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According to WHO, Ergonomics is defined as “ that branch of community medicine, which deals with the study of health promotion, health protection & maintenance of highest degree of physical, mental & social well-being of workers in all occupations”
It is the study of humans at work in order to understand the complex relationship among people, machines, job demands and work methods in order to minimize gaps between task demands and human capacities in activities of work and daily living. [Maxcy-public health]
Ergonomics as the science of “designing the job to fit the worker, instead of forcing the worker to fit the job. [International Ergonomics Society]
The presentation begins with a brief history of how cancer epidemiology evolved, and what is the status at present. After describing the burden of the disease of cancer globally and in India, the presentation includes a brief description of Cancer causes and prevention including screening activities. It also talks about the national Cancer Registry Program, NPCDCS and NCCP.
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1. OCCUPATIONAL CANCER
Professor E.E.U. Akang
OCCUPATIONAL HEALTH UNIT, DEPT. OF PREVENTIVE
MEDICINE & PRIMARY CARE, COLLEGE OF MEDICINE,
UNIVERSITY OF IBADAN
2011/2012 ACADEMIC CALENDAR
MPH (OH) 0HS 702
24 October 2012
2. Lecture Outline
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Definitions (Cancer, Occupational cancer)
Epidemiological considerations
Carcinogenesis- basic principles
Classes (IARC groups) of carcinogens
Strategies for identification of carcinogens
Primary prevention of occupational cancer
Topical issues
Closing remarks
3. Lecture Outline
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Definitions (Cancer, Occupational cancer)
Epidemiological considerations
Carcinogenesis- basic principles
Classes (IARC groups) of carcinogens
Strategies for identification of carcinogens
Primary prevention of occupational cancer
Topical issues
Closing remarks
4. What is cancer?
• A malignant (“potentially lethal”) neoplasm
(“new growth”) that invades normal tissues and
spreads (metastasises) to distant sites
• Neoplasms are growths resulting from clonal
proliferation of cells following progressive
accumulation of hereditary and acquired insults
resulting in mutations of genes that control cell
proliferation and cell death
5. What is occupational cancer?
• Cancer specifically attributed to significant
levels of exposure to an agent* in the
workplace and occurring among substantial
numbers of workers.
• Substantial: > 10,000 workers
• Significant: As much as, or more than, in the
general environment
*An agent that has been causally linked with
development of cancer is called a carcinogen
Siemiatycki et al, Environ Hlth Persp, 2004, http://www.ehponline.org
6. Lecture Outline
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Definitions (Cancer, Occupational cancer)
Epidemiological considerations
Carcinogenesis- basic principles
Classes (IARC groups) of carcinogens
Strategies for identification of carcinogens
Primary prevention of occupational cancer
Topical issues
Closing remarks
7. What is the global and national
burden of cancer?
• 5 million female and 6 million male new cancer
cases worldwide (of which 100,000 occur in
Nigeria) annually
• >6 million deaths worldwide annually
• >50% of patients with cancer live in developing
countries, which have <10% of the resources for
cancer therapy
9. What is the global burden of
occupational cancer?
• POPULATION ATTRIBUTABLE FRACTION (RISK
PER CENT)
This is defined as the fraction (percentage) of the
diseased persons in the population whose
disease would have been prevented had the
exposure been absent
In the case of occupational cancers, a crude
estimate for this percentage is between 2-10%
10. What is the relevance of occupational
cancer epidemiology?
1. 50% of known human carcinogens are substances
found principally in the workplace
2. Many cases of cancer are directly attributable to
occupational exposure
3. Control measures can often be implemented once
an occupational carcinogen has been identified
4. The discovery of occupational carcinogens has
importance outside the factory walls
5. Provides a basis for compensating victims
6. Improves our understanding of carcinogenesis
Siemiatycki et al, Environ Hlth Persp, 2004, http://www.ehponline.org
10
11. Lecture Outline
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Definitions (Cancer, Occupational cancer)
Epidemiological considerations
Carcinogenesis- basic principles
Classes (IARC groups) of carcinogens
Strategies for identification of carcinogens
Primary prevention of occupational cancer
Topical issues
Closing remarks
12. What do we know about
carcinogenesis in general?
Carcinogenesis is a multi-hit, multi-stage process
Results from the cumulative effect of repeated
prolonged exposure to environmental carcinogens
in concert with inherent genetic/other susceptibility
•>80% NATURE- environment- <10% NURTUREgenes
Radiation, Chemicals, Viruses
60% of all cancers are PREVENTABLE
Carcinogens may be
1. Genotoxic (interact with and alter DNA)
2. Epigenetic (affect gene expression)
13. Historical landmarks
• 1775, Percivall Pott in London- scrotal cancer
among chimney sweeps
• 1895, Rehn, in Germany- cluster of three cases of
bladder cancer in workers at a local factory
producing aniline dyestuffs from coal tar
• Early 20th century- certain constituents of tar, soot,
and oils, known as polycyclic aromatic
hydrocarbons, were found to cause cancer in
laboratory animals
• 1970, IARC recommended that a compendium on
carcinogenic chemicals be prepared by experts
14. What do we know about
occupational carcinogens?- 1
Exposure may be acquired via
1
INHALATION
average concentration of the substance in the
breathing zone over a reference period (8 hours for
long-term, and 15 minutes for short-term exposure)
2
DERMAL CONTACT
potential dose rate predominantly to the hands and
forearms (2000 cm2) is calculated using a
mathematical model
3
INGESTION
not quantifiable
15. What do we know about
occupational carcinogens?- 2
Occupationally related cancers are characterized
by a long latent period—time between first
exposure and clinical presentation (usually >1015 years) and up to 40-50 years in some cases
(i.e. presentation can be in retirement rather
than while still at work).
An occupationally related tumour does not differ
substantially, either pathologically or clinically,
from its “naturally occurring” counterpart.
16. Lecture Outline
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Definitions (Cancer, Occupational cancer)
Epidemiological considerations
Carcinogenesis- basic principles
Classes (IARC groups) of carcinogens
Strategies for identification of carcinogens
Primary prevention of occupational cancer
Topical issues
Closing remarks
17. IARC classes of carcinogens
On the basis of epidemiological, animal and in
vitro experimental studies, occupational agents
linked with cancer have been categorised into 4
major groups by the IARC
1
2A
2B
3
4
Carcinogenic to humans (21%)
Probably carcinogenic to humans (16%)
Possibly carcinogenic to humans (63%)
Not classifiable
Not carcinogenic to humans
18. GROUP 1 (DEFINITE)CARCINOGENS
40% (40) IARC group 1 carcinogens are occupational.
Others include radiation, viruses and lifestyle factors
PHYSICAL AGENTS
ASSOCIATED CANCERS
Ionizing radiation
Breast cancer, leukaemia, skin cancer
Unltraviolet light
Skin cancer
Asbestos
Lung cancer, mesothelioma
CHEMICAL AGENTS ASSOCIATED CANCERS
Arsenic
Skin cancer, lung cancer
Vinyl chloride
Liver angiosarcoma
Aromatic amines
Bladder cancer
19. IARC Group 1 occupations and industries
Aluminium production
Haematite mining
Auramine
Iron and steel founding
Boot and shoe
Isopropanol
Coal gasification
Magenta
Coke production
Painter
Furniture & cabinet making Rubber industry
19
20. GROUP 2A (PROBABLE) CARCINOGENS
30 IARC group 2A carcinogens are occupational.
CHEMICAL AGENTS
ASSOCIATED CANCERS
Polyaromatic hydrocarbons
Lung, bladder & skin cancer
Wood & Fossil fuel products Skin cancer
Plastic & rubber byproducts Bladder cancer
Chlorinated hydrocarbons
Several cancers
Inorganic lead compounds
Lung cancer
Aromatic amine dyes (e.g.
benzidine-based dyes)
Bladder cancer
21. IARC Group 2A occupations and
industries
Art glass manufacturing
•
Cobalt metal manufacturing
Hairdresser or barber
Petroleum refining
21
22. IARC Group 2B occupational carcinogens
117 IARC group 2B carcinogens are occupational.
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Refractory ceramic fibres
Nickel alloys
Carbon black
Gasoline engine exhaust
Gasoline
Bitumens
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Styrene
Acrylonitrile
Chloroform
Dichloromethane
Some pesticides
Welding fumes
22
23. Lecture Outline
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Definitions (Cancer, Occupational cancer)
Epidemiological considerations
Carcinogenesis- basic principles
Classes (IARC groups) of carcinogens
Strategies for identification of carcinogens
Primary prevention of occupational cancer
Topical issues
Closing remarks
24. Strategies for discovering
occupational carcinogens
• Epidemiological surveys
• Animal experimentation (toxicological studies)
• Other experimental studies
Ames mutagenicity test (Salmonella, E. coli)
Mammalian in vitro mutagenicity test (Chinese
hamster lung derived cells)
Mouse in vivo clastogenicity assay
25. Lecture Outline
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Definitions (Cancer, Occupational cancer)
Epidemiological considerations
Carcinogenesis- basic principles
Classes (IARC groups) of carcinogens
Strategies for identification of carcinogens
Primary prevention of occupational cancer
Topical issues
Closing remarks
26. Primary prevention of
occupational cancer
• Recognition of hazards and risks
• Education of management and workforce
• Elimination of exposure (substitution,
automation)
• Reduction of exposure
• Provision of personal protective equipment
• Limiting access
• Adequate facilities for showering, changing, etc.
• Legislative provisions
Veys, 1996, http://dx.doi.org/10.1136/bmj.313.7057.615
27. Lecture Outline
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Definitions (Cancer, Occupational cancer)
Epidemiological considerations
Carcinogenesis- basic principles
Classes (IARC groups) of carcinogens
Strategies for identification of carcinogens
Primary prevention of occupational cancer
Topical issues
Closing remarks
28. Topical issues in occupational
cancer
•May be a significant and under estimated problem
in developed and developing countries
•Challenges include exposure assessment, sample
size, confounding factors, manpower to conduct
research, ethical issues, legislation (particularly in
developing countries)
•Confounding factors include age, social class,
“healthy worker” effect
•Interaction- different joint effect of 2+ carcinogens
(i.e. synergy (multiplicative) and antagonism)
29. Lecture Outline
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Definitions (Cancer, Occupational cancer)
Epidemiological considerations
Carcinogenesis- basic principles
Classes (IARC groups) of carcinogens
Strategies for identification of carcinogens
Primary prevention of occupational cancer
Topical issues
Closing remarks
30. Closing remarks
• Occupational cancer affords significant
opportunities for research
• Cancers related to the workplace can be
reduced by the implementation of primary
prevention and by increased vigilance of
occupational health workers
• Advocacy is essential to raise awareness of
general public, legislators, employers and
workers
31. THANKS FOR LISTENING!
A little learning is a dang'rous thing;
Drink deep, or taste not the Pierian
spring.
31
Editor's Notes
Industrial workers have long served as sentinels for the general population with regard to environmental hazards. Although many chemicals found in the industrial setting can also be found in the environment, industrial workers often have more intense and prolonged exposures to chemicals than does the general population. Consequently, cancers in humans caused by these substances are often first noted in the workplace.
Many of the well-established and suspected chemical carcinogens were identified through occupational studies. One of the earliest examples occurred more than 200 years ago when, in 1775, Percivall Pott, a London surgeon, described a high frequency of cancer of the scrotum among chimney sweeps. A century later, other scientists noted similar cancers among gas plant workers in Germany and among oil shale workers in Scotland. Some 40 years later, certain constituents of tar, soot, and oils, known as polycyclic aromatic hydrocarbons, were found to cause cancer in laboratory animals, thus identifying the specific substances causing cancer among workers in these occupations. Preventive action was taken in Denmark, where the chimney sweeps' guild, spurred by Pott's report, urged its members to take daily baths. The success of this action was noted in a report in the 1892 British Medical Journal, "Why Foreign Sweeps Do Not Suffer From Scrotal Cancer”, which pointed out that the sweeps of Northern Europe seemed to benefit from this hygiene measure, but English sweeps, apparently ignoring such recommendations, continued to develop cancer.
This saga became the model for many later investigations of workplace carcinogens. Such studies have focused on
Observation of unusual cancers, or a high incidence of common cancers, among groups of workers
Searches for responsible agents
Demonstration that the agent can cause cancer in laboratory animals; and
Implementation of preventive programs.
Cancer is the colloquial expression used by medical workers and laypersons alike to refer to malignant neoplasm. A neoplasm is a lesion formed by autonomous clonal expansion of abnormal cells that have a selective growth advantage over their neighbouring cells; and a malignant neoplasm is one which, if not promptly eradicated, will inexorably invade surrounding tissues and vascular channels, metastasize to distant sites and will inevitably result in death of the afflicted patient.
Occupational cancer may be defined as cancer that may be specifically attributed to significant (i.e. more so than in the general environment) levels of exposure to an agent in the workplace and occurring in substantial (i.e. greater than 10,000) numbers of workers.
Cancer is a cosmopolitan problem, afflicting approximately five million women and six million men annually, worldwide (Ferlay et al, 2004). It is the second leading cause of death among both males and females in developed countries (Pamies and Crawford, 1996). Twenty per cent of all deaths in the US and UK are due to cancer, compared to 6-13% in developing countries. In the United States alone, 4.6 million new cases were reported to the National Cancer Data Base between 1985-1994 (Menck et al., 1998). Paradoxically, over 50% of cancer patients live in developing countries, which have less than 10% of the human resources, finance and technological infrastructure to effectively tackle the problems of cancer prevention, diagnosis and care (Durosinmi, 2006). In Nigeria alone, it has been estimated that there are 100,000 new cases of cancer per year, which was expected to increase to about 500,000 cases annually by the year 2010 (Durosinmi, 2006). The total burden of cancer may be expected to escalate proportionally with advances in the control of communicable diseases, increasing longevity, and ever-increasing industrialization of both third world and developed countries.
This composite bar chart indicates the enormity of the problem of cancer in graphic detail. The five major cancer killers world-wide are lung cancer, female breast cancer, cancer of the large bowel, gastric cancer and male prostate cancer.
Cancer is a cosmopolitan problem, afflicting approximately five million women and six million men annually, worldwide (Ferlay et al, 2004). It is the second leading cause of death among both males and females in developed countries (Pamies and Crawford, 1996). Twenty percept of all deaths in the US and UK are due to cancer, compared to 6-13% in developing countries. In the United States alone, 4.6 million new cases were reported to the National Cancer Data Base between 1985-1994 (Menck et al., 1998). Paradoxically, over 50% of cancer patients live in developing countries, which have less than 10% of the human resources, finance and technological infrastructure to effectively tackle the problems of cancer prevention, diagnosis and care (Durosinmi, 2006). In Nigeria alone, it has been estimated that there are 100,000 new cases of cancer per year, which was expected to increase to about 500,000 cases annually by the year 2010 (Durosinmi, 2006). The total burden of cancer may be expected to escalate proportionally with advances in the control of communicable diseases, increasing longevity, and ever-increasing industrialization of both third world and developed countries.
Carcinogenesis- General principles
Cancer formation is a multistage process resulting from the cumulative effects of multiple extrinsic physical, chemical and biological agents interacting with endogenous host factors. Generally, it is estimated that cancer is contributed to in 80% of cases by environmental factors, and in only a minority of cases (probably less than 10%) are primary genetic disorders responsible for cancer. Some of the environmental factors implicated in carcinogenesis include
Physical agents (ultraviolet, X and gamma irradiation)
Chemical agents (polycyclic aromatic hydrocarbons, aromatic amines/azo dyes, alkylating agents and natural carcinogens such as aflatoxins and nitrosamines), and
Biological agents (Hepatitis B and C viruses, Human T cell lymphoma virus type 1, Human Papilloma Virus types 16 and 18, Epstein-Barr virus and Human Herpes Virus type 8/Kaposi Sarcoma Herpes Virus, Helicobacter pylori, Schistosoma haematobium and Clonorchis sinensis, for example).
Endogenous host factors such as immune suppression, endocrine stimulation (prostate, breast, liver, thyroid and endometrial cancer), diet (vitamin A/C deficiency, high fat diet, low fibre diet), the occurrence of premalignant lesions (dysplasia, metaplasia, chronic inflammation and hamartomas) and hereditary or genetic factors may also contribute to carcinogenesis.
Epidemiological studies contribute to a better knowledge of aetiological risk factors and occupations responsible for the outcome of these cancers and allow quantification of the risk of cancer linked to different situations of exposure. Beside classical epidemiological studies, molecular epidemiology aims at identifying molecular targets of occupational agents. This approach may allow a better knowledge of the part played by occupational agents in these multifactorial diseases (Pairon, 2002).
1775, Percivall Pott, a London surgeon, described a high frequency of cancer of the scrotum among chimney sweeps. A century later, other scientists noted similar cancers among gas plant workers in Germany and among oil shale workers in Scotland. in 1895, Rehn, a German surgeon working in Frankfurt, treated a cluster of three cases of bladder cancer in workers at a local factory producing aniline dyestuffs from coal tar. Some 40 years later, certain constituents of tar, soot, and oils, known as polycyclic aromatic hydrocarbons, were found to cause cancer in laboratory animals
In the occupational setting, cancer may be acquired by inhalation, dermal contact or by ingestion (Env. Hlth. Criteria, WHO, 1999). Inhalation exposure is assessed by determining the average concentration of the substance in the breathing zone averaged over a reference period (8 hours for long-term, and 15 minutes for short-term exposure). Exposure to skin is determined by calculating the potential dose rate predominantly to the hands and forearms (2000 cm2) using a mathematical model. Cumulative inhalation or dermal exposure is determined by the product of the average intensity and time. Ingestion exposure usually cannot be quantified.
It must be noted that the methods of assessment of carcinogen exposure have not been standardised to universally accepted levels
Studies of occupational groups remain an important component of the current effort to identify the causes of human cancer. A listing and summary of evidence regarding occupational factors that may cause human cancer can be found in some critical monographs published by the International Agency for Research on Cancer (IARC) and the World Health Organisation, respectively. These volumes deal with cancer risks from individual chemicals, and mixtures of chemicals, in selected occupations or industries, and review issues such as risk assessment, testing for biomarkers, and testing for carcinogenicity.
The evaluations in the IARC monographs are based on epidemiological data from studies in humans, bioassays in animals, and data from short-term tests and laboratory experiments. For the monographs, experts in carcinogenesis evaluate the available data for individual chemicals, chemical groups, industrial processes, or specific occupations and assign each to a category of risk. When there is enough evidence from epidemiologic studies to support a causal association with cancer, the chemical, chemical group, process, or exposure is assigned to Group 1 (e.g., asbestos, benzene, chromium, vinyl chloride, coke production, furniture manufacturing, and nickel refining). Chemicals that are carcinogenic in laboratory animals, but for which human data may be limited or lacking, are typically placed in Group 2. Those considered to be probably carcinogenic to humans appear in Group 2A (e.g., acrylonitrile, cadmium, formaldehyde, and silica), and those considered to be possibly carcinogenic to humans are placed in Group 2B (including butadiene, carbon tetrachloride, chlorophenoxy herbicides, DDT, styrene, and tetrachloroethylene). The other categories are considered not classifiable as to carcinogenicity (Group 3), or not carcinogenic to humans (Group 4).
The agents carcinogenic to humans and those probably or possibly carcinogenic to humans do not fall into any particular class of substances. They include metals (arsenic, chromium, nickel, cadmium), solvents (benzene, styrene, carbon tetrachloride, dichloromethane), organic and inorganic dusts (leather or wood dusts, asbestos, silica), chemicals used to construct polymers (acrylonitrile, formaldehyde, vinyl chloride), and pesticides (ethylene oxide, amitrole, chlorophenoxy herbicides, DDT, toxaphene).
Studies of occupational groups remain an important component of the current effort to identify the causes of human cancer. A listing and summary of evidence regarding occupational factors that may cause human cancer can be found in some critical monographs published by the International Agency for Research on Cancer (IARC) and the World Health Organisation, respectively. These volumes deal with cancer risks from individual chemicals, and mixtures of chemicals, in selected occupations or industries, and review issues such as risk assessment, testing for biomarkers, and testing for carcinogenicity.
The evaluations in the IARC monographs are based on epidemiological data from studies in humans, bioassays in animals, and data from short-term tests and laboratory experiments. For the monographs, experts in carcinogenesis evaluate the available data for individual chemicals, chemical groups, industrial processes, or specific occupations and assign each to a category of risk. When there is enough evidence from epidemiologic studies to support a causal association with cancer, the chemical, chemical group, process, or exposure is assigned to Group 1 (e.g., asbestos, benzene, chromium, vinyl chloride, coke production, furniture manufacturing, and nickel refining). Chemicals that are carcinogenic in laboratory animals, but for which human data may be limited or lacking, are typically placed in Group 2. Those considered to be probably carcinogenic to humans appear in Group 2A (e.g., acrylonitrile, cadmium, formaldehyde, and silica), and those considered to be possibly carcinogenic to humans are placed in Group 2B (including butadiene, carbon tetrachloride, chlorophenoxy herbicides, DDT, styrene, and tetrachloroethylene). The other categories are considered not classifiable as to carcinogenicity (Group 3), or not carcinogenic to humans (Group 4).
The agents carcinogenic to humans and those probably or possibly carcinogenic to humans do not fall into any particular class of substances. They include metals (arsenic, chromium, nickel, cadmium), solvents (benzene, styrene, carbon tetrachloride, dichloromethane), organic and inorganic dusts (leather or wood dusts, asbestos, silica), chemicals used to construct polymers (acrylonitrile, formaldehyde, vinyl chloride), and pesticides (ethylene oxide, amitrole, chlorophenoxy herbicides, DDT, toxaphene).