Published on 27/12/2011
Occupational factors weigh heavily upon people's health. Occupational diseases are many and varied: cancers, hearing impairments, respiratory and musculoskeletal disorders, depressive and psychological disorders, allergy and skin disorders, occupational asthma, reproductive disorders, cardiovascular diseases, etc. Risk factors to which workers are exposed are also many and varied. In addition to the tens of thousands of classical types of chemical pollution that exist in many industries, there are also physical factors (noise, temperature, vibrations, radiation, etc.), biological agents (health-care environments, agribusiness and cleaning sectors, among others) many physical and postural constraints (carrying heavy loads, working in uncomfortable and painful positions, repetitive movements), constraints related to mental loads and stress, timetables, pace of work, etc. that can be quite severe and have an impact on operators’ health. We are well aware today of the considerable impact of psychological and social factors related to the organization of labour, and their consequences on health involve both somatic and mental aspects.
There are methodology challenges to monitoring the risks posed by the non-specific nature of most labour-related conditions, by the fact that they are most often multifactorial in nature, and by the timeframes of the disease’s onset, which can sometimes be quite long and move the diagnosis of the disease away from the period of exposure to the occupational trigger factor. As most of the existing health information systems include no occupational data that would make such monitoring possible, it is necessary to build tools and programs specifically designed to monitor occupational risks that combine monitoring the health status and monitoring occupational exposures. In line with its monitoring and surveillance missions, InVS’s Department of Occupational Health (DST) devotes part of its efforts to implementing surveillance systems (population cohorts, tools that make it easier to assess the population's occupational exposure, business or sector cohorts, monitoring mortality by cause and industry, etc.). Furthermore, the DST has developed, either by itself or under a partnership, a number of epidemiological programs to monitor health in the workplace in certain priority areas: musculoskeletal disorders, health conditions linked to exposure to asbestos, occupational asthma, mental health, cancers, etc. The DST is also building networks of occupational health physicians tasked with reporting any health problems related to the occupational activity in question. Furthermore, the analysis of certain sections of major population health surveys is handled by the DST, in partnership with other institutions. The DST works in close cooperation with Interregional Epidemiology Units whenever the former receives reports of any abnormal events occurring in the workplace, as this might lead to investigations in the field. DST also works with various social security schemes.
Some of the Department’s activities are included in governmental plans such as the 2009-2013 Cancer Plan, or the 2009-2013 Occupational Health Plan; in particular, the Department is tasked with centralizing data on occupational injuries and diseases stemming from various social security schemes.
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AZF health cohort
The “AZF” health cohort was set up in May 2003 at the Toulouse CPAM health examination centre. Each year, at the anniversary date of the first health examination, volunteers have received a self-completion health and occupational questionnaire. The cohort is starting its last year of follow-up (self-completion questionnaires and health checks), ending in December 2009.
This topic is intended mainly for the 3,000 volunteers of the cohort. It includes a short description of the cohort and a selection of the main results.
Diseases of an occupational nature
A disease is said to be occupational if it results directly from a worker's exposure to agents or if it results from the conditions in which a worker exercises his or her occupation.
In France, the compensation system for occupational diseases is managed by social security schemes and funded by employers. As a result, it covers only salaried workers. Compensation is based on the presumption of occupational origin if the disease appears on one of the restrictive lists (tables of occupational diseases) and provided all the conditions mentioned in those tables have been met. Furthermore, since 1993, there is an additional system that recognizes, under specific conditions, certain ailments as being occupational but which do not meet all the conditions mentioned in the tables or are not listed in the tables. In order to be recognized as such, individual cases are examined by regional committees for the recognition of occupational diseases, which rule on the connection between the occurrence of the disease and working conditions.
Statistical data on recognized and compensated occupational diseases are produced on a regular basis by social security schemes. Extensive research indicates that this data is far from reflecting the reality of the health impact of occupational risks. Several reasons might explain this, including a significant underreporting of such ailments.
The concept of disease of an occupational nature, defined as a disease likely to have an occupational origin but which is not listed in the tables of compensable occupational diseases, was introduced by the legislator as early as 1919 with a dual purpose: preventing occupational diseases, and better understanding occupational pathology as well as extending or revising the tables. Even though all medical doctors are legally required to report such diseases (Section L.461-6 of the Social Security Code) few physicians actually report diseases of an occupational nature. The few cases that have been reported come mainly from occupational physicians and have so far only been partially processed, due to a lack of systemization and centralization.
Espri programme (post-occupational surveillance of subjects exposed to asbestos)
In France, between 11,000 and 23,000 of the 280,000 annual incident cases of cancer allegedly have occupational causes. Although they occur most often after retirement there is currently no standardized system for post-occupational surveillance of members affiliated to the various Social Security regimes. A regulatory framework solely for former salaried workers exists since 1995 but it is still poorly implemented as it is little known.
Following InVS’s recommendations in 2001 (the “Espaces” study) the social security scheme for self-employed professionals (RSI) asked InVS in 2003 to set up the Espri programme. In its current phase Espri focuses on surveillance of subjects who were exposed to asbestos during their professional career; surveillance is based on recommendations from the 1999 consensus conference on the medical follow-up of people exposed to asbestos (the only existing reference guideline).
Health and labour cohort – agricultural occupations (Coset-MSA)
In order to improve the epidemiological surveillance of occupational health within the French population InVS’s Department of Occupational Health wanted to provide itself with a general longitudinal mechanism for health surveillance in the workplace: the Coset programme.
Data for this program is collected from active members of the main social security schemes:
- for the general scheme the Coset program will be based on data from the Constances cohort (Inserm) by using the information required for its surveillance objective;
- for the agricultural scheme, the DST, in partnership with the Mutualité sociale agricole (MSA), is setting up a cohort of active members within the scheme;
- the option of following self-employed members is currently under consideration.
Epidemiological analysis broken down by occupation and industrial sector is based on national and international classifications and most of the time requires coding of information collected. The quality of such coding directly affects the quality of work and results. Within this framework, InVS’s Department of Occupational Health has developed tools that make coding and coding standardization easier. The topic provides general information on job coding (by occupation and industrial sector) for the epidemiology of occupational risks as well as the main principles to be complied with. Available classification systems as well as the tools to help in coding jobs and industrial sectors (CAPS) are presented.
Job-exposure matrices – Matgéné
InVS’s Department of Occupational Health has set up and coordinates several programs aimed at producing matrices that establish linkages between current or past occupational activities and exposures to physical, chemical, biological or organizational agents: the Matgéné programme, involving job-exposure matrices in the general population, the Matphyto programme, involving farming-exposure matrices to phytosanitary products among the agricultural workers, and the Sumex programme for the production in 2003 of an exposure matrix to chemical agents based on assessments from the Sumer survey (Ministry of Labour).
Briefly described, a job-exposure matrix is a cross-tabulation of job titles and indicators of exposure to one or several agents. Exposures can then be automatically assigned to individuals depending on their job titles.
This topic presents methods used, the main achievements, some applications to population samples in France, as well as the work currently underway.
Musculoskeletal disorders (MSD) refer to a series of peri-articular conditions that can affect various structures of the upper and lower limbs as well as the back: tendons, muscles, joints, nerves and the vascular system. The term “overuse pathology” is also frequently used in France. Depending on the structure affected, disorders will be classified as tendinitis, tenosynovitis, bursitis or entrapment neuropathy (such as the carpal tunnel syndrome).
MSDs include diverse conditions with various and often multiple causes: disorders can appear without being linked to one's occupation, such as in the case of some diseases or certain activities outside of work, but they are first and foremost a large-scale occupational health problem. MSDs are currently one of the issues of greatest concern in terms of occupational health because of their constant increase in industrialized countries, individual consequences in terms of suffering, reduced employability and potential interruption of one's working life, and also because of their cost and consequences on the company's operation. Requests for compensation due to MSDs are increasing year after year in most industrialized countries. In France, they currently account for 76% of compensable occupational diseases.
MSDs are often associated with activities in the agricultural sector as well as in many industrial sectors (packaging, assembly, mounting, etc.): agri-food industries, clothing industry, footwear industry, manufacturing of electronic and electrical products, automobile industry, etc. These are sectors where repetitive manual labour is particularly prevalent, but the problem has also appeared in other sectors little affected until now, such as tertiary sectors.