination, reduced lung function and antibodies to the causal agent found in the serum.

Agents: Mouldy hay and straw, bird excreta and bloom.
Occupations at risk: Agriculture, horticulture, forestry. caring or handling birds.

Musculoskeletal System

Resources

Risk factors causing Musculoskeletal disorders (MSD) can be found in virtually every workplace from commerce to agriculture, health service and construction. An estimated 11.6 million working days are lost each year due to work-related MSD’s.

Working practices that are associated with an increased incidence of MSD’s are:

  • Repetitive and heavy lifting
  • Bending and twisting repeating an action too frequently
  • Uncomfortable working position
  • Exerting too much force
  • Working too long without breaks
  • Static postures
  • Adverse working environment (e.g. hot, cold)

Psychosocial factors (e.g. high job demands, time pressures and lack of control) which impact on a workers general wellbeing are also thought to lead to an increase in incidence of MSD’s.

Symptoms related to MSD can be divided into two major categories

(i) Back pain

(ii) Upper Limb Disorders:

Condition: Back pain

This is the commonest cause of injury and lost time in the workplace, it is seen in nearly every occupation and industry. Approximately 119 million working days are lost annually due to back pain in the UK.

Agents: Multifactorial: occupational and non occupational

Heavy manual handling: repetitive /awkward bending

Static postures

Occupations at risk: Nursing, construction work, miners.

Condition: Upper Limb Disorder (ULD)

The term upper limb disorders (ULD) is now used instead of ‘repetitive strain injury’ (RSI). ULD is an umbrella term for a range of disorders of the hand, wrist, arm, shoulder and neck. It describes conditions characterised by discomfort and or persistent pain in the soft tissue structures of the neck and upper limb areas. Physical signs may or may not be present, and the condition is caused or aggravated by work factors. It is categorised as follows:

Type 1: Where there is a clear diagnosis e.g. frozen shoulder, carpal tunnel syndrome.

Type 2: Where there is no proven underlying pathology e.g. diffuse non specific forearm pain

Agents: ULD are usually multifactorial conditions: occupational and non occupational factors co exist but work place features include static muscle activity and repeated or forceful dynamic activity.

Occupations at risk: Meat packers and cutters, Assembly line workers.

Hand Arm Vibration Syndrome

Resources

Also known as ‘Vibration White Finger’. Symptoms can result from almost any vibrating source in contact with the hands (and the feet in some situations) if the vibration is sufficiently intense.

Condition: HAVS

Hand arm vibration syndrome, also known as HAVS consists of

  • Circulatory disturbances: vasospasm with local finger blanching where the term “white finger” developed..
  • Sensory and motor disturbances: numbness, loss of finger co-ordination and dexterity, clumsiness and inability to perform intricate tasks.
  • Musculoskeletal disturbances: muscle, bone, and joint disorders.

Agents: Pneumatic tools: air compressed and electrical, Sanders, drills, fettling tools, jack hammers, chainsaws, brush saws, hedge trimmers.

Occupations at risk: Forestry workers, Mining and engineering industry, foundry workers

Mental Health Disorders

Resources

Mental health complaints now form the largest cited cause of long term sickness absences in the UK. This is due mainly to stress, anxiety and depression. However, the prevalence of mental health disorders such as schizophrenia and bipolar disorder has remained overall static. Mental health disorders will be considered under the following headings.

  • Major mental health conditions e.g.: schizophrenia, bipolar disorder, psychotic disorders
  • Common mental health conditions e.g. anxiety, stress, depression
  • Post Traumatic Stress Disorder
  • Alcohol and substance abuse

Condition: Major Mental Health Conditions

The incidences of conditions such as schizophrenia and bipolar disorder have remained almost constant over the last ten years.

The impact these disorders have on an individual to manage within the workplace will depend on the severity of the symptoms at any one time. It is possible that someone with a psychosis may function normally in the workplace for many months or years until they develop an exacerbation of their symptoms. Recognising an exacerbation of symptoms and providing the right support will be important in managing the employee and their ability to remain or return to employment. Employment that requires high technical skills or a high degree of responsibility might be more difficult for the individual to return to. There are some forms of employment where a history of psychiatric disease may preclude employment e.g. diving, off shore work (unless fully free of symptoms and off medication for at least one year), public service vehicle drivers, and pilots. Efforts to address maintaining people with severe disease within suitable employment are now being more actively addressed and there are a number of organisations providing support and advice to individuals and their families.

Condition: Common Mental Health Conditions

(i) Depression and anxiety disorders

Common symptoms of anxiety include:

Palpitations, headaches, backache, breathing difficulties

Feeling tense, on edge, worrying about things.

Panic attacks .

Common symptoms of depression include:

Lack of concentration at home and work

Impaired sleep

Feeling low, bouts of crying.

Poor appetite, lethargy, low motivation

(ii) Stress

Stress occurs when there is an imbalance between demands made upon an individual and their perceived ability to meet those demands. In particular, an individual’s perception of their control over the demands being made upon them.

Common symptoms of stress include:

Irritability, aggression or obsessive behaviour

Lack of concentration

Indecision

Increased alcohol consumption

Poor time keeping

Frequent short term absence

Non specific physical symptoms-headaches, sweating, palpitations, nausea

Causes of work-related stress:

  • Job content
    Overload, under load, time pressure, deadlines
  • Work organisation
    Shifts, unsociable hours, restructuring
    Organisational culture; communications, feedback, support.
  • Work role
    Role clarity, role conflict.
  • Interpersonal relationships
    Harassment, bullying, verbal and physical abuse.
  • Career structure
    Under promotion, over promotion, pay structure, redundancy
  • Physical environment
    Noise, temperature, space, lighting
  • Home-work interface
    Childcare responsibilities, transport problems

Condition: Substance abuse

Drug and alcohol misuse can have a devastating effect on users, and those people who have contact with them: family, friends, and co-workers.

It has been defined as a condition which may cause an individual to experience social, psychological, physical or legal problems related to addiction or one-off use, and is focused on problems rather than types of drugs.

Symptoms and signs of substance abuse are dependent on the drug taken, mode of administration, the quantity and the setting. The most common features can also be signs of a physical or mental health problem, and hence it is important to exclude such causes first.

Common features are:

  • Change in behaviour or performance at work
  • Sedation; varying levels of consciousness
  • Stimulation; hyperactivity
  • Aggression
  • Increased levels of sickness absence.

Condition: Post Traumatic Stress Disorder (PTSD)

The essential features of PTSD are the development of characteristic symptoms following psychologically distressing event outside the range of usual human experience (i.e. outside the range of such common experiences as simple bereavement, chronic illness, business losses and marital conflict. The symptoms need to be present for longer than I month.

Characteristic symptoms include:

  • Re-experiencing the traumatic event
  • Avoidance of stimuli associated with the event
  • Numbing of general responsiveness
  • Increased arousal
  • Flash backs

Occupations at risk: There is a close inter-relationship between personality, workplace environment and social economic factors. Some occupations have a higher incidence of mental health problems than others. Health care workers have a high incidence of mental health problems. Ambulance personnel have one of the highest rate of stress in healthcare workers. Doctors have high incidence of alcohol abuse and suicide. Other occupations that have high levels of stress and depression include teachers and army personnel.

PTSD is seen particularly in occupations such as the police force, fire fighters and the armed forces.

Symptoms of Poisoning

Resources

There are many chemicals that are used in occupation that can be poisonous. These can be broadly separated into conditions that cause peripheral nerve disorders ( Peripheral neuropathies) and central nervous system disorders,

Common symptoms of poisoning include:

  • Drowsiness/altered perception/tiredness/headaches.
  • Dizziness
  • Nausea
  • Abdominal pain/ constipation
  • Tingling or loss of sensation in the extremities

Condition: Peripheral neuropathies

Agents: Lead, arsenic, organophosphate pesticides ,

Occupations at risk: Lead battery production, gardeners

Condition: Central nervous system disorders

Agents: Manganese, Benzene, Styrene, Perchloroethylene.

Occupation at risk: Chemical industry, dry cleaning

PESTICIDES

The term pesticide refers to the way some chemicals are used. There are many differing types of chemicals used as pesticides and therefore a variety of side effects and toxic effects that can occur from their use.

Types of pesticides include:

  • Herbicides – To kill pest plants, mainly weeds
  • Rodenticides – To kill warm blooded pests
  • Insecticides- To kill spiders and insects

Most insecticides are readily absorbed through the skin. The rate of absorption is greater in very vascular areas such as the scalp and when the skin is hot. Insects are usually at their height in the summer, when the weather is hot. Therefore the need to be adequately covered when spraying is important to reduce the risk of exposure, even in high temperatures.

The most health relevant insecticide is the cholinesterase group which cause over stimulation and then paralysis of the muscarinic and nicotinic receptors. An example of this group is the organophosphate insecticides eg malathion. Complications include severe bronchorrhea, seizures, weakness, and neuropathy. Respiratory failure is the most common cause of death from severe exposure. Pralidoxime is the specific antidote to acute poisoning and must be given within 4 – 6 hours to be effective. Chronic exposure to organophosphates can lead to neuropsychiatric, extrapyramidal and other neurological symptoms. It has been described as causing a chronic fatigue like syndrome in farm workers exposed to the pesticide following sheep dipping.

ADVERSE EFFECTS OF GASES

Adverse effects of gases either asphyxiate or irritate.

Asphyxiation:

This occurs due to displacement of Oxygen or due to a temporary change of a metabolically active protein e.g. carbon monoxide poisoning.

Irritation:

This occurs when a gas is inhaled that has a pH away from 7.4 such as the aldehydes e.g. formaldehyde

Two irritant gases are generated from the constituents of air itself. Ozone results from the action of ultraviolet light on air; oxides of nitrogen result from the heating of air to flame temperature when oxygen and nitrogen chemically combine. Both ultraviolet and strongly heated air occur during arc welding.

Hearing

Resources

1. ABC Work Related Disorders: Hearing Loss BMJ 1996; 313:223-226

2. Health, Environment & Work – Noise induced hearing loss

Condition: Noise Induced Hearing Loss

Prolonged repeated exposure to noise can lead to hearing loss, which is often permanent. This is due to destruction of hair cells in the cochlea and is typified by hearing loss at 4000 Hz. This hearing loss is ‘sensorineural’ and is called ‘Noise Induced Hearing Loss’ (NIHL).

Other symptoms related to prolonged noise exposure include:

  • Tinnitus
  • Vertigo
  • ‘Loudness recruitment’. Here at a certain volume perceived sound suddenly becomes more intense.
  • Non-auditory effects; these are other symptoms that are associated with hearing loss and include annoyance, distraction, fatigue, and sleep disturbance

Agents: Exposure to noisy environments e.g. Armed Forces, construction sites, airfields.

Hobbies: motor cycling, playing drums, rock concerts, shooting

Occupations at risk: Air traffic controllers, construction, printing

Cancer

Resources

ABC Work Related Disorders: Occupational Cancer BMJ 1996; 313:615-619

Other work-related causes of cancer

Apart from asbestos dust, some well-recognised occupational carcinogens include fine hardwood dust which causes nasopharyngeal carcinoma, benzene which causes myeloid leukaemia, and vinyl chloride which causes Angiosarcoma of the liver. Importantly, the major constituent of quartz and sand, silica (SiO2), has been classified as a human carcinogen by the International Agency for Research on Cancer. This applies to fine particles that are likely to be liberated in high energy industrial processes and not, of course, to child’s play in a sand pit or on a beach.

What to ask a worker when you suspect work-related cancer

In regard to particular cancers, enquiries about the following jobs/substances/exposures would be appropriate:

  • Mesothelioma – a rare cancer that can arise spontaneously but largely as a result of exposure to asbestos – construction and demolition work involving asbestos-containing products, applying and removing insulation on steam pipes – (lagging); manufacture or fitting of motor vehicle brake blocks or clutch facings; the mining of asbestos (overseas)
  • Squamous cell carcinoma of the skin – outdoor work involving exposure to sunlight with skin which is insufficiently protected
  • Lung cancer – very smoky atmosphere, heavy asbestos exposure, or asbestos plus smoking; work that involves months or years of exposure to inhaling fine particles originating from sand or quartz – silica
  • Bladder cancer – work with tar or pitch; some dyestuffs
  • Myeloid leukaemia – benzene (C6H6, benzene, an organic chemical liquid)
  • Carcinoma of the nasal cavity – furniture manufacturing generating fine hardwood dust

Apart from dermatitis and cancer, there are two other groups of conditions that should be mentioned in the context of ‘could it be my work, doc?’. The first group, pneumoconioses, is of declining incidence; the second group, ‘syndromes’ ascribed to causes and medically under-defined illnesses, are becoming more prominent in the compensation area.

There are many known or suspected carcinogens. The most widely accepted list is that of the International Agency for Research on Cancer (IARC).

Examples of such cancers are:

Melanoma

Angiosarcoma of liver

Lung cancer

Bladder cancer transitional cell tumours

Bone marrow cancer

Carcinogen Related cancer Occupations at risk
Sunlight exposure Melanoma Agriculture, fishing, forestry
Vinyl chloride monomer Angiosarcoma of liver Chemical Industry (plastic manufacture)
Arsenic, chromium compounds Lung Metal Industry e.g. chromium plating
Aromatic amines Bladder Dye manufacturing, rubber product manufacturing
Ionising radiation, cytotoxic drugs Bone marrow Radiographers, pharmaceutical industry

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