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      New avenues for prevention of occupational cancer: a global policy perspective

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          Recent estimates demonstrated that occupational cancer accounted for 27% of the 2.4 million deaths due to work-related diseases.1–3 In numerical terms, this estimate means that the number of deaths attributable to occupational cancer annually increased from 666 000 deaths in 2011 to 742 000 deaths in 2015.2 3 This increase could be explained by different variables such as the evidence on new carcinogens, the methods of estimation, changes in the industry distribution of workers and the growing and ageing of the population. The International Labour Organization (ILO) released global data showing this increase in the number of fatal work-related cancers that occur every year,3 4 whereas, in the European Union (EU) alone, occupational cancer was responsible for 102 500 deaths in 2011 and 106 300 in 2015.2–5 Considering these data, it is clear that occupational cancer now represents the primary cause for work-related deaths globally and in many regions of the world, and the numbers continue to grow. In spite of efforts for prevention and control by several international organisations, institutions and authorities, the level of occupational cancer mortality and morbidity has remained high. Part of the reason for this is that current burden reflects the effect of past exposures and so provides little insight into the effectiveness of recent (in the last two decades) control measures. However, burden estimates do indicate that systems in place in past decades do not appear to have been effective enough, and there is good reason to suspect many of these systems, or systems similar to them, remain in place in many regions. For this reason, occupational cancer prevention was a key theme of the 32nd International Congress on Occupational Health (ICOH) held in Dublin from 29 April to 4 May 2018.6 The Dublin Statement on Occupational Health ‘New Avenues for Prevention of Occupational Cancer and Other Severe Occupational Health Hazards’, adopted unanimously by the ICOH 2018 Congress, summarises the needs and presents the main elements of the fight against occupational cancer in the years to come.7 In this regard, it should be noted that one of the most interesting insights that came out during the ICOH Congress concerned the importance of the implementation of policy on the prevention of occupational cancer. To achieve this ambitious objective, it is necessary to invest significant human and economic resources defining, implementing and promoting a global strategy and action plan, which should be based on integrated interventions and tools intervening on multiple operational levels and ranging from research to prevention and control (online supplementary table 1). 10.1136/oemed-2018-105546.supp1 Supplementary file 1 Obviously, we are not at a starting point, and important progress has been made (see, eg, the UN 2030 Agenda for Sustainable Development or the 70th World Health Assembly Resolution No. 70.32 of 2017 on cancer prevention and control in the context of an integrated approach)7; nevertheless, there is still much work to be done. For example, in the regulatory context, the carcinogenic hazard identification and risk assessment of a substance, agent and/or working process are important prerequisites for risk management. Indeed, identifying occupational carcinogens is an essential research effort since these data represent the basis on which to define prevention and surveillance measure priorities. Furthermore, a strengthening in the evaluation (and definition) of occupational carcinogens is needed to obtain more appropriate and realistic estimates of the global burden of occupational cancer (online supplementary table 1). However, to achieve this target, it is also essential to have reliable information on key exposure characteristics (eg, number of exposed workers; environmental and biological monitoring data). Different sources of information (national registers or exposure measurement databases—see online supplementary table 1) are available at both international and national level.8 9 Moreover, in this context, it should be noted that there are also international and national exposure information systems, which are based on expert estimations of numbers of exposed workers and their level of exposure to occupational carcinogens.8 Exposure registers, databases and expert estimations are valuable tools to characterise the workers’ exposure to occupational carcinogens. Nevertheless, their use in the broader context of establishing global policies to tackle and prevent occupational cancers is still limited for several reasons (online supplementary table 1). First of all, these instruments do not cover all occupational carcinogens and regions (eg, the ExpoSYN is an exposure measurement database developed for the SYNERGY research project and focused on five lung carcinogens and was based on data from Europe and Canada).9 Furthermore, they should be made more informative through refinement (eg, data by gender and exposure levels), expansion (CAREX is based on the 15 EU countries in 1990) and regular updating (eg, the CAREX estimates of exposure prevalence and numbers of exposed workers refer to the period 1990–1993, and updates were carried out only for Finland, Italy and Spain).10 In this regard, another critical issue is the lack of harmonisation of the different registers, databases and expert estimates. Therefore, there is a clear need to globally harmonise the existing sources of information on exposure in order to achieve a more accurate and reliable basis for the estimation of global burden of occupational cancer. It should be pointed out that the assessment of exposure remains the single best instrument for identification and quantification of problems benchmarking and documentation of progress. With regard to the prevention and protection area of interest, there are several primary and/or secondary prevention measures that can be used in workplaces to ensure the health protection of workers exposed to carcinogens. According to the ILO convention C-139 on occupational cancer, ‘carcinogenic substances or agents must be replaced by non-carcinogenic substances or agents or by less harmful substances or agents’. Such an intervention strategy has been adopted for asbestos, which currently has been banned in 55 countries.11 However, the programmes and policies for the complete and global elimination of a carcinogen require important resources and global implementation. In fact, asbestos is still widely used today (approximately 2 030 000 tons of this substance are consumed annually).11 Furthermore, it is not always technically possible to completely eliminate a carcinogenic substance or agent from the workplace. In this regard, in years to come, a fundamental contribution to the elimination of the use of occupational carcinogens could be provided by technological innovation which, through continuous scientific progress and identification of innovative working processes, could lead to the substitution of these harmful substances. Meanwhile, the application of technical, organisational or procedural preventive measures to reduce workers’ exposure to occupational carcinogens is even more relevant (online supplementary table 1). Therefore, the adoption (or the updating) of specific occupational exposure limits (OELs) for these substances has become increasingly important. In this regard, very recently (on 5 April 2018), the European Commission proposed to further amend the Carcinogens and Mutagens Directive 2004/37/EC, establishing new OEL values for five cancer-causing chemicals (online supplementary table 1). Previously (May 2016 and January 2017), similar initiatives had been undertaken to protect workers from occupational cancers related to exposure to another 21 substances. Another area of intervention, which offers ample room for improvement in terms of prevention activities, is linked to the development and dissemination of specific training and information campaigns (eg, ‘No time to lose’ and ‘The Roadmap on Carcinogens’) to raise awareness of occupational cancer risks. The Roadmap on Carcinogens was started by the Conference organised by the EU Presidency of The Netherlands in 2016 followed by the Austrian Presidency at the Vienna Conference by EU governments, workers and employers in September 2018, and the next step will be the Finnish EU Presidency in 2019. ICOH has had a key role from the very beginning of this process.12 Indeed, the currently available data show that awareness is still not sufficiently developed, and this is a critical issue9 since a greater understanding of health risks related to occupational carcinogen exposure would ensure an improvement in compliance with the several preventive and protective measures and/or with good working practices. With regard to secondary prevention measures and control activities, a global policy aimed at effectively addressing the burden of occupational cancer should include not only interventions to limit or avoid future exposures but also actions to safeguard and protect the health of workers who have previously been exposed to occupational carcinogens. The follow-up of carcinogen-exposed workers is a very important topic, especially considering that many cancers have a long latency period after the initial exposure. Moreover, with increasing life expectancy, continued surveillance and screening (for some cancers) extending beyond retirement become even more important. For example, the Consensus Report ‘Asbestos, asbestosis and cancer. The Helsinki Criteria for Diagnosis and Attribution 2014’ suggested that the follow-up of highly asbestos-exposed workers should be continued at least for up to 30 years after the cessation of exposure.13 In this context, the use of appropriate organised screening programmes (such as low-dose CT for formerly asbestos-exposed workers) would increase the chances of an early diagnosis of occupational cancer, thus potentially reducing mortality and increasing the chances of surviving disease (online supplementary table 1). Moreover, follow-up, using specific structured questionnaires and/or checklists in order to investigate and identify past or current exposures, is necessary from a compensation point of view. In conclusion, the Global Policy Forum ‘Prevention of Occupational Cancer: Global Policies and Strategies’ highlighted the need to define a global policy on this topic as an urgent matter. Indeed, despite the important progress made in recent years, further efforts are required at all levels. Information provided in this article can help in determining which interventions and actions are most urgent and therefore support the development of a priority action strategy to control and reduce occupational cancer as effectively as possible.

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          Most cited references 6

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          Global Estimates of the Burden of Injury and Illness at Work in 2012

          This article reviews the present indicators, trends, and recent solutions and strategies to tackle major global and country problems in safety and health at work. The article is based on the Yant Award Lecture of the American Industrial Hygiene Association (AIHA) at its 2013 Congress. We reviewed employment figures, mortality rates, occupational burden of disease and injuries, reported accidents, surveys on self-reported occupational illnesses and injuries, attributable fractions, national economic cost estimates of work-related injuries and ill health, and the most recent information on the problems from published papers, documents, and electronic data sources of international and regional organizations, in particular the International Labor Organization (ILO), World Health Organization (WHO), and European Union (EU), institutions, agencies, and public websites. We identified and analyzed successful solutions, programs, and strategies to reduce the work-related negative outcomes at various levels. Work-related illnesses that have a long latency period and are linked to ageing are clearly on the increase, while the number of occupational injuries has gone down in industrialized countries thanks to both better prevention and structural changes. We have estimated that globally there are 2.3 million deaths annually for reasons attributed to work. The biggest component is linked to work-related diseases, 2.0 million, and 0.3 million linked to occupational injuries. However, the division of these two factors varies depending on the level of development. In industrialized countries the share of deaths caused by occupational injuries and work-related communicable diseases is very low while non-communicable diseases are the overwhelming causes in those countries. Economic costs of work-related injury and illness vary between 1.8 and 6.0% of GDP in country estimates, the average being 4% according to the ILO. Singapore's economic costs were estimated to be equivalent to 3.2% of GDP based on a preliminary study. If economic losses would take into account involuntary early retirement then costs may be considerably higher, for example, in Finland up to 15% of GDP, while this estimate covers various disorders where work and working conditions may be just one factor of many or where work may aggravate the disease, injury, or disorders, such as traffic injuries, mental disorders, alcoholism, and genetically induced problems. Workplace health promotion, services, and safety and health management, however, may have a major preventive impact on those as well. Leadership and management at all levels, and engagement of workers are key issues in changing the workplace culture. Vision Zero is a useful concept and philosophy in gradually eliminating any harm at work. Legal and enforcement measures that themselves support companies and organizations need to be supplemented with economic justification and convincing arguments to reduce corner-cutting in risk management, and to avoid short- and long-term disabilities, premature retirement, and corporate closures due to mismanagement and poor and unsustainable work life. We consider that a new paradigm is needed where good work is not just considered a daily activity. We need to foster stable conditions and circumstances and sustainable work life where the objective is to maintain your health and work ability beyond the legal retirement age. We need safe and healthy work, for life.
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            Occupational exposure to carcinogens in the European Union.

            To construct a computer assisted information system for the estimation of the numbers of workers exposed to established and suspected human carcinogens in the member states of the European Union (EU). A database called CAREX (carcinogen exposure) was designed to provide selected exposure data and documented estimates of the number of workers exposed to carcinogens by country, carcinogen, and industry. CAREX includes data on agents evaluated by the International Agency for Research on Cancer (IARC) (all agents in groups 1 and 2A as of February 1995, and selected agents in group 2B) and on ionising radiation, displayed across the 55 industrial classes. The 1990-3 occupational exposure was estimated in two phases. Firstly, estimates were generated by the CAREX system on the basis of national labour force data and exposure prevalence estimates from two reference countries (Finland and the United States) which had the most comprehensive data available on exposures to these agents. For selected countries, these estimates were then refined by national experts in view of the perceived exposure patterns in their own countries compared with those of the reference countries. About 32 million workers (23% of those employed) in the EU were exposed to agents covered by CAREX. At least 22 million workers were exposed to IARC group 1 carcinogens. The exposed workers had altogether 42 million exposures (1.3 mean exposures for each exposed worker). The most common exposures were solar radiation (9.1 million workers exposed at least 75% of working time), environmental tobacco smoke (7.5 million workers exposed at least 75% of working time), crystalline silica (3.2 million exposed), diesel exhaust (3.0 million), radon (2.7 million), and wood dust (2.6 million). These preliminary estimates indicate that in the early 1990s, a substantial proportion of workers in the EU were exposed to carcinogens.
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              Asbestos, asbestosis, and cancer, the Helsinki criteria for diagnosis and attribution 2014: recommendations.


                Author and article information

                Occup Environ Med
                Occup Environ Med
                Occupational and Environmental Medicine
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                June 2019
                14 May 2019
                : 76
                : 6
                : 360-362
                [1 ] departmentDepartment of Occupational and Environmental Medicine, Epidemiology and Hygiene , Italian Workers’ Compensation Authority (INAIL) , Monte Porzio Catone (Rome), Italy
                [2 ] departmentSchool of Public Health , University of Sydney , Sidney, New South Wales, Australia
                [3 ] departmentFaculty of Occupational Medicine , Royal College of Physicians of Ireland , Dublin, Ireland
                [4 ] departmentSection of Occupational Medicine, Department of Public Health , University of Naples Federico II , Naples, Italy
                [5 ] departmentDepartment of Public Health/Occupational Health , University of Helsinki , Helsinki, Finland
                [6 ] departmentIARC Monographs Section , International Agency for Research on Cancer (IARC) , Lyon, France
                [7 ] International Commission on Occupational Health (ICOH) , Milan, Italy
                Author notes
                [Correspondence to ] Dr Sergio Iavicoli, Occupational Medicine Department, Italian Workers’ Compensation Authority (INAIL), Rome I-00040, Italy; s.iavicoli@
                © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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                asbestos, occupational health, protection, regulation, workers


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