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

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.

Clinical Misdiagnosis of Cutaneous Malignant Tumors as Melanocytic Nevi or Seborrheic Keratosis: A Retrospective Analysis of a Chinese Population

Purpose

The rising incidence and mortality associated with cutaneous malignant tumours highlight the importance of early diagnosis of these tumors. In clinical practice, these tumors are often misdiagnosed as benign skin lesions such as melanocytic nevi (MN) and seborrheic keratosis (SK) because of their similar morphologic features. The incidence and clinicopathological subtypes of cutaneous malignancies in East Asia populations significantly differ from those in fair-skinned groups. However, studies on misdiagnoses in Eastern countries are lacking. Therefore, this study focused on the clinical and pathological features of cutaneous malignant tumors misdiagnosed as MN or SK in a Chinese population.

Patients and Methods

A total of 4592 samples clinically diagnosed as MN (n = 3503) or SK (n = 1089) from July 2014 to June 2022 were collected and evaluated retrospectively. The clinical and pathological data were analyzed to identify associated factors.

Results

Pathological assessments showed that 2.5% (86/3503) of the specimens clinically diagnosed as MN were malignancies, predominantly basal cell carcinoma (BCC, 84.9%, 73/86), followed by malignant melanoma (MM, 8.1%, 7/86) and squamous cell carcinoma (SCC, 7.0%, 6/86). Similarly, 5.7% (62/1089) of the specimens clinically diagnosed as SK were malignant tumors, of which BCC (50.0%, 31/62) was the most common, followed by SCC (41.9%, 26/62) and MM (8.1%, 5/62). In both types of specimens, advanced age and facial lesions were risk factors for malignancy misdiagnosis. The malignancy rate, mean age, and proportion of SCC in the specimens clinically diagnosed as SK were higher than those in the specimens clinically diagnosed as MN. Dermoscopy significantly reduced the rate of misdiagnosis of these tumors as MN or SK.

Conclusion

In China, cutaneous malignant tumors misdiagnosed as MN or SK are not uncommon in clinical practice, and active introduction of noninvasive diagnostic techniques is essential to distinguish them.

Global, regional and national burdens of non-melanoma skin cancer attributable to occupational exposure to solar ultraviolet radiation for 183 countries, 2000-2019: A systematic analysis from the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury

BACKGROUND

A World Health Organization (WHO) and International Labour Organization (ILO) systematic review reported sufficient evidence for higher risk of non-melanoma skin cancer (NMSC) amongst people occupationally exposed to solar ultraviolet radiation (UVR). This article presents WHO/ILO Joint Estimates of global, regional, national and subnational occupational exposures to UVR for 195 countries/areas and the global, regional and national attributable burdens of NMSC for 183 countries, by sex and age group, for the years 2000, 2010 and 2019.

METHODS

We calculated population-attributable fractions (PAFs) from estimates of the population occupationally exposed to UVR and the risk ratio for NMSC from the WHO/ILO systematic review. Occupational exposure to UVR was modelled via proxy of occupation with outdoor work, using 166 million observations from 763 cross-sectional surveys for 96 countries/areas. Attributable NMSC burden was estimated by applying the PAFs to WHO's estimates of the total NMSC burden. Measures of inequality were calculated.

RESULTS

Globally in 2019, 1.6 billion workers (95 % uncertainty range [UR] 1.6-1.6) were occupationally exposed to UVR, or 28.4 % (UR 27.9-28.8) of the working-age population. The PAFs were 29.0 % (UR 24.7-35.0) for NMSC deaths and 30.4 % (UR 29.0-31.7) for disability-adjusted life years (DALYs). Attributable NMSC burdens were 18,960 deaths (UR 18,180-19,740) and 0.5 million DALYs (UR 0.4-0.5). Men and older age groups carried larger burden. Over 2000-2019, attributable deaths and DALYs almost doubled.

CONCLUSIONS

WHO and the ILO estimate that occupational exposure to UVR is common and causes substantial, inequitable and growing attributable burden of NMSC. Governments must protect outdoor workers from hazardous exposure to UVR and attributable NMSC burden and inequalities.

Sun-protective behaviors and sunburn among US adults

Individuals can reduce the risk of developing skin cancer by minimizing ultraviolet sunlight exposure, though recent trends in sun-protective behaviors remain to be investigated. To evaluate sun-protective behaviors and sunburn among US adults. We analyzed data from the 2010, 2015, and 2020 National Health Interview Survey (NHIS), an annual, cross-sectional survey conducted by the US Census Bureau. Multivariable regression models were stratified by demographic variables and constructed to evaluate sun-protective behaviors and sunburn avoidance across time. From 2010 through 2020, US adults had significantly increased prevalence of seeking shade (p value, 0.003), wearing wide-brimmed hats (< 0.001), wearing long-sleeved shirts (< 0.001), using sunscreen (< 0.001), and avoiding sunburns (< 0.001) and significantly decreased prevalence of sun avoidance (< 0.001). Disparities in sun-protective behaviors also exist among different sexes, ages, education levels, and those reporting higher sun sensitivity. This cross-sectional study found that by 2020, US adults had an increased prevalence of wearing sun-protective clothing and sunscreen use, though decreased prevalence of sun avoidance. Although certain sun-protective behaviors have become more prevalent, the incidence of skin cancer continues to rise. Efforts to understand drivers of sun-protective behaviors and targeted intervention efforts are needed.

System dynamics simulation of occupational health and safety management causal model based on NetLogo

The occupational health and safety management factors of construction enterprises are critical influencing factors in their training management, and their causal principles are topics that warrant profound exploration. Drawing upon the conventional five factors, this study initially posited and authenticated a causal model among them, subsequently employing system dynamics on the NetLogo platform to dynamically simulate the model, and ultimately scrutinizing the interrelations and dynamic influence degree among the factors. The results show that the direct causes of management factors include human factors (weight coefficient of 0.583) and method factors (weight coefficient of 0.405), and environmental factors directly affect human factors (weight coefficient of 0.994), whereas material factors directly affect method factors (weight coefficient of 0.918). At the same time, it can be seen from the dynamic simulation results that the influence of human factors and method factors on management factors increases sharply in the nascent phase of the simulation cycle (the highest slope is .90), gradually decreases in the intermediary phase (the slope of the inflection point is .11), and is relatively stable in the final phase (the slope is less than 0.11). Three main conclusions have been drawn from this. Firstly, management factors are directly and positively affected by human factors and method factors respectively. Secondly, the interplay between diverse factors evinces a confluence of periodicity and exponential attributes. Thirdly, in each management cycle (set at 381 steps), the main focus is on controlling the causal factors in the early stages of management, with pivotal control points in steps 25 and 100, and the principal management factors comprising the management organization, operating procedures, and protective measures.

The prevalences and levels of occupational exposure to dusts and/or fibres (silica, asbestos and coal): A systematic review and meta-analysis 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), with contributions from a large number of individual experts. Evidence from human, animal and mechanistic data suggests that occupational exposure to dusts and/or fibres (silica, asbestos and coal dust) causes pneumoconiosis. In this paper, we present a systematic review and meta-analysis of the prevalences and levels of occupational exposure to silica, asbestos and coal dust. These estimates of prevalences and levels will serve as input data for estimating (if feasible) the number of deaths and disability-adjusted life years that are attributable to occupational exposure to silica, asbestos and coal dust, for the development of the WHO/ILO Joint Estimates.

OBJECTIVES

We aimed to systematically review and meta-analyse estimates of the prevalences and levels of occupational exposure to silica, asbestos and coal dust among working-age (≥ 15 years) workers.

DATA SOURCES

We searched electronic academic databases for potentially relevant records from published and unpublished studies, including Ovid Medline, PubMed, EMBASE, and CISDOC. We also searched electronic grey literature databases, Internet search engines and organizational websites; hand-searched reference lists of previous systematic reviews and included study records; and consulted additional experts.

STUDY ELIGIBILITY AND CRITERIA

We included working-age (≥ 15 years) workers in the formal and informal economy in any WHO and/or ILO Member State but excluded children (< 15 years) and unpaid domestic workers. We included all study types with objective dust or fibre measurements, published between 1960 and 2018, that directly or indirectly reported an estimate of the prevalence and/or level of occupational exposure to silica, asbestos and/or coal dust.

STUDY APPRAISAL AND SYNTHESIS METHODS

At least two review authors independently screened titles and abstracts against the eligibility criteria at a first stage and full texts of potentially eligible records at a second stage, then data were extracted from qualifying studies. We combined prevalence estimates by industrial sector (ISIC-4 2-digit level with additional merging within Mining, Manufacturing and Construction) using random-effects meta-analysis. Two or more review authors assessed the risk of bias and all available authors assessed the quality of evidence, using the ROB-SPEO tool and QoE-SPEO approach developed specifically for the WHO/ILO Joint Estimates.

RESULTS

Eighty-eight studies (82 cross-sectional studies and 6 longitudinal studies) met the inclusion criteria, comprising > 2.4 million measurements covering 23 countries from all WHO regions (Africa, Americas, Eastern Mediterranean, South-East Asia, Europe, and Western Pacific). The target population in all 88 included studies was from major ISCO groups 3 (Technicians and Associate Professionals), 6 (Skilled Agricultural, Forestry and Fishery Workers), 7 (Craft and Related Trades Workers), 8 (Plant and Machine Operators and Assemblers), and 9 (Elementary Occupations), hereafter called manual workers. Most studies were performed in Construction, Manufacturing and Mining. For occupational exposure to silica, 65 studies (61 cross-sectional studies and 4 longitudinal studies) were included with > 2.3 million measurements collected in 22 countries in all six WHO regions. For occupational exposure to asbestos, 18 studies (17 cross-sectional studies and 1 longitudinal) were included with > 20,000 measurements collected in eight countries in five WHO regions (no data for Africa). For occupational exposure to coal dust, eight studies (all cross-sectional) were included comprising > 100,000 samples in six countries in five WHO regions (no data for Eastern Mediterranean). Occupational exposure to silica, asbestos and coal dust was assessed with personal or stationary active filter sampling; for silica and asbestos, gravimetric assessment was followed by technical analysis. Risk of bias profiles varied between the bodies of evidence looking at asbestos, silica and coal dust, as well as between industrial sectors. However, risk of bias was generally highest for the domain of selection of participants into the studies. The largest bodies of evidence for silica related to the industrial sectors of Construction (ISIC 41-43), Manufacturing (ISIC 20, 23-25, 27, 31-32) and Mining (ISIC 05, 07, 08). For Construction, the pooled prevalence estimate was 0.89 (95% CI 0.84 to 0.93, 17 studies, I2 91%, moderate quality of evidence) and the level estimate was rated as of very low quality of evidence. For Manufacturing, the pooled prevalence estimate was 0.85 (95% CI 0.78 to 0.91, 24 studies, I2 100%, moderate quality of evidence) and the pooled level estimate was rated as of very low quality of evidence. The pooled prevalence estimate for Mining was 0.75 (95% CI 0.68 to 0.82, 20 studies, I2 100%, moderate quality of evidence) and the pooled level estimate was 0.04 mg/m3 (95% CI 0.03 to 0.05, 17 studies, I2 100%, low quality of evidence). Smaller bodies of evidence were identified for Crop and animal production (ISIC 01; very low quality of evidence for both prevalence and level); Professional, scientific and technical activities (ISIC 71, 74; very low quality of evidence for both prevalence and level); and Electricity, gas, steam and air conditioning supply (ISIC 35; very low quality of evidence for both prevalence and level). For asbestos, the pooled prevalence estimate for Construction (ISIC 41, 43, 45,) was 0.77 (95% CI 0.65 to 0.87, six studies, I2 99%, low quality of evidence) and the level estimate was rated as of very low quality of evidence. For Manufacturing (ISIC 13, 23-24, 29-30), the pooled prevalence and level estimates were rated as being of very low quality of evidence. Smaller bodies of evidence were identified for Other mining and quarrying (ISIC 08; very low quality of evidence for both prevalence and level); Electricity, gas, steam and air conditioning supply (ISIC 35; very low quality of evidence for both prevalence and level); and Water supply, sewerage, waste management and remediation (ISIC 37; very low quality of evidence for levels). For coal dust, the pooled prevalence estimate for Mining of coal and lignite (ISIC 05), was 1.00 (95% CI 1.00 to 1.00, six studies, I2 16%, moderate quality of evidence) and the pooled level estimate was 0.77 mg/m3 (95% CI 0.68 to 0.86, three studies, I2 100%, low quality of evidence). A small body of evidence was identified for Electricity, gas, steam and air conditioning supply (ISIC 35); with very low quality of evidence for prevalence, and the pooled level estimate being 0.60 mg/m3 (95% CI -6.95 to 8.14, one study, low quality of evidence).

CONCLUSIONS

Overall, we judged the bodies of evidence for occupational exposure to silica to vary by industrial sector between very low and moderate quality of evidence for prevalence, and very low and low for level. For occupational exposure to asbestos, the bodies of evidence varied by industrial sector between very low and low quality of evidence for prevalence and were of very low quality of evidence for level. For occupational exposure to coal dust, the bodies of evidence were of very low or moderate quality of evidence for prevalence, and low for level. None of the included studies were population-based studies (i.e., covered the entire workers' population in the industrial sector), which we judged to present serious concern for indirectness, except for occupational exposure to coal dust within the industrial sector of mining of coal and lignite. Selected estimates of the prevalences and levels of occupational exposure to silica by industrial sector are considered suitable as input data for the WHO/ILO Joint Estimates, and selected estimates of the prevalences and levels of occupational exposure to asbestos and coal dust may perhaps also be suitable for estimation purposes. Protocol identifier: https://doi.org/10.1016/j.envint.2018.06.005. PROSPERO registration number: CRD42018084131.

Digitally measuring solar ultraviolet radiation in outdoor workers: A study protocol for establishing the use of electronic personal dosimeters in Portugal

Introduction

The rising incidence of skin cancer over the years has made it a significant public and occupational health issue. However, skin cancer is highly preventable, mainly through reduced exposure to solar ultraviolet radiation (UVR), which can be achieved by a variety of individual and collective protective measures and interventions. The relative risk associated with different patterns of exposure to solar UVR differs for the subtypes of keratinocyte cancers (KC). Specifically, whether the exposure is intermittent or continuous, and occurs in an occupational or leisure/recreational setting. The main aim of the study using this protocol is to contribute to raising public and policy awareness on solar UVR-inflicted occupational skin cancers in Lisbon. This will be achieved by performing direct measurements of the solar UVR dose received by outdoor workers using a digital platform. Results will likely contribute to further understanding the risk estimates for keratinocyte cancer estimations in this population.

Methods

A prospective observational study will be conducted in Lisbon, Portugal. Personal electronic dosimeters (GENESIS-UV system) integrated with a digital platform will be used to assess occupational solar UVR doses of gardeners, masons, and gravediggers of the municipality of Lisbon. Two hundred and ten outdoor workers will be selected to wear the dosimeter for 1 month each, between April and October during their daily working hours. A digital web-based platform that offers private access to information through dashboard visualization will provide information for the outdoor workers and facilitate communication with the participants.

Discussion

The expected results of the overall proposal comprise the occupational solar UVR doses, expressed in standard erythemal dose (SEDs) per day of outdoor work for 7 months. Study data will provide outdoor workers with information on their personal solar UVR exposure during their working hours and an estimate of their risk of developing skin cancer. It is expected that the occupational solar UVR doses of the outdoor workers in Portugal will be above the threshold of 1 to 1.33 SED/day, due to the latitude of Lisbon and the nature of the occupations. The results prospectively should flow into the design of adequate prevention campaigns for skin cancer in outdoor workers.

Photoprotection in occupational dermatology

Skin cancer has become a substantial matter of public health and in the workplace, accounting for a significant share of all reported occupational diseases. The most important external factor in the development of skin cancer is exposure to solar ultraviolet radiation. Outdoor workers have already been identified as a high-risk category. The need for interventions to improve the sun protection behavior of outdoor workers has recently been understood. Outdoor workers' risk perceptions and attitudes toward sun protection methods are likely to influence practical sun protection behavior at work, and despite the fact that many workers have expressed interest in improving their sun protection behavior, outdoor workers' unique needs are still neglected. Occupational dermatology is predicted to become more concerned with photoprotection in the decades ahead. Preventive action against the rapidly increasing number skin cancer cases is in great demand around the globe. In terms of preventive measures, the full range of available options should be used as needed to address the current difficulties in a goal-oriented way. This will almost certainly only be achievable if preventative efforts on a collective and individual level are successfully paired with support from policymakers to inspire long-term change.

Cumulative UV Exposure or a Modified SCINEXA™-Skin Aging Score Do Not Play a Substantial Role in Predicting the Risk of Developing Keratinocyte Cancers after Solid Organ Transplantation-A Case Control Study

The risk of keratinocyte cancer is determined by intrinsic and extrinsic factors, which also influence skin aging. Few studies have linked skin aging and UV exposure with the incidence of non-melanoma skin cancer (NMSC). We evaluated signs of actinic skin damage and aging, individual UV burden, and melanocortin-1 receptor (MC1R) variants. A total of 194 organ transplant recipients (OTR) who suffered from NMSC were compared to 194 tumor-free controls matched for gender, age, type of transplanted organ, post-transplantation (TX) period, and immunosuppressive therapy. Compared with the cases, the controls scored higher in all skin aging scores and there were no differences in UV burden except for intentional whole-body UV exposure for specific UV scenarios and periods of life in favor of cases. The number of NMSCs correlated with all types of skin aging scores, the extent of intentional sun exposure, older age, longer post-TX period, shorter interval from TX to first NMSC, and specific MC1R risk groups. Multivariable models revealed a 7.5-fold risk of developing NMSC in individuals with actinic keratosis; 4.1- or 3.6-fold in those with green or blue eyes, respectively; and a 1.9-fold increased risk in the MC1R medium- + high-risk group. In the absence of skin aging contributing to NMSC development, certain MC1R risk types may identify OTR at risk for high tumor burden.

Estimating the population exposed to a risk factor over a time window: A microsimulation modelling approach from the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury

OBJECTIVES

Burden of disease estimation commonly requires estimates of the population exposed to a risk factor over a time window (yeart to yeart+n). We present a microsimulation modelling approach for producing such estimates and apply it to calculate the population exposed to long working hours for one country (Italy).

METHODS

We developed a three-model approach: Model 1, a multilevel model, estimates exposure to the risk factor at the first year of the time window (yeart). Model 2, a regression model, estimates transition probabilities between exposure categories during the time window (yeart to yeart+n). Model 3, a microsimulation model, estimates the exposed population over the time window, using the Monte Carlo method. The microsimulation is carried out in three steps: (a) a representative synthetic population is initiated in the first year of the time window using prevalence estimates from Model 1, (b) the exposed population is simulated over the time window using the transition probabilities from Model 2; and (c) the population is censored for deaths during the time window.

RESULTS

We estimated the population exposed to long working hours (i.e. 41-48, 49-54 and ≥55 hours/week) over a 10-year time window (2002-11) in Italy. We populated all three models with official data from Labour Force Surveys, United Nations population estimates and World Health Organization life tables. Estimates were produced of populations exposed over the time window, disaggregated by sex and 5-year age group.

CONCLUSIONS

Our modelling approach for estimating the population exposed to a risk factor over a time window is simple, versatile, and flexible. It however requires longitudinal exposure data and Model 3 (the microsimulation model) is stochastic. The approach can improve accuracy and transparency in exposure and burden of disease estimations. To improve the approach, a logical next step is changing Model 3 to a deterministic microsimulation method, such as modelling of microflows.

Sun protection and occupation: Current developments and perspectives for prevention of occupational skin cancer

A substantial proportion of all reported occupational illnesses are constituted by skin cancer, making this disease a serious public health issue. Solar ultra-violet radiation (UVR) exposure is the most significant external factor in the development of skin cancer, for which the broad occupational category of outdoor workers has already been identified as high-risk group. Sun protection by deploying adequate technical, organizational, and person-related measures has to be understood as a functional aspect of workplace safety. To prevent skin cancers brought on by-typically cumulative-solar UVR exposure, outdoor workers must considerably lower their occupationally acquired solar UVR doses. Estimating cumulative sun exposure in outdoor workers requires consideration of the level of solar UVR exposure, the tasks to be done in the sun, and the employees' solar UVR preventive measures. Recent studies have highlighted the necessity for measures to enhance outdoor workers' sun protection behavior. In the coming decades, occupational dermatology is expected to pay increasing attention to sun protection at work. Also, the field of dermato-oncology will likely be concerned with sky-rocketing incidences of occupational skin cancers. The complete range of available alternatives should be utilized in terms of preventive actions, which seems pivotal to handle the present and future challenges in a purposeful manner. This will almost definitely only be possible if politicians' support is effectively combined with communal and individual preventive actions in order to spur long-term transformation.

The effect of occupational exposure to welding fumes on trachea, bronchus and lung cancer: A systematic review and meta-analysis 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 the producers of the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury (WHO/ILO Joint Estimates). Welding fumes have been classified as carcinogenic to humans (Group 1) by the WHO International Agency for Research on Cancer (IARC) in IARC Monograph 118; this assessment found sufficient evidence from studies in humans that welding fumes are a cause of lung cancer. In this article, we present a systematic review and meta-analysis of parameters for estimating the number of deaths and disability-adjusted life years from trachea, bronchus, and lung cancer attributable to occupational exposure to welding fumes, to inform the development of WHO/ILO Joint Estimates on this burden of disease (if considered feasible).

OBJECTIVES

We aimed to systematically review and meta-analyse estimates of the effect of any (or high) occupational exposure to welding fumes, compared with no (or low) occupational exposure to welding fumes, on trachea, bronchus, and lung cancer (three outcomes: prevalence, incidence, and mortality).

DATA SOURCES

We developed and published a protocol, applying the Navigation Guide as an organizing systematic review framework where feasible. We searched electronic databases for potentially relevant records from published and unpublished studies, including Medline, EMBASE, Web of Science, CENTRAL and CISDOC. We also searched grey literature databases, Internet search engines, and organizational websites; hand-searched reference lists of previous systematic reviews; and consulted additional experts.

STUDY ELIGIBILITY AND CRITERIA

We included working-age (≥15 years) workers in the formal and informal economy in any Member State of WHO and/or ILO but excluded children (<15 years) and unpaid domestic workers. We included randomized controlled trials, cohort studies, case-control studies, and other non-randomized intervention studies with an estimate of the effect of any (or high) occupational exposure to welding fumes, compared with occupational exposure to no (or low) welding fumes, on trachea, bronchus, and lung cancer (prevalence, incidence, and mortality).

STUDY APPRAISAL AND SYNTHESIS METHODS

At least two review authors independently screened titles and abstracts against the eligibility criteria at a first review stage and full texts of potentially eligible records at a second stage, followed by extraction of data from qualifying studies. If studies reported odds ratios, these were converted to risk ratios (RRs). We combined all RRs using random-effects meta-analysis. Two or more review authors assessed the risk of bias, quality of evidence, and strength of evidence, using the Navigation Guide tools and approaches adapted to this project. Subgroup (e.g., by WHO region and sex) and sensitivity analyses (e.g., studies judged to be of "high"/"probably high" risk of bias compared with "low"/"probably low" risk of bias) were conducted.

RESULTS

Forty-one records from 40 studies (29 case control studies and 11 cohort studies) met the inclusion criteria, comprising over 1,265,512 participants (≥22,761 females) in 21 countries in three WHO regions (Region of the Americas, European Region, and Western Pacific Region). The exposure and outcome were generally assessed by job title or self-report, and medical or administrative records, respectively. Across included studies, risk of bias was overall generally probably low/low, with risk judged high or probably high for several studies in the domains for misclassification bias and confounding. Our search identified no evidence on the outcome of having trachea, bronchus, and lung cancer (prevalence). Compared with no (or low) occupational exposure to welding fumes, any (or high) occupational exposure to welding fumes increased the risk of acquiring trachea, bronchus, and lung cancer (incidence) by an estimated 48 % (RR 1.48, 95 % confidence interval [CI] 1.29-1.70, 23 studies, 57,931 participants, I² 24 %; moderate quality of evidence). Compared with no (or low) occupational exposure to welding fumes, any (or high) occupational exposure to welding fumes increased the risk dying from trachea, bronchus, and lung cancer (mortality) by an estimated 27 % (RR 1.27, 95 % CI 1.04-1.56, 3 studies, 8,686 participants, I² 0 %; low quality of evidence). Our subgroup analyses found no evidence for difference by WHO region and sex. Sensitivity analyses supported the main analyses.

CONCLUSIONS

Overall, for incidence and mortality of trachea, bronchus, and lung cancer, we judged the existing body of evidence for human data as "sufficient evidence of harmfulness" and "limited evidence of harmfulness", respectively. Occupational exposure to welding fumes increased the risk of acquiring and dying from trachea, bronchus, and lung cancer. Producing estimates for the burden of trachea, bronchus, and lung cancer attributable to any (or high) occupational exposure to welding fumes appears evidence-based, and the pooled effect estimates presented in this systematic review could be used as input data for the WHO/ILO Joint Estimates. PROTOCOL IDENTIFIER: https://doi.org/10.1016/j.envint.2020.106089.

Improved self-attention generative adversarial adaptation network-based melanoma classification

Melanoma is one of the widespread skin cancers that has affected millions in past decades. Detection of skin cancer at preliminary stages may become a source of reducing mortality rates. Hence, it is required to develop an autonomous system of reliable type for the detection of melanoma via image processing. This paper develops an independent medical imaging technique using Self-Attention Adaptation Generative Adversarial Network (SAAGAN). The entire processing model involves the process of pre-processing, feature extraction using Scale Invariant Feature Transform (SIFT), and finally, classification using SAAGAN. The simulation is conducted on ISIC 2016/PH2 datasets, where 10-fold cross-validation is undertaken on a high-end computing platform. The simulation is performed to test the model efficacy against various images on several performance metrics that include accuracy, precision, recall, f-measure, percentage error, Matthews Correlation Coefficient, and Jaccard Index. The simulation shows that the proposed SAAGAN is more effective in detecting the test images than the existing GAN protocols.

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.

Stimulating Sunscreen Use Among Outdoor Construction Workers: A Pilot Study

Background

Outdoor workers (OW) receive a higher dose of ultraviolet radiation (UVR) compared to indoor workers (IW) which increases the risk of non-melanoma skin cancer (NMSC). Regular sunscreen use reduces the NMSC risk, however, adequate sun-safety behavior among OW is poor. The main objective was to conduct method- and intervention-related elements of a future intervention trial among OW, based on providing sunscreen and assessing sunscreen use on group- and individual level.

Methods

This pilot study was conducted at a construction site in the Netherlands from May-August 2021. Nine dispensers with sunscreen (SPF 50+) were installed at the worksite. OW (n = 67) were invited to complete two (cross-sectional) questionnaires on sun-safety behavior, before and after providing sunscreen. Stratum corneum (SC) samples for the assessment of UV-biomarkers were collected from the forehead and behind the ear from 15 OW and 15 IW. The feasibility of the following elements was investigated: recruitment, (loss to) follow-up, outcome measures, data collection, and acceptability of the intervention.

Results

The first questionnaire was completed by 27 OW, the second by 17 OW. More than 75 percent of the OW were aware of the risks of sun exposure, and 63% (n = 17) found sunscreen use during worktime important. The proportion of OW never applying sunscreen in the past month was 44.4% (n = 12) before, and 35.3% (n = 6) after providing sunscreen. A majority of OW (59.3%, n = 16) found sunscreen provision encouraging for sunscreen use, the dispensers easy to use (64.7%, n = 17) and placed in practical spots (58.8%, n = 18). Collecting SC-samples was fast and easy, and several UV-biomarkers showed higher levels for sun-exposed compared to less exposed body parts. There was no significant difference in UV-biomarker levels between OW and IW.

Conclusions

This pilot study revealed low sunscreen use among OW despite providing sunscreen, overall satisfaction with the sunscreen, and the sufficient awareness of the risks of UVR-exposure. Collecting SC-samples at the workplace is feasible and several UV-biomarkers showed to be promising in assessing UVR-exposure. The low participation rate and high loss to follow-up poses a challenge for future intervention studies.

Assessing the quality of evidence in studies estimating prevalence of exposure to occupational risk factors: The QoE-SPEO approach applied in the systematic reviews 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) have produced the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury (WHO/ILO Joint Estimates). For these, systematic reviews of studies estimating the prevalence of exposure to selected occupational risk factors have been conducted to provide input data for estimations of the number of exposed workers. A critical part of systematic review methodology is to assess the quality of evidence across studies. In this article, we present the approach applied in these WHO/ILO systematic reviews for performing such assessments on studies of prevalence of exposure. It is called the Quality of Evidence in Studies estimating Prevalence of Exposure to Occupational risk factors (QoE-SPEO) approach. We describe QoE-SPEO's development to date, demonstrate its feasibility reporting results from pilot testing and case studies, note its strengths and limitations, and suggest how QoE-SPEO should be tested and developed further.

METHODS

Following a comprehensive literature review, and using expert opinion, selected existing quality of evidence assessment approaches used in environmental and occupational health were reviewed and analysed for their relevance to prevalence studies. Relevant steps and components from the existing approaches were adopted or adapted for QoE-SPEO. New steps and components were developed. We elicited feedback from other systematic review methodologists and exposure scientists and reached consensus on the QoE-SPEO approach. Ten individual experts pilot-tested QoE-SPEO. To assess inter-rater agreement, we counted ratings of expected (actual and non-spurious) heterogeneity and quality of evidence and calculated a raw measure of agreement (P_i) between individual raters and rater teams for the downgrade domains. P_i ranged between 0.00 (no two pilot testers selected the same rating) and 1.00 (all pilot testers selected the same rating). Case studies were conducted of experiences of QoE-SPEO's use in two WHO/ILO systematic reviews.

RESULTS

We found no existing quality of evidence assessment approach for occupational exposure prevalence studies. We identified three relevant, existing approaches for environmental and occupational health studies of the effect of exposures. Assessments using QoE-SPEO comprise three steps: (1) judge the level of expected heterogeneity (defined as non-spurious variability that can be expected in exposure prevalence, within or between individual persons, because exposure may change over space and/or time), (2) assess downgrade domains, and (3) reach a final rating on the quality of evidence. Assessments are conducted using the same five downgrade domains as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach: (a) risk of bias, (b) indirectness, (c) inconsistency, (d) imprecision, and (e) publication bias. For downgrade domains (c) and (d), the assessment varies depending on the level of expected heterogeneity. There are no upgrade domains. The QoE-SPEO's ratings are "very low", "low", "moderate", and "high". To arrive at a final decision on the overall quality of evidence, the assessor starts at "high" quality of evidence and for each domain downgrades by one or two levels for serious concerns or very serious concerns, respectively. In pilot tests, there was reasonable agreement in ratings for expected heterogeneity; 70% of raters selected the same rating. Inter-rater agreement ranged considerably between downgrade domains, both for individual rater pairs (range P_i: 0.36-1.00) and rater teams (0.20-1.00). Sparse data prevented rigorous assessment of inter-rater agreement in quality of evidence ratings.

CONCLUSIONS

We present QoE-SPEO as an approach for assessing quality of evidence in prevalence studies of exposure to occupational risk factors. It has been developed to its current version (as presented here), has undergone pilot testing, and was applied in the systematic reviews for the WHO/ILO Joint Estimates. While the approach requires further testing and development, it makes steps towards filling an identified gap, and progress made so far can be used to inform future work in this area.

Photoprotection by clothing: A review

Clothing is recognized by leading health agencies as a primary method to protect against the harmful effects of photodamage caused by ultraviolet (UV) radiation and visible light. The photoprotective capacity of clothing is commonly measured as the ultraviolet protective factor (UPF). While the technology driving photoprotective clothing has been well-established, there continues to be efforts to discover new materials to improve the UPF of clothing. Here, we show increased Google searches for photoprotective clothing over the last decade, suggesting a high level of public interest in photoprotective clothing. In addition, we investigate the frequency of UPF-graded photoprotective clothing sold by large retail stores featured in Fortune 1000. We review factors that alter the UPF of clothing and describe emerging textile technologies used to increase clothing's photoprotective capacity. Finally, we compare how photoprotective clothing is regulated among different countries, the importance of photoprotective clothing in occupational health, and research in visible light and clothing photoprotection.

Burden of disease induced by public overexposure to solar ultraviolet radiation (SUVR) at the national and subnational levels in Iran, 2005-2019

Estimating the burden of diseases induced by overexposure to solar ultraviolet radiation (SUVR) can help to prioritize environmental health interventions. The age-sex specific and cause-specific mortality and disability-adjusted life years (DALYs) attributable to overexposure to SUVR at the national and subnational levels in Iran, 2005-2019 were estimated. The burden of disease induced by overexposure to SUVR was quantified in four steps as follows: (1) estimating exposure to SUVR, (2) estimating total incidences and deaths of target causes, (3) assessing population attributable fractions of the target causes for the SUVR, and (4) calculating the attributable burden of disease. The attributable DALYs, deaths, age-standardized DALY rate, and age-standardized death rate at the national level were determined to be respectively 21896, 252, 42.59, and 0.56 in 2005 and were respectively changed to 28665, 377, 38.76, and 0.53 in 2019. The contributions of causes in the attributable DALYs at the national level were different by year and sex and for both sexes in 2019 were as follows: 46.15% for cataract, 20.36% for malignant skin melanoma, 16.07% for sunburn, 12.41% for squamous-cell carcinoma, and 5.01% for the other five causes. The contributions of population growth, population ageing, risk exposure, and risk-deleted DALY rate in the temporal variations of the attributable burden of disease in the country were +20.73%, +20.68%, +2.01%, and -12.51%. The highest and lowest provincial attributable age-standardized DALY rates in 2019 were observed in Fars (46.8) and Ardebil (32.7), respectively. The burden of disease induced by exposure to SUVR caused relatively low geographical inequality in health status in Iran. Due to increasing trends of the SUVR as well as the attributable burden of disease, the preventive interventions against the SUVR overexposure should be considered in the public health action plan all across the country.

Assessor burden, inter-rater agreement and user experience of the RoB-SPEO tool for assessing risk of bias in studies estimating prevalence of exposure to occupational risk factors: An analysis from the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury

BACKGROUND

As part of the development of the World Health Organization (WHO)/International Labour Organization (ILO) Joint Estimates of the Work-related Burden of Disease and Injury, WHO and ILO carried out several systematic reviews to determine the prevalence of exposure to selected occupational risk factors. Risk of bias assessment for individual studies is a critical step of a systematic review. No tool existed for assessing the risk of bias in prevalence studies of exposure to occupational risk factors, so WHO and ILO developed and pilot tested the RoB-SPEO tool for this purpose. Here, we investigate the assessor burden, inter-rater agreement, and user experience of this new instrument, based on the abovementioned WHO/ILO systematic reviews.

METHODS

Twenty-seven individual experts applied RoB-SPEO to assess risk of bias. Four systematic reviews provided a total of 283 individual assessments, carried out for 137 studies. For each study, two or more assessors independently assessed risk of bias across the eight RoB-SPEO domains selecting one of RoB-SPEO's six ratings (i.e., "low", "probably low", "probably high", "high", "unclear" or "cannot be determined"). Assessors were asked to report time taken (i.e. indicator of assessor burden) to complete each assessment and describe their user experience. To gauge assessor burden, we calculated the median and inter-quartile range of times taken per individual risk of bias assessment. To assess inter-rater reliability, we calculated a raw measure of inter-rater agreement (Pi) for each RoB-SPEO domain, between Pi = 0.00, indicating no agreement and Pi = 1.00, indicating perfect agreement. As subgroup analyses, Pi was also disaggregated by systematic review, assessor experience with RoB-SPEO (≤10 assessments versus > 10 assessments), and assessment time (tertiles: ≤25 min versus 26-66 min versus ≥ 67 min). To describe user experience, we synthesised the assessors' comments and recommendations.

RESULTS

Assessors reported a median of 40 min to complete one assessment (interquartile range 21-120 min). For all domains, raw inter-rater agreement ranged from 0.54 to 0.82. Agreement varied by systematic review and assessor experience with RoB-SPEO between domains, and increased with increasing assessment time. A small number of users recommended further development of instructions for selected RoB-SPEO domains, especially bias in selection of participants into the study (domain 1) and bias due to differences in numerator and denominator (domain 7).

DISCUSSION

Overall, our results indicated good agreement across the eight domains of the RoB-SPEO tool. The median assessment time was comparable to that of other risk of bias tools, indicating comparable assessor burden. However, there was considerable variation in time taken to complete assessments. Additional time spent on assessments may improve inter-rater agreement. Further development of the RoB-SPEO tool could focus on refining instructions for selected RoB-SPEO domains and additional testing to assess agreement for different topic areas and with a wider range of assessors from different research backgrounds.

Tendências na Mortalidade por Câncer de Pele não Melanoma no Brasil e suas Macrorregiões

Introdução: O câncer de pele não melanoma (CPNM) e o mais comum entre todas as malignidades. Objetivo: Descrever as tendências da mortalidade por CPNM no Brasil e nas suas Macrorregiões, de 2001 a 2018. Método: As taxas de mortalidade ajustadas por idade e estratificadas por sexo foram apresentadas por 100 mil pessoas-ano. Uma análise autorregressiva foi implementada para avaliar tendências, Mudança Percentual Anual (MPA) e intervalos de confiança de 95% (IC 95%). Resultados: Houve 27.550 óbitos por CPNM no Brasil com maior frequência em homens (58,1%) e entre pessoas de 70 anos e mais (64,3%). As taxas globais foram de 2,25 (homens) e 1,22 (mulheres) por 100 mil pessoas-ano. As tendências seguiram em elevação no Brasil, em homens (MPA: 2,91%; IC95%: 1,96%; 3,86%) e em mulheres (MPA: 3,51%; IC95%: 2,68%; 4,34%). O mesmo ocorreu na Região Norte, em homens (MPA: 9,75%; IC95%: 7,68%; 11,86%) e em mulheres (MPA: 10,38%; IC95%: 5,77%; 15,21%), bem como na Região Nordeste, em homens (MPA: 9,98%; IC95%: 5,59%; 14,57%) e em mulheres (MPA: 8,34%; IC95%: 3,29%; 13,64%). Conclusão: Os óbitos por CPNM não são raridade no Brasil. O país e as Regiões Norte e Nordeste experimentaram taxas com tendência em elevação. Norte e Nordeste são as Regiões mais próximas da Linha do Equador e as menos desenvolvidas socioeconomicamente. Nessas Macrorregiões, um sinergismo entre diferentes tipos de desigualdades e exposições ambientais pode estar promovendo um aumento dos óbitos por esse tipo de câncer considerado totalmente evitável.

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.

Spatiotemporal analysis of solar ultraviolet radiation based on Ozone Monitoring Instrument dataset in Iran, 2005-2019

The solar ultraviolet radiation (UVR) at national, provincial and county levels in Iran during 2005-2019 were determined based on Ozone Monitoring Instrument (OMI) dataset. The temporal (annual and monthly) trends and spatial distributions of the UVR in terms of erythemally weighted daily dose (EDD), erythemally weighted irradiance at local solar noon time (EDR), and UV index and the major factors influencing the spatiotemporal trends were analyzed. The population-weighted average values of EDD, EDR, and UV index in Iran were respectively 3631 J/m², 176.3 mW/m², 7.1 in 2005 and rose by 0.22% per year to 3744 J/m², 181.7 mW/m², and 7.3, respectively in 2019, but the annual trend was not statistically significant. The EDD in Iran during the study period exhibited the highest monthly average value in June (6339 J/m²) and the lowest one in December (1263 J/m²). The solar UVA/UVB ratios at the national level during 2005-2019 were considerably lower in summer. The EDD provincial average values in the study period were in the range of 2717 (Gilan) to 4424 J/m² (Fars). The spatiotemporal variations of the solar UVR parameters were well described by the linear models as a function of cloud optical thickness (COT), ozone column amount, surface albedo, latitude, and altitude (R² > 0.961, p value < 0.001) and the temporal changes of the solar UVR parameters were mainly caused by the COT. The results indicated that non-burning exposure to solar UVR in summer can be more efficient for vitamin D synthesis due to higher contribution of UVB in the solar UVR. The spatial distributions and temporal trends should be considered to determine the optimal duration, time and condition of exposure to the solar UVR for the public and occupational training and public health measures.

The effect of exposure to long working hours on depression: A systematic review and meta-analysis 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 the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury (WHO/ILO Joint Estimates), supported by a large number of individual experts. Evidence from previous reviews suggests that exposure to long working hours may cause depression. In this article, we present a systematic review and meta-analysis of parameters for estimating (if feasible) the number of deaths and disability-adjusted life years from depression that are attributable to exposure to long working hours, for the development of the WHO/ILO Joint Estimates.

OBJECTIVES

We aimed to systematically review and meta-analyse estimates of the effect of exposure to long working hours (three categories: 41-48, 49-54 and ≥55 h/week), compared with exposure to standard working hours (35-40 h/week), on depression (three outcomes: prevalence, incidence and mortality).

DATA SOURCES

We developed and published a protocol, applying the Navigation Guide as an organizing systematic review framework where feasible. We searched electronic academic databases for potentially relevant records from published and unpublished studies, including the WHO International Clinical Trial Registers Platform, Medline, PubMed, EMBASE, Web of Science, CISDOC and PsycInfo. We also searched grey literature databases, Internet search engines and organizational websites; hand-searched reference lists of previous systematic reviews; and consulted additional experts.

STUDY ELIGIBILITY AND CRITERIA

We included working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State but excluded children (aged <15 years) and unpaid domestic workers. We included randomized controlled trials, cohort studies, case-control studies and other non-randomized intervention studies with an estimate of the effect of exposure to long working hours (41-48, 49-54 and ≥55 h/week), compared with exposure to standard working hours (35-40 h/week), on depression (prevalence, incidence and/or mortality).

STUDY APPRAISAL AND SYNTHESIS METHODS

At least two review authors independently screened 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. Missing data were requested from principal study authors. We combined odds ratios using random-effects meta-analysis. Two or more review authors assessed the risk of bias, quality of evidence and strength of evidence, using Navigation Guide and GRADE tools and approaches adapted to this project.

RESULTS

Twenty-two studies (all cohort studies) met the inclusion criteria, comprising a total of 109,906 participants (51,324 females) in 32 countries (as one study included multiple countries) in three WHO regions (Americas, Europe and Western Pacific). The exposure was measured using self-reports in all studies, and the outcome was assessed with a clinical diagnostic interview (four studies), interview questions about diagnosis and treatment of depression (three studies) or a validated self-administered rating scale (15 studies). The outcome was defined as incident depression in all 22 studies, with first time incident depression in 21 studies and recurrence of depression in one study. We did not identify any study on prevalence of depression or on mortality from depression. For the body of evidence for the outcome incident depression, we had serious concerns for risk of bias due to selection because of incomplete outcome data (most studies assessed depression only twice, at baseline and at a later follow-up measurement, and likely have missed cases of depression that occurred after baseline but were in remission at the time of the follow-up measurement) and due to missing information on life-time prevalence of depression before baseline measurement. Compared with working 35-40 h/week, we are uncertain about the effect on acquiring (or incidence of) depression of working 41-48 h/week (pooled odds ratio (OR) 1.05, 95% confidence interval (CI) 0.86 to 1.29, 8 studies, 49,392 participants, I² 46%, low quality of evidence); 49-54 h/week (OR 1.06, 95% CI 0.93 to 1.21, 8 studies, 49,392 participants, I² 40%, low quality of evidence); and ≥ 55 h/week (OR 1.08, 95% CI 0.94 to 1.24, 17 studies, 91,142 participants, I² 46%, low quality of evidence). Subgroup analyses found no evidence for statistically significant (P < 0.05) differences by WHO region, sex, age group and socioeconomic status. Sensitivity analyses found no statistically significant differences by outcome measurement (clinical diagnostic interview [gold standard] versus other measures) and risk of bias ("high"/"probably high" ratings in any domain versus "low"/"probably low" in all domains).

CONCLUSIONS

We judged the existing bodies of evidence from human data as "inadequate evidence for harmfulness" for all three exposure categories, 41-48, 48-54 and ≥55 h/week, for depression prevalence, incidence and mortality; the available evidence is insufficient to assess effects of the exposure. Producing estimates of the burden of depression attributable to exposure to long working appears not evidence-based at this point. Instead, studies examining the association between long working hours and risk of depression are needed that address the limitations of the current evidence.

The prevalence of occupational exposure to noise: A systematic review and meta-analysis 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), with contributions from a large network of individual experts. Evidence from mechanistic and human data suggests that occupational exposure to noise may cause cardiovascular disease. In this paper, we present a systematic review and meta-analysis of the prevalence of occupational exposure to noise for estimating (if feasible) the number of deaths and disability-adjusted life years from cardiovascular disease that are attributable to exposure to this risk factor, for the development of the WHO/ILO Joint Estimates.

OBJECTIVES

We aimed to systematically review and meta-analyse estimates of the prevalence of occupational exposure to noise.

DATA SOURCES

We searched electronic academic databases for potentially relevant records from published and unpublished studies, including Ovid Medline, PubMed, EMBASE, and CISDOC. We also searched electronic grey literature databases, Internet search engines, and organizational websites; hand-searched reference list of previous systematic reviews and included study records; and consulted additional experts.

STUDY ELIGIBILITY AND CRITERIA

We included working-age (≥15 years) workers in the formal and informal economies in any WHO Member and/or ILO member State, but excluded children (<15 years) and unpaid domestic workers. We included all study types with an estimate of the prevalence of occupational exposure to noise, categorized into two levels: no (low) occupational exposure to noise (<85dBA) and any (high) occupational exposure to noise (≥85dBA).

STUDY APPRAISAL AND SYNTHESIS METHODS

At least two review authors independently screened 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. We combined prevalence estimates using random-effect meta-analysis. Two or more review authors assessed the risk of bias and the quality of evidence, using the RoB-SPEO tool and QoE-SPEO approach developed specifically for the WHO/ILO Joint Estimates.

RESULTS

Sixty-five studies (56 cross-sectional studies and nine cohort studies) met the inclusion criteria, comprising 157,370 participants (15,369 females) across 28 countries and all six WHO regions (Africa, Americas, Eastern Mediterranean, Europe, South-East Asia, and Western Pacific). For the main analyses, we prioritized the four included studies that surveyed national probability samples of general populations of workers over the 58 studies of workers in industrial sectors and/or occupations with relatively high occupational exposure to noise. The exposure was generally assessed with dosimetry, sound level meter, or official or company records; in the population-based studies, it was assessed with validated questions. Estimates of the prevalence of occupational exposure to noise are presented for all 65 included studies, by country, sex, 5-year age group, industrial sector, and occupation where feasible. The pooled prevalence of any (high) occupational exposure to noise (≥85dBA) among the general population of workers was 0.17 (95% confidence interval 0.16 to 0.19, 4 studies, 108,256 participants, 38 countries, two WHO regions, I2 98%, low quality of evidence). Subgroup analyses showed that pooled prevalence differed substantially by WHO region, sex, industrial sector, and occupation.

CONCLUSIONS

Our systematic review and meta-analysis found that occupational exposure to noise is prevalent among general populations of workers. The current body of evidence is, however, of low quality, due to serious concerns for risk of bias and indirectness. Producing estimates of occupational exposure to noise nevertheless appears evidence-based, and the pooled effect estimates presented in this systematic review are suitable as input data for the WHO/ILO Joint Estimates (if feasible). Protocol identifier: 10.1016/j.envint.2018.09.040 PROSPERO registration number: CRD42018092272.

The effect of occupational exposure to noise on ischaemic heart disease, stroke and hypertension: A systematic review and meta-analysis 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), with contributions from a large number of individual experts. Evidence from mechanistic data suggests that occupational exposure to noise may cause cardiovascular disease (CVD). In this paper, we present a systematic review and meta-analysis of parameters for estimating the number of deaths and disability-adjusted life years from CVD that are attributable to occupational exposure to noise, for the development of the WHO/ILO Joint Estimates.

OBJECTIVES

We aimed to systematically review and meta-analyse estimates of the effect of any (high) occupational exposure to noise (≥85 dBA), compared with no (low) occupational exposure to noise (<85 dBA), on the prevalence, incidence and mortality of ischaemic heart disease (IHD), stroke, and hypertension.

DATA SOURCES

A protocol was developed and published, applying the Navigation Guide as an organizing systematic review framework where feasible. We searched electronic academic databases for potentially relevant records from published and unpublished studies up to 1 April 2019, including International Trials Register, Ovid MEDLINE, PubMed, Embase, Lilacs, Scopus, Web of Science, and CISDOC. The MEDLINE and Pubmed searches were updated on 31 January 2020. We also searched grey literature databases, Internet search engines and organizational websites; hand-searched reference lists of previous systematic reviews and included study records; and consulted additional experts.

STUDY ELIGIBILITY AND CRITERIA

We included working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State but excluded children (<15 years) and unpaid domestic workers. We included 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 noise on CVD prevalence, incidence or mortality, compared with the theoretical minimum risk exposure level (<85 dBA).

STUDY APPRAISAL AND SYNTHESIS METHODS

At least two review authors independently screened 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. We prioritized evidence from cohort studies and combined relative risk estimates using random-effect meta-analysis. To assess the robustness of findings, we conducted sensitivity analyses (leave-one-out meta-analysis and used as alternative fixed effects and inverse-variance heterogeneity estimators). At least two review authors assessed the risk of bias, quality of evidence and strength of evidence, using Navigation Guide tools and approaches adapted to this project.

RESULTS

Seventeen studies (11 cohort studies, six case-control studies) met the inclusion criteria, comprising a total of 534,688 participants (39,947 or 7.47% females) in 11 countries in three WHO regions (the Americas, Europe, and the Western Pacific). The exposure was generally assessed with dosimetry, sound level meter and/or official or company records. The outcome was most commonly assessed using health records. We are very uncertain (low quality of evidence) about the effect of occupational exposure to noise (≥85 dBA), compared with no occupational exposure to noise (<85 dBA), on: having IHD (0 studies); acquiring IHD (relative risk (RR) 1.29, 95% confidence interval (95% CI) 1.15 to 1.43, two studies, 11,758 participants, I² 0%); dying from IHD (RR 1.03, 95% CI 0.93-1.14, four studies, 198,926 participants, I² 26%); having stroke (0 studies); acquiring stroke (RR 1.11, 95% CI 0.82-1.65, two studies, 170,000 participants, I² 0%); dying from stroke (RR 1.02, 95% CI 0.93-1.12, three studies, 195,539 participants, I² 0%); having hypertension (0 studies); acquiring hypertension (RR 1.07, 95% CI 0.90-1.28, three studies, four estimates, 147,820 participants, I² 52%); and dying from hypertension (0 studies). Data for subgroup analyses were missing. Sensitivity analyses supported the main analyses.

CONCLUSIONS

For acquiring IHD, we judged the existing body of evidence from human data to provide "limited evidence of harmfulness"; a positive relationship is observed between exposure and outcome where chance, bias, and confounding cannot be ruled out with reasonable confidence. For all other included outcomes, the bodies of evidence were judged as "inadequate evidence of harmfulness". Producing estimates for the burden of CVD attributable to occupational exposure to noise appears to not be evidence-based at this time.

PROTOCOL IDENTIFIER

10.1016/j.envint.2018.09.040.

PROSPERO REGISTRATION NUMBER

CRD42018092272.

Reviews in environmental health: How systematic are they?

BACKGROUND

Synthesizing environmental health science is crucial to taking action to protect public health. Procedures for evidence evaluation and integration are transitioning from "expert-based narrative" to "systematic" review methods. However, little is known about the methodology being utilized for either type of review.

OBJECTIVES

To appraise the methodological strengths and weaknesses of a sample of "expert-based narrative" and "systematic" reviews in environmental health.

METHODS

We conducted a comprehensive search of multiple databases and identified relevant reviews using pre-specified eligibility criteria. We applied a modified version of the Literature Review Appraisal Toolkit (LRAT) to three environmental health topics that assessed the utility, validity and transparency of reviews.

RESULTS

We identified 29 reviews published between 2003 and 2019, of which 13 (45%) were self-identified as systematic reviews. Across every LRAT domain, systematic reviews received a higher percentage of "satisfactory" ratings compared to non-systematic reviews. In eight of these domains, there was a statistically significant difference observed between the two types of reviews and "satisfactory" ratings. Non-systematic reviews performed poorly with the majority receiving an "unsatisfactory" or "unclear" rating in 11 of the 12 domains. Systematic reviews performed poorly in six of the 12 domains; 10 (77%) did not state the reviews objectives or develop a protocol; eight (62%) did not state the roles and contribution of the authors, or evaluate the internal validity of the included evidence consistently using a valid method; and only seven (54%) stated a pre-defined definition of the evidence bar on which their conclusions were based, or had an author disclosure of interest statement.

DISCUSSION

Systematic reviews produced more useful, valid, and transparent conclusions compared to non-systematic reviews, but poorly conducted systematic reviews were prevalent. Ongoing development and implementation of empirically based systematic review methods are required in environmental health to ensure transparent and timely decision making to protect the public's health.

Frog Skin Derived Peptides With Potential Protective Effects on Ultraviolet B-Induced Cutaneous Photodamage

Hyla annectans is a tree frog living in the southwestern plateau area of China where there is strong ultraviolet radiation and long duration of sunshine. So their naked skin may possess chemical defense components that protect it from acute photo-damage. However, no such peptide or components has been identified till to date. In the current work, two novel peptides (FW-1, FWPLI-NH2 and FW-2, FWPMI-NH2) were identified from the skin of the tree frog. Five copies of FW-1 and four copies of FW-2 are encoded by an identical gene and released from the same protein precursor, which possess 167 amino acid residues. FW-1 and -2 can exert significant anti-inflammatory functions by directly inhibiting Ultraviolet B irradiation (UVB)-induced secretion of inflammatory cytokines such as tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6). They may achieve this function by modulating the UV-induced stress signaling pathways such as Mitogen-activated protein kinases (MAPK) and Nuclear Factor Kappa B (NF-κB). Besides, FW-1 and -2 showed potential antioxidant effects on epidermis by attenuating the UVB-induced reactive oxygen species (ROS) production through an unknown mechanism. Considering small peptides' easy production, storage, and potential photo-protective activity, FW-1/2 might be exciting leading compounds or templates for the development of novel pharmacological agents for the suppression of UVB-induced skin inflammation. Moreover, this study might expand our knowledge on skin defensive mechanism of tree frog upon UVB irradiation.

Ultraviolet radiation and risk of cutaneous melanoma and squamous cell carcinoma in males and females in the Norwegian Offshore Petroleum Workers cohort

BACKGROUND

Increased risk of cutaneous melanoma and squamous cell carcinoma (SCC) has been reported among petroleum workers, but few studies include females, exposure data on ultraviolet radiation (UVR), and potential confounding factors. We aimed to examine UVR exposure in relation to risk of melanoma and SCC among male and female offshore petroleum workers. We also examined the association between UVR exposure and melanoma (Breslow) thickness.

METHODS

The Norwegian Offshore Petroleum Workers (NOPW) cohort (n = 27,917) holds information on sunbathing, indoor tanning, sunburns, sunscreen use, and other lifestyle factors recorded in 1998. Linkage to the Cancer Registry of Norway gave information on cancer diagnosis through 2017. We used Cox and logistic regression to estimate hazard ratios (HRs) of skin cancer and odds ratios (OR) of thick (≥1 mm) melanomas, respectively, with 95% confidence intervals (CIs).

RESULTS

Melanoma risk increased with increasing frequency of sunbathing after age 20 (ptrend  = 0.031), sunburn average intensity (ptrend  = 0.028), and sunscreen use (HR = 2.16; 95% CI: 1.42 -3.27 for almost always vs. never/rarely). The risk of thick melanoma was inversely associated with sunbathing frequency after age 20 (OR = 0.38; 95% CI: 0.16 - 0.90 for ≥4 weeks/year vs. 1 week/year). SCC risk increased with increasing frequency of indoor tanning after age 20 (HR = 2.72; 95% CI: 1.22 - 6.05 for ≥3 times/months vs. never), sunburn average intensity (ptrend  < 0.001), and sunscreen use (ptrend  < 0.001).

CONCLUSIONS

Our results support associations between UVR exposure and skin cancer risk in male and female offshore petroleum workers. This occupational group may be especially relevant for targeted sun protection advice.

Effect of Occupational Health and Safety Training for Chinese Construction Workers Based on the CHAID Decision Tree

Background: Occupational health and safety (OHS) training is an important way to prevent construction safety risks. However, the effectiveness of OHS training in China is questionable. In this study, the CHAID (chi-squared automatic interaction detection) decision tree, chi-square analysis, and correlation analysis were used to explore the main, secondary, weak, unrelated, and expectation factors affecting the effectiveness of training. It is the first to put forward the "five-factor method" of training effectiveness. It is found that training effectiveness is positively correlated with job responsibilities, OHS training, and job satisfaction. It is also significantly related to job certificate, training time, training method, and working time. However, the effectiveness of training has nothing to do with personal age, marital status, educational level, job type, and whether or not they have experienced industrial accidents. And the workers on site expect the enterprise to provide security and opportunities such as physical safety, training and learning, and future career development. The results show that OHS system training should be strengthened in the construction industry, and classified training should be carried out according to post responsibility, training methods, job satisfaction, and working hours.

Emerging OSH Issues in Installation and Maintenance of Floating Solar Photovoltaic Projects and Their Link with Sustainable Development Goals

Objective

Emerging issues of occupational safety and health (OSH) in floating solar photovoltaic projects (FSPV) have rarely been addressed to achieve the Sustainable Development Goals (SDGs). The current scoping review has been planned to demonstrate OSH issues experienced by the workers engaged in the installation and maintenance of FSPV projects and existing ergonomics design interventions in the solar photovoltaic industry with a focus on the FSPV sector.

Methods

A literature review was conducted from four major electronic databases (Science Direct, Google Scholar, Web of Science, and Scopus) using predefined keywords and following the PRISMA framework for the period 1965–2020. A total of 49 studies under five headings, namely a) overview of key reasons for the emergence of floating solar photovoltaic projects, b) occupational risks of workers engaged in the solar PV industry/FSPV sector, c) occupational risks in workplaces/occupations similar to floating solar photovoltaics projects, d) availability of training modules and occupational standards, and e) design interventions/approaches in the solar PV industry/floating photovoltaics sector were analyzed.

Results

It emerged that workers are exposed to multifarious occupational risk factors such as heat, solar radiation, ergonomic risks, electrocution, fire, hazardous substances, adverse weather conditions, and psychosocial factors. These risks have not been adequately addressed with required interventions in the FSPV sector. Intervention opportunities include designing innovative tools, lowering of loads, redesigning workplace layouts, introducing job aids, automation, task rotation, job enlargement, design of training modules, OSH standards and changes in work organization/shift, etc.

Conclusion

This review is a first-of-its-kind effort to highlight the contextual risk factors in the emerging FSPV sector and the need for addressing them through ergonomics design interventions for successfully achieving the Sustainable Development Goals.

Solar Ultraviolet Radiation Risk Estimates-A Comparison of Different Action Spectra and Detector Responsivities

Studies assessing the dose–response relationship for human skin cancer induction by solar ultraviolet radiation (UVR) apply a range of methods to quantify relevant UVR doses, but information about the comparability of these datasets is scarce. We compared biologically weighted effectivities applying the most relevant UVR action spectra in order to test the ability of certain UVR detectors to mimic these biological effects at different times during the day and year. Our calculations were based on solar spectra measured at Dortmund, Germany (51.5° N) and at Townsville, Australia (19.3° S), or computed for latitudes 20° S and 50° N. Convolutions with the CIE action spectra for erythema and non-melanoma skin cancer (NMSC) and with ICNIRP’s weighting function showed comparable solar zenith angle (SZA) dependences with little influence of season or latitude. A different SZA dependence was found with Setlow’s action spectrum for melanoma induction. Calculations for a number of UVR detector responsivities gave widely discrepant absolute irradiances and doses, which were nevertheless related to those calculated with both CIE spectra by correction factors largely independent of the SZA. Commonly used detectors can thus provide quite accurate estimates of NMSC induction by solar UVR, whereas they may be inadequate to mimic melanoma induction.

The effect of occupational exposure to ergonomic risk factors on osteoarthritis of hip or knee and selected other musculoskeletal diseases: A systematic review and meta-analysis 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), with contributions from a large network of experts. Evidence from mechanistic data suggests that occupational exposure to ergonomic risk factors may cause selected other musculoskeletal diseases, other than back or neck pain (MSD) or osteoarthritis of hip or knee (OA). In this paper, we present a systematic review and meta-analysis of parameters for estimating the number of disability-adjusted life years from MSD or OA that are attributable to occupational exposure to ergonomic risk factors, for the development of the WHO/ILO Joint Estimates.

OBJECTIVES

We aimed to systematically review and meta-analyse estimates of the effect of occupational exposure to ergonomic risk factors (force exertion, demanding posture, repetitiveness, hand-arm vibration, lifting, kneeling and/or squatting, and climbing) on MSD and OA (two outcomes: prevalence and incidence).

DATA SOURCES

We developed and published a protocol, applying the Navigation Guide as an organizing systematic review framework where feasible. We searched electronic academic databases for potentially relevant records from published and unpublished studies, including the International Trials Register, Ovid Medline, EMBASE, and CISDOC. We also searched electronic grey literature databases, Internet search engines and organizational websites; hand-searched reference list of previous systematic reviews and included study records; and consulted additional experts.

STUDY ELIGIBILITY AND CRITERIA

We included working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State but excluded children (<15 years) and unpaid domestic workers. We included randomized controlled trials, cohort studies, case-control studies and other non-randomized intervention studies with an estimate of the effect of occupational exposure to ergonomic risk factors (any exposure to force exertion, demanding posture, repetitiveness, hand-arm vibration, lifting, kneeling and/or squatting, and climbing ≥ 2 h/day) compared with no or low exposure to the theoretical minimum risk exposure level (<2 h/day) on the prevalence or incidence of MSD or OA.

STUDY APPRAISAL AND SYNTHESIS METHODS

At least two review authors independently screened 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. Missing data were requested from principal study authors. We combined odds ratios using random-effect meta-analysis. Two or more review authors assessed the risk of bias and the quality of evidence, using Navigation Guide tools adapted to this project.

RESULTS

In total eight studies (4 cohort studies and 4 case control studies) met the inclusion criteria, comprising a total of 2,378,729 participants (1,157,943 females and 1,220,786 males) in 6 countries in 3 WHO regions (Europe, Eastern Mediterranean and Western Pacific). The exposure was measured using self-reports in most studies and with a job exposure matrix in one study and outcome was generally assessed with physician diagnostic records or administrative health data. Across included studies, risk of bias was generally moderate. Compared with no or low exposure (<2 h per day), any occupational exposure to ergonomic risk factors increased the risk of acquiring MSD (odds ratio (OR) 1.76, 95% confidence interval [CI] 1.14 to 2.72, 4 studies, 2,376,592 participants, I² 70%); and increased the risk of acquiring OA of knee or hip (OR 2.20, 95% CI 1.42 to 3.40, 3 studies, 1,354 participants, I² 13%); Subgroup analysis for MSD found evidence for differences by sex, but indicated a difference in study type, where OR was higher among study participants in a case control study compared to study participants in cohort studies.

CONCLUSIONS

Overall, for both outcomes, the main body of evidence was assessed as being of low quality. Occupational exposure to ergonomic risk factors increased the risk of acquiring MSD and of acquiring OA of knee or hip. We judged the body of human evidence on the relationship between exposure to occupational ergonomic factors and MSD as "limited evidence of harmfulness" and the relationship between exposure to occupational ergonomic factors and OA also as "limited evidence of harmfulness". These relative risks might perhaps be suitable as input data for WHO/ILO modelling of work-related burden of disease and injury. Protocol identifier: https://doi.org/10.1016/j.envint.2018.09.053 PROSPERO registration number: CRD42018102631.

Developing indices to identify hotspots of skin cancer vulnerability among the Non-Hispanic White population in the United States

PURPOSE

Skin cancer is the most common, yet oftentimes preventable, cancer type in the United States. Exposure to ultraviolet radiation from sunlight is the most prominent environmental risk factor for skin cancer. Besides environmental exposure, demographic characteristics such as race, age, and socioeconomic status may make some groups more vulnerable. An exploratory spatial clustering method is described for identifying clusters of vulnerability to skin cancer incidence and mortality based on composite indices, which combine data from environmental and demographic risk factors.

METHODS

Based on county-level ultraviolet data and demographic risk factors, two vulnerability indices for skin cancer were generated using an additive percentile rank approach. With these indices, univariate local Moran's I spatial autocorrelation identified significant clusters, or hotspots, of neighboring counties with high overall vulnerability indices. Clusters were identified separately for skin cancer incidence and mortality.

RESULTS

Counties with high vulnerabilities were spatially distributed across the United States in a pattern that generally increased to the South and West. Clusters of counties with high skin cancer incidence vulnerability were mostly observed in Utah and Colorado, even with highly conservative levels of significance. Meanwhile, clusters for skin cancer mortality vulnerability were observed in southern Alabama and west Florida as well as across north Alabama, north Georgia and up through the Tennessee-North Carolina area.

CONCLUSIONS

Future skin cancer research and screening initiatives may use these innovative composite vulnerability indices and identified clusters to better target resources based on anticipated risk from underlying demographic and environmental factors.

Occupation and cutaneous melanoma: a 45-year historical cohort study of 14·9 million people in five Nordic countries

BACKGROUND

The age-adjusted incidence of cutaneous melanoma (CM) in the Nordic countries has increased during the last 60 years. Few prospective population-based studies have estimated the occupational variation in CM risk over time.

OBJECTIVES

To determine occupational variation in CM risk.

METHODS

A historical prospective cohort study with a 45-year follow-up from 1961 to 2005 (Nordic Occupational Cancer Study, NOCCA) based on record linkages between census and cancer registry data for Nordic residents aged 30-64 years in Denmark, Finland, Iceland, Norway and Sweden. National occupational codes were converted to 53 occupational categories, and stratified into indoor, outdoor and mixed work, and into socioeconomic status. The standardized incidence ratios (SIRs) were estimated as observed number of CM cases divided by the expected number calculated from stratum-specific person-years and national CM incidence rates.

RESULTS

During a follow-up of 385 million person-years, 83 898 incident cases of CM were identified. In all countries combined, men with outdoor work had a low SIR of 0·79 [95% confidence interval (CI) 0·77-0·81] and men with indoor work had a high SIR of 1·09 (95% CI 1·07-1·11). Differences in women pointed in the same direction. High socioeconomic status was associated with an excess risk: SIR 1·34 (95% CI 1·28-1·40) in men and SIR 1·31 (95% CI 1·26-1·36) in women. Technical, transport, military and public safety workers with potential skin exposure to carcinogens had excess risks.

CONCLUSIONS

Occupational variation in CM risk may be partly explained by host, socioeconomic and skin exposure factors. Differences in CM risk across socioeconomic groups attenuated slightly over time.

Protection Against Solar Ultraviolet Radiation in Outdoor Construction Workers: Study Protocol for a Non-randomized Controlled Intervention Study

Introduction: Non-melanoma skin cancer (NMSC) incidence is increasing, and occupational solar exposure contributes greatly to the overall lifetime ultraviolet radiation (UVR) dose. This is reflected in an excess risk of NMSC showing up to three-fold increase in outdoor workers. Risk of NMSC can be reduced if appropriate measures to reduce UVR-exposure are taken. Regular use of sunscreens showed reduced risk of NMSC. However, sun-safety behavior in outdoor workers is poor. The objective of this study is to investigate the effectiveness of an intervention aiming at increasing sunscreen use by construction workers.

Methods: This non-randomized controlled intervention study is comprised of two intervention and two control groups recruited at four different construction sites in the Netherlands. The study population comprises ~200 construction workers, aged 18 years or older, followed during 12 weeks. The intervention consists of providing dispensers with sunscreens (SPF 50+) at construction sites and regular feedback on the application achieved by continuous electronic monitoring. All groups will receive basic information on UV-exposure and skin protection. Stratum corneum (SC) samples will be collected for measurement of biomarkers to assess internal UV-dose. External UV-dose will be assessed by personal UV-sensors worn by the workers during work-shifts in both groups. To detect presence of actinic keratosis (AK) or NMSC, a skin check of body parts exposed to the sun will be performed at the end of the study. The effect of the intervention will be assessed from data on self-reported sunscreen use by means of questionnaires collected on baseline and after 12 weeks of intervention (primary outcome). Levels of SC biomarkers of internal UV-dose, external UV-dose, number of sunburn episodes, and prevalence of NMSC including AK will be assessed as secondary outcomes. The electronically monitored sunscreen consumption will be assessed as process outcome.

Discussion: This study is intended to provide evidence of the effectiveness of a technology-driven intervention to increase sunscreen use in outdoor construction workers. Furthermore, it will increase insight in the UV-protective behavior, external and internal UV-exposure, and the prevalence of NMSC, including AK, in construction workers.

Trial Registration: The Netherlands Trial Register (NTR): NL8462 Registered on March 19, 2020.

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.

The effect of exposure to long working hours on alcohol consumption, risky drinking and alcohol use disorder: A systematic review and meta-analysis 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), with contributions from a large network of experts. Evidence from mechanistic data suggests that exposure to long working hours may increase alcohol consumption and cause alcohol use disorder. In this paper, we present a systematic review and meta-analysis of parameters for estimating the number of deaths and disability-adjusted life years from alcohol consumption and alcohol use disorder that are attributable to exposure to long working hours, for the development of the WHO/ILO Joint Estimates.

OBJECTIVES

We aimed to systematically review and meta-analyse estimates of the effect of exposure to long working hours (three categories: 41-48, 49-54 and ≥55 h/week), compared with exposure to standard working hours (35-40 h/week), on alcohol consumption, risky drinking (three outcomes: prevalence, incidence and mortality) and alcohol use disorder (three outcomes: prevalence, incidence and mortality).

DATA SOURCES

We developed and published a protocol, applying the Navigation Guide as an organizing systematic review framework where feasible. We searched electronic bibliographic databases for potentially relevant records from published and unpublished studies, including the WHO International Clinical Trials Register, Ovid MEDLINE, PubMed, Embase, and CISDOC on 30 June 2018. Searches on PubMed were updated on 18 April 2020. We also searched electronic grey literature databases, Internet search engines and organizational websites; hand-searched reference list of previous systematic reviews and included study records; and consulted additional experts.

STUDY ELIGIBILITY AND CRITERIA

We included working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State but excluded children (<15 years) and unpaid domestic workers. We considered for inclusion randomized controlled trials, cohort studies, case-control studies and other non-randomized intervention studies with an estimate of the effect of exposure to long working hours (41-48, 49-54 and ≥55 h/week), compared with exposure to standard working hours (35-40 h/week), on alcohol consumption (in g/week), risky drinking, and alcohol use disorder (prevalence, incidence or mortality).

STUDY APPRAISAL AND SYNTHESIS METHODS

At least two review authors independently screened 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 publications related to qualifying studies. Two or more review authors assessed the risk of bias, quality of evidence and strength of evidence, using Navigation Guide and GRADE tools and approaches adapted to this project.

RESULTS

Fourteen cohort studies met the inclusion criteria, comprising a total of 104,599 participants (52,107 females) in six countries of three WHO regions (Americas, South-East Asia, and Europe). The exposure and outcome were assessed with self-reported measures in most studies. Across included studies, risk of bias was generally probably high, with risk judged high or probably high for detection bias and missing data for alcohol consumption and risky drinking. Compared to working 35-40 h/week, exposure to working 41-48 h/week increased alcohol consumption by 10.4 g/week (95% confidence interval (CI) 5.59-15.20; seven studies; 25,904 participants, I2 71%, low quality evidence). Exposure to working 49-54 h/week increased alcohol consumption by 17.69 g/week (95% confidence interval (CI) 9.16-26.22; seven studies, 19,158 participants, I2 82%, low quality evidence). Exposure to working ≥55 h/week increased alcohol consumption by 16.29 g/week (95% confidence interval (CI) 7.93-24.65; seven studies; 19,692 participants; I2 82%, low quality evidence). We are uncertain about the effect of exposure to working 41-48 h/week, compared with working 35-40 h/week on developing risky drinking (relative risk 1.08; 95% CI 0.86-1.36; 12 studies; I2 52%, low certainty evidence). Working 49-54 h/week did not increase the risk of developing risky drinking (relative risk 1.12; 95% CI 0.90-1.39; 12 studies; 3832 participants; I2 24%, moderate certainty evidence), nor working ≥55 h/week (relative risk 1.11; 95% CI 0.95-1.30; 12 studies; 4525 participants; I2 0%, moderate certainty evidence). Subgroup analyses indicated that age may influence the association between long working hours and both alcohol consumption and risky drinking. We did not identify studies for which we had access to results on alcohol use disorder.

CONCLUSIONS

Overall, for alcohol consumption in g/week and for risky drinking, we judged this body of evidence to be of low certainty. Exposure to long working hours may have increased alcohol consumption, but we are uncertain about the effect on risky drinking. We found no eligible studies on the effect on alcohol use disorder. Producing estimates for the burden of alcohol use disorder attributable to exposure to long working hours appears to not be evidence-based at this time. PROTOCOL IDENTIFIER: https://doi.org/10.1016/j.envint.2018.07.025.

PROSPERO REGISTRATION NUMBER

CRD42018084077.

The prevalence of occupational exposure to ergonomic risk factors: A systematic review and meta-analysis 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), with contributions from a large network of experts. Evidence from mechanistic and human data suggests that occupational exposure to ergonomic (or physical) risk factors may cause osteoarthritis and other musculoskeletal diseases (excluding rheumatoid arthritis, gout, and back and neck pain). In this paper, we present a systematic review and meta-analysis of the prevalence of occupational exposure to physical ergonomic risk factors for estimating the number of disability-adjusted life years from these diseases that are attributable to exposure to this risk factor, for the development of the WHO/ILO Joint Estimates.

OBJECTIVES

We aimed to systematically review and meta-analyse estimates of the prevalence of occupational exposure to ergonomic risk factors for osteoarthritis and other musculoskeletal diseases.

DATA SOURCES

We searched electronic bibliographic databases for potentially relevant records from published and unpublished studies, including Ovid Medline, EMBASE, and CISDOC. We also searched electronic grey literature databases, Internet search engines and organizational websites; hand-searched reference list of previous systematic reviews and included study records; and consulted additional experts.

STUDY ELIGIBILITY AND CRITERIA

We included working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State but excluded children (<15 years) and unpaid domestic workers. The exposure was defined as any occupational exposure to one or more of: force exertion, demanding posture, repetitive movement, hand-arm vibration, kneeling or squatting, lifting, and/or climbing. We included all study types with an estimate of the prevalence of occupational exposure to ergonomic risk factors.

STUDY APPRAISAL AND SYNTHESIS METHODS

At least two review authors independently screened 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. We combined prevalence estimates using random-effect meta-analysis. Two or more review authors assessed the risk of bias and the quality of evidence, using the ROB-SPEO tool and QoE-SPEO approach developed specifically for the WHO/ILO Joint Estimates.

RESULTS

Five studies (three cross-sectional studies and two cohort studies) met the inclusion criteria, comprising 150,895 participants (81,613 females) in 36 countries in two WHO regions (Africa, Europe). The exposure was generally assessed with questionnaire data about self-reported exposure. Estimates of the prevalence of occupational exposure to ergonomic risk factors are presented for all five included studies, disaggregated by country, sex, 5-year age group, industrial sector or occupational group where feasible. The pooled prevalence of any occupational exposure to ergonomic risk factors was 0.76 (95% confidence interval 0.69 to 0.84, 3 studies, 148,433 participants, 35 countries in the WHO Europe region, I² 100%, low quality of evidence). Subgroup analyses found no statistically significant differences in exposure by sex but differences by age group, occupation and country. No evidence was found for publication bias. We assessed this body evidence to be of low quality, based on serious concerns for risk of bias due to exposure assessment only being based on self-report and for indirectness due to evidence from two WHO regions only.

CONCLUSIONS

Our systematic review and meta-analysis found that occupational exposure to ergonomic risk factors is highly prevalent. The current body of evidence is, however, limited, especially by risk of bias and indirectness. Producing estimates for the burden of disease attributable to occupational exposure to ergonomic risk factors appears evidence-based, and the pooled effect estimates presented in this systematic review may perhaps be used as input data for the WHO/ILO Joint Estimates. Protocol identifier:https://doi.org/10.1016/j.envint.2018.09.053. PROSPERO registration number: CRD42018102631.

The effect of occupational exposure to welding fumes on trachea, bronchus and lung cancer: A protocol for a systematic review and meta-analysis 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), with contributions from a large network of experts. Welding fumes have been classified as carcinogenic to humans (Group 1) by the International Agency for Research on Cancer (IARC); this assessment found sufficient evidence from studies in humans that welding fumes are a cause of lung cancer. In this article, we present the protocol for a systematic review of parameters for estimating the number of deaths and disability-adjusted life years from trachea, bronchus and lung cancer attributable to occupational exposure to welding fumes, to inform the development of the WHO/ILO Joint Estimates.

OBJECTIVES

We aim to systematically review and meta-analyse estimates of the effect of occupational exposure to welding fumes on trachea, bronchus and lung cancer, applying the Navigation Guide systematic review methodology as an organizing framework.

DATA SOURCES

We will search electronic bibliographic databases for potentially relevant records from published and unpublished studies, including Medline, EMBASE, Web of Science, and CISDOC. 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 Member State of WHO and/or ILO but exclude children (<15 years) and unpaid domestic workers. The eligible risk factor will be occupational exposure to welding fumes, measured directly or indirectly (i.e., through proxy of relevant occupation, work task, job-exposure matrix, expert judgment or self-report). The eligible outcomes will be trachea, bronchus and lung cancer. We will include randomized controlled trials, cohort studies, case-control studies and other non-randomized intervention studies with an estimate of the relative effect of any occupational exposure to welding fumes on the prevalence of, incidence of or mortality from trachea, bronchus and lung cancer, compared with the theoretical minimum risk exposure level of no occupational exposure to welding fumes.

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. Two or more review authors will assess risk of bias and the quality of evidence, using the Navigation Guide tool or approach. If feasible, we will combine relative risks using meta-analysis. We will report results using the preferred reporting items for systematic reviews and meta-analyses guidelines (PRISMA).

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.

Role of occupational and recreational sun exposure as a risk factor for keratinocytic non-melanoma skin cancers: an Italian multicenter case-control study

BACKGROUND

Sun exposure is the main external risk factor for keratinocytic non-melanoma skin cancer (NMSC). Outdoor workers are at increased risk, but the relationship of NMSC with occupational solar exposure is often confounded by concurrent recreational sun exposure. We compared the percentage of outdoor workers in NMSC patients versus controls without history of NMSC and assessed occupational and recreational sun exposure in both groups, evaluating also other risk factors and use of protective measures.

METHODS

Adult NMSC patients and controls without history of NMSC or actinic keratoses, matched for sex and age range, were recruited in the Departments of Dermatology of seven Italian University Hospitals, with a 1:2 patient/control ratio whenever possible. Data were collected using specifically designed questionnaires.

RESULTS

Eight hundred thirty-four patients and 1563 controls were enrolled. History of outdoor work was significantly (P=0.033) more frequent in patients. Patients were more sun exposed from outdoor leisure activities (P=0.012) and sunbathed for longer periods (P=0.13) and between 12 pm and 3.30 pm (P=0.011). Cumulative sun exposure during hobbies was similar between patients and controls in outdoor workers, higher (P<0.05) in patients among indoor workers. Patients and controls with history of outdoor work were more sun exposed at work than during leisure activities (P<0.001). Use of sunscreens by outdoor workers was very low, particularly at work (19.9%). Patients used sunscreens more than controls (P=0.002).

CONCLUSIONS

Occupational and recreational sun exposure are relevant risk factors for outdoor and indoor workers respectively. Sunscreens are alarmingly underused, particularly at work, and are used mainly by patients.

The effect of exposure to long working hours on ischaemic heart disease: A systematic review and meta-analysis 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), with contributions from a large network of experts. Evidence from mechanistic data suggests that exposure to long working hours may cause ischaemic heart disease (IHD). In this paper, we present a systematic review and meta-analysis of parameters for estimating the number of deaths and disability-adjusted life years from IHD that are attributable to exposure to long working hours, for the development of the WHO/ILO Joint Estimates.

OBJECTIVES

We aimed to systematically review and meta-analyse estimates of the effect of exposure to long working hours (three categories: 41-48, 49-54 and ≥55 h/week), compared with exposure to standard working hours (35-40 h/week), on IHD (three outcomes: prevalence, incidence and mortality).

DATA SOURCES

We developed and published a protocol, applying the Navigation Guide as an organizing systematic review framework where feasible. We searched electronic databases for potentially relevant records from published and unpublished studies, including MEDLINE, Scopus, Web of Science, CISDOC, PsycINFO, and WHO ICTRP. We also searched grey literature databases, Internet search engines and organizational websites; hand-searched reference lists of previous systematic reviews; and consulted additional experts.

STUDY ELIGIBILITY AND CRITERIA

We included working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State but excluded children (aged < 15 years) and unpaid domestic workers. We included randomized controlled trials, cohort studies, case-control studies and other non-randomized intervention studies which contained an estimate of the effect of exposure to long working hours (41-48, 49-54 and ≥55 h/week), compared with exposure to standard working hours (35-40 h/week), on IHD (prevalence, incidence or mortality).

STUDY APPRAISAL AND SYNTHESIS METHODS

At least two review authors independently screened 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. Missing data were requested from principal study authors. We combined relative risks using random-effect meta-analysis. Two or more review authors assessed the risk of bias, quality of evidence and strength of evidence, using Navigation Guide and GRADE tools and approaches adapted to this project.

RESULTS

Thirty-seven studies (26 prospective cohort studies and 11 case-control studies) met the inclusion criteria, comprising a total of 768,751 participants (310,954 females) in 13 countries in three WHO regions (Americas, Europe and Western Pacific). The exposure was measured using self-reports in all studies, and the outcome was assessed with administrative health records (30 studies) or self-reported physician diagnosis (7 studies). The outcome was defined as incident non-fatal IHD event in 19 studies (8 cohort studies, 11 case-control studies), incident fatal IHD event in two studies (both cohort studies), and incident non-fatal or fatal ("mixed") event in 16 studies (all cohort studies). Because we judged cohort studies to have a relatively lower risk of bias, we prioritized evidence from these studies and treated evidence from case-control studies as supporting evidence. For the bodies of evidence for both outcomes with any eligible studies (i.e. IHD incidence and mortality), we did not have serious concerns for risk of bias (at least for the cohort studies). No eligible study was found on the effect of long working hours on IHD prevalence. Compared with working 35-40 h/week, we are uncertain about the effect on acquiring (or incidence of) IHD of working 41-48 h/week (relative risk (RR) 0.98, 95% confidence interval (CI) 0.91 to 1.07, 20 studies, 312,209 participants, I² 0%, low quality of evidence) and 49-54 h/week (RR 1.05, 95% CI 0.94 to 1.17, 18 studies, 308,405 participants, I² 0%, low quality of evidence). Compared with working 35-40 h/week, working ≥55 h/week may have led to a moderately, clinically meaningful increase in the risk of acquiring IHD, when followed up between one year and 20 years (RR 1.13, 95% CI 1.02 to 1.26, 22 studies, 339,680 participants, I² 5%, moderate quality of evidence). Compared with working 35-40 h/week, we are very uncertain about the effect on dying (mortality) from IHD of working 41-48 h/week (RR 0.99, 95% CI 0.88 to 1.12, 13 studies, 288,278 participants, I² 8%, low quality of evidence) and 49-54 h/week (RR 1.01, 95% CI 0.82 to 1.25, 11 studies, 284,474 participants, I² 13%, low quality of evidence). Compared with working 35-40 h/week, working ≥55 h/week may have led to a moderate, clinically meaningful increase in the risk of dying from IHD when followed up between eight and 30 years (RR 1.17, 95% CI 1.05 to 1.31, 16 studies, 726,803 participants, I² 0%, moderate quality of evidence). Subgroup analyses found no evidence for differences by WHO region and sex, but RRs were higher among persons with lower SES. Sensitivity analyses found no differences by outcome definition (exclusively non-fatal or fatal versus "mixed"), outcome measurement (health records versus self-reports) and risk of bias ("high"/"probably high" ratings in any domain versus "low"/"probably low" in all domains).

CONCLUSIONS

We judged the existing bodies of evidence for human evidence as "inadequate evidence for harmfulness" for the exposure categories 41-48 and 49-54 h/week for IHD prevalence, incidence and mortality, and for the exposure category ≥55 h/week for IHD prevalence. Evidence on exposure to working ≥55 h/week was judged as "sufficient evidence of harmfulness" for IHD incidence and mortality. Producing estimates for the burden of IHD attributable to exposure to working ≥55 h/week appears evidence-based, and the pooled effect estimates presented in this systematic review could be used as input data for the WHO/ILO Joint Estimates.

The effect of exposure to long working hours on stroke: A systematic review and meta-analysis 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), with contributions from a large network of individual experts. Evidence from mechanistic data and prior studies suggests that exposure to long working hours may cause stroke. In this paper, we present a systematic review and meta-analysis of parameters for estimating the number of deaths and disability-adjusted life years from stroke that are attributable to exposure to long working hours, for the development of the WHO/ILO Joint Estimates.

OBJECTIVES

We aimed to systematically review and meta-analyse estimates of the effect of exposure to long working hours (three categories: 41-48, 49-54 and ≥55 h/week), compared with exposure to standard working hours (35-40 h/week), on stroke (three outcomes: prevalence, incidence, and mortality).

DATA SOURCES

A protocol was developed and published, applying the Navigation Guide to systematic reviews as an organizing framework where feasible. We searched electronic databases for potentially relevant records from published and unpublished studies, including Ovid MEDLINE, PubMed, EMBASE, Scopus, Web of Science, CISDOC, PsycINFO, and WHO ICTRP. We also searched grey literature databases, Internet search engines, and organizational websites; hand-searched reference lists of previous systematic reviews; and consulted additional experts.

STUDY ELIGIBILITY AND CRITERIA

We included working-age (≥15 years) individuals in the formal and informal economy in any WHO and/or ILO Member State but excluded children (aged < 15 years) and unpaid domestic workers. We included randomized controlled trials, cohort studies, case-control studies and other non-randomized intervention studies with an estimate of the effect of exposure to long working hours (41-48, 49-54 and ≥55 h/week), compared with exposure to standard working hours (35-40 h/week), on stroke (prevalence, incidence or mortality).

STUDY APPRAISAL AND SYNTHESIS METHODS

At least two review authors independently screened titles and abstracts against the eligibility criteria at a first review stage and full texts of potentially eligible records at a second stage, followed by extraction of data from qualifying studies. Missing data were requested from principal study authors. We combined relative risks using random-effects meta-analysis. Two or more review authors assessed the risk of bias, quality of evidence and strength of evidence, using the Navigation Guide and GRADE tools and approaches adapted to this project.

RESULTS

Twenty-two studies (20 cohort studies, 2 case-control studies) met the inclusion criteria, comprising a total of 839,680 participants (364,616 females) in eight countries from three WHO regions (Americas, Europe, and Western Pacific). The exposure was measured using self-reports in all studies, and the outcome was assessed with administrative health records (13 studies), self-reported physician diagnosis (7 studies), direct diagnosis by a physician (1 study) or during a medical interview (1 study). The outcome was defined as an incident non-fatal stroke event in nine studies (7 cohort studies, 2 case-control studies), incident fatal stroke event in one cohort study and incident non-fatal or fatal ("mixed") event in 12 studies (all cohort studies). Cohort studies were judged to have a relatively low risk of bias; therefore, we prioritized evidence from these studies, but synthesised evidence from case-control studies as supporting evidence. For the bodies of evidence for both outcomes with any eligible studies (i.e. stroke incidence and mortality), we did not have serious concerns for risk of bias (at least for the cohort studies). Eligible studies were found on the effects of long working hours on stroke incidence and mortality, but not prevalence. Compared with working 35-40 h/week, we were uncertain about the effect on incidence of stroke due to working 41-48 h/week (relative risk (RR) 1.04, 95% confidence interval (CI) 0.94-1.14, 18 studies, 277,202 participants, I² 0%, low quality of evidence). There may have been an increased risk for acquiring stroke when working 49-54 h/week compared with 35-40 h/week (RR 1.13, 95% CI 1.00-1.28, 17 studies, 275,181participants, I² 0%, p 0.04, moderate quality of evidence). Compared with working 35-40 h/week, working ≥55 h/week may have led to a moderate, clinically meaningful increase in the risk of acquiring stroke, when followed up between one year and 20 years (RR 1.35, 95% CI 1.13 to 1.61, 7 studies, 162,644 participants, I² 3%, moderate quality of evidence). Compared with working 35-40 h/week, we were very uncertain about the effect on dying (mortality) of stroke due to working 41-48 h/week (RR 1.01, 95% CI 0.91-1.12, 12 studies, 265,937 participants, I² 0%, low quality of evidence), 49-54 h/week (RR 1.13, 95% CI 0.99-1.29, 11 studies, 256,129 participants, I² 0%, low quality of evidence) and 55 h/week (RR 1.08, 95% CI 0.89-1.31, 10 studies, 664,647 participants, I² 20%, low quality of evidence). Subgroup analyses found no evidence for differences by WHO region, age, sex, socioeconomic status and type of stroke. Sensitivity analyses found no differences by outcome definition (exclusively non-fatal or fatal versus "mixed") except for the comparison working ≥55 h/week versus 35-40 h/week for stroke incidence (p for subgroup differences: 0.05), risk of bias ("high"/"probably high" ratings in any domain versus "low"/"probably low" in all domains), effect estimate measures (risk versus hazard versus odds ratios) and comparator (exact versus approximate definition).

CONCLUSIONS

We judged the existing bodies of evidence for human evidence as "inadequate evidence for harmfulness" for all exposure categories for stroke prevalence and mortality and for exposure to 41-48 h/week for stroke incidence. Evidence on exposure to 48-54 h/week and ≥55 h/week was judged as "limited evidence for harmfulness" and "sufficient evidence for harmfulness" for stroke incidence, respectively. Producing estimates for the burden of stroke attributable to exposures to working 48-54 and ≥55 h/week appears evidence-based, and the pooled effect estimates presented in this systematic review could be used as input data for the WHO/ILO Joint Estimates. PROTOCOL IDENTIFIER: https://doi.org/10.1016/j.envint.2018.06.016.

PROSPERO REGISTRATION NUMBER

CRD42017060124.

Risk of cataract in health care workers exposed to ionizing radiation: a systematic review

Background:

The eye is an important sensory organ occupationally exposed to ionizing radiation (IR) in healthcare workers (HCWs) engaged in medical imaging (MI). New evidence highlights the possible induction of cataract at IR exposure levels to be much lower than expected in the past.

Objective:

Conduct an updated review on the current evidence on cataract risk in healthcare workers exposed to IR.

Methods:

Published scientific studies on cataract risk in IR exposed healthcare workers were collected through a systematic search of two biomedical databases (MEDLINE and Scopus). Data from included studies was extracted and summarized. Study quality was also assessed.

Results:

All 21 eligible studies reported an increased prevalence of cataract, especially posterior subcapsular cataract, in IR exposed HCWs with a higher prevalence in interventional cardiology staff.

Discussion:

Our review synthesizes the latest evidence to support the hypothesis of a significantly increased risk of occupational cataract in healthcare workers operating MI and exposed to IR, especially in interventional cardiologists. Data also support a dose-response relationship between IR exposure and the prevalence of opacities, especially posterior subcapsular opacities.

Conclusions:

Findings highlight the need for effective control measures including appropriate training, adherence to protective procedures, and a constant use of shields and eye personal protective equipment in healthcare workers with optical exposure to IR. Periodic health surveillance programs, possibly including lens evaluation, are also important to monitor cataract risk in these MI operators.

Global evidence on occupational sun exposure and keratinocyte cancers: a systematic review

Individual studies have suggested that the association between occupational exposure to solar ultraviolet radiation (UVR) and the development of keratinocyte cancers (KCs) may only be valid in populations of European ancestry living in certain geographical regions. Comparative global data are scarce and so this review aimed to summarize current evidence on the association between occupational exposure to solar UVR and the development of KCs, with a specific focus on geographical location and skin colour. Ovid MEDLINE, PubMed, Embase and Web of Science were searched for potentially relevant records. Extracted data were summarized by study, country and region. We included one prospective cohort study and 18 case-control studies (n = 15 233) from 12 countries in regions where the majority of the population is white skinned (Americas, Europe and Oceania). Eighteen of the 19 studies reported effect estimates suggesting an increased risk of basal cell carcinoma (BCC) and/or squamous cell carcinoma (SCC) among outdoor workers. Only 11 studies found a significantly increased risk and many had imprecise estimates. There was a significantly increased risk of BCC and SCC in individual studies in North America, Latin America and the Caribbean, Western Europe and Southern Europe, but not across regions or countries. Overall, 95% of studies reported higher risks among outdoor workers, although the increases in risk were statistically significant in just over half of the studies. Well-designed and sufficiently powered occupational case-control and cohort studies with adequate adjustment for confounding factors and other risk factors are required to provide more accurate risk estimates for occupational KC.

Sun protection habits and behaviors of a group of outdoor workers and students from the agricultural and construction sectors in north-Italy

Background:

Despite the relevant frequency of ultraviolet induced adverse health effects in workers, solar ultraviolet radiation (UVR) exposure is an occupational risk not adequately minimized in Italy.

Objective:

To assess the characteristics and prevalence of sun exposure habits and behaviors in a group of students and outdoor workers (OW) from the agricultural and construction sectors of a north-Italian region.

Methods:

Based on a previously developed standardized questionnaire, we collected full information on individual sun exposure habits at work and during leisure activities.

Results:

In 2018, 380 high school students and OW from the agricultural and construction sectors participated in a sun-safety campaign. More than a third (39.0%) of OW reported never using sunglasses, 52.8% never applied sunscreens at work, and a quarter never wear a UV protective hat. Considering leisure-time, students reported more frequent sunburns compared to OW: 25.0% vs. 13.8%; half (51.6%) of students and a third (36.4%) of OW reported never wearing a UV protective hat. A third (30.1%) of students and 37.2% of OW never or only seldom applied sunscreens on holidays.

Discussion:

The majority of OW in our study reported poor protective solar exposure habits. Young students of the construction and agricultural sectors indicated even worse sun-protective behaviors, both during apprenticeship and leisure activities. Our study highlights the low health literacy related to solar UVR in OW and apprentices. Further educational initiatives are required in Italy to improve the adoption of protective behaviors during outdoor activities.