Measured occupational solar UVR exposures of lifeguards in pool settings

Exposure to UV Radiation in Lifeguards on Barcelona's Beaches: An Underestimated Occupational Risk

BACKGROUND

The development of skin cancer is closely related to high exposure to UV radiation. Lifeguards are at an increased risk of excessive sun exposure.

OBJECTIVES

The main objective of this study was to measure the exposure of Barcelona's beach lifeguards to UV radiation.

METHODS

Measurements in the work chair were taken every 30min on a typical working day from 10:45 am to 19:15 pm. These measurements were carried out on four different days. These data were used to calculate the erythematous doses received during working hours, as well as those potentially received throughout the summer season. Vitamin D production was also estimated for the four days that the radiation received was measured, and the amount generated was calculated for the entire summer season.

RESULTS

Exposure to UV radiation among Barcelona lifeguards far exceeds safety limits. In some locations, the exposure to UVB radiation is more than 16 times the minimum erythematous dose for phototype II skin.

LIMITATIONS

This study assessed the radiation received during only four days. However, is a much higher number than most of the published papers.

CONCLUSION

Although the health risks of excessive exposure to UV radiation are known, Barcelona's beach lifeguards are insufficiently protected.

Exposure to UV Radiation in Lifeguards on Barcelona's Beaches: An Underestimated Occupational Risk

BACKGROUND

The development of skin cancer is closely related to high exposure to UV radiation. Lifeguards are at an increased risk of excessive sun exposure.

OBJECTIVES

The main objective of this study was to measure the exposure of Barcelona's beach lifeguards to UV radiation.

METHODS

Measurements in the work chair were taken every 30min on a typical working day from 10:45 am to 19:15 pm. These measurements were carried out on four different days. These data were used to calculate the erythematous doses received during working hours, as well as those potentially received throughout the summer season. Vitamin D production was also estimated for the four days that the radiation received was measured, and the amount generated was calculated for the entire summer season.

RESULTS

Exposure to UV radiation among Barcelona lifeguards far exceeds safety limits. In some locations, the exposure to UVB radiation is more than 16 times the minimum erythematous dose for phototype II skin.

LIMITATIONS

This study assessed the radiation received during only four days. However, is a much higher number than most of the published papers.

CONCLUSION

Although the health risks of excessive exposure to UV radiation are known, Barcelona's beach lifeguards are insufficiently protected.

Occupational Sun Exposure Among Physical Education Teachers in Primary and Secondary Schools in Andalusia, Spain

Chronic sun exposure and sunburns are the main preventable causes of skin cancer. Due to the nature of their work, physical education teachers are at high risk for occupational skin cancer. This descriptive, cross-sectional study analyzes primary and secondary physical education teachers in Andalusia, Spain. All participants were invited to monitor their ultraviolet (UV) radiation exposure using individual biologic dosimeters and record their photoprotection practices over 3 workdays. The teachers spent an average of 2.7 h outdoors and the mean personal UV radiation exposure was 309.9 J/m2 per day, a value three times higher than international recommendations. Based on the photoprotection diary, it was determined that classes held outdoors were not scheduled outside the hours with the highest UV index and that the percentage of participants who followed the photoprotective practices of remaining in the shade or wearing a hat during outdoor lessons were less than 20% and 60%, respectively. The results on sun exposure and photoprotection practices show a need for organizational and educational intervention strategies to mitigate sun exposure and increase compliance with photoprotection measures to reduce skin cancer risk among these workers and promote early diagnosis of the disease.

Protective Measures From Solar Ultraviolet Radiation for Beach Lifeguards in Tuscany (Italy): Shade and Clothing Strategies

Background

The exposure to solar ultraviolet radiation is a significant risk factor generally underestimated by outdoor workers and employers. Several studies have pointed out that occupational solar exposure increased eye and skin diseases with a considerable impact on the lives and productivity of affected workers.The main purpose of this study was to evaluate the effectiveness against ultraviolet radiation of some measures recently undertaken for the protection of lifeguards in a coastal area of Tuscany.

Methods

Different shading structures (gazebos and beach umbrella) were tested during a sunny summer's day on a sandy beach by means of two radiometers; the UV protection offered by some T-shirts used by lifeguards was also tested in the laboratory with a spectrophotometer.

Results

The analysed shading structures strongly reduced the ultraviolet radiation by up to 90%, however a not always negligible diffuse radiation is also present in the shade, requiring further protective measures (T-shirt, sunglasses, sunscreen, etc.); the tested T-shirts showed a very good-excellent protection according to the Australian/New Zealand standard.

Conclusion

Results obtained in this study suggest how the adoption and dissemination of good practices, including those tested, could be particularly effective as a primary prevention for lifeguards who are subjected to very high levels of radiation for long periods.

Ultraviolet exposure of competitors during a Tokyo Olympic Sailing Regatta Test Event

BACKGROUND

Overexposure to sunlight is the main cause of skin cancer. Photoprotection practices and sunburn play a crucial role in skin cancer prevention.

OBJECTIVES

This study aimed to quantify the risk of sun exposure and to evaluate photoprotection practices in Spanish sailors during Olympic competitions.

METHODS

Solar daily ultraviolet (UV) radiation cycle, personal UV dosimetry, photoprotection practices and sunburn checking were followed during three consecutive days of competition among sailors from the Spanish Olympic Sailing Team during a Tokyo Olympic Regatta Test Event.

RESULTS

A total of 13 sailors (7 women), with mean age of 27.6 ± 4.7 years and sports experience of 17.7 ± 5.4 years, were studied. The most common phototypes were type III (53.8%) and type II (38.5%). The rate of sunburn checked was high (46.2%). The mean daily personal UV exposure received was 761.0 ± 263.6 J/m² , 3.0 ± 1.1 minimal erythemal dose and 7.6 ± 2.6 standard erythemal dose, seven times greater than the maximum permissible UV light exposure values for an 8 h working day. The use of a T-shirt was the most common practice (94.2%), followed by the use of shade (50.2%), hat/cap (44.0%), sunglasses (26.1%) and sunscreen (11.8%).

CONCLUSIONS

Olympic sailor's studies presented high levels of UV radiation received, high rate of sunburn and insufficient adherence to sun-protective behaviours (especially, to use of sunscreen) to prevent sunburn, the main cause of skin cancer. Sport Federations should develop educational campaigns addressing sun-related exposure habits and photoprotection behaviours to reduce the risk of skin cancer among these athletes.

Criteria for Occupational Health Prevention for Solar UVR Exposed Outdoor Workers-Prevalence, Affected Parties, and Occupational Disease

Non-melanoma skin cancer (NMSC) is the most common cancer in western countries. Legislative bodies and stakeholders like WHO and EU strongly promote protection against solar UVR, especially in workers. Occupational health prevention must be introduced as a strong instrument in workers protection also with regard to occupational disease issues. To date, criteria for both occupational health prevention and occupational disease are missing and the identification of risk groups has no metric basis. Here I report a criteria analysis based on the largest comprehensive data set of occupational ultraviolet radiation exposure of outdoor workers. With detailed research on occupation-specific dosimetric measurements of 45.000 measurement days in 176 occupations and sub-occupations, it is possible to map criteria for occupational health prevention specifically and to identify affected occupations. The number of employees affected can be elucidated worldwide. For the first time, a direct link to retrospective occupational disease criteria could be established. Of the 176 occupations and sub-occupations selected for this work, 153 (=87%) exceed the criterion for occupational health prevention and thus need special attention. This includes all occupations with annual exposures of more than 150 SED. Employment figures for the EU and the world yield the total number of affected workers to be 36.1 million and more than 500 million, respectively. These new criteria for occupational health prevention are valid and in good agreement with international research on limit values by WHO and ICNIRP. If applied correctly and consistently, these criteria can prevent occupational disease. It will be possible to identify occupations and sub-occupations that have an urgent need for prevention to avoid chronic skin damage leading to cancer. This research serves as a basis for policy making and clinical risk identification, as well as for daily practice of occupational physicians and employers responsible for risk assesment.

A Case Study of UV Exposure Risk in Sydney during the 2019/2020 New South Wales Bushfires

During summer 2019/2020, Sydney, Australia, experienced several days of extreme air pollution and low visibility due to bushfires. This research presents a case study that investigates the erythemal UV irradiance and resulting one-hour erythemal and 8-hour actinic exposures during the worst of these days. Air quality, meteorological and UV data used in the analysis was readily available online or by request from governmental agencies. Analysis showed that even for the lowest visibility day (which had a minimum visibility of less than a kilometre) on 10^th December 2019, there was a cumulative one-hour erythemal UV exposure of over 4 SED (Standard Erythema Dose) and a cumulative 8-hour exposure of 17 SED by the late afternoon. The one-hour exposure exceeded that for a minimum erythemal dose. Even on this extremely hazy day, these cumulative exposures are enough to exceed the recommended daily exposure limit for actinic exposures weighted with the health sensitivity spectrum for the skin and eyes set by the International Commission of Non-Ionizing Radiation Protection.

National and subnational burden of disease attributable to occupational exposure to solar ultraviolet radiation (SUVR) in Iran, 2005-2019

Overexposure to solar ultraviolet radiation (SUVR) can cause skin and eye adverse effects for outdoor workers. In this study, the burden of disease induced by occupational exposure to SUVR and its spatiotemporal trend at national and sub-national levels in Iran, 2005-2019 were assessed. The attributable burden of disease was assessed using the following five datasets: (1) distribution of occupational exposure to SUVR, (2) total incidences and deaths of health outcomes of SUVR exposure, (3) population attributable fractions of the health outcomes of SUVR exposure, (4) age-gender distribution of outdoor workers, and (5) disability-adjusted life year (DALY) calculation constants. During 2005-2019, the attributable DALYs increased from 2442 to 2907 and the attributable DALY rate (per 100,000 workers) slightly decreased from 11.94 to 11.91. The share of YLL in the attributable burden of disease was in the range of 43%-46%. Out of nine causes, about 90% of the attributable burden of disease in 2019 was related to cataracts (29.9%), malignant skin melanoma (27.4%), squamous-cell carcinoma (18.6%), and sunburn (17.2%). During the study period, the attributable DALY rate in women increased by 60.95% (from 5.04 to 8.11) and in men decreased by 2.06% (from 13.03 to 12.76). The total attributable DALYs and DALY rate rose by age during 2005-2019. The contributions of population growth, risk-deleted DALY rates, exposure risk, and population age structure in temporal changes of the attributable burden of disease were 19.27%, 9.13%, -1.35%, and -14.8%, respectively. The three highest attributable DALY rates in 2019 were observed in South Khorasan (21.28), Chahar Mahal and Bakhtiari (17.42), and Kordestan (17.26), respectively. The preventive interventions against SUVR overexposure, regular screenings, and early treatments with an emphasis on occupations with continuous sun exposure and provinces with increasing attributable DALY rates should be considered in the occupational health action plan in the country.

"Beach Lifeguards' Sun Exposure and Sun Protection in Spain"

BACKGROUND

Sunburn is the main avoidable cause of skin cancer. Beach lifeguards spend many hours exposed to the effects of solar radiation during their work day, precisely at times of the year when levels of solar irradiation are highest. The aim of this study is to quantify the risk to beach lifeguards of sun exposure.

METHODS

A descriptive cross-sectional study was carried out in the Western Costa del Sol, southern Spain, during the summer of 2018. The research subjects were recruited during a skin cancer prevention course for beach lifeguards. All participants were invited to complete a questionnaire on their habits, attitudes, and knowledge related to sun exposure. In addition, ten were specially monitored using personal dosimeters for three consecutive days, and the results were recorded in a photoprotection diary. A descriptive analysis (mean and standard deviation for the quantitative variables) was performed, and inter-group differences were evaluated using the Mann-Whitney U test.

RESULTS

Two hundred fifteen lifeguards completed the questionnaire, and 109 met the criteria for inclusion in this analysis. The mean age was 23.8 years (SD: 5.1), 78.0% were male, 71.5% were phototype III or IV (Fitzpatrick's phototype), and 77.1% had experienced at least one painful sunburn during the previous summer. The mean daily personal ultraviolet exposure per day, the minimal erythema dose, and the standard erythema dose, in J/m2, were 634.7 [standard deviation (SD): 356.2], 2.5 (SD: 1.4) and 6.35 (SD: 3.6), respectively.

CONCLUSION

Beach lifeguards receive very high doses of solar radiation during the work day and experience correspondingly high rates of sunburn. Intervention strategies to modify their sun exposure behavior and working environment are necessary to reduce the risk of skin cancer for these workers and to promote early diagnosis of the disease.

Review on Occupational Personal Solar UV Exposure Measurements

During leisure time, people can decide if they want to expose themselves to solar ultraviolet (UV) radiation and to what extent. While working, people do not have this choice. Outdoor workers are exposed to solar UV radiation (UVR) on a daily basis. This may pose a certain health risk, which can be estimated when the personal solar UVR exposure (PE) is known. During past decades, a variety of studies were conducted to measure PE of outdoor workers and our knowledge of the PE of outdoor workers has increased remarkably. As shown by this review, studies clearly indicate that PE of most outdoor workers exceeds the internationally proposed threshold limit value, which is comparable to 1.0 to 1.3 standard erythema dose (SED), respectively, to 1.1 to 1.5 UV Index received over one hour. Besides working in a high UVR environ, monotonic workflow (limited movement, nearly static posture) is a risk factor. In such cases, PE can be higher than ambient UVR. In this review, we provide also a list of milestones, depicting the progress and the most important findings in this field during the past 45 years. However, in many respects our knowledge is still rudimentary, for several reasons. Different measuring positions have been used so that measured PE is not comparable. Few studies were designed to enable the extension of measured PE to other locations or dates. Although the importance of a proper calibration of the measuring devices in respect to the changing solar spectrum was pointed out from the beginning, this is often not performed, which leads to high uncertainties in the presented PE levels. At the end of our review, we provide some key points, which can be used to evaluate the quality of a study respectively to support the design of future studies.

Sun Exposure during Water Sports: Do Elite Athletes Adequately Protect Their Skin against Skin Cancer?

Excessive sun exposure is the main avoidable cause of skin cancer. Outdoor sports performed without adequate photoprotection are risky practices in this respect. This study examines whether elite athletes in water sports (specifically surfing, windsurfing, and sailing) take appropriate measures to protect their skin from the sun, and whether there are differences in this respect according to age, gender, or sports discipline. This study is based on a questionnaire-based health survey. World championship competitors completed a self-administered questionnaire on their sun protection and exposure habits, as well as sunburns during the last sports season. In total, 246 participants, with an age range of 16–30 years, completed the questionnaire. Of these, 49.6% used inadequate sun protection. Those who protected their skin appropriately tended to be older than those who did not (average age = 23.28 and 20.69 years, respectively; p = 0.000). There were no significant differences in sun protection habits between male and female athletes. The rate of sunburn was very high (76.7%). A high proportion (22.5%) of participants never used sunscreen. Elite athletes in water sports are at real risk of skin lesions from overexposure to the sun, associated with inadequate photoprotection practices. Campaigns to raise awareness and to promote the early detection of skin cancer should target these risk groups.

Sun-protection Behaviors Among Active Members of the United States Lifesaving Association

BACKGROUND: Ultraviolet radiation exposure is the most prominent modifible risk factor for developing both melanoma and non-melanoma skin cancers. OBJECTIVE: We sought to elucidate sun-protective behaviors among active members of the United States Lifesaving Association (USLA), a nationwide nonprofit organization comprising beach lifeguards, and to identify positive and negative predictors of sun protective behaviors. METHODS: This was a pilot, cross-sectional survey study. All USLA lifeguards aged 18 years or older were invited to complete a 19-item survey. Data were collected anonymously at the 2018 USLA National Lifeguard Championships in Virginia Beach, Virginia. Participant characteristics and sun-protective behaviors (e.g., hat, sunglasses, protective clothing, sunscreen, and seeking shade) were surveyed. A composite score (0-10 points) was created based on sun-protective behaviors. Simple linear regression models were fit to assess the relationship between lifeguard characteristics and the sun-behavior composite score and a multiple linear regression model was used to assess their overall positive or negative effect on composite scores. RESULTS: A total of 215 USLA lifeguards completed the survey study; of these, 64.2% were male and the average age was 34.2 years. The most common sun-protective behavior was wearing sunglasses (85%), followed by applying sunscreen (65%), wearing a hat (46.7%), seeking shade (38.6%), and wearing protective clothing (34.0%). The overall average composite score was 7.5±1.9 points. In the multiple linear regression model, female sex (β=-0.85; p=0.0012), desiring a tan (β=-1.26; p=0.0008), and working more summer daytime hours (β=-0.49; p=0.049) negatively impacted composite scores. CONCLUSIONS: USLA beach lifeguards are subject to sun-exposure patterns and practiced sun-protective behaviors that potentially place them at higher risk for skin cancer.

Improved protection of outdoor workers from solar ultraviolet radiation: position statement

The vast majority of non-melanoma skin cancer (NMSC) is attributable to excessive exposure to ultraviolet radiation (UVR). Outdoor workers are exposed to an UVR dose at least 2 to 3 times higher than indoor workers and often to daily UVR doses 5 times above internationally recommended limits. The risk of UVR workplace exposure is vastly neglected, and the evident future challenges presented in this statement are contrasted with the current situation regarding legal recognition, patient care and compensation. While prevention is crucial to reduce cancer risks for outdoor workers, it is as much of relevance to better protect them through legally binding rules and regulations. Specific actions are outlined in five recommendations based on a Call to Action (table 1). The role of health professionals, including dermatologists, in this context is crucial.

The Epidemiology of Skin Cancer and Public Health Strategies for Its Prevention in Southern Africa

Skin cancer is a non-communicable disease that has been underexplored in Africa, including Southern Africa. Exposure to solar ultraviolet radiation (UVR) is an important, potentially modifiable risk factor for skin cancer. The countries which comprise Southern Africa are Botswana, Lesotho, Namibia, South Africa, and Swaziland. They differ in population size and composition and experience different levels of solar UVR. Here, the epidemiology and prevalence of skin cancer in Southern African countries are outlined. Information is provided on skin cancer prevention campaigns in these countries, and evidence sought to support recommendations for skin cancer prevention, especially for people with fair skin, or oculocutaneous albinism or HIV-AIDS who are at the greatest risk. Consideration is given to the possible impacts of climate change on skin cancer in Southern Africa and the need for adaptation and human behavioural change is emphasized.

RoB-SPEO: A tool for assessing risk of bias in studies estimating the prevalence of exposure to occupational risk factors from the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury

BACKGROUND

The World Health Organization (WHO) and the International Labour Organization (ILO) are developing joint estimates of the work-related burden of disease and injury (WHO/ILO Joint Estimates). For this, systematic reviews of studies estimating the prevalence of exposure to selected occupational risk factors will be conducted to provide input data for estimations of the number of exposed workers. A critical part of systematic review methods is to assess risk of bias (RoB) of individual studies. In this article, we present and describe the development of such a tool, called the Risk of Bias in Studies estimating Prevalence of Exposure to Occupational risk factors (RoB-SPEO) tool; report results from RoB-SPEO's pilot testing; note RoB-SPEO's limitations; and suggest how the tool might be tested and developed further.

METHODS

Selected existing RoB tools used in environmental and occupational health systematic reviews were reviewed and analysed. From existing tools, we identified domains for the new tool and, if necessary, added new domains. For each domain, we then identified and integrated components from the existing tools (i.e. instructions, domains, guiding questions, considerations, ratings and rating criteria), and, if necessary, we developed new components. Finally, we elicited feedback from other systematic review methodologists and exposure scientists and agreed upon RoB-SPEO. Nine experts pilot tested RoB-SPEO, and we calculated a raw measure of inter-rater agreement (Pi) for each of its domain, rating Pi < 0.4 as poor, 0.4 ≤ Pi ≥ 0.8 as substantial and Pi > 0.80 as almost perfect agreement.

RESULTS

Our review found no standard tool for assessing RoB in prevalence studies of exposure to occupational risk factors. We identified six existing tools for environmental and occupational health systematic reviews and found that their components for assessing RoB differ considerably. With the new RoB-SPEO tool, assessors judge RoB for each of eight domains: (1) bias in selection of participants into the study; (2) bias due to a lack of blinding of study personnel; (3) bias due to exposure misclassification; (4) bias due to incomplete exposure data; (5) bias due to conflict of interest; (6) bias due to selective reporting of exposures; (7) bias due to difference in numerator and denominator; and (8) other bias. The RoB-SPEO's ratings are low, probably low, probably high, high or no information. Pilot testing of the RoB-SPEO tool found substantial inter-rater agreement for six domains (range of Pi for these domains: 0.51-0.80), but poor agreement for two domains (i.e. Pi of 0.31 and 0.33 for biases due to incomplete exposure data and in selection of participants into the study, respectively). Limitations of RoB-SPEO include that it has not yet been fully performance-tested.

CONCLUSIONS

We developed the RoB-SPEO tool for assessing RoB in prevalence studies of exposure to occupational risk factors. The tool will be applied and its performance tested in the ongoing systematic reviews for the WHO/ILO Joint Estimates.

Solar Ultraviolet Radiation Exposure among Outdoor Workers in Three Canadian Provinces

Introduction

Solar ultraviolet radiation (UVR) exposure places outdoor workers at risk of skin cancer and exposure is difficult to control. In response, the Sun Safety at Work Canada (SSAWC) project was undertaken (2014–2016). The purpose of this substudy was to characterize the UVR exposure levels of outdoor workers in the SSAWC project.

Methods

Thirteen workplaces in the provinces of British Columbia, Ontario, and Nova Scotia participated in an exposure monitoring campaign (late summer/early fall 2016). Study participants were workers from power utilities and municipalities. Participants wore a UVR measurement badge (light-sensitive polysulfone plastic) on their wrist, shoulder, or hardhat. Badge calibration and absorbance measurements were performed in the AusSun Research Lab. Personal UVR doses are presented as standard erythemal doses (SED) and compared with the internationally recommended exposure limit (1.3 SED), as well as to the total available UVR by date. Generalized linear models were used to examine determinants of solar UVR for personal UVR dose (for both SED and percent of ambient UVR). Models considered badge placement, date, province, industry, main job task, and the hours spent outdoors.

Results

Mean personal UVR dose of participating workers was 6.1 SED (nearly 5× the recommended limit). Just 14% of workers experienced ‘acceptable’ levels of solar radiation; 10% were exposed at >10 times the limit. In univariate analyses, workers in Ontario had the highest levels (mean 7.3 SED), but even in the lowest exposed province (British Columbia), the mean personal UVR dose was 4.5 SED. Utility workers had double the exposure of municipal workers (10.4 and 5.5 SED, respectively). In the determinants of exposure models, the differences by province were muted, but utility line workers and those in general maintenance had higher predicted exposures. Those who wore their badge on their hardhat also had higher values of SED in the fully adjusted determinants models.

Conclusions

Solar ultraviolet overexposure among outdoor workers is a concern, even in a country like Canada with relatively low ambient UVR. Implementation of sun safety programs should be supported in an effort to reduce exposure in this vulnerable group of workers.

WHO/ILO work-related burden of disease and injury: Protocol for systematic reviews of occupational exposure to solar ultraviolet radiation and of the effect of occupational exposure to solar ultraviolet radiation on melanoma and non-melanoma skin cancer

BACKGROUND

The World Health Organization (WHO) and the International Labour Organization (ILO) are developing a joint methodology for estimating the national and global work-related burden of disease and injury (WHO/ILO joint methodology), with contributions from a large network of experts. In this paper, we present the protocol for two systematic reviews of parameters for estimating the number of deaths and disability-adjusted life years from melanoma and non-melanoma skin cancer (or keratinocyte carcinoma) from occupational exposure to solar ultraviolet radiation, to inform the development of the WHO/ILO joint methodology.

OBJECTIVES

We aim to systematically review studies on occupational exposure to solar ultraviolet radiation (Systematic Review 1) and systematically review and meta-analyse estimates of the effect of occupational exposure to solar ultraviolet radiation on melanoma and non-melanoma skin cancer (Systematic Review 2), applying the Navigation Guide systematic review methodology as an organizing framework and conducting both systematic reviews in tandem and in a harmonized way.

DATA SOURCES

Separately for Systematic Reviews 1 and 2, we will search electronic academic databases for potentially relevant records from published and unpublished studies, including Ovid Medline, PubMed, EMBASE, and Web of Science. We will also search electronic grey literature databases, Internet search engines and organizational websites; hand-search reference list of previous systematic reviews and included study records and consult additional experts.

STUDY ELIGIBILITY AND CRITERIA

We will include working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State, but exclude children (<15 years) and unpaid domestic workers. For Systematic Review 1, we will include quantitative studies on the prevalence of relevant levels of occupational exposure to solar ultraviolet radiation (i.e. <0.33 SED/d and ≥0.33 SED/d) and of the total working time spent outdoors, stratified by country, sex, age and industrial sector or occupation, in the years 1960 to 2018. For Systematic Review 2, we will include randomized controlled trials, cohort studies, case-control studies and other non-randomized intervention studies with an estimate of the effect of any occupational exposure to solar ultraviolet radiation (i.e., ≥0.33 SED/d) on the prevalence of, incidence of or mortality due to melanoma and non-melanoma skin cancer, compared with the theoretical minimum risk exposure level (i.e. <0.33 SED/d).

STUDY APPRAISAL AND SYNTHESIS METHODS

At least two review authors will independently screen titles and abstracts against the eligibility criteria at a first stage and full texts of potentially eligible records at a second stage, followed by extraction of data from qualifying studies. At least two review authors will assess the risk of bias and the quality of evidence, using the most suited tools currently available. For Systematic Review 2, if feasible, we will combine relative risks using meta-analysis. We will report results using the guidelines for accurate and transparent health estimates reporting (GATHER) for Systematic Review 1 and the preferred reporting items for systematic reviews and meta-analyses guidelines (PRISMA) for Systematic Review 2.

PROSPERO REGISTRATION NUMBER

CRD42018094817.

Solar Radiation Exposure and Outdoor Work: An Underestimated Occupational Risk

A considerably high number of outdoor workers worldwide are constantly exposed for the majority of their working life to solar radiation (SR); this exposure is known to induce various adverse health effects, mainly related to its ultraviolet (UV) component. The skin and the eye are the principal target organs for both acute and long-term exposure. Actinic keratosis, non-melanoma skin cancers, and malignant melanoma are the main long-term adverse skin effects, whereas in the eye pterygium, cataracts, and according to an increasing body of evidence, macular degeneration may be induced. Despite this, SR exposure risk is currently undervalued, if not neglected, as an occupational risk factor for outdoor workers. SR exposure is influenced by various environmental and individual factors, and occupation is one of the most relevant. For a better understanding of this risk and for the development of more effective prevention strategies, one of the main problems is the lack of available and adequate methods to estimate SR worker exposure, especially long-term exposure. The main aims of this review were to provide a comprehensive overview of SR exposure risk of outdoor workers, including the UV exposure levels and the main methods recently proposed for short-term and cumulative exposure, and to provide an update of knowledge on the main adverse eye and skin effects. Finally, we also outline here preventive interventions to reduce occupational risk.

Sun sensitivity and sun protective behaviors during sun exposure among indoor office workers in the American Midwest

BACKGROUND/PURPOSE

Sun sensitivity, a confounder between sun exposure and sun protection, is often overlooked. We examined how sun exposure and sun protection behaviors among indoor workers varied by sun sensitivity.

METHODS

Sun exposure and sun protection diaries over a 45-day period from Midwestern United States indoor workers were examined. We categorized sun sensitivity (fair and non-fair complexion) using tanning inability and sunburn tendency. Total exposure (sunrise to sunset) and peak exposure (10 am and 4 pm) lasting at least 60 minutes were examined. Percentages of time using sun protection were reported. We determined associations between fair complexion, mean sun exposure, and mean sun protection times with logistic regression.

RESULTS

Fair individuals spent less time in the sun than non-fair individuals, but a greater proportion of time using sun protection behaviors, including sunscreen with SPF 30+ (odds ratio (OR) = 1.36; 95% confidence interval (95% CI) = 0.98, 1.87)), or wearing long-sleeved shirts (OR = 2.89; 95% CI = 1.24, 6.73).

CONCLUSION

Fair individuals spent less time in the sun and practiced more sun protective behaviors than non-fair individuals. This complex association between sun sensitivity, sun protection and sun exposure has not consistently been addressed in studies of skin cancer.

Levels of Occupational Exposure to Solar Ultraviolet Radiation in Vancouver, Canada

INTRODUCTION

Outdoor workers are at high risk of exposure to solar ultraviolet radiation (UVR), a known human carcinogen. In Canada, no objective measures of UVR exposure are available for occupational settings.

METHODS

The Outdoor Workers Project collected UVR exposure data among outdoor workers in Vancouver, Canada during the summer of 2013. Objective measures of exposure were taken for one week using calibrated electronic UVR dosimeters. Additional data was collected from workers on skin cancer risk factors, family history of skin cancer, and job type; as well as meteorological data for sampling days. Marginal models were constructed to examine the worker, job and meteorological determinants of UVR exposure levels, as measured in standard erythemal dose (SED).

RESULTS

Seventy-eight workers were recruited, of which 73 had at least 1 day of measured UVR exposure for this analysis. Participants were mostly male, young and Caucasian. Mean exposure (corrected for repeated measures) was 1.08 SED. Exposure measures were highly variable even in the same workplace, ranging from 0.01 SED to 19.2 SED. Younger age, working in land-based construction, and sunnier weather forecasts led to higher levels of UVR exposure.

CONCLUSIONS

Exposure levels capable of causing sunburn were common in this study of outdoor workers, in a location not typically associated with high sun exposure.

Vitamin D response of older people in residential aged care to sunlight-derived ultraviolet radiation

The aim of this study was to determine the vitamin D response to sunlight ultraviolet radiation in older people. Increases in vitamin D depended on the season of exposure, but the changes were small. Natural sun exposure is not a practical intervention for vitamin D deficiency in this population.

PURPOSE

The purpose of this study is to measure the ultraviolet radiation (UVR) exposure of those in residential aged care in an earlier trial of sunlight exposure and to determine its effect on their vitamin D response.

METHODS

Attendance data, demographic, clinical and biochemical variables for 248 participants were used for a secondary analysis of a previous cluster randomized trial of sunlight exposure and falls. The ambient solar UV Index data were used to calculate the participants' UVR dose. Multiple linear regression was used to test if UVR exposure over 6 months, as measured by the standard erythemal dose (SED), was a predictor of vitamin D response, controlling for age, gender, BMI, calcium intake, baseline vitamin D and season of exposure.

RESULTS

The median 25-hydroxyvitamin D (25OHD) was 32.4 nmol/L at baseline and 34.6 nmol/L at 6 months (p = 0.35). The significant predictors of 25OHD at 6 months were UVR exposures in spring-summer (coefficient = 0.105, 95 % confidence interval (CI) 0.001-0.209, p = 0.05) and autumn-winter (coefficient = 0.056, 95 % CI 0.005-0.107, p = 0.03) and baseline vitamin D (adjusted coefficient = 0.594, 95 % CI 0.465-0.724, p = 0.00). In those starting sunlight sessions in spring, an increase of 1 unit in log SED was associated with 11 % increase in 25OHD.

CONCLUSIONS

Natural UVR exposure can increase 25OHD levels in older people in residential care, but depends on the season of exposure. However, due to inadequate sun exposure, 25OHD did not reach optimal levels. Nevertheless, where sun exposure is encouraged in this group, the focus for the start of exposure should be in the months of spring or autumn, as this timing was associated with a vitamin D response.

Skin cancer preventative behaviors in state park workers: a pilot study

OBJECTIVES

Considering the potential for occupational sun exposure among state park workers, the purpose of this pilot study was to identify skin cancer knowledge, health beliefs, self-efficacy, and sun protection behaviors (SPBs) among state park employees.

METHODS

The current study used a cross-sectional survey research design with state park workers in a Southern state. Of the 94 possible employees who could have participated in the study, 87 completed the survey.

RESULTS

Assessment of the participants' skin cancer knowledge demonstrated an average correct response rate of 68.8 %. While the vast majority (87.4 %) believed that skin cancer is a serious disease, a minority (42.5 %) believed they would develop skin cancer sometime during their lifetime, and even fewer (35.6 %) believed their risk was higher than average. Collectively, workers reported low levels of SPBs. The most commonly reported barriers to sun protection were "inconvenient," "too hot to wear," and "forget to protect." Half of the participants (50.6 %) were highly confident in their ability to wear long pants while in the sun. About the same proportion of participants was highly confident they could wear a wide-brimmed hat (21.8 %) and sunscreen (20.7 %).

CONCLUSIONS

Based on available evidence, a need exists to develop individual and worksite programs and interventions to increase skin cancer prevention behaviors among this occupational group. This data could serve as a baseline to monitor and evaluate the efficacy of these interventions.

Sociodemographic and Psychological Correlates of Sun Protection Behaviors among Outdoor Workers: A Review

Outdoor workers are at a higher risk for developing skin cancer due to their increased sun exposure. The primary objective of this review was to synthesize the current research literature that addresses sociodemographic and psychological factors related to sun protection behaviors in outdoor workers. Two additional purposes were to provide an overview of sun exposure and describe sun protection behaviors of outdoor workers. To identify the studies for this review, a methodical search was performed in the PubMed, PsycInfo, MEDLINE, and ERIC databases. Fifteen studies met the review criteria. Despite regular and prolonged sun exposure, many outdoor workers fail to engage in sufficient sun protection behaviors. Correlates of outdoor workers' sun protection behaviors include being female, older age, being white, personal skin cancer history, time (hours/years) spent at work, sun safety training, perceived prioritization of sun protection, concern about sun exposure, workplace support, families' expectations, and familial information giving. However, limited attention is given to designing theoretically grounded studies to identify factors to inform future research. There is a need to conduct research based on solid theoretical foundations that explains the relationships among the factors in this domain.

Skin Cancer Knowledge, Beliefs, Self-Efficacy, and Preventative Behaviors among North Mississippi Landscapers

There are slightly over one million workers in the landscape service industry in the US. These workers have potential for high levels of solar ultraviolet radiation exposure, increasing their risk of skin cancer. A cross-sectional sample of 109 landscapers completed a self-administered questionnaire based on Health Belief Model (HBM). The participants correctly answered 67.1% of the knowledge questions, 69.7% believed they were more likely than the average person to get skin cancer, and 87.2% perceived skin cancer as a severe disease. Participants believed that the use of wide-brimmed hats, long sleeved shirts/long pants, and sunscreen was beneficial but reported low usage of these and other sun protective strategies. The primary barriers to using sun protection were “I forget to wear it” and “it is too hot to wear.” Of the HBM variables, perceived benefits outweighing perceived barrier (r = .285, P = .003) and self-efficacy (r = .538, P = .001) were correlated with sun protection behaviors. The reasons for absence of the relationship between perceived skin cancer threat and sun protection behaviors could be lack of skin cancer knowledge and low rate of personal skin cancer history.

Optical properties of a long dynamic range chemical UV dosimeter based on solvent cast polyvinyl chloride (PVC)

The dosimetric properties of the recently introduced UV dosimeter based on 16 μm PVC film have been fully characterised. Drying the thin film in air at 50 °C for at least 28 days was found to be necessary to minimise the temperature effects on the dosimeter response. This research has found that the dosimeter response, previously reported to be mainly to UVB, has no significant dependence on either exposure temperature or dose rate. The dosimeter has negligible dark reaction and responds to the UV radiation with high reproducibility. The dosimeter angular response was found to have a similar pattern as the cosine function but deviates considerably at angles larger than 70°. Dose response curves exhibit monotonically increasing shape and the dosimeter can measure more than 900 SED. This is about 3 weeks of continuous exposure during summer at subtropical sites. Exposures measured by the PVC dosimeter for some anatomical sites exposed to solar radiation for twelve consecutive days were comparable with those concurrently measured by a series of PPO dosimeters and were in line with earlier results reported in similar studies.

Urinary levels of thymine dimer as a biomarker of exposure to ultraviolet radiation in humans during outdoor activities in the summer

The incidence of skin cancer is rising rapidly in many countries, presumably due to increased leisure time exposure to solar ultraviolet radiation (UVR). UVR causes DNA lesions, such as the thymine dimer (T=T), which have been causatively linked to the development of skin cancer. T=T is clearly detectable in urine and may, thereby, be a potentially valuable biomarker of UVR exposure. The objective of this study was to evaluate the relationship between UVR exposure and urinary levels of T=T in a field study involving outdoor workers. Daily ambient and personal exposure of 52 beach lifeguards and agricultural workers to UVR were determined (employing 656 personal polysulphone dosimeters). In 22 of these subjects, daily urinary T=T levels (120 samples) were measured, the area of skin exposed calculated and associations assessed utilizing mixed statistical models. The average daily UVR dose was approximately 600 J/m(2) (7.7 standard erythemal doses), i.e. about 20% of ambient UVR. T=T levels were correlated to UVR dose, increasing by about 6 fmol/µmol creatinine for each 100 J/m(2) increase in dose (average of the three preceding days). This is the first demonstration of a relationship between occupational UVR exposure and urinary levels of a biomarker of DNA damage. On a population level, urinary levels of T=T can be used as a biomarker for UVR exposure in the field.

Vitamin D beliefs and associations with sunburns, sun exposure, and sun protection

The main objective of this study was to examine certain beliefs about vitamin D and associations with sun exposure, sun protection behaviors, and sunburns. A total of 3,922 lifeguards, pool managers, and parents completed a survey in 2006 about beliefs regarding vitamin D and sun-related behaviors. Multivariate ordinal regression analyses and linear regression analysis were used to examine associations of beliefs and other variables. Results revealed that Non-Caucasian lifeguards and pool managers were less likely to agree that they needed to go out in the sun to get enough vitamin D. Lifeguards and parents who were non-Caucasian were less likely to report that sunlight helped the body to produce vitamin D. A stronger belief about the need to go out in the sun to get enough vitamin D predicted more sun exposure for lifeguards. For parents, a stronger belief that they can get enough vitamin D from foods predicted greater sun protection and a stronger belief that sunlight helps the body produce vitamin D predicted lower sun exposure. This study provides information regarding vitamin D beliefs and their association with certain sun related behaviors across different demographic groups that can inform education efforts about vitamin D and sun protection.

Applicability of the polysulphone horizontal calibration to differently inclined dosimeters

Polysulphone (PS) dosimetry has been a widely used technique for more than 30 years to quantify the erythemally effective UV dose received by anatomic sites (personal exposure). The calibration of PS dosimeters is an important issue as their spectral response is different from the erythemal action spectrum. It is performed exposing a set of PS dosimeters on a horizontal plane and measuring the UV doses received by dosimeters using calibrated spectroradiometers or radiometers. In this study, data collected during PS field campaigns (from 2004 to 2006), using horizontal and differently inclined dosimeters, were analyzed to provide some considerations on the transfer of the horizontal calibration to differently inclined dosimeters, as anatomic sites usually are. The role of sky conditions, of the angle of incidence between the sun and the normal to the slope, and of the type of surrounding surface on the calibration were investigated. It was concluded that PS horizontal calibrations apply to differently inclined dosimeters for incidence angles up to approximately 70° and for surfaces excluding ones with high albedo. Caution should be used in the application of horizontal calibrations for cases of high-incidence angle and/or high albedo surfaces.

Changes in sunburn and tanning attitudes among lifeguards over a summer season

BACKGROUND

Skin cancer is one of the most common cancers in the United States. Lifeguards are at increased risk of excessive sun exposure and sunburn.

OBJECTIVES

We sought to examine changes in: (1) sunburn frequency over a summer while controlling for sun exposure, sun protection habits, and participation in a skin cancer prevention program; and (2) tanning attitudes while controlling for participation in the program.

METHODS

Participants in this study were lifeguards (n = 3014) at swimming pools participating in the Pool Cool program in 2005. Lifeguards completed surveys at the beginning and end of the summer. Sequential regression analyses were used to assess changes in sunburn frequency and tanning attitudes.

RESULTS

Sunburn frequency decreased between baseline and follow-up. Having a sunburn over the summer was significantly predicted by baseline sunburn history, ethnicity, skin cancer risk, and sun exposure. The tanning attitude, "People are more attractive if they have a tan," was significantly predicted from baseline tanning attitude and ethnicity. The second tanning attitude, "It helps to have a good base suntan," was significantly predicted by baseline tanning attitude, ethnicity, basic/enhanced group, and moderate skin cancer risk.

LIMITATIONS

Self-reported data and limited generalizability to lifeguards at other outdoor pools are limitations.

CONCLUSION

The findings showed that previous sunburn history is an important predictor of sunburn prospectively. In addition, a more risky tanning attitude is an important predictor of future attitudes toward tanning. Active involvement in targeted prevention programs may help to increase preventive behavior and health risk reduction.

Seasonal variation in measured solar ultraviolet radiation exposure of adults in subtropical Australia

Generating accurate population-specific public health messages regarding sun protection requires knowledge about seasonal variation in sun exposure in different environments. To address this issue for a subtropical area of Australia, we used polysulphone badges to measure UVR for the township of Nambour (26 degrees latitude) and personal UVR exposure among Nambour residents who were taking part in a skin cancer prevention trial. Badges were worn by participants for two winter and two summer days. The ambient UVR was approximately three times as high in summer as in winter. However, participants received more than twice the proportion of available UVR in winter as in summer (6.5%vs 2.7%, P < 0.05), resulting in an average ratio of summer to winter personal UVR exposure of 1.35. The average absolute difference in daily dose between summer and winter was only one-seventh of a minimal erythemal dose. Extrapolating from our data, we estimate that ca. 42% of the total exposure received in the 6 months of winter (June-August) and summer (December-February) is received during the three winter months. Our data show that in Queensland a substantial proportion of people's annual UVR dose is obtained in winter, underscoring the need for dissemination of sun protection messages throughout the year in subtropical and tropical climates.