Document jm81NZZQmqMKQv3x5wjqDqXK2

Dec-30-99 08:31am From- T-342 P.08/08 F-573 Volume 5,Number 1 January/March 1999 ORLGINAL ARTICLES 1 incidcncc of'\$'ork-relareti .isrhma i n rhc L:niu.tl Srares 9 Hack SUppi~rTsand Hack Injuries: A Secorid \'isit 14 I'ulrnonaq Func1ion of Never-smoking Chinese 20 Social Inremc-ntionf o r Bcnwnisrn in Brazil EDUCATION AND PRACTICE 26 Sur~c.ill;lric-acr~id Occupadon;il Health SPECIAL CONlRIBUflONS-SOEH CONFERENCE 30 /'opm: Inrrniadonal .%gcncyEfforts to Prorec.1 Workers and die En\ironrnenr 38 /'op.r !ifanaging the Ecos)wem f o r Safe Drinking bTater 50 I'qimr Intersecroral Approach t o Reducing Blood I.ead Levels 56 / + ~ p iT: he Impact of Globaliznriori in Mexico's Siigar IndUSTr) EDITORIAL 61 Global C:orporare Pcilicies and lnternacional "Doublr Srandards" COMMENTARY 65 I'ectpk~enreredScience ;md (;lotxilization in Public Heallii Policy. LETTER 72 .\gc-rrta1ed Sperm .Abnormalities in (:hernoby1 Salvage Wor-kzi-s Dec-30-99 08:23am From- T-342 P.02/08 F-573 * Socio-medicalIntervention in Occupational Health: Benzenism in Brazil LIA GIRALDO DA SILVA AUGUSTO, MD, PHD, ANNICK FONTBONNE, MD, PHD, EDUAROO MAlA FREESE DE CARVALHO, MD, PHD, TEREZA CARLOTA PlRES NOVAES, MSC This review describes the authors' experience with 2,ooO cases ofbenzene poisoning reported beiween 1983 and 1995 use of benzene in Brazil and its production for export. aUthoughthe bone-marrow toxiciy and carcinogenicity in Cubario, an industrial section of SPo Paulo, Brazil. investi- of benzene haw been recognized internationally for gred through die integration of epidermology and clinical research. Conflicting eronomic inrerests were reflected in disputes about medical criteria for evaluation of poisoned workers. a b u t proper means or conducting workplace hygiene evaluations, abour benzene exposure standards. and about compensation for chronic bone-marrow damage. Ke,v words: benzenism; henlatologic alterations; social medicine; occupational health. many years, these effects of benzene were riot officialh recognized in Brazil until 1994. Recognition of the outbreak of benzenism also produced discussion and some conflicts about the way to conuol the problem from an epidemiologic and environmental point of\iew. U?latms the best means of e s tablishing a causal relationship between work in the steel industry and the occurrence of bone-marrow de- IN1 J OCCUP ENVIRON HEALTH 1999;5:20-25 ____. . -................. -- pression? How should epidemiologic surveillance and individual health sumeillancebe conducted? What were the most practical methods for environmental and bio- Acluster of ca..es ofbenzene poisoning was identified among steel workers of a coke-oven opcration in the city of' Cubatso, Brazil (near S 5 a Paillo). in 1983. The initial cases had only nonspecific symptoms of fatigue and headache, but were found upon hematologic referral to have peripheral blood abnormalities (macrocytosis,giant platelets, and leukopenia/neuuopenia). In 1985, more than 1300 cases were reported in this region. From coke-oven operations in Ciih~t50alone, we diagnosed nearly 2,000 cases between 1983and 1995. The exposed workers were principally coke-oven operators and maintenance people, but the levels of benzene contamination were so high logical monitoring? Of course, the most coniroversial question was: how would workers receive compensation and social security measures be implemei~~ed?"'~2 It was in this context that we studied the effect of benzene on che hematopoietic system, the reasons for the extensive human exposure to benzene in the steel-andiron and the economics ofthe benzene pro- ducrion process in Brazil.? The participants in rhese studies included scientists from different fields: physicians specialized in public health and occupational medicine, clinical hematologists, analytical chemists, biochemists, producrion engineers, and safety specialists. that some administrative personnel were probably ex- posed. The identification of beazenism in Cubatgo was an important event in the community. Intense industrial pollution of the air and water in Cubat50 had been previously studied, but the associated health problems had not been considered in depth. As the workers became aware of the extent of the poisoning, rhe epidemic became a national issue, and implementation of prevenrive measures began to occur. The national importance of the outbreak was underlined by the wide indusuial .... .... ................... EPIDEMIOLOGICSURVEILLANCE In 1983, the Health Department of SHo Paulo's newlyelected state government launched initiatives 10 monitor the health of industrial workers. The Baixacka Santisra region. which includes the town ofCubado'became an early focus of this effort. %. pilot project was designed in response to this request. Its initial suareg):was based on epidemiologic sun.rillance. The legal instrunitnu available at the time were the National and State Sanitary Codes, pro.viding quite limited authority to intervene in workplace health problems. The Brazilian Received from the Depuurment of Community Health of .Q~cu Ministry of Labor legitimated the latter's monopoly in MagdhHrs Rcxarch Center/O%aldo Cruz Fowitlation/Bmilian public inwwention and regulation of labor-manage- Health hfinisny. Pernamhuco.Brad. ment relations-which included risks and health dam- Addresscorrespondenceand reprint requestst6 Dr. L a Ciraldoda ages as well as preventive measures. For this reason, we Siha .zujiusto, NFXXPqLbf-FlOCRVZ. Rwa dos Coelhos WJ.1" and.. Bairro dos Coelhos, Recife, Pernamhrico. Bratik CEP 50070- had to define imemention instruments, supported by 5 5 0 fax: ti (55) (81) 2316271;enail <ginldo~rl~~ca.com.br>. the health authorin. of the State Health Deparunenr? Dec-30-99 08:24am From- T-342 P.O3/08 F-573 jar c]&fied workers' health problems and diseases as lncommon events"and therefore an appropriate sub :ct for public health surveillance. This allowed worklace inspections to extend beyond ventilation and hyirne evaluations of bathrooms, dining areas, lodgings, nd orher physical spaces.Air monitoring data "ere not xrensive,but several times documented levels in excess #f1,000 ppm (parts per million) of benzene. Qllditatl~'e )bservationalso showed visual concamination of the air ,ith coke-own emissions. We then developed an infhmadori system that in.luded: 1) mandatory norificatioij of health prot>lems `or some specific high-risk situations, d i n g into acmunt the npe of industrial production and known sorkplace hazards in C;uh~do2;j epidemiologic inves Ligation of norifred cases; and 3) provision o f full incdical assistance LO the affetcted workers. For c ' w iclentification, we adopted h e Same notification instrumcnrs used for infectious diseases. M`e also employed a hospitalization bulletin as a secondary source of information, and created a new bulletin for registering the workers' general morbidity, obtained from the companies' ambulatory medical services.The case definition employed was based on clinical reports of hematologic illness, screening blood counu, or the results of bone-marrow biopsies (Table 1). From 1983no 1995,over 1.000workers employed in a steel-and-iron factory in CubacSo, Sio Paulo, were relieved of their work hecause of hematologic alterations that followed occupational and environmental e x p c ~ sures to henzene.'.4*6,.7 A follow-up of 61 typical patients wiith chronic net!uopenia s e c o n d q to chronic occupational benzene exposure from the steel i n d u s q of Cubatso city was performed between 1985 and 1990. All patiens were men between 20 and 60 years of age, and 80% were millwrights (maintenance workers). The mean duration of exposure was 65 months. Bone-marrow studies of this group showed histologic or cytologic abnormalities in 98.6%. Granulocyte precursors were reduced in 93.0%; erythroblasts were reduced in 24.5%; mepAkaryohlasts were reduced in 43.8%, with atypia in 87.7% of the formed cells. One patient had global hyperplasia. By the lift-table method, the probabilityof normalizing the peripheral blood count was 52% years afirr removal of the environmental and occupational exposure. T h e nomalization of rhr blood count appeared to be physioiogic compensation rather than a return to normal hematopoietic function, since bonernarrow srudies of workers with normalized blood counts still showed ren- granulocytopenia. HEMATOLOGICSCREENING AND WORKER PARTICIPATION At the beginning of case identification, the diagnostic cfion was concennmled on obsemed alterations in the TABLE 1 Protocol for Evaluation 01 Benzene Effects InWorkefs wlth Benzene Exposureand Abnormal BloodCounts Prior hematologic tests were evoluoted to estimate the date of probable onset of the obnormol peripheralblood count. When no prior blood count was ovalloble for comparison.0 cllriicol history and examination were done to evaluate the presence ofother conditions that could Cause the Idenhfied hemotologicabnormollty.If no such condition was identified. the abnormal bloodcount was attributed to benzene exposure. When (un)other disease(s) was (were) tdenffied. o biopsy wos conducted to evaluatethe presence of bone marrow odasia. pripheral blood cells. Although qualititative alterations of platelets and erythrocytes were frequently ohsened. neutropenia was the most common finding and quickly hecame recognized as a hallmark of benzene poisuning. This suggested that screening based on peripheral blood counh might be possible. Screening also occurred outside h e workplace under the jurisdicuon of labor union medical services, uith acGve participaion of the workers in the process. This was necessa? because it was unfortunately common for plant occupational physicians to conceal from the workers the damage caiised by benzene exposures. The rccc.~iilionof quantitative alterations in the blood counr as a manifestation of benzene poisoning in 1983was a major step. Up to that time, the only condition recognized as related to benzene exposure was aplastic anemia, which was generally fatal. Even though the leukemogenic effect of benzene is well recognized in the literature, leukemia c'ases in workers who had esperiencetl constant exposures to benzene were recognjzrd by the Brazi1i.m compensation (social srrurity) system only in exceptional cases. Emphashing the peripheral blood alterations made it possible, for the first time, for affected workers to obtain compensation through the social security system for hematologic injuries. Benzeneexposed workers who had hematologic alterations compatible with benzene intoxication, and who did not haw other pathologic conditions that could explain them,were considered as "cornpenuted hypersensitives" and were prohibited fiom fui-dirr cxposure.8.9This policy was reinforced by the findings of rhe follow-up study (described above) demonstradng persistent bone-marrow abnormalities in workers whose peripheral blood counts had returned to normal. Econoniic interesrs also influenced the debare regarding the significance of the observed hematologic abnormalities. Even confronted with irrefutable e& dence of benzene hematotoxicity and of serious enti- ronmental pollution within the workplace,16 some occupational physicians and plant managers insisted that there was a simply a problem of incorrectly applying "normal hematologic values" to the plant workforces. . Dec-30-99 08:25am From- T-342 P.04/08 F-573 .22 Augustoet ai _ _-- _-- __ ----INT J OCCUP LFJVIRON HEALTI Dec-30-99 08:27am From- T-342 P.05/08 F-573 Mainrer,ur~cew o i ~ ewi hiou: raspriotor ondprorxtive clothing ______-- VOL 5/NO 1, JAN-MAR l W 9 Ai: ponunon m,grares rnrn surrounding communiP# -__c Benzenismin Brazil 23 Dec-30-99 08:29am From- T-342 P 06/08 F-573 These managers and physicians suggested that, in fact, the reductions of leukocytes and neutrophils were relared, in the majority of cases,either to an ethnic (black race) factor or 10 an endemic disease (schistosomiasis, HW infection, or tuberculosis)in the workers' home regions.11This creared mnrc confusion than clarification. but did allow factory management and the social securiy system to deny the existence of a public health p r o b lem in work environments where benzene was present. Follow-up studies refuted the hypothesis that neutropenia was a sensitiveearly sign of benzene poisoning. Because of the large hnctional reserve present in the bone marrow, biopsies or aspirates frequently showed that central damage w s present even when peripheral blood alterations in benzeneexposed subjects were minimal. Typically, the bone marrow exhibited decreases in leukocytes, erythrocytes, arid platelet stem cells, but the effects on the l e ~ k o c p cp~ar,ticularly granulocytes, were the most severe.1.Y .kccording 10 Snyderet al.,*z the physiologc process compensating for loss of central cells is more efiicient for eryhrocyte and platelet precursors than for granulocytic line. The findings of these follow-up studies underlined the importance of recognizing the earliest alterations in the peripheral blood-even small decreases in the count of neutrophi1s.l.' Neutropenia in benzeneexposed workers also became identified bv the Program of Epidemiologic Surveillance of h e .%IO Paul0 State Health Department asa Sentinel Health Event (sentryevent). This allowed identification of high-risk exposure situations, in particular steel-makingoperations, and identified potentially exposed co-workers for purposes of screening, using serial blood counts. However, t h i s policy had some unfortunate results: occupational medicine physicians and other experts focused exclusively on evaluation ofthe peripheral blood, often disregarding effects of benzene on the cenml nervoussystem,manifested as headache, drowsiness, fatigue, and nausea. EFFECTS ON MEDICAL SERVICES AND MEDICAL PROVIDERS One unintended effect of the diagnostic criteria was the massive number of hematologic examinations, co rhe extent rhat testing laboratories actually enjoyed increased revenues and profits.There were also frequent invitations to pathologists to discuss normal hematologic values. A seminar was held in the town of S5o Roque-SP,in 1987,organized by the Brazilian Societyo f Hcmatotherapv and Hematology and the Brazilian College of Hematology. Various hematologists and public health physicians who attended the event and who had a strong ethical and social commitment presented arguments contradicting rhose physicians and company managers seeking to reduce the standards for heniatv logic normality. This seminar poinccd out a series of options LO collectivelysolve the problem. Discontented, the company physicians organized a meeting at the 06Paul0 Medical Association, in 1993, in order to again question the criteria for diagnosis of benzene p& soning endorsed by the Brazilian public organs of Security, Labor, and Health. Our position is that only should hematologic evaluation be maintained I central to identifying henzenum cases, but also ail uauon of neuropsychological, immunologic, and cyto. genetic damages should be included. Up to now the h. ter disorders have been largely ignored. EXPOSURE STANDARDS Brazilian legislation, until 1994, allowed exposure to 8 ppm (parts per million) of benzene for 48 hours each week.13 This legislation permitted exposure, based on environmental evaluation's14 at excessive levels. Since 1976, orhcr countrieshave reconimendcd reducing the benzrire-cxposurc limit to 1 ppm,l5 or even IO a b gether eliminate allowable exposure. with the justific;t. uon that benzene is a human carcinogen.16 Brazilian legislation with respecr to occupational medicine is still supported by the so-called "risk-factor model," whose main characteristic is a monocausal a p proach. and, in the case of chemical risks, relies on enVironmental and biological exposure limits, mostly derived from experimental toxicologicstudies. *: This daes not take into account the superposition of various en\+ ronmental factors in the work process, work organization aspects, biological variability and individual sus ceptibiliy, or other preexisting illness factors. This model ofenvironmenrd evaluation I>asedo n is@ lated quantitative measures was first challenged in 1982 by technicians from Fundacentro (Center of Research of the Brazilian Labor Ministry) with regard LO the question of benzene, and in 1993a new regulatory directive for health surveillancewas issued in SBo Paulo. which in its turn inspired other regulatory instruments at the federal 1 e ~ e l . i ~ ~ ~ CONCLUSION This rare example of worker empowerment in latin America demonstrates the power of education in [he political arena. More than 3,001,benzene poisoning victims asserted their right to occupational health and safety. By so doing, they forever changed the social climare of work in Brazil. 24 Augwoetal. IN1J OCCUP ENVIRONHEALTH Dec-30-99 08:30am From- T-342 P.O7/D8 F-573 3. Rub .MA. Fbtudo Morfolbgico de Mcdula h a ern Packrile Neutrop+nicos da Industria Sideni+ca de Cubado, Esrado de S o Paulo. Campinas. Brazil, Tesc de naurorad'>,F, CM da VNIGlhlP, 1989. 4. August0 U3.Berolismo ern urna Sidenigici. Revista de Saude Ocupacional e Seguranca-SOS. 1984; IO,Julho. ;krosro, Setern- b m . 15.34'7. 5. Secretaria de Euado drr Situdc de S o Paulo.Rrsolu~ao69.Iristi- cui a notif!ica& de agmvos a saildc decorrenles do inbalho no municipio de Cuhatio. Chiiubro 1984. 6. .iugus~oI X S s\igorirro AC, Sniua C-+. .Uwrapks hisuk5gicasde m d u k bsca wcundhia a exposigao ao benreno e a rr.olu(io hrrnatol6gica do rangue prrifciico em pacicnrrs a comeudos. Rc. vista BraJikira dc Sarrde Ocupncional. 199:3;2I (%j, ahril. r n ~ eo junlw:8.549% 7. Minislerio do Trabalho. Secretaria de Squrazica e h i d e no Trabalaho. P o r d a 03. Brasilia. r)i;irio Oficial da L'niso, !k@I . 191)4:()ine 3)51:3745. 8. Insutuio Nacional de Prrvidrncia Social. Circular !!W.80Paulo. 1985. 9. Instiiuio Nacicinal de .%giridadc Social. Cirrulx 04, Sio Paul,, 1987. IO. ;inon. C!m pducntc ma medula 6ssra. Superinirressanw. 1994; (May 12. 1I . Arrito M.G.Augusw LGS. Insalubridwleno Trabalho. Meio .Ambientc c Raca: o c a w dos uahalhadarcs das sidei brgica. Ed. Ccofro de Fsudos das Kelac&s do Tnhalho c Lkipialdades. S o Pdulo. Bmil. lwJT. 36 pp. 12. Snyder R,Jowa 1, Wtz G, blf G , Rushmorc T. FCmnaliOn of rcacrivC rnelabolitesfrom benzene. Arch foxicol. 1987;60:614. IS. Ministerio do Trabdho, Stcrelaria de !%gum@e Medicina d o Tnbalho. Cunsolida~odas leis do trabalho. Bm-lia. D e o Oficial da L!niio. Ponaria 371-1,1978;June 8. 14. Iicber RK.Trabalho em Tunios c &os @uUimicos: 0Horhio de Trabalho como Fator lncervenienie no Elcito T6xico. S5o Paulo, Brazil, Uissenacio de Mesuado. Faculdade de Saiide P6blicd da L'SP. 1991. 15. Occupational .Safety and Health Ariminisurtiwi. Occupational exposure 10 benzene: Final rule. L X F R PART 1910. September 11. 1987. 16. lriternational Agency for Research on Cancer. Benzene. Monugraphs on the Enluation of Chrcinogcnic Risk of Chemicals LO Humans. Lyon. France. 1984;B. 17. Wakarnatusu CL. Femicola NACX;. Intoxira~ioProfissional por &nwno. In: Mendes R. cap. 15. Medicina do Tnbalho/ DocnCac Clcupacionais Primeira Edicio. Sm-ier. S5o Paulo, Brazil. 479-86. 18. Nobaes TCP. Cruenxncr G. Detenninaq5odos teores de bcnrcno em wlventes orghicos indusuiais cornerciali7ados no Brad e pmposm para a preveiipo do rixo poiencial de henzolisrno. Rsvista Brasileira de Saiide Ocup-dcional. I981;S(%) :&70. 19. Fundaccnuo.laudo Tgcnicode Avaliariiode Areas Insalubrrs da (:OSIPA--Vol~ime da (hqueria. 1981 {mimemu). 20. Funll;rccnuo. Propsra para a organizacaode eswumras de controle de exposicao a0 bmwno: cornpetrriciase rcspon*lbilidades. Arualidades em Prevencio de Acidenrcs. 1988;19(227):5-10. 21. Secretaria de Estado da .Wide de G o Pdulo. Resolucio 184. Norma TCcniu Referenu!ao Diagnostico da Inioxicacb e Cum- role da fiporiC5o chpcional ao Bcnteno. DiMo Oticial d o Es- tado. 1993;St.cec.1. 10N107).S o Paulo. Brazil. 9/6/1999. 5/NO 1 , JAISMAR 1999