Present state of benzene-inducedoccupational disease in Germany Hermann M. Bolt Leibniz Research Centre for Working Environment and Human Factors at the TH Dortmund, Germany
Historical Developments in Germany✽ after end of 18th century: ✽ mechanization of production ✽ freedom of occupation and trade (end of guild system)✽ consequences: ✽ decreasing importance of handicrafts ✽ development of factory system ✽ child labor, night labor, shift work
Early Governmental Regulations in Germany✽ 1839 First occupational safety law in Prussia: Prussian child protection law✽ 1845 Prussian Trade Law: Founding of health insurance companies for factory workers✽ 1853 Factory inspectors✽ 1881 „Imperial Message“
Otto von BismarckChancellor of the German Reich „Der eiserne Kanzler“ 1815 - 1898
Bismarck‘s appeal to parliament (Reichstag) on May 9th 1884✽ Give the worker the right to work, as long as he is healthy✽ Ensure that he is nursed when he is ill✽ Secure him a living when he is old
Keystones of Bismarck‘s Social Legislation ✽ Imperial Message of Nov. 11th 1881 (birth of the German social security system) ✽ 1883 Health Insurance Law compulsory insurance ✽ 1884 Occupational Accident Insurance ✽ 1889 Invalidity Insurance Law Pensions at age 70, disability pensions
Occupational Accident Insurance✽ Organization: Deutsche Gesetzliche Unfallversicherung (DGUV) ✽ Berufsgenossenschaften ✽ More than 25 associations according to trades ✽ e.g. Chemical Industry ✽ Metal industry ✽ Civil administration ✽ Health care ✽ Agriculture ✽ Shipping ✽ State and Federal Insurance Associations ✽ for civil servants and students
Occupational Accident Insurance✽ Membership ✽ Only employers are members ✽ Compulsory membership if there are any employees ✽ No compulsory membership for self-employed persons ✽ Employees are not members but „insured persons“
Aspects for the individual✽ Acknowledged occupational accident or disease ✽ Superior quality of treatment ✽ Unlimited continuation of payment of wages ✽ Vocational retraining if necessary ✽ Compensation for loss of income ✽ Indemnities payed in addition to pensions (old age, disability) or to occupational income
Procedure of confirmation (acknowledgement) of occupational disease (I)✽ Suspected occupational disease is reported to the insurance by a physician, by the employer, or by a health insurance company✽ Every physician or dentist and every employer is legally obliged to report a case of suspected occupational disease
Procedure of confirmation (acknowledgement) of occupational disease (II) 1 Report of case 2 Occupational accident insurance decides to investigate or to refute the case due to formal reasons or extreme lack of plausibility 3 Investigation of occupational history, conditions of the worksite (exposure etc.), collection of data (measurements etc.) and medical reports 4 - Technical report - opinion of government medical officer - independent medical expertise (opinion) 5 Decision by a board of trustees (representatives of employers and trade unions)
Procedure of confirmation (acknowledgement) of occupational disease (III)✽ Primary decision of insurance association ✽Contradiction by insured person✽ Final decision of insurance companyLaw suit primary court court of appeal etc.
How is an occupational disease established?✽ In general: ✽ Only those diseases which have been officially recognized by the Federal Government can be compensated ✽ Official List of Occupational Diseases
Specific apects of occupational diseases✽ The list of occupational diseases is based on the recommendations of a scientific committee✽ The Federal Government is free to exclude diseases from the list or to place specific restrictions on acknowledgement ✽ Restriction to certain occupations, limit dose for cumulative exposure etc.✽ The risk factor must be certain ✽ A statistical association between an occupation and a disease is not sufficient✽ Group justice, not individual justice✽ The eligible group must be exposed to the risk factor to a higher degree than the rest of the population. ✽ However, courts have ruled that in general this higher exposure should lead to a higher risk of illness, in general doubling the relative risk or odds ratio!
German List of Occupational Diseases (BK List)✽ 65 enumerated entities, classified in 6 groups 1. Diseases caused by chemical factors (e.g. benzene) 2. Diseases caused by physical factors 3. Diseases caused by infectious agents or parasites 4. Diseases of the airways, the lung, the pleura and the peritoneum 5. Skin diseases 6. Other diseases
Official prodecure for a new BK New scientific knowledge Medical Committee Occuptional Diseases at the Federal Minister for Work and Social Affairs Official Publication by the Federal Minister (GMBl) Official introduction of the new BK by the Minister
Key points from the Scientific Justification of BK 1318„Occupational benzene exposures can induce non-malignant and malignant diseases of the blood andlymphatic system. The primary effect is suppression ofblood cell formation due to toxic bone marrow depression.“„Because of the pathophysiological mode of action thatincludes alteration of the haematopoetic stem cell pool,benzene can cause all haematolymphatic system diseasesof which the cells are derived from the omnipotent stemcell. Chronic long-term occupational exposure is a pre-condition (Schönberger, Mehrtens, Valentin, 7th ed, 2003).“
Specific diseases under BK 1318Toxic damage of the bone marrow: „leukopenia, lymphopenia, thrombocytopenia, pancytopenia“Aplastic anaemia and myelodysplastic syndromeLeukaemiaNon-Hodgkin lymphoma (!)Myeloproliferative diseases: „CML, polycythaemia vera, essential thrombocythaemia, osteomyelosclerosis“
Scientific Justification of BK 1318: cut-off point for compensation of leukaemia = 10 ppm-years!!!! !!!!
Leukemia and „stem-cell near“ non-Hodgkin lymphomas*:Hints for retrospective exposure evaluation (sufficient for BK 1318?) Listing typical work situations of -extreme 1y sufficient for compensation -high 2-5 y sufficient for compensation -medium 6-10 y sufficient for compensation -low evaluation case-by-case benzene exposures (related to the time of exposure, in view of increasing regulatory limitations for benzene) *Limit of 10 ppm-years also for CLL, aplastic anemia and myelodysplastic syndrome!
From the Scientific Justification of BK 1318: „conditions of extreme exposure intensity“ – 1 year sufficient Open gasoline puming (ships, trucks, container) until 1982 Benzene alkylation and ethyl benzene synthesis in the former GDR Cleaning (also hand cleaning) with gasoline until 1985 Spraying with benzene containing solvents (before 1970) Working in tar, pitch, asphalt laboratories (extractions with benzene) (before 1970) Cleaning of gasoline tanks until 1980 Cleaning of benzene tanks/containers
From the Scientific Justification of BK 1318:„conditions of high exposure intensity“ – 2-5 years sufficient Working in cokeries or gasworks before 1990 (2 y) or before 1999 (4 y) Benzene manufacturing before 1999 (4 y) Working in plants for ethylene synthesis before 1990 Servicing gasoline tanks before 1999 (4 y) Servicing benzene containing pipelines or pumps until 1999 (4 y) Servicing automobiles / gasoline containing parts until 1980 (2 y) Servicing automobile carburettors until 1985 (2 y)
From the Scientific Justification of BK 1318:„conditions of medium exposure intensity“ – 6-10 years sufficient Working in benzene extraction or processing until 1990 Filling gasoline into trucks or vessels since 1990 Filling gasoline into trucks or vessels until 1990 (7 y) Driving gasoline trucks until 1999 Closed loading of gasoline (vessels) since 1982 Unloading in foundries Laboratory analytical work with gasoline (6 y) Laminating with benzene-containing solvents (1970-1979)
From the Scientific Justification of BK 1318:„conditions of low exposure intensity“ – evaluation case by case Exposure as bystander in cokeries; petrochemical industry works Fuelling automobiles after 1970 Cleaning tanks for Diesel/heating oil or kerosine (ca. 0.004 vol% benzene) Handling solvents with <0.1 % benzene after 1980 (West Germany) Other solvent mixtures containing benzene: case by case evaluation
Non-Hodgkin lymphoma (including multiple myeloma)and myeloproliferative disorders, including CML„For the rest of the listed diseases a sufficient exposure is assumed for conditions ofextreme exposure intensity of 2-5 y, or ofhigh exposure intensity of 6 and more years, although the present epidemiological evidence is insufficient.“
Benzene-induded occupational disease in Germany (BK 1303 + 1318 combined, http://www.dguv.de)Year BK acknowledged New pensions Deaths2008 110 98 432009 168 152 462010 186 174 51 Average costs to the system per case: € 100,000.--
Own experience at IfADogiving independent medical expertise (opinion) on pending BK 1303/1318 casessince 2007 [official publication GMBl dated 1 Sep 2007]: 33 cases
Cases reviewed at IfADo, 2007-2012Cumulative benzene exposure of our BK 1303/1318 cases: mean 22.7 ppm-years [range 3.2 – 174 ppm-years] Thank you for your attention!
Acknowledgementto my colleagues in occupational medicine (and former coworkers): T. Brüning(Bochum), V. Hath (Homburg/Saar) and E. Hallier (Göttingen, not on the picture),all having significantly contributed to benzene Perekop, Luxemburg