Long-term ethylene oxide exposure trends in US hospitals: relationship with OSHA regulatory and enforcement actions

Interventions to Reduce Exposures in the Workplace: A Systematic Review of Intervention Studies Over Six Decades, 1960-2019

Background: Reducing occupational ill-health from chemical and biological agents is realized primarily through the mitigation and elimination of hazardous exposures. Despite evidence of declining exposure in European and North-American workplaces, comprehensive studies of the effectiveness of workplace interventions for reducing hazardous exposure and associated work-related ill-health seem rare. We reviewed occupational intervention studies targeting exposure to chemical and biological agents, and determined trends in frequency and quality of such studies. Methods: We searched Embase, Medline, and Web of Science for peer-reviewed original articles on occupational intervention studies published 1960-2019, aimed at reducing workers' exposure to dusts, gases, fumes, or liquids of chemical, biological, or mineral nature, or workers' risks for associated health outcomes. The frequency of articles, intervention types, intervention endpoints, and study quality of published intervention studies between 1960 and 2019 and according to 10-year intervals were analyzed. Results: Of 3,663 retrieved articles, 146 intervention studies were identified and reviewed, of which 63 concerned control measures, 43 behavioral change, 28 use of personal protective equipment, and 12 workplace policies. Intervention endpoints were occupational exposures (73%), health outcomes (22%), and a combination of both (5%). Of reviewed studies, 38% involved a control group, 16% randomized the intervention, 86% were planned interventions, and 86% compared exposure or health outcomes pre and post intervention. Over time the number of intervention studies identified in this search increased from none during 1960-1969 to ~60 during 2000-2009 and 2010-2019, respectively. The study quality improved over time, with no studies during 1960-1989 that complied with the highest quality criteria. During 2000-2009 and 2010-2019 16 and 12% of studies, respectively, were judged to be of highest quality. Conclusion: Despite an improvement over the last six decades in the frequency and quality of intervention studies targeting exposure to chemicals and biological agents, the absolute number of intervention studies remains low, particularly when considering only high quality studies. Occupational exposure to chemical and biological agents is still causing excessive disease in workforces worldwide. To reduce occupational ill-health caused by these exposures, it is important to expand the evidence on (cost-)effectiveness and transferability of interventions to reduce exposure and health effects.

Interventions to prevent injuries in construction workers

BACKGROUND

Construction workers are frequently exposed to various types of injury-inducing hazards. There are a number of injury prevention interventions, yet their effectiveness is uncertain.

OBJECTIVES

To assess the effects of interventions for preventing injuries in construction workers.

SEARCH METHODS

We searched the Cochrane Injuries Group's specialised register, CENTRAL (issue 3), MEDLINE, Embase and PsycINFO up to April 2017. The searches were not restricted by language or publication status. We also handsearched the reference lists of relevant papers and reviews.

SELECTION CRITERIA

Randomised controlled trials, controlled before-after (CBA) studies and interrupted time-series (ITS) of all types of interventions for preventing fatal and non-fatal injuries among workers at construction sites.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed their risk of bias. For ITS studies, we re-analysed the studies and used an initial effect, measured as the change in injury rate in the year after the intervention, as well as a sustained effect, measured as the change in time trend before and after the intervention.

MAIN RESULTS

Seventeen studies (14 ITS and 3 CBA studies) met the inclusion criteria in this updated version of the review. The ITS studies evaluated the effects of: introducing or changing regulations that laid down safety and health requirements for the construction sites (nine studies), a safety campaign (two studies), a drug-free workplace programme (one study), a training programme (one study), and safety inspections (one study) on fatal and non-fatal occupational injuries. One CBA study evaluated the introduction of occupational health services such as risk assessment and health surveillance, one evaluated a training programme and one evaluated the effect of a subsidy for upgrading to safer scaffoldings. The overall risk of bias of most of the included studies was high, as it was uncertain for the ITS studies whether the intervention was independent from other changes and thus could be regarded as the main reason of change in the outcome. Therefore, we rated the quality of the evidence as very low for all comparisons.Compulsory interventionsRegulatory interventions at national or branch level may or may not have an initial effect (effect size (ES) of -0.33; 95% confidence interval (CI) -2.08 to 1.41) and may or may not have a sustained effect (ES -0.03; 95% CI -0.30 to 0.24) on fatal and non-fatal injuries (9 ITS studies) due to highly inconsistent results (I² = 98%). Inspections may or may not have an effect on non-fatal injuries (ES 0.07; 95% CI -2.83 to 2.97; 1 ITS study).Educational interventionsSafety training interventions may result in no significant reduction of non-fatal injuries (1 ITS study and 1 CBA study).Informational interventionsWe found no studies that had evaluated informational interventions alone such as campaigns for risk communication.Persuasive interventionsWe found no studies that had evaluated persuasive interventions alone such as peer feedback on workplace actions to increase acceptance of safe working methods.Facilitative interventionsMonetary subsidies to companies may lead to a greater decrease in non-fatal injuries from falls to a lower level than no subsidies (risk ratio (RR) at follow-up: 0.93; 95% CI 0.30 to 2.91 from RR 3.89 at baseline; 1 CBA study).Multifaceted interventionsA safety campaign intervention may result in an initial (ES -1.82; 95% CI -2.90 to -0.74) and sustained (ES -1.30; 95% CI -1.79 to -0.81) decrease in injuries at the company level (1 ITS study), but not at the regional level (1 ITS study). A multifaceted drug-free workplace programme at the company level may reduce non-fatal injuries in the year following implementation by -7.6 per 100 person-years (95% CI -11.2 to -4.0) and in the years thereafter by -2.0 per 100 person-years (95% CI -3.5 to -0.5) (1 ITS study). Introducing occupational health services may result in no decrease in fatal or non-fatal injuries (one CBA study).

AUTHORS' CONCLUSIONS

The vast majority of interventions to adopt safety measures recommended by standard texts on safety, consultants and safety courses have not been adequately evaluated. There is very low-quality evidence that introducing regulations as such may or may not result in a decrease in fatal and non-fatal injuries. There is also very low-quality evidence that regionally oriented safety campaigns, training, inspections or the introduction of occupational health services may not reduce non-fatal injuries in construction companies. There is very low-quality evidence that company-oriented safety interventions such as a multifaceted safety campaign, a multifaceted drug workplace programme and subsidies for replacement of scaffoldings may reduce non-fatal injuries among construction workers. More studies, preferably cluster-randomised controlled trials, are needed to evaluate different strategies to increase the employers' and workers' adherence to the safety measures prescribed by regulation.

A systematic literature review of the effectiveness of occupational health and safety regulatory enforcement

BACKGROUND

We aimed to determine the strength of evidence on the effectiveness of legislative and regulatory policy levers in creating incentives for organizations to improve occupational health and safety processes and outcomes.

METHODS

A systematic review was undertaken to assess the strength of evidence on the effectiveness of specific policy levers using a "best-evidence" synthesis approach.

RESULTS

A structured literature search identified 11,947 citations from 13 peer-reviewed literature databases. Forty-three studies were retained for synthesis. Strong evidence was identified for three out of nine clusters.

CONCLUSIONS

There is strong evidence that several OHS policy levers are effective in terms of reducing injuries and/or increasing compliance with legislation. This study adds to the evidence on OHS regulatory effectiveness from an earlier review. In addition to new evidence supporting previous study findings, it included new categories of evidence-compliance as an outcome, nature of enforcement, awareness campaigns, and smoke-free workplace legislation. Am. J. Ind. Med. 59:919-933, 2016. © 2016 Wiley Periodicals, Inc.

Interventions to prevent injuries in construction workers

BACKGROUND

Construction workers are frequently exposed to various types of injury-inducing hazards. A number of injury prevention interventions have been proposed, yet their effectiveness is uncertain.

OBJECTIVES

To assess the effects of interventions to prevent injuries in construction workers.

SEARCH METHODS

We searched the Cochrane Injuries Group's specialised register, CENTRAL, MEDLINE, EMBASE, PsycINFO, OSH-ROM (including NIOSHTIC and HSELINE), Scopus, Web of Science and EI Compendex to September 2011. The searches were not restricted by language or publication status. The reference lists of relevant papers and reviews were also searched.

SELECTION CRITERIA

Randomised controlled trials, controlled before-after (CBA) studies and interrupted time series (ITS) of all types of interventions for preventing fatal and non-fatal injuries among workers at construction sites.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed study quality. For ITS, we re-analysed the studies and used an initial effect, measured as the change in injury-rate in the year after the intervention, as well as a sustained effect, measured as the change in time trend before and after the intervention.

MAIN RESULTS

Thirteen studies, 12 ITS and one CBA study met the inclusion criteria. The ITS evaluated the effects of the introduction or change of regulations (N = 7), a safety campaign (N = 2), a drug-free workplace programme (N = 1), a training programme (N = 1), and safety inspections (N = 1) on fatal and non-fatal occupational injuries. One CBA study evaluated the introduction of occupational health services such as risk assessment and health surveillance.The overall risk of bias among the included studies was high as it was uncertain for the ITS studies whether the intervention was independent from other changes and thus could be regarded as the main reason of change in the outcome.The regulatory interventions at national or branch level showed a small but significant initial and sustained increase in fatal (effect sizes of 0.79; 95% confidence interval (CI) 0.00 to 1.58) and non-fatal injuries (effect size 0.23; 95% CI 0.03 to 0.43).The safety campaign intervention resulted in a decrease in injuries at the company level but an increase at the regional level. Training interventions, inspections or the introduction of occupational health services did not result in a significant reduction of non-fatal injuries in single studies.A multifaceted drug-free workplace programme at the company level reduced non-fatal injuries in the year following implementation by -7.6 per 100 person-years (95% CI -11.2 to -4.0) and in the years thereafter by -2.0 per 100 person-years per year (95% CI -3.5 to -0.5).

AUTHORS' CONCLUSIONS

The vast majority of technical, human and organisational interventions that are recommended by standard texts of safety, consultants and safety courses have not been adequately evaluated. There is no evidence that introducing regulations for reducing fatal and non-fatal injuries are effective as such. There is neither evidence that regionally oriented safety campaigns, training, inspections nor the introduction of occupational health services are effective at reducing non-fatal injuries in construction companies. There is low-quality evidence that company-oriented safety interventions such as a multifaceted safety campaign and a multifaceted drug workplace programme can reduce non-fatal injuries among construction workers. Additional strategies are needed to increase the compliance of employers and workers to the safety measures that are prescribed by regulation. Continuing company-oriented interventions among management and construction workers, such as a targeted safety campaign or a drug-free workplace programme, seem to have an effect in reducing injuries in the longer term.

Job strain exposures vs. stress-related workers' compensation claims in Victoria, Australia: developing a public health response to job stress

We present a comparative analysis of patterns of exposure to job stressors and stress-related workers' compensation (WC) claims to provide an evaluation of the adequacy of claims-driven policy and practice. We assessed job strain prevalence in a 2003 population-based survey of Victorian [Australia] workers and compared these results with stress-related WC statistics for the same year. Job strain prevalence was higher among females than males, and elevated among lower vs. higher occupational skill levels. In comparison, claims were higher among females than males, but primarily among higher skill-level workers. There was some congruence between exposure and WC claims patterns. Highly exposed groups in lower socio-economic positions were underrepresented in claims statistics, suggesting that the WC insurance perspective substantially underestimates the job stress problems for these groups. Thus to provide a sufficient evidence base for equitable policy and practice responses to this growing public health problem, exposure or health outcome data are needed as an essential complement to claims statistics.

Working in light vehicles--a review and conceptual model for occupational health and safety

Occupational light vehicle (OLV) use is the leading cause of work related traumatic deaths in Westernised countries. Previous research has focused primarily on narrow contexts of OLV-use such as corporate fleet vehicles. We have proposed a comprehensive systems model for OLV-use to provide a framework for identifying research needs and proposing policy and practice interventions. This model presents the worker as the locus of injury at the centre of work- and road-related determinants of injury. Using this model, we reviewed existing knowledge and found most studies focused only on company car drivers, neglecting OLV-users in non-traditional employment arrangements and those using other vehicle types. Environmental exposures, work design factors and risk and protective factors for the wider OLV-user population are inadequately researched. Neither road- nor work-related policy appropriately addresses OLV-use, and population surveillance relies largely on inadequate workers compensation insurance data. This review demonstrates that there are significant gaps in understanding the problem of OLV-use and a need for further research integrating public health, insurance and road safety responses. The model provides a framework for understanding the theory of OLV-use OHS and guidance for urgently needed intervention research, policy and practice.

DNA adducts in granulocytes of hospital workers exposed to ethylene oxide

BACKGROUND

Ethylene oxide (EtO), an important industrial chemical intermediate and sterilant, is classified as a human carcinogen. Occupational EtO exposure in many countries is regulated at 1 ppm (8-hr TWA), but levels of EtO-DNA adducts in humans with low occupational EtO exposures have not been reported.

METHODS

We examined the formation of N7-(2'-hydroxyethyl)guanine (N7-HEG), a major DNA adduct of EtO, in 58 EtO-exposed sterilizer operators and six nonexposed workers from ten hospitals. N7-HEG was quantified in granulocyte DNA (0.1-11.5 microg) by a highly sensitive and specific gas chromatography-electron capture-mass spectrometry method. Cumulative exposure to EtO (ppm-hour) was estimated during the 4-month period before the collection of blood samples.

RESULTS

There was considerable inter-individual variability in the levels of N7-HEG with a range of 1.6-241.3 adducts/10(7) nucleotides. The mean levels in the nonexposed, low (< or =32 ppm-hour), and high (>32 ppm-hour) EtO-exposure groups were 3.8, 16.3, and 20.3 adducts/10(7) nucleotides, respectively, after the adjustment for cigarette smoking and other potential confounders, but the differences were not statistically significant.

CONCLUSIONS

This study has demonstrated for the first time, detectable levels of N7-HEG adducts in granulocytes of hospital workers with EtO exposures at levels less than the current U.S. standard of 1 ppm (8-hr TWA). A nonsignificant increase in adduct levels with increasing EtO exposure indicates that further studies of EtO-exposed workers are needed to clarify the relationship between EtO exposure and N7-HEG adduct formation.

Pollution prevention--occupational safety and health in hospitals: alternatives and interventions

An integrated pollution prevention (P(2)) and occupational safety and health (OSH) worksite intervention and alternatives assessment strategy was developed in hospitals. It was called the Pollution Prevention-Occupational Safety and Health (P(2)OSH) assessment for the "Sustainable Hospitals Project." Methods included (a) developing a participatory intervention model for introducing more environmentally sound, healthy, and safe materials and work practices for specific hospital procedures; (b) developing an integrated P(2)OSH survey to evaluate environmental and occupational impacts of the intervention; and (c) conducting and evaluating interventions by applying the P(2)OSH assessment pre- and post-intervention. Eleven interventions were performed in six hospitals: an aliphatic fixative replaced xylene in three histology laboratories; a mercury reduction plan was implemented in three clinical laboratories; digital imaging replaced wet chemical film processing in three radiology departments; a less toxic aldehyde replaced formaldehyde in one hospital histopathology laboratory; and conventional mopping was replaced by microfiber mopping in one hospital. Occupational and environmental health and safety impacts were observed for all interventions. The alternatives generally were beneficial, although each had limitations that resulted in process and task changes with potentially negative P(2) and/or OSH impacts. When these were identified in the pilot phase they could be addressed before full-scale implementation. The P(2)OSH method shifts the focus of occupational and environmental hygiene from hazard control to substitution. Because few ideal alternatives exist, the emphasis is on a continuous process to identify, implement, and evaluate alternatives, rather than on a particular alternative. Occupational and environmental health and safety professionals have an important role as agents in hospital organizational change and in the search for healthier and safer alternatives. Through these activities they can become involved in the design/redesign of products, materials, and processes, thus expanding their traditional role.