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PLAINTIFF'S EXHIBIT AL-1218 CENTBJS FOR DISEASE CONTROL April 27, 1984 / Vol. 33 / No 16 213 Leading Work-fl^R^^biseases and Injuries -- United StanO^/ 216 A System to Convert ICO Oia^^^|ic BOTY AND MORTALITY WEEKLY REPORT CocfetsM-Aic<ihQj Fle,5,%ar1ch.,,., 223 Update ffespirattfry vlru^sAUsiUrritfcrT - SCIENCES , UNtVffcSlTY Of PITTSBURGH ------------------------------------------------------------- j--------m aa m Leading Work-Related Diseases and Injuries -- United States The National Institute for Occupational Safety and Health INIOSHI has developed a suggest ed list of the 10 leading work-relateddiseases'Sndinjuries, ^irnmaries of three of these catego ries ("Occupational Lung Diseases," "Musculoskeletal Injuries." and-^OccvogjignaJ Cancers") have recently been published (1-3). The fourth category ')Amputations, FracturesTtye Loss.~' Lacerations, and Traumatic Death,"is summarizef!below SEVERE OCCUPATIONAL TRAUMATIC INJURfl Severe occupational traumatic injuries usualljt occu/ suddenly on the job and are either fatal or require immediate medical care. Data on thesetevents are available from several dif ferent sources, including: the National Electronic inju/y Surveillance System (NEISS) of the Consumer Product Safety Commission (4); the Supplementary Data System (SDS) of the Bureau of Labor Statistics (BLS) (5): the Annual SuWey of Occupational Injuries and Illnesses conducted by the BLS IS); and the National SafetyriCouncil (71. The National Safety Council and the Annual Survey of the BLS estimate occupational traumatic deaths. These sources report different aspects of the problem because of differences in the scope of events that each system tries to reflect. NEISSrepo^ts cases of occupational trauma from a representative sample of U.S. hospital emergency rpoms. SDS records information from Workers' Compensation claims filed in 33 states. As required by the Occupational Safety and Health Administration, the Annual Survey of tne BLS reports traumatic events occurring in the private sector; thus, it does not include trailmatic events in the public sector, on farms with 10 or fewer employees, and in firms regulated by oth^r federal health and safety laws. The National Safety Council reports data fr^m the National Health Survey (based on 41.000 annual interviews with heads of households) and data from several participating public and private organizations. The definition of "recordable injury" varies considerably among these systems. /j ; Because of these differences, it is not easy to achieve a reliable national composite of severe occupational traumatic injuries. Within the limitations of these data sources. NIOSH es timates that at least 10.000,000 persons suffer traumatic injuries on the job each year. About 30% (at least 3,000,000) of these injuries are severe, ind at least 10.000 are fatal. Traumatic Deaths: Each year, an estimated 10AD00 persons are killed on the job. The major causes of these deaths are (1) highway motpr-vehicle incidents, including to and from work and job-related travel (34%); (2) falls (13%);/<3) nonhighway industrial-vehicle incidents (11%). (4) blows (other than by vehicles or equipment) 18%); and 15) electrocutions (7%) (Table 1). Industries with the highest estimated rates of fatal traumatic injury are (1) mining and quarrying. (2) agriculture (including forestry and fishing), and (3) construction (Table 2). Amputations: Although amputations account for less than 1% of estimated injuries, they often impair a worker's skills. An estimated 21,000 workers suffered amputations in 1982. Based on NEISS data, approximately 93% of these amputations were of fingers (8); and 4%. of hands and toes. Amputations of fingers most frequently resulted from fingers being caught U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES / PUBLIC HEALTH SERVICE MJ41a)R 1^4-', 3S>'. 511971 0068 214 MMWR April 27, 1984 Leading Work-Related Diseases -- Continued in machines or hand tools (1 1%l or cut by moving objects, such as saws or sheers (10%!. Other important sources of amputations included presses (6%), belts (5%). powered hand tools (2%). and doors or gates (2%). Other specific sources accounted for less than 2% each of occupational amputations. According to SDS data, amputations occurred in a wide range of industries and occupa tions. The largest single proportion of amputations (2%) occurred in the manufacture ol mis cellaneous plastic products, and machine operators had the largest proportion of occupational amputations (8%).' Fractures . Falls and blows from falling objects produce many types of injuries, the less severe forms being contusions, abrasions, and sprains. During 1982, an estimated 400,000 work-related fractures occurred. SDS data for 1980 included approximately 208.000 com pensation claims for fractures. The most frequently listed sources of fractures included floors (13%). the ground (10%), and metal items (7%), suggesting falls as the main cause of such injuries. Specifically, falls to a working surface accounted for 15% of the fractures; blows from unspecified or falling objects accounted for 31%. Fractures occurred most frequently among truck drivers (5%), miscellaneous laborers (4%), and construction laborers (3%).* Eye Loss: Although it is difficult to measure the extent of eye loss or blindness among workers, NIOSH estimates (based on NEISS data) indicate that approximately 900,000 oc cupational eye'injuries occurred in 1982. For 84% of these, the trauma was minor, caused mostly by foreign bodies (eg.. pieces of metal, wood, or glass) in the eyes. Bums and avulsions --44% of which were caused by chemicals or acids--accounted for nearly 15% of the estimated occupational eye injuries." Lacerations: An estimated 2,250,000 work-related lacerations occurred in 1982, repre senting 24% of all job-relatsd injuries treated in hospital emergency rooms. Data from com pensation claims described in SDS indicate that fingers (48%), arms (24%), legs (13%), and the head and neck (9%) were most likely to be seriously lacerated. These lacerations resulted primarily from being struck by an object (32%) or from striking against a stationary object (25%). The major sources of lacerations are knives (13%), other sharp metal items (13%), saws (6%), glass items (5%), nails (5%), and machines (3%). The settings in which workers in- "The remaining percentages are divided among a variety of specific categories, each accounting for less than the smallest percentage given. TABLE 1. Distribution of occupational traumatic deaths, by cause--United States, 1980-1981* Cause Percentage Highway motor-vehicles incidents Falls Industrial vehicles or equipment Blows (other than by vehicles or equipment} Electrocutions Gun shots Aircraft crashes Entrapment Fires Plant machinery operations Explosions Gas inhalations Other 34.1 12.6 11A 8.0 6.8 4.5 3.4 3.4 3.4 3.4 2.3 2.3 4.5 Total 100.0 `Adapted from Bureau of Labor Statistics: Occupational Injuries and Illnesses in the United States by Industry, 1981. U.S. Department of Labor Bulletin 2164, January 1983. These revised statistics pertain to private-sector establishments (excluding nonmetal mining and railroads) with 11 or more employees. Vol. 33 Leadir curred eery st Repent Editori "accid this cc public al injui uninte De workp injurie severr gineei workf such mach robot hazar helmi tema serioi for pr Refer, 1. C( 2. C( 3. a 4. Ct 5M 1! 6. Bi U 7. N B. C 9C ^Inju TAB Stat Indus Minir Agric Cons Tran Gov Ser\ Mar Trac Ad the met forr stat AprflW.H#4 IS uwl or dicer) (10%) nils (6%). powered hand l lor less then 2% each of f industries and occupathe manufacture of misoportion of occupational rpes of injuries, the less an estimated 400,000 ximately 208,000 comfractures included floors the main cause of such of the fractures; blows ccurred most frequently >n laborers (3%).' oss or blindness among oximately 900,000 ocuma was minor, caused in the eyes. Bums and unted for nearly 1 5% of ocurred in 1982, reprelooms. Data from com- (24%), legs (13%), and ese lacerations resulted inst a stationary object arp metal items (13%), gs in which workers in- each accounting for less luae--United States, Percentage 34.1 12.5 11.4 8.0 6.8 4.5 3.4 3.4 3.4 3.4 2.3 2.3 4.5 100.0 ; in the United States by revised statistics pertain 11 or more employees. Vol. 33/No. 16 MMWR 215 Leading Work-Related Diseases -- Continued curred the largest proportion of lacerations were eating and drinking establishments (7%). gro cery stores (4%), general building construction (2%), and meat packing (2%).' Reported by Div of Safety Research, Natrona! Institute for Occupational Safety and Health. CDC Editorial Note: Recent analyses of potential life lost due to various causes indicate that "accidents and adverse effects" are the leading cause of the loss of potential years of life in this country (3). Occupational injuries occur at a rate* twice that of injuries in the home or in public places ( 7), and severe traumatic injuries are an important component of all occupation al injuries. Severe occupational trauma is second only to motor-vehicle incidents as a cause of unintentional death in the United States ( 7). Despite the number of occupational injuries, effective prevention is practiced in many workplaces, and approximately 48% of all employment establishments report no recordable injuries in a given year (6). As with other occupational health hazards, the prevention of severe occupational traumatic injuries rests on the basic principles of control technology: en gineering controls, work practices, personal protective equipment, and monitoring of the workplace for emerging hazards. Severe occupational traumatic injuries can be prevented by such specific measures as physical barriers between the worker and the source of injury le g., machine guards, light curtains, worker-independent safety circuits, proximity sensors on robots); changes in the design of tools leg., knives and slicers) and tasks to reduce the "hazard; use of personal protective equipment (e g., seat belts, protective eye- and footwear, helmets, harnesses); training of workers in the safe performance of tasks; and repeated sys tematic inspection of the workplace for emerging or previously undetected hazards. A visible, serious, and persistent commitment to safety by both management and labor appears crucial for preventing severe occupational traumatic injuries. References 1. CDC. Leading work-related diseases and injuries --United States. MMWR 1 983,32 24-6. 32 2. CDC. Leading work-related diseases and injuries --United States. MMWR 1 983;32.1 89-9 1 3. CDC. Leading work-related diseases and injuries --United States. MMWR 1984:3312 5-8. 4. CDC.Occupational injury surveillance --United States MMWR 1981.30:578-9. 5. McCaffrey D. Work-related amputations by type and prevalence. Monthly Labor Review 1981;3:35-41. 6. Bureau of Labor Statistics. Occupational injuries and illnesses in the United States by industry. 1978 (Annual). Washington, D C.: Bureau of Labor Statistics. 7. National Safety Council. Accident facts. 1983 Edition. Chicago. Illinois: National Safety Councii. 8. CDC. Occupational finger injuries--United Slates, 1982. MMWR 1983:32:589-91. 9. CDC. Table V. MMWR 1984:33:209. ^Injuries per million exposure hours. TABLE 2. Occupational traumatic death rates per 100,000 workers, by industry--United States, 1982* Industry Rate Mining and quarrying Agriculture Construction Transportation and public utilities Government Services Manufacturing Trade 55 52 40 26 10 6 6 5 'Adapted from (7) Accident Facts. National Safety Council. 1983 Edition. These rates are estimated by the National Safety Council based on data from the National Center for Health Statistics, state depart ments of health, state industrial commissions, and the Bureau of Labor Statistics Agriculture includes forestry and fishing; services includes finance, insurance, and real estate, government includes federal, state, and local; trade includes wholesale and retail April 26. 1985 ed in a city in the neighbor:cal disease made recognirealed that the age distributtivitis. and laboratory find- jted the presence of more :ase definition for sporadic erized by: s after onset of fever. >f fever: meningitidis'. im3 and negative by culture ative for known pathogenic ens. ther than the outbreak peri,PF task force, consisting of js, as well as CDC investigas been placed on collecting iterial. ren, has not been previously not yet revealed an etiologrpidemic cases identified to i observed. With clusters of Dradic illness is hindered by f meningococcemia. particbest categorized as purpura d characterized by purpura, two forms: acute, resulting several days to weeks after rts of this second form of in are unknown. Additional tilian health authorities and hould be directed to the Re>f Bacterial Diseases. CDC; ence laboratory. Vol. 34/No. 16 MMWR Purpuric Fever - Continued Reference 1- Spicer TE. Rau JM Purpura fulminans Am J Med 1 976.6 1 566-71 219 Perspectives in Disease Prevention and Health Promotion Leading Work-Related Diseases and Injuries --United States The National Institute for Occupational Safety and Health (N/OSHI has developed a sug gested list of the leading work-related diseases and injuries /Table 1). The first four categories have been described previously 11-4); a discussion of the fifth category. "Cardiovascular Dis eases, " appears below. CARDIOVASCULAR DISEASES Cardiovascular diseases, including hypertensive disease (International Classification of Dis eases 9th Revision (ICD) codes 401-405), ischemic heart disease (ICD codes 410-414). other forms of heart disease (ICD codes 420-429), and cerebrovascular disease (ICD codes 430-438). are responsible for more deaths in the United States each year than any other category of disease (5). In 1980. cardiovascular diseases claimed over 960,000 lives, with ischemic heart disease responsible for over 565,000 of these deaths (6). Although the rates of death from cardiovascular diseases have declined gradually over the last decade, coronary atherosclerosis and acute myocardial infarction remain the leading causes of death in the United States. The role of occupation as a factor in cardiovascular disease is far from clear (7). Most in vestigators believe that personal risk factors, such as cigarette smoking, blood pressure, diet, personality, and heredity, are more important than environmental factors (8). Specific data are sparse on the role of occupational factors. Nevertheless, some occupational factors are clearly associated with heart diseases, and evidence on other factors is accumulating (9). Be- Table 1. The 10 leading work-related diseases and injuries -- United States, 1982* 1. Occupational lung diseases: asbestosis. byssinosis, silicosis, coal workers' pneumoconiosis, lung cancer, occupational asthma 2. Musculoskeletal iniuries: disorders of the back, trunk, upper extremity, neck, lower extremity; traumatically induced Raynaud's phemonenon 3. Occupational cancers (other than lung): leukemia; mesothelioma: cancers of the bladder nose, and liver 4. Severe occupational traumatic injuries: amputations, fractures, eye loss, lacerations, and traumatic deaths 5. Cardiovascular diseases: hypertension, coronary artery disease, acute myocardial infarction 6. Disorders of reproduction: infertility, spontaneous abortion, teratogenesis 7. Neurotoxic disorders, peripheral neuropathy, toxic encephalitis, psychosep, extreme personality changes (exposure-related) 8. Noise-induced loss of hearing 9. Dermatologic conditions: dermatoses, bums (scaldingsl, chemical bums, contusions (abrasions) 10. Psychologic disorders. neuroses, personality disorders, alcoholism, drug dependency `The conditions listed under each category are to be viewed as selected examples, not comprehensive definitions of the category. 220 MMWR April 26. 1985 Leading Work-Related Diseases and Injuries - Continued cause heart diseases are still so prevalent in the United States, identifying and preventing oc cupational factors that result in even a small increase in the relative risk of cardiovascular dis ease would involve large numbers of persons. Thus, preventing any occupational contribution to this problem would be an important public health measure In 1 978, an ad hoc task force was formed by the American Heart Association to review the data regarding the environmental impact on cardiovascular disease IS) Its report. "The Impact of the Environment on Cardiovascular Disease," was published in 1 981 The task force identi fied and reviewed si* environmental factors that have potential impact on cardiovascular health, water hardness; trace elements; inhalant occupational exposures; carbon monoxide, noise and radiofrequency; and physical and psychosocial stress The workplace is a specific source of potential exposure for all but the first. Metals, Dusts. Trace Elements. The development of congestive heart failure that results from restrictive lung disease (cor pulmonale) has been observed in studies of occupational res piratory diseases, such as chronic beryllium disease and silicosis. Other metals, such as antimo ny. cobalt, and lead, have been implicated as possible causes of cardiovascular diseases. Occupational Inhalants and Other Chemical Exposures. These include: 1. Carbon monoxide: Carbon monoxide decreases the oxygen-carrying capacity of hemo globin and thus reduces the oxygen supply available to heart muscle and other tissues In persons with preexisting coronary artery disease, occupational exposures to carbon monoxide may precipitate acute cardiovascular events, such as untoward changes in cardiac rhythm. In animal studies, life-threatening arrhythmias, such as ventricular tachy cardia and ventricular fibrillation, have been observed in response to exposures to carbon monoxide that produced a carboxyhemoglobin concentration of 9& and above. In one study of workers, short-term exposure to carbon monoxide at levels within the current Occupational Safety and Health Administration permissible exposure limit (50 ppm) was associated with decreased exercise tolerance and electrocardiographic evidence of myocardial ischemia. In another study among Finnish foundry workers ex posed to carbon monoxide, the overall prevalence of angina pectoris was increased; this was most pronounced among workers who also smoked. Among British steelworkers, investigators found end-of-shift carboxyhemoglobin saturations substantially higher among blast furnace workers than among steelworkers in other jobs. This was observed for both smoking and nonsmoking employees. 2. Carbon disulfide. Carbon disulfide, a widely used solvent, has been shown to increase . the risk of cardiovascular disorders, including coronary artery disease and hypertension. in both epidemiologic and experimental studies. It has also been shown to pose a signifi cant risk for coronary death (70). The atherogenic potential of carbon disulfide involves both cerebrovascular and cardiovascular systems. ; 3. Halogenated hydrocarbons. Acute exposures to many common industrial solvents le g , chloroform, trichloroethylene) and fluorocarbon aerosol propellants have precipitated sudden death probably due to cardiac arrhythmias in workers exposed at high levels. Other common aerosols or solvents may be arrhythmogenic at concentrations permitted by current occupational exposure standards. A recent study of pathologists exposed to monochlorodifluoromethane (a fluorocarbon aerosol propellant) in hospitals showed an increased incidence of "palpitations" at levels of exposure far below the recommended standard. 4. Nitroglycerin and nitrates. Workers exposed to nitroglycerin and nitrates during the manufacture of explosives experienced increased risk of cardiac chest pain, myocardial infarction, and sudden death, particularly after a period of time away from exposure. The mechanism is thought to be "rebound vasospasm" as a consequence of withdrawal from exposure. April 26. 1985 ng and preventing ocof cardiovascular disupational contribution >ociation to review the Its report. "The Impact The task force identiact on cardiovascular es; carbon monoxide, vorkplace is a specific 'art failure that results as of occupational resnetals. such as antimoscular diseases, jde: ying capacity of hemo:le and other tissues. In I exposures to carbon untoward changes in :h as ventricular tachyonse to exposures to ion of 9% and above. <ide at levels within the issible exposure limit d electrocardiographic h foundry workers ex iris was increased; this g British steelworkers. ,is substantially higher >bs. This was observed een shown to increase ease and hypertension, hown to pose a signifiirbon disulfide involves ndustrial solvents le g., ants have precipitated ixposed at high levels, ncentrations permitted athologists exposed to in hospitals showed an low the recommended md nitrates during the chest pain, myocardial jay from exposure. The tquence of withdrawal Vol. 34/No. 16 MMWR Leading Work-Related Diseases and Injuries -- Continued 221 Noise Tens of millions of workers are exposed to high levels of sustained and or intermit tent noise in the workplace A number of studies have demonstrated that single exposures to noise cause transient increases in blood pressure. Chronic exposure to occupational noise has also been associated with sustained increases in blood pressure, particularly in workers with noise-induced hearing loss (7 1,12). Increases in serum cholesterol and changes in circulating hormones have been observed in humans in association with noise. In studies of animals, ab normalities in platelet aggregation have been documented following exposure to noise Psychosocial Stress. Stress has long been thought to adversely affect the cardiovascular system (13). A relationship between psychologic factors and cardiovascular disease is sup ported by the correlation between "Type A personality" and such disorders. A 1976 assess ment suggested that "work-overload." role conflicts, and thwarted career goals were related to evidence of cardiovascular disease. A prospective evaluation of health changes among air traffic controllers, published in 1978. showed an increased prevalence of hypertension among controllers, attributed by the authors to difficulties in coping with working conditions. An updated analysis of the Framingham heart study in 1980 (14,151. indicated that rates of coronary heart disease were nearly twofold greater among women employed in clerical jobs than among housewives. Significant predictors of the risk of coronary heart disease included a "nonsupportive supervisor" and decreased job mobility. Occupation may also affect the risk of cardiovascular disease in a spouse. Men whose wives worked in white collar jobs were ob served to experience heart disease at a rate three times greater than men whose wives worked in clerical or blue collar jobs or were housewives. Similarly, men appeared to have a higher risk of cardiovascular disease if they had well-educated, working wives who reported nonsuppor tive supervisors or few opportunities for job promotion. These and similar results suggest that adjustments to the conflicting demands of job and family may be important factors in the risk of cardiovascular disease. Recent evaluations of data from a large random sample of the Swedish working male population (76), and from other surveys, also suggest that certain working conditions, such as limited autonomy and heavy workloads, are associated with clinical indicators of coronary heart disease. Epidemiologic studies are clearly needed to define the significance of these and other oc cupational stress factors in the etiology of cardiovascular diseases. Such physical stresses as noise, vibration, and heat also merit investigation for possible interaction with the psychologic risk factors of cardiovascular disease. Reported by Div of Surveillance. Hazard Evaluations, and Field Studies. National Institute for Occupational Safety and Health. CDC. Editorial Note: Because cardiovascular diseases are so prevalent, they clearly affect large numbers of workers in the United States. A proportion of these diseases are caused or ag gravated by risk factors in the work environment. NIOSH is currently collecting epidemiologic data to properly evaluate the role of the workplace in these diseases. Since some occupational exposures clearly contribute to the morbidity and mortality attri butable to cardiovascular diseases, further epidemiologic research is essential to define the extent of their occupational role and to define etiologic mechanisms. In addition, since cardio vascular diseases cause so much mortality in the United States, preventing even a small in crease in relative risk due to occupational exposures would have major consequences to the public health. That mortality from cardiovascular disease has declined markedly in recent years indicates that these diseases are preventable. The workplace is an important focus for efforts to prevent cardiovascular disease because: (1) it is the source of some preventable environmental exposures and psychosocial stresses that adversely affect cardiovascular health; (2) it offers unique opportunities for health promo tion activities that encourage workers to improve their personal health behaviors (e.g.. smoking 222 MMWR April 26, 1985 Leading Work-Reiated Diseases and injuries -- Continued cessation, appropriate exercise, and sound nutrition) and; 13) it provides an advantageous set ting for delivering preventive services, such as screening for hypertension. References' 1 CDC Leading work-related diseases and injuries-- United States MMWR 1983.32 24-6.32 2 CDC Leading work-related diseases and injuries --United States MMWR 1983:32 189-91 3 CDC Leading work-related diseases and injuries --United States MMWR 1983.33 125-3 4. CDC Leading work-related diseases and injuries --United States MMWR 1984.33 21 3-5 5. Office on Smoking and Health. The health consequences of smoking Cardiovascular disease a report of the Surgeon General Rockville. Maryland: Public Health Service. US Department of Health and Human Services. 1 983 6 Levy Rl. Moscowitz J Cardiovascular research decades of progress, a decade of promise Science 1982:217 121-9. 7 Rosenman KD. Cardiovascular disease and environmental exposure Br J Ind Med 1 979.36 85-97. 8. Harlan WR. Sharret AR. Weill H, Turino GM. Berhani NO. Resnekov L. Impact of the environment on cardiovascular disease, report of the American Heart Association Task Force on environment and the cardiovascular system Circulation 1981.63.243A-6A. 9. Jenkins CD. Psychologic and social precursors of coronary disease. N Engl J Med 1971.284 244-55.307-1 7. 'Additional references are available on request from the National Institute for Occupational Safely and Heatth,*COC. (Continued on page 227) TABLE I. Summary--cases of specified notifiable diseases. United States Disease Apr 20. 1985. 16ih Week Enomg Apr 2 1. 1984 Median 1980-1 984 Cumuletiv e 16th We Ending Apr 20. 1985 Apr 21. 1904 Median t?8C ' 994 Acquired Immunodelioency Syndrom* (AlOS> A$epiK meningitis Encephalitis Primary larthropod-Dome & unspecI Posi-inlect>oos Gonorrhea CrvUian Military Hepatitis Type A Type 0 Non A Non 0 _ Unspecified legonelkos4 Leprosy Malaria Mea$>ei Total* Indigenous imported Meningococcal infections Total Civilian Military Mumps PerluSSiS PuDelia (German measles! Syphilis (Primary & Secondary! Civilian Military Tone Shock Syndrome Tuberculosis Tularemia Typhoid lever Typhus lever, net-borne (RMSF! Ratxes. arumal 156 41 10 2 15.279 252 44S 463 88 114 10 15 15 94 79 IS 52 51 1 82 25 5 490 3 11 476 5 1 71 86 63 21 4 15.630 358 423 493 73 115 1 4 26 128 116 12 72 71 1 93 118 16 552 6 16 432 10 8 126 N 63 14 4 17.485 484 423 412 N 166 N 4 23 86 N N 81 81 93 21 68 564 6 N S69 2 6 8 160 2.04 t 1.066 271 40 239.292 5.485 6 458 7.535 1.600 1.594 160 107 199 803 600 203 935 934 1 1.275 387 122 7.551 56 110 5.857 24 77 14 1.366 1.095 1.228 250 31 248.229 6.224 6.463 7.539 1.086 1.436 152 62 206 876 773 105 1.104 1.102 2 1.156 651 172 i 8.705 102 144 6.159 19 99 30 1.467 N 1 228 250 29 283 524 8 203 7 169 6.248 N 2 607 N 62 231 878 N N 1.104 1.102 5 1.708 328 799 9.335 115 N 7.396 31 114 26 1.752 TABLE II. Notifiable diseases of low frequency. United States Anthrax Botulism Foodborne Infant (Calif 3) Other Brucellous (Md. t.Okla 21 Cholera Congenital rubella syndrome Oiphtbena (Colo 1) Leptospirosis Cum 1985 1 13 26 8 Plague Poliomyelitis. Total Paralytic Psittacosis (Cahf 11 Rabies, human Tetanus (Upstate NY l.Mich 11 Trichinosis (Upstate N.Y. 1. Calif 2. Alaska 2) Typhus fever, flea-borne (endemic, munnel Cum 1985 1 1 42 15 28 3 `Twelve of the 94 reported cases lor this week were imported from e foreign country or can oe directly traceable to a known internationally imported case within two generations UN Nfv Mi NH Vt M* RI Co- MIC Up: N> Nj Pa fM Oh mo Wi: w> lom Mo N( s: Nei fta> SOe- M0 ct Va W NC SC Ga Fla S *y Ter Ala Mi: WAn La Ok Te MC Mo Ida w, Coi Nk Arc Uta Nev PA' On Ca Ala Ha Gu PF VI Pa H ending April 26. 1985 Aft CuS*t BvAgfYt*(0 *6b 2b 44 1-24 * 1 p&i- 1 766 264 88 32 46 50 i 103 30 1 5 6 3 116 - 41 79 46 16 4 7 3 25 a 1 5 6 20 3 4 4 4 ~ 63 21 8 2 3 1 37 1 1 5 3 5 1 42 lb 6 1 3 1 30 b 5 2 1 9 73 15 3 2 1 7 51 14 3 3 2 5 111 54 16 3 17 9 18 8 1 1 526 220 54 20 21 37 a 69 23 14 4 8 4 5 38 12 2 2 1 1 ? 49 20 4 2 2 2 5 93 31 7 2 2 B z 108 50 12 6 4 10 ' 46 16 3 2 4 a 41 17 4 1 2 4 5 84 51 8 1 2 4 a 851 324 155 51 57 64 7 28 12 3 4 4 1 37 23 6 2 3 4 7 30 961 1 1 123 39 23 7 9 1 t 3 36 19 12 3 3 2 ; 62 20 10 3 7 5 240 100 62 19 19 14 a 36 10 1 14 i 52 24 9 6 2 1 7 112 35 19 6 5 13 7 32 13 2 1 3 63 20 2 75 : 377 149 40 36 40 37 i 38 18 4 9 5 4 Z 24 9441 5 ~ 63 27 1 1 2 14 5 52 31 4 3 5 18 5 1 11 64 30 7 9 9 4 15 4 1 1 32 7 3 4 S 3 - 71 18 5 5 5 9 1.117 A8 49 i 13 3 41 s 60 j 157 52 34 9 81 i 103 a 97 115 * 121 94 41 - 51 389 132 61 52 105 74 16 7 5 4 7 11 11 6 5 2 20 5 6 4 4 54 21 10 3 9 17 4 4 4 5 512 26 3 2 7 4 25 9 3 1 15 32 18 3 6 17 53 1 1 3 3 6 51 18 11 40 17 6 13 3 1 18 6 1 6 13 4 12 45 63 8.148 2.641 875 362 413 627 -c* population* o* 1 00 000 oi cate Mit f*d fetal drains at not counts I O' me current eefc Com Vol. 34/No. 16 MMWR Leading Work-Related Diseases and Injuries - Continued 10 Nurminen M. Mutanen P. Tolonen M. Hernberg S Quantitated ejects ot carbon disulfide exposure, elevated blood pressure and aging on coronary mortality Am J Epidemiol 1 982. 115 1 07-1 8 Talbott E. Helmkamp J. Matthews K. Kuller L. Cottington E. Redmond G Occupational noise expo sure. noise-mduced hearing loss, and the epidemiology of high blood pressure Am j Epidemiol 1985.121 501-14 Fouriaud C. Jacquinet-Salord MC. Degoulet P. et al. Influence of socioprofessional conditions on blood pressure levels and hypertension control Epidemiologic study of 6.665 subjects m the Paris district Am J Epidemiol 1 984; 1 20 72-86 13 Jenkins CO Psychosocial risk factors for coronary heart disease Acta Med Scand '.SuppD 1982.660 123-36 14 Haynes SG. Femleib M. Kannel WB. The relationship of psychosocial factors to coronary heart dis ease m the Framingham Study. Ill Eight-year incidence of coronary heart disease Am j Epidemiol 1980; 1 1 1 37-58. 15 Haynes SG. Femleib M. Women, work and coronary heart disease prospective findings from the Framingham heart study Am J Public Health 1 980.70.133-41. 16 Karasek R. 8aker 0. Marxer F. Ahlbom A. Theorell T Job decision latitude, job demands, and cardio vascular disease a prospective study of Swedish men. Am J Public Health 1981,71 694-705 Epidemiologic Notes and Reports Disseminated Mycobacterium bovis Infection from BCG Vaccination of a Patient with Acquired Immunodeficiency Syndrome In December 1982. Kaposi's sarcoma and acquired immunodeficiency syndrome (AIDSI were diagnosed in a 29-year-old white homosexual man. A trial of vinblastine sulfate failed to decrease the progression of his skin lesions. In February 1984. when seen in a clinic in Tijuana. Mexico, he was given a BCG vaccination. The expected local lesion from the BCG vaccination healed normally within the next few weeks. In June, he developed chills and fever to 39.4 C (1 03 FI, weakness, fatigue, anorexia, and a mild headache. In July, the site of BCG vaccination on his left arm ulcerated, draining a small amount of pus and blood. A previously enlarged lymph node in the left axilla increased substantially in size and became very tender. Because of the possibility of disseminated BCG infection, treatment was begun with INH 300 mg/day. ethambutol 25 mg/kg/day. and pyridoxine. He rapidly became afebrile and regained his feeling of well-being. The ulcer healed slowly, and the enlarged lymph node decreased in size and tender ness. Two blood cultures taken June 28 and a culture of the ulcerating lesion taken July 16 grew Mycobacterium bovis, BCG strain. A blood culture taken July 23, just before therapy, grew M. fortuitum. Reported by RE Winters, MD. School of Medicine, University of California, Los Angeles, LQ Hanh, MD. Tuberculosis Control Unit, Los Angeles County Dept of Health Svcs, J Chin, MD. State Epidemiologist, California State Dept of Health Svcs; Div of Tuberculosis Control, Center for Prevention Svcs, AIDS Br, Oiv of Viral Diseases. Center for Infectious Diseases. CDC. Editorial Note: BCG vaccine contains live mycobacteria derived from a strain of M. bovis at tenuated through years of serial passage in culture by Calmette and Guerin at the Pasteur In stitute, Lille. France. Although BCG has been widely used throughout the world, its use in the United States is limited to those uncommon situations in which uninfected persons are repeat edly exposed to infectious tuberculosis, and other means of preventing infection cannot be applied (J). BCG has also been used to stimulate the immune system of patients with various cancers, especially malignant melanoma, with the objective of causing regression of the tumors (2). As with any vaccine containing live organisms, however, it is contraindicated in persons with severely impaired immune responses, including those with AIDS, because dis seminated infection with the organism contained in the vaccine may result. M. bovis and M. tuberculosis (the M tuberculosis complex) are pathogenic for man and are >d State*. 1984-1985 t--I--i--i--r--r TOTAL DEATHS VTIONS L 203 L 240 L no to Y ^IiS--tom1i7--*i--1r1--its--ISi--r1 Apn UAY JUH tcan Academy of Family Physiater and at least cough or sore nd influenza deaths include all where influenza is listed on the sources). OCCUPATIONAL HAZARDS -- The 10 leading work-related diseases and injuries. United States 1. Occupational lung diseases 2. Musculoskeletal injuries 3. Occupational cancers (other than lung) 4. Severe occupational traumatic injuries 5. Cardiovascular diseases 6. Disorders of reproduction 7. Neurotoxic disorders 8. Noise-induced loss of hearing 9. Dermatologic conditions 10. Psychologic disorders Based on an evaluation of current occupational problems in the United States, the National In stitute for Occupational Safety and Health (NIOSH) has developed and published" a suggested list of the 10 leading work-related diseases and injuries. Three criteria were used to develop the list: the disease's or injury's frequency of occurrence, its severity in the individual case, and its amenability to preventive efforts. The list is suggested with three purposes: 1) to en courage deliberation and debate among professionals about the major problems in this field of public health, 2) to assist in setting national priorities for efforts to prevent health problems related to work, and 3) to convey to a diverse audience the concerns of the leadership of NIOSH and the focus of the Institute's activities. This tabulation serves as a guide for the NIOSH research program. Efforts are now under way to develop a comprehensive control strategy for each problem on the list and to study the need for establishing or modifying stan dards. The list is intended to be dynamic; it will be reviewed periodically for necessary updat ing as knowledge increases and as conditions change and are brought under better control. "CDC. Leading work-related diseases and injuries--United States. MMWR 1983:32:25-6. 32. 97 OCCUPATIONAL HAZARDS OCCUPATIONAL HAZARDS -- Occupational lung diseases The U S. Public Health Service (PHSI objective for occupational lung diseases in the year 1990 states that among workers newly exposed after 1985. there should be virtually no new cases of four preventable occupational diseases --asbestosis. byssinosis. silicosis, and coal workers' pneumoconiosis. Because no national reporting system currently exists for these dis eases. mortality data are used to monitor trends for some occupational lung diseases Impor tant deficiencies in these data, however, detract from their value as a surveillance tool Mor tality data may underestimate the problem because lung diseases may not be listed on the death certificate or may not. if listed, be selected as the underlying cause of death In addition, mortality data do not explain the course of disease development or the exposures that lead to disease development. Thus, present trends may not accurately reflect future patterns of mor bidity and mortality from these diseases. Because information on the incidence and course of disease is essential for mounting an effec tive prevention/control program, surveillance methods must be developed to detect environ mental hazards that lead to occupational lung disease and to track the incidence of these dis eases. NIOSH is collaborating with the Conference of State and Territorial Epidemiologists to establish a reporting system for occupational diseases, and initial efforts have involved oc cupational lung diseases. In addition, both the Surveillance Cooperative Agreements Between NIOSH and States (SCANS) and the NIOSH Cooperative Agreement Program for Capacity Building in Occupational Safety and Health are supporting pilot projects to evaluate several types of reporting mechanisms. OCCUPATIONAL HAZARDS -- Musculoskeletal injuries Musculoskeletal disorders are currently the leading cause of lost workdays among American workers. The PHS has stated that by the year 1990, lost workdays due to injuries should be reduced to 55/100 workers annually. At the present time, comprehensive and reliable surveil lance data are lacking in this area. The principal musculoskeletal injuries result from cumulative trauma associated with repetitive work activities --such as assembly-line production--and from acute trauma associated with a wide variety of tasks. A work activity is termed a traumatogen if it presents excess biome chanical stress to muscles, tendons, ligaments, nerves, joints, and supporting vasculature. Common traumatogens include bending, twisting, reaching, gripping, pinching, kneeling, squatting, and lifting. NIOSH is studying several aspects of musculoskeletal disorders and has prepared a Manual for Detecting Cumulative Trauma Disorders of the Upper extremity. This manual identifies the elements of job tasks that are implicated in musculoskeletal disorders of the wrist, hand, arm, and shoulder, and describes methods for preventing these disorders. al lung diseases in the year re should be virtually no new 'yssinosis, silicosis, and coal currently exists for these disational lung diseases. Impor:asa surveillance tool. Mor;es may not be listed on the ig cause of death. In addition, or the exposures that lead to iflect future patterns of mor- ;ential for mounting an effecdeveloped to detect environ:k the incidence of these disTerritorial Epidemiologists to rial efforts have involved ocerative Agreements Between ament Program for Capacity projects to evaluate several : workdays among American lays due to injuries should be ehensive and reliable surveil- ma associated with repetitive :ute trauma associated with a if it presents excess biomeand supporting vasculature, gripping, pinching, kneeling. s and has prepared a Manual ilty. This manual identifies the irders of the wrist, hand, arm, ers. OCCUPATIONAL HAZARDS OCCUPATIONAL HAZARDS -- Selected occupational cancers ICD-9 155 1600 161 158, 163 170 187.7 188 Condition Industry/occupation . Hemangiosarcoma of the liver Vmyf chloride polymerization Industry vintners Malignant neoplasm of nasal cavities Woodworkers, cabmet/furmture makers Boot and shoe producers Radium chemists, processors dial painters Nickel smelting and refining Malignant neoplasm Asbestos industries and utilizers Of larynx Mesothelioma {peritoneum! {pleura! Asbestos industries and utilizers Malignant neoplasm Radium chemists, processors, dial of bone painters Malignant neoplasm of scrotum Automatic lathe operators, metalworkers Coke oven workers, petroleum refiners, tar distillers Malignant neoplasm Rubber and dye workers of bladder 189 204 205 207.0 Malignant neoplasm of kidney; other, and unspecified urinary organs Lymphoid leukemia, acute Myeloid leukemia, acute Erythroleukemia Coke oven workers Rubber industry Radiologists Occupations with exposure to benzene Radiologists Occupations with exposure to benzene Agent Vinyl chloride monomer Arsenical pesticides Hardwood dusts Unknown Radium Nickel Asbestos Asbestos Radium Mmeralcuttmg oils Soots and tars, tar distillates Benzidine, aloha and beta naphthyiamme. auramine. magenta. 4-aminobiphenyt. 4-mtrophenyl Coke oven emissions Unknown Ionizing radiation Benzene Ionizing radiation Benzene Exposure to certain chemicals has been shown to produce cancer in humans; many of these chemicals are found in the workplace. The increased volume and diversity of synthetic chemi cals manufactured since World War II have raised concern about possible increased rates of occupational cancer. As exposed cohorts of workers age, this issue may become more clear. The PHS has stated that by the year 1990 generic standards and other forms of technology transfer should be established, when possible, for standardized employer attention to such major common problems as carcinogenic hazards and medical monitoring requirements. NIOSH conducts investigations to determine whether work within certain occupational groups or specific occupational exposures are associated with an increased risk of acquiring cancer. The ultimate objective is to determine whether specific industrial chemicals cause cancer. OCCUPATIONAL HAZARDS OCCUPATIONAL HAZARDS -- Severe occupational traumatic injuries In 1981. about one of every 1 2 workers in the private sector was involved in an occupational iniury requiring treatment beyond first aid. The National Safety Council estimates that 2 1 mil lion workers experienced disabling injuries in 1 981 and that 70.000 of them were permanent ly impaired. In all. the toll on human and economic resources is enormous; the estimated total cost for workplace injuries in 1981 reached $32.5 billion. The PHS has stated that by the year 1990 the rate of work-related iniuries should be reduced to 8.3 cases/100 full-time workers. Although comprehensive and reliable surveillance data are currently lacking in this area, data from the National Electronic Injury Surveillance System (NEISS). which tabulates occupational injuries treated at 66 representative U S. hospital emergency rooms, show a considerable rise in such injuries since 1981 Severe occupational traumatic injuries include amputations, fractures, lacerations, eye loss, burns, and fatalities. NIOSH researchers are investigating the causes and possible prevention for such problems as traumatic injury hazards associated with machines, high-risk occupa tions and activities in the construction industry, and exposure to hazardous energy sources during maintenance and servicing tasks. OCCUPATIONAL HAZARDS--Neurotoxic disorders As many as 150 major industrial chemicals are considered neurotoxic at levels at or below the level needed to produce other adverse health effects. Exposure to these chemicals results in miid-to-severe neurotoxic effects, including changes in motor, sensory, and cognitive func tion. From 1972 to 1974, NIOSH conducted the National Occupational Hazard Survey (NOHSI to identify a variety of potential hazards in the workplace. One hazard identified was industrial exposure to lead, and data from NOHS have been used to pinpoint sites for target ing resources to combat the problem. The county map generated from NOHS data shows ap proximate sites of greatest workplace exposures to lead. Although lead poisoning is a wellknown neurotoxic disorder, lead is still used in industries widely distributed throughout the United States. In 1 976-1980. 92% of adult males in the United States with blood lead levels over 30 p.g/dl worked in jobs that had been judged in 1972 as having potential for occupa tional exposure to lead. Btood lead levels of 30 p.g/dl are currently accepted as indicating cause for concern. injuries s involved in an occupational ouncil estimates that 2.1 mil00 of them were permanentnormous: the estimated total ed injuries should be reduced jnd reliable surveillance data iic Injury Surveillance System representative U S. hospital 1981. ctures. lacerations, eye loss, uses and possible prevention machines, high-risk occupato hazardous energy sources OCCUPATIONAL HAZARDS -- Distribution of facilities potentially using inorganic leads.'by county. United States, 1972-1674 rotoxic at levels at or below Ure to these chemicals results , sensory, and cognitive funcOccupational Hazard Survey :e. One hazard identified was d to pinpoint sites for targetd from NOHS data shows apugh lead poisoning is a wellly distributed throughout the States with blood lead levels having potential for occuparently accepted as indicating OCCUPATIONAL HAZARDS OCCUPATIONAL HAZARDS -- Noise-induced loss of hearing The Occupational Safety and Health Administration estimates that 9.4 million U S workers (7 9 million active and 1.5 million retired) are or have been in jobs where noise-exposure levels are 80 decibels (dBA) or higher. Increased risk of hearing loss due to occupational noise generally begins at this level. As a result, about 1.6 million workers (1 7%) may have at least mild hearing loss resulting from this occupational noise exposure. 1.1 million (11%) may have measurable hearing loss, and nearly 0 5 million may have moderate-to-severe loss. These es timates generally agree with the findings of surveys by NIOSH, which indicate that one of four persons 55 years of age or older exposed to an average of 90 dBA over a working lifetime has experienced a significant loss of hearing Occupational noise-induced hearing loss is preventable. The PHS has stated that by 1990 the prevalence of occupational noise-induced hearing loss should be reduced by 41 5.000 cases. NIOSH has developed a program with three goals for reducing noise-induced hearing loss: 1) to establish baseline data on occupational noise-induced hearing loss by monitoring the history of hearing-loss claims. 2) to determine the relative hazards from different types of noise and to define the interactions between noise and other hazards in the workplace, and 3) to develop initiatives in environmental controls and behavioral methods that foster hearing conservation. at 9.4 million U S. workers jobs where noise-exposure is due to occupational noise jrs (17%) may have at least 1.1 million (11%) may have le-to-severe loss. These eslich indicate that one of four IBA over a working lifetime has stated that by 1990 the educed by 415.000 cases. noise-induced hearing loss: iring loss by monitoring the irds from different types of zards in the workplace, and methods that foster hearing OCCUPATIONAL HAZARDS OCCUPATIONAL HAZARDS -- Typical A-weighted noise levels in decibels* PxCUUATtC CHIPPER lot S It > dBA 'JO -T- TEXTILE LOOM 0- - UENAGE OCk-n-BOll BAND NEWSPAPER PRESS OCSEL TRUCK 40 mpft (of 50 10 PASSENGER CAR 50mph lot SOM > 90 80 - - BOWER lawn MOWER fat operator ton MILLING MACHINE <41 Ml GARBAGE Disposal (at 3n| TO + * VACUUM CLEANER CONVERSATION (at Jill GO - - AIR CONDITIONING WINOOW UNIT (at JJ h | 50 QUIET ROOM *0 - - The decibel is a logarithmic measure of sound intensity; the "A-weighted scale" is used to weigh the various frequency components of the noise to approximate the response of the human ear. OCCUPATIONAL HAZARDS OCCUPATIONAL HAZARDS -- Dermatologic conditions Dermatologic conditions of occupational origin were estimated to account for more than 40.of all reported occupational illnesses each year from 1972 through 1981. As much as 1 -- of the workforce may be affected by occupational skin disease at any given time. Although com prehensive and reliable surveillance data are lacking, the estimated cost in lost productivity from all occupational skin disease is nearly Si 0 million annually. Efforts are under way to create an increased awareness of the toxicity of substances found in the workplace and to improve the protection afforded to workers. NIOSH is particularly con cerned with the degree of protection afforded by commercially available chemical protective clothing materials and products. The basic thrust of the NIOSH chemical protective clothing program is to provide users with information on which to base decisions for selecting and using such clothing. OCCUPATIONAL HAZARDS -- Investigating problems with respirators The Federal Mine Safety and Health Amendments Act of 1977 authorizes a program for ap proving respirators. It is carried out jointly by NIOSH and the Mine Safety and Health Adminis tration (MSHA). This program is conducted in accordance with requirements published in the Code of Federal Regulations, Title 30, Part 1 1 (30 CFR 11). The Occupational Safety and Health Administration and several other federal regulatory agencies require that respirators used in industry be approved by NIOSH and MSHA. NIOSH receives reports of problems identified in approved respirators from respirator users and from investigations carried out by manufacturers. Such problems may be due to faulty design and/or function. From July 1, 1983, through June 30, 1984. NIOSH received 35 reports of problems with respirators. Investigations revealed that 21 (60%) of these involved self-contained breathing devices; nine showed deficiencies that were classified as lifethreatening or likely to cause illness or injury. When serious problems are found, i.e., deficiencies that could affect health and safety, users are alerted immediately. If a manufacturer is unable to identify and notify the purchasers of defective respirators, NIOSH will issue a general warning to users of respirators and to other interested persons. 24 MMWft 1990Prevention Objectives -- Continued . January 2l are sponsoring workshops with schools of medicine and public health to identify ways of corporating prevention methods into training programs for health professionals. The Disease Prevention and Health Promotion (in the Office of the Assistant Secretary f0r the National Center for Health Statistics, and CDC are identifying existing sources of data ^ the additional data needed to track progress toward the 1990 Objectives. PHS will aiSo COo sider and analyze the seminar's recommendations during the program-planning process t0f fiscal year ^ 985 and beyond. References 1. U-S. Public Health Service. Promoting health/preventmg disease, objectives for the nation Washington. D.C.: U.S. Public Health Service. 1980. 2. CDC. Model standards for community preventive health services. Atlanta. Georgia. Centers for ease Control, 1979. 3. CDC Sexually transmitted diseases: treatment guidelines. 1982. MMWR 1902 3m suppl):31S-62S. o.2 lated Di iurveilla* The U.S ntion of here sf --asbest as well Leading Work-Related Diseases and Injuries -- United States The National Institute for Occupational Safety and Health (N/OSHl has recently developed a suggested list of the 10 leading work-related diseases and injuries (Table V. Three enters were used to develop the list: the disease's or injury's frequency of occurrence, its severity m the individual case, and its amenability to prevention. The list is suggested with thru purposes: V to encourage deliberation and debate among professionals about the major prob lems in this field of public health, 2) to assist in setting national priorities for efforts to prevent health problems related to work, and 3) to convey to a diverse audience the concerns of the leadership of NIOSH and the focus of the Institute's activities. The list is intended to be dynamic: it will be reviewed periodically for necessary updating as knowledge increases and as conditions change and are brought under better control. The following article contains a detailed discussion of occupational lung disease, the prob lem top-ranked on the fist: future articles will elaborate on the others. OCCUPATIONAL LUNG DISEASES The lung is both a target organ and a portal of entry for toxic substances. The likelihood of toxic exposure is high; for example, an estimated 1.2 million workers each year are potentially exposed to silica dust alone \2). The recognition of occupational lung diseases may be difficult, since the latent period for such diseases may be long --as long as 1 5 years for silico sis and 30 years or more for asbestos-related diseases. Other factors, such as cigarette smoking, may also contribute significantly to the disease process and hence obscure the association between work and the disease 13). Six important components of occupational lung diseases are described below. Each is preventable, although years of effective control measures will be required to eliminate dis eases of long latency Because of the rapid rate at which new potentially toxic agents are introduced into the workplace, vigorous pre-market toxicologic testing of agents and effective disease, is assoc -chest tightness lKJn has disablet causal agentls) Silicosis: Alt centuries, the pr Nearly 60.000 operations, and degree of silicos Coal worker rently employed TABLE 1. Th. t Occupi asbestcoal w lung cs 2. Muscu disordextrerr traurtu phemc 3 Occup leuken the bit 4 Ampu lacera 5 Cardie hyper*. Oiseas `The cond-iions definitions of th M/UW mb' 32; 2W -26,32. 21.198, Jlth to identify way,. Q(, rofessionals. The Of1jce'0' Ont Secretary for Heai;M (isting sources of data ano ectives. PHS will also con. jram-planning process f0j objectives for the ,,3,fot| 'ta. Georgia. Centers for ois. 1982. MMWR 1982:31), - United States SHI has recently developed ies liable 1). Three criteria "if occurrence, its severity in t is suggested with three onals about the majorproborities for efforts to prevent jdience the concerns of the The list is intended to be is knowledge increases and ional lung disease, the probtrs. ibstances. The likelihood of jrs each year are potentially *nal lung diseases may be i long as 1 5 years for sifrcofactors, such as cigarette ?ss and hence obscure the i described oelow Each is e required to eliminate dispotentially toxic agents are ;tng of agents and effective Vl. 32/No. 2 MMWR ^rk-^slated Diseases and Injuries - Continued *" 25 diseaso surveillance are essential if epidemics of occupational lung diseases are to be #voided. The U S. Public Health Service has established the following national objective for the prevention of occupational lung diseases: "by 1990. among workers newly exposed after 1905. there should be virtually no new cases of four preventable occupational diseases-asbestosis, byssinosis. silicosis, and coal workers' pneumoconiosis" These diseases, as well as lung cancer and occupational asthma, are briefly discussed below. Asbestosis: Asbestosis is charactenzed by diffuse, extensive scarring of the lung and pro gressive shortness of breath. Once established, the disease progresses even after exposure ends, there is no specific treatment. The latent period is 10-20 years. Smoking appears to in crease the risk of death from asbestosis by a factor of two to three. Longitudinal studies of groups of asbestos insulation workers and shipyard workers have revealed that 10%-18% may be expected to die of asbestosis (51. Byssinosis: This condition, characterized by both acute (reversible) and chronic lung -disease, is associated with inhalation of the dusts of cotton, flax, or hemp. Symptoms include rchest tightness." cough, and obstruction of the small airways. Severely impaired lung func tion has disabled an estimated 35,000 current and retired textile workers (6). The specific causal agent(s) in the various dusts are yet to be identified ( 7). Silicosis: Although the ill effects of exposure to free crystalline silica have been known for centuries, the prevalence of disabling silicosis remains high in certain groups of workers (S). Nearly 60.000 currently exposed workers in mines and foundries, in abrasive blasting operations, and in stone, clay, and glass manufacturing may be expected to suffer some degree of silicosis (9). Coal workers' pneumoconiosis (CWP): The estimated prevalence of CWP among cur rently employed coal miners is about 4.5%. Approximately 0.2% of coal workers have been di- TABLE 1. The ten leading work-related diseases and injuries -- United States, 1982* t. Occupational lung diseases, asbestosis, byssinosis, silicosis, coal workers' pneumoconiosis, lung cancer, occupational asthma 2. Musculoskeletal injuries, disorders of the back, trunk, upper extremity, neck, lower extremity, traumaticaliy induced Raynaud's phemonenon 3. Occupational cancers (other than lung). leukemia, mesothelioma, cancers of the bladder, nose, and liver ! | 4 Amputations, fractures, eye loss, I lacerations, and traumatic deaths J5 1 j Cardiovascular diseases hypertension, coronary artery disease, acute myocardial infarction 6 Disorders of reproduction. infertility, spontaneous abortion, teratogenesis 7. Neurotoxic disorders: peripheral neuropathy, toxic encephalitis, psychoses, extreme personality changes (exposure-related) 8 Noise-induced loss of hearing 9. Dermatologic conditions, dermatoses, bums (scaldings). chemical bums, contusions (abrasions) 10 Psychologic disorders. neuroses, personality disorders, alcoholism, drug dependency 'rne conditions listed under each category are to be viewed as selected examples, not comprehensive cehnitions of the category 26 MMWR January 21. I983 Vol. 32'No- 2 Work-Related Diseases and Injuries -- Continued agnosed as having progressive massive fibrosis, a potentially disabling form of CWP (10). |n 1974, there were an estimated 19.400 cases of CWP. Some 4.000 deaths each year are attributed to legislatively defined "black lung disease" (9). Industrial bronchitis, another medical condition associated with exposure to coal dust may lead to decreased ventilation capacity but it is not well correlated with chest roentgenographic changes 111). TAt Lung cancer: The single most important cause of lung cancer is tobacco smoke 172). However, numerous occupational agents are associated with lung cancer, including arsenic, asbestos, chloroethers. chromates, ionizing radiation, nickel, and polynuclear aromatic hydrocarbon compounds (79). Tobacco smoke may interact synergistically with some of these agents (e g., asbestos) to sharply increase the risk (5). Of special concern in this regard are workers currently or previously exposed to asbestos (estimated from 7.6 to 13.2 million) (I4t 15): as many as 6,000 asbestos-related lung cancers may occur annually 175). ...UD STATES O ATLANTIC * ,,uV Occupational asthma: Hypersensitivity reactions to a wide variety of occupational organic and inorganic agents can cause asthma and hypersensitivity pneumonitis. The prevalence of bccupationa) asthma varies from 10% to nearly 100% of workers in certain occupations (76). Many agents are incriminated as etiologic for occupational asthma, including grain dusts. (Continued on page 32) TABLE t. Summary-cases specified notifiable diseases. United States ,VN CENTRAL Disease 2nd Week EnOmg January IS. 1983 January 16. 1982 Median 1978-1982 Cumuiat vt. Second Week Ending January 15 1983 January 16. 1982 Median <978-1982 VNSoOOiikk Neo* Aseptic meningitis Encaphabtis Gonorrhea Hepatitis Primary (arthropod-borne iunspec) Post-infectious Civilian Military Type A TypeS Non A. Non S Unsoeofied leg^neOout Leprosy Malana Measles Total indigenous Imported* Meningococcal infections Mumps Total Civilian Military Pertussis RuPeda (Carmen measles) Syphilis (Primary & Secondary! Civilian Toiic-shock syndrome Tuberculosis Tutaremit Typhoid (ever Trphus (ever. t>ck-Oome (RMSH Rabies, animal 89 18 t 16.968 621 323 3S0 44 139 10 1 10 49 49 41 IS 12 666 21 7 377 11 73 82 12 18.672 630 313 277 21 152 6 7 6 H N 5t 51 91 to as S82 12 N 314 10 2 78 65 12 1 18.672 496 378 283 N 152 N 1 9 61 N N 51 51 231 15 46 564 5 N 399 6 77 161 33 1 35.052 963 701 677 70 232 20 9 14 4 3 1 90 88 2 97 23 27 1.294 23 11 636 14 1 158 TABLE U. Notifiable diseases of low frequency. United States 159 20 1 38 313 1.054 631 578 33 263 8 1 16 H N 87 87 133 51 1 160 N 591 14 151 114 20 1 35.012 1.054 731 S18 N 275 N S ATLANTIC 80 N N 85 85 W S CENTRAL 899 MOUNTAIN Mo"t 'dar>o WyO Co*o 140 N Me* Ar.r UN<'.?j.n Amhrai Botulism Foodbome intent <C*M 11 Other Brucellosis (Va 1 Idaho l) Cholera Congenital rubella tynaron-e Diphtheria L*ptOSO<rOS>S (C*'i< 1) Cum 1983 t Paralytic Psittacosis lUostaieNY i. Cadi 1) 2 Rat>e* human Tetanus (Oreg 11 1 Tnch.nosn {Mass 1) Typhys lever, flea-borne lendemic. 'nur-'e! Cum 1983 PwAaCsl*f'C Oreq Cai-I Aias* 'for measles only, imported cates includes both oul-ol-state tf>d fom^n importationi 32 MMWR January 21. 1983 Work-Related Diseases and Injuries -- Continued flour, metals, inorganic chemicals, isocyanates, enzymes, and fungi. The list of agents asso ciated with hypersensitivity pneumonitis is also long. If exposure continues, these conditions may result in progressive, irreversible pulmonary fibrosis. Reported by Div of Surveillance, Hazard Evaluation, and Field Studies. Office of Director. NfOSH. CDC. References 1. US. House of Representatives, 95lh Congress. Performance of the Occupational Safety and Health Act. Hearings before a Subcommittee of the Committee on Government Operations. April 27. 1977. Washington. 0 C. U.S. Government Printing Office. 1977. 2 National Inshtute tor Occupational Safety and Health. National occupational hazard survey. 1972-74. Cincinnati. Ohio. National Institute for Occupational Safety and Health. 1977. (DHEW (NIOSHj publication no. 78-114}. 3 Sehkoff U. Churg J, Hammond EC- Relation between exposure to asbestos and mesothelioma N Engl J Med 1965;272 560-5. 4. US Public HeaMh Service Promoting health/preventmg disease objectives for the nation Washington. DC.. US Public Health Service. 1980:41. 5 Hammond EC. Selikoff IJ. Seidman H. Asbestos exposure, cigarette smoking and death rates. Inter national Conference on Health Hazards of Asbestos Exposure. NY Acad So. June 24. 1978. 6. Occupational Safety and Health Administration. Occupational exposure to cotton dust. Federal Register 1978:43.27350-463. 7 Schilling R Worldwide problems of byssmosis. Chest 1981.7914 Suppl) 3S-5S. 8 Ziskind M Jones RN. Weill H. Silicosis. Am Rev Respir Ds 1976; 113 643-65 9 Department of Labor, Office of the Assistant Secretary for Policy Evaluation and Research Interim report lo Congress on occupational diseases. Washington, D C. Department of Labor. June 1980 10 Morgan WK, Lapp NL Respiratory disease in coal miners. Am Rev Respir Dis 1976.113 531-59 11. Rogan JM. Attfield MD. Jacobsen M. Rae S, Walker DD, Walton WH Role of dust m the working en vironment in development of chronic bronchitis in British coal miners Br J Ind Med 1973:30 217-26 12. Doll R. Peto R The causes of cancer: quantitative estimates of avoidable risks of cancer m the United States today JNCI 1 981 ;66 1191 -308, 13 Cole P. Merietti F. Chemical agents and occupational cancer J Environ Pathol Toxicol 1980:3 399-417. 14 Enterline P Proportion of cancer due to exposure to asbestos. In. Peto R. Schneiderman M. eds Banbury report 9 Quantification of occupational cancer. Cold Spring Harbor Laboratory. 1981:19-36. 15 Nicholson WJ. Perkel G. Selikoff IJ Cancer from occupational asbestos exposure projections 1980-2000 In Peto R. Schneiderman M. eds Banbury report 9: Quantification of occupational cancer Cold Spring Harbor Laboratory. 1981 87-111. 16 Clark Tj, Godfrey S. eds Asthma Philadelphia:W8 Saunders, 1977. V< in if ci in in dt yf e> Vi Cl c: 8 ` ;v" o c tl A *\ 'i i: Ii 1 C Epidemiologic Notes and Reports Impact of Influenza on a Nursing Home Population -- New York During December 1982. 49 (60.5ao) of 81 residents at a skilled-nursmg facility m upstate New York experienced mfluenza-like illness 11) with elevated temperature 1^ 37 8 C (100.0 F] oral or ^ 38 C (100 4 F] rectal) and at least one of the following symptoms: cough, congestion, or sore throat. Six of the clinically diagnosed cases occurred sporadically before December 18, when the main cluster began, and the outbreak peaked on December 21 511971 0087 .* week ending APr,l 1B 1 *3 . 14 MMWR 189 poisoning -- Continued ^ve almost always been caused by S aureus In 1981, eight ol nme ham-associated ^^gVs were caused by this organism (The etiologic agent of the ninth outbreak was effect of USDA intervention cannot be assessed, since production of the specialty product was discontinued after investigation of these outbreaks ffrspectives in Disease Prevention and Health Promotion Leading Work-Related Diseases and Injuries -- United States The National Institute for Occupational Safety end Health IN/OSHI has developed a sugMSted list of the 10 leading work-related diseases and injuries (Table 1). Problems in the first pttgory, occupational lung diseases, were recently described My, a discussion of the second fftegory. musculoskeletal injuries, appears below. 45 29 1 2 95 56 30 1 433 873 364 66 43 13 31 22 7 42 26 1 1 168 107 43 54 32 1 7 113 417 70 226 25 121 73 37 22 116 75 24 1 /6 1 14 42 52 29 16 1 25 90 21 661 N Met 99 409 53 149 21 * Cok) 29 21 7 130 84 26 73 43 18 15 13 1 158 104 30 17 7 7 44 21 19 96 63 20 1 876 22 99 20 81 105 517 77 33 133 64 171 157 167 131 40 39 1.2 B1 14 80 14 47 71 340 53 28 101 49 103 110 126 89 30 26 359 4 10 4 24 23 97 16 4 19 14 43 20 39 30 5 7 *5 11 tl 8 161 2 7T59 799 359 431 hiosi o, which have OoCKjlii.onv ol 100 000 o ceath c*n,f.cte was l.ia Fctai deaths are h0 'nb**% *'* P*r"*' cewhts tor the current weak Corr MMWR MUSCULOSKELETAL INJURIES (n 1982, musculoskeletal injuries accounted for 580.000 (1 8c) of the estimated 3.2 mil- lon emergency-room-treated occupational injuries in the United States (21 Physical demands of many jobs make the musculoskeletal system highly vulnerable to a variety of oc cupational injuries and illnesses. Manual handling of materials, repetitive motions, and vibrawn are especially important etiologic factors in the development of these disorders Injuries associated with the manual handling of materials (e g , unaided lifting and towering): Low back injuries, often due to improper manual handling of materials, are the larg,$t single subset of musculoskeletal injuries. The Bureau of Labor Statistics recently reported ifist approximately one million workers sustained back injuries in 1980 and that back injuries account for one of every five injuries and illnesses in the workplace. Approximately one-lourth of all workers' compensation indemnity expenditures in eight states were for back injuries (3). Repetitive motion-associated trauma: Repetitive motion can cause "cumulative trauma disorders." including carpal tunnel syndrome, tendinitis, ganglionitis, tenosynovitis, bursitis, md epicondylitis. These disorders may be caused or aggravated by repeated twisting or awk ward postures, particularly when combined with high force. The population at risk includes persons employed in such industries or occupations as construction, food preparation, clerical work, product fabrication, and mining. Data from the National Occupational Hazard Survey suggest that 1 5V20% of workers in these jobs are potentially at risk of cumulative trauma disorders (4). Data from the Bureau of Labor Statistics indicate that in 1980 approximately 23,200 occupational injuries were asso ciated with repeated trauma (5). Vibration-associated injuries : An estimated seven million workers in such occupations as vehicle operation are intermittently exposed to whole-body vibration, which significantly stresses the musculoskeletal system (6). Although the effects are poorly understood, prelimi nary data suggest that low back pain, vertebrogemc pain, and degenerative disk disease may be associated with whole-body vibration (7.81. 647 An estimated 1.2 million workers are exposed to "segmental" vibration, i.e.. vibration prin cipally of a part or parts of the body, of which the principal sources are handheld power tools, such as chain saws and jackhammers 19). These exposures are associated with "vibration syndrome." characterized by intermittent numbness and blanching of the fingers with reduced sensitivity to heat, cold, and pain (f 0) Vibration syndrome may affect up to 90?i ol workers in such occupations as chipping, grinding, and chain sawing [11). Reported by Oiv of Surveillance. Hazard Evaluations, and Field Studies. Div ol Safely Research. NIOSH. CDC ifo-qt. 511971 0088 190 MMWR Work-Related Diseases and Injuries -- Continued APrinS, i983 Editorial Note: Musculoskeletal injuries can be prevented or reduced with such appropnai intervention measures as 1 Substitution, Machines, such as hoists, cranes, and dollies, can substitute for workers, some aspects of the manual handling of materials 2 Improved equipment design Research has shown that improved design of some vibra* mg tools virtually eliminates hazardous vibration; suspension or isolation systems ma be added to vehicles to greatly reduce whole-body vibration 3. Task design. Manual tasks can be altered to minimize biomechanical stress to the worker [12\ 4. Worker education Injuries due to musculoskeletal stresses may be reduced by pre placement strength testing, training in proper ways to do a task, and on-site programs of exercise and physical therapy. 5 Variation of work practices. Periodic rotation of workers into jobs with different physi cal demands may help reduce the sequelae of biomechanical stress References 1 CDC leading wcrk-relaied diseases and injuries --United States MMWR 1 983,3212} 24-6, 32 2 NIOSH. Division of Safety Research Unpublished data 3 Bureau of Labor Statistics Back injuries associated with lifting (work injury report) Washington D C : U S Government Printing Office. Bulletin 2144.August, 1982,1 4. National Institute for Occupational Safety and Health National occupational hazard survey 1972-1974 Cincinnati Nationallnstitute for Occupational Safety and Health, 1977 (DHEW (NIOSh' publication no. 78-1 14). 5. Bureau of Labor Statistics Occupational injuries and illnesses in the United States by industry. 1980 Washington. D C : U S Government Printing Office. Bulletin 2l30:Apnl 1982:32 6 Haber LD. Disabling effects of chronic disease and impairment. J Chronic Dis 1 971:24{6-7) 469-87 7. Armstrong TJ. Foulke JA. Joseph BS. Goldstein SA. Investigation of cumulative trauma disorders in t poultry processing plant. Am Ind Hyg Assoc J 1 982,43(2). 103-16 8 Gruber GJ. Ziperman HH Relationship between whole-body vibration and morbidity patterns among motoT coach operators Cincinnati- National Institute for Occupational Safety and Health, Sept 1974 (NIOSH publication no. 75-104) vl. 32/No. 14 ^grk-ftelared Diseases. 2 Goober GJ Relations/., truck drivers Cincinnat publication no 75-104 10 Washerman DE. Badg (American Society of $. It Taylor W, Pelmear PL. Acta Chir Scand 1 976. National institute for C National Institute for C 81-122. Cvrrent Trends Update: Ir United States Mo/ chne in influenza outbn Mexico) reported regio reports of influenza vir dine in influenza activ, despite increases in in excess in the ratio of p 121 cities for the thirt. ratio was 4.1 (Figure 2) FIGURE 2. Indicator: TABLE 1. The ten leading work-related diseases and injuries -- United States, 1982? 1. Occupational lung diseases. asbestosis. byssmosis, silicosis, coal workers' pneumoconiosis, lung cancer, occupational asthma 2 Musculoskeletal injuries: disorders of the back, trunk, upper extremity, neck, lower extremity, traumaticaily induceo Raynauos phemonenon 3 Occupational cancers (other than lung) leukemia: mesothelioma, cancers of the bladder, nose, and liver 4 Amputations, fractures, eye loss, lacerations, and traumatic deaths 5. Cardiovascular diseases: hypertension, coronary arterydisease, acute myocardial infarction 6. Disorders of reproduction infertility, spontaneous abortion, teratogenesis 7 Neurotoxic disorders: peripheral neuropathy, toxic encephalitis, psychoses, extreme personality changes (exposure-related) B Noise-induced loss of hearing 9 Dermatologic conditions. dermatoses, burns (scaldmgs). chemical burns, contusions (abrasions) 10 Psychologic disorders neuroses, personality disorders, alcoholism, drug dependency The conditions listed under each category are to be viewed as selected examples, not comprehensive definitions of the category HOOJ 00' *00- 00' 700 00 I 400 sw ... t MO too 100 0 TC IWM ? * Ao,"lS. 1883 ) or reduceo rrv.1l. such app,opt,3u lollies can substitute for worker* at improved design of some v.brdl spension or isolation systems ms ibration mi2e biomechanical stress to the , 32/No. 14 MMWR 191 yj0rk-Related Diseases and Injuries - Continued Gruber GJ Relationship between whole-body vibration and morbidity patterns among interstate truck drivers Cincinnati. National Institute for Occupational Safety and Health. Sept 1974 (NIOSH publication no 75-104) jq vVasserman DE. Badger DW, Doyle TE. Margolies L Indusirial vibration --an overview ASSE (American Society of Safely Engineers) Journal 1974. i 9 38-43 It Tay)or W. Pelmear PL. Raynaud's phenomenon of occupational origin An epidemiological survey Acta Chir Scand 1976,[SupplJ(465) 27-32 t2 National institute for Occupational Safety and Health Work practices for manual lifting Cincinnati National Institute lor Occupational Safety and Health. March 1981 (DHHS (NIOSH) publication no 81-122 stresses may be reduced by pre. to do a task, and on-site programs kers into jobs with different phYS). ;hanicai stress Current Trends Update: Influenza Activity -- United States, Worldwide s.MlWWR 1983.32t2) 24-6. 32 ung twork injury report) Washington 982:1 iationa) occupational hazara surve lety and Health. 1977 IDHEW (MOSh n the United States by industry, 19g 30.April 1982.32 J Chronic Dis 1971 24{6-7};469-87 non of cumulative trauma disorders in a 3-16. iibration and morbidity patterns among National Safety and Health, Sept 1974 United States. Morbidity reports collected weekly by each state indicate a continuing de cline in influenza outbreaks. For the week ending April 9. 1 983. 2 states (Kentucky and New Mexico! reported regional activity, and no state reported widespread activity. In recent weeks, reports of influenza virus isolations from collaborating laboratories have also indicated a de cline m influenza activity (Figure 2). Most isolates (89%) continue to be type AIH3N2) virus, despite increases in influenza B and type A(HINI). For the week ending April 9. 1983, an excess in the ratio of pneumonia and influenza (P&l) deaths to total deaths was reported from 121 cities for the thirteenth consecutive week The observed ratio was 5.2 and the expected ratio was 4.1 (Figure 2). FIGURE 2. Indicators of influenza activity -- United States, 1982-1983 ries -- United States, 1982* iers of reproduction ity. spontaneous aoortion, genesis toxic disorders, eral neuropathy, toxic halitis. psychoses. ie personality changes iure-related) induced loss of hearing itologic conditions loses, burns (scaiamgsl. cat burns, contusions ons) otoaic disorders ;es. personality disorders. ilism. drug depenoencv ectedexamples, not comprehensive LABOfUTOffV PUOMOSia O* MTIUCNZa' *T BOIATK7MS MICMV1 ttirtb WJ u z*. s 1? irooTte to esc > 'a*ti.no***TTtooouoMeCoccai* tO COklAO*T*rt iA*0*Aro*Kf fflCLUO**) ril 511971 0090 WORK-RELATED 511971 0067 * R eorder 21 1/3