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Background: A study was undertaken to estimate the prevalence of untreated asthma in older adults.Methods: A cross sectional population based survey of 6000 men and women aged 65 years and over was performed in 21 general practices in north Bristol, south west England. The main outcome measure was untreated asthma as defined by a two stage process comprising a respiratory questionnaire (symptoms suggestive of asthma or doctor diagnosed asthma not receiving respiratory treatment) followed by lung function tests (significant reversibility following bronchodilators or corticosteroids and/or significant within day variability in peak expiratory flow).Results: 4792 of the 6000 participants (80%) completed the respiratory questionnaire and, of those not receiving respiratory treatment, 55 reported a previous doctor diagnosis of asthma and a further 696 had symptoms suggestive of asthma. Lung function testing in 280 of 501 randomly selected individuals from these groups resulted in 38 being defined as having asthma and an estimated population prevalence for untreated asthma of 2.4% (95% CI 1.6% to 3.6%) in men and 1.2% (95% CI 0.7% to 2.1%) in women. Most subjects (84%) with untreated asthma had moderate or severe disease. Untreated asthma was most common in individuals with doctor diagnosed asthma (21%) and those with breathlessness or wheeze (13-20%).Conclusion: Untreated asthma in the elderly is a common and important problem. Opportunistic use of appropriate lung function tests in older people with a history of doctor diagnosed asthma or wheeze or breathlessness at rest could identify untreated asthmatics who might benefit from treatment. [ABSTRACT FROM AUTHOR]

Background: Several studies have linked air pollution by nitrogen dioxide (NO(2)) with increased hospital admissions for asthma in children. Exacerbations of asthma in children are often precipitated by upper respiratory infections. It is therefore possible that NO(2) increases the risk of airways obstruction when asthmatic children develop upper respiratory infections.Methods: To test this hypothesis a sample of 114 asthmatic children aged 7-12 years were followed for a total of up to 13 months. Probable upper respiratory infections were identified by consensus review of daily symptom diaries, and episodes of airways obstruction from serial records of peak expiratory flow (PEF). Personal exposures to NO(2) were measured with Palmes tubes that were changed weekly. Generalised estimating equations were used to assess the relative risk (RR) of an asthmatic exacerbation starting within seven days of an upper respiratory infection according to estimated NO(2) exposure during the one week period from two days before to four days after the onset of the infection.Results: The children were followed for an average of 34 weeks during which 318 upper respiratory infections and 224 episodes of reduced PEF were diagnosed. PEF episodes were much more likely to occur in the seven days following the onset of an upper respiratory infection than at other times. Estimated exposures to NO(2) at the time of infections were generally low (geometric mean 10.6 microg/m(3)). Compared with exposures of < or = 8 microg/m(3), exposures of >28 microg/m(3) were associated with a RR of 1.9 (95% confidence interval 1.1 to 3.4) for the development of an asthmatic episode within seven days of an infection.Conclusions: The findings give some support to the hypothesis that NO(2) increases the risk of asthmatic exacerbations following respiratory infections, even at relatively low levels of exposure. Further studies in populations with higher exposures would be useful. [ABSTRACT FROM AUTHOR]

Objective: To investigate the risk factors for low back pain in hospital nurses, with particular emphasis on the role of specific nursing activities.Methods: A cross sectional survey of 2405 nurses employed by a group of teaching hospitals was carried out. Self administered questionnaires were used to collect information about occupational activities, non-occupational risk factors for back symptoms, and history of low back pain.Results: The overall response rate was 69%. Among 1616 women, the lifetime prevalence of back pain was 60% and the one year period prevalence 45%. 10% had been absent from work because of back pain for a cumulative period exceeding four weeks. Rates in men were generally similar to those in women. In women back pain during the previous 12 months was weakly associated with height, and was significantly more common in those who reported frequent non-musculoskeletal symptoms such as headache and low mood. After adjustment for height and non-musculoskeletal symptoms, significant associations were found with frequency of manually moving patients around on the bed, manually transferring patients between bed and chair, and manually lifting patients from the floor. In contrast, no clear increase in risk was found in relation to transfer of patients with canvas and poles, manually lifting patients in and out of the bath, or lifting patients with mechanical aids. Confirmation of these findings is now being sought in a prospective study of the same population.Conclusions: This study confirms that low back pain is highly prevalent among nurses and is associated with a high level of sickness absence. People who often report non-musculoskeletal symptoms were significantly more likely to report low back pain. Specific manual handling tasks were associated with an increased risk of back pain; however, no such association was found with mechanised patient transfers. [ABSTRACT FROM AUTHOR]

Objectives: To explore the relative merits of clinical and radiological examination in defining hand osteoarthritis (OA) for epidemiological purposes.Methods: A total of 976 women aged 45-64 years were selected from the general population and underwent a structured interview, clinical examination of the hand joints and radiography of the hands and knees. The inter-relationship of the clinical and radiological findings was examined, and also the association of each with hand symptoms and the presence of knee OA.Results: Clinical and radiographic signs of hand OA generally correlated with each other, and each was associated with hand symptoms to a similar degree. When analysed in combination, they were only marginally better at predicting symptoms than when tested individually. However, when they were examined in relation to radiographic features of knee OA, there was a significantly stronger association with radiographic features of hand OA than with clinical features.Conclusions: Hand radiology provides a better overall assessment of osteoarthritis than physical examination of the interphalangeal joints or carpo-metacarpal joint; in situations where radiology is not available clinical examination is a viable substitute. [ABSTRACT FROM AUTHOR]

To explore whether the characteristics of coal mine dust that predispose to chronic airways obstruction are the same as those associated with pneumoconiosis, mortality from the two disease was compared in coal miners in 22 counties of England and Wales during 1979-80 and 1982-90. The proportional mortality ratios (PMRs) for coal workers' pneumoconiosis varied from 135 (95% confidence interval (95% CI) 16-488) in Leicestershire to 3825 (95% CI 1538-7881) in South Glamorgan. The PMRs for chronic bronchitis and emphysema were consistently higher than those in other occupations, but showed much less geographical variation and did not correlate geographically with those for pneumoconiosis. These findings indicate that the pathogenetic mechanisms by which coal mine dust causes chronic bronchitis and emphysema depend on different features of the dust from those producing pneumoconiosis. Also, they suggest that current social security regulations in Britain, which require evidence of pneumoconiosis as a condition of compensation for chronic bronchitis and emphysema in coal miners, may discriminate unfairly against claimants from some regions. [ABSTRACT FROM AUTHOR]

The hazard of scrotal cancer from cutting oils was first recognized in the 1950s, and led to various control measures including the introduction of solvent refined oils, use of splash guards, provision of protective clothing and washing facilities and education of workers to encourage early detēction and treatment of tumours. To assess how effective these controls have been, we have analyzed occupational mortality from scrotal cancer in England and Wales during 1979–80 and 1982–90. Over this 11-year period 85 deaths were attributed to the disease in men aged 20–74. This represents a reduction in mortality from the 1960s. Significantly elevated proportional mortality ratios (PMRs) were found in press and machine tool setters (PMR 1,678, five deaths), centre lathe turners (PMR 1,099, three deaths) and machine tool operators (PMR 303, eight deaths), but all of the metal machinists who died of scrotal cancer had been born before 1930, and could have worked with cutting oils before controls were introduced. These findings are reassuring, but continued monitoring of scrotal cancer incidence and mortality is required. [ABSTRACT FROM PUBLISHER]

Background: Patterns of sickness absence shed useful light on disease occurrence and illness-related behaviours in working populations., Methods: We analysed prospectively collected, pseudonymized data on 959 356 employees who were continuously employed by National Health Service trusts in England from 1 January 2019 to 31 July 2020, comparing the frequency of new sickness absence in 2020 with that at corresponding times in 2019., Results: After exclusion of episodes directly related to COVID-19, the overall incidence of sickness absence during the initial 10 weeks of the pandemic (March-May 2020) was more than 20% lower than in corresponding weeks of 2019. Trends for specific categories of illness varied substantially, with a fall by 24% for cancer, but an increase for mental illness. A doubling of new absences for pregnancy-related disorders during May-July of 2020 was limited to women with earlier COVID-19 sickness absence., Conclusions: Various factors will have contributed to the large and divergent changes that were observed. The findings reinforce concerns regarding delays in diagnosis and treatment of cancers and support a need to plan for a large backlog of treatment for many other diseases. Further research should explore the rise in absence for pregnancy-related disorders among women with earlier COVID-19 sickness absence., (© The Author(s) 2021. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To quantify occupational risks of COVID-19 among healthcare staff during the first wave (9 March 2020-31 July 2020) of the pandemic in England., Methods: We used pseudonymised data on 902 813 individuals employed by 191 National Health Service trusts to explore demographic and occupational risk factors for sickness absence ascribed to COVID-19 (n=92 880). We estimated ORs by multivariable logistic regression., Results: With adjustment for employing trust, demographic characteristics and previous frequency of sickness absence, risk relative to administrative/clerical occupations was highest in 'additional clinical services' (care assistants and other occupations directly supporting those in clinical roles) (OR 2.31 (2.25 to 2.37)), registered nursing and midwifery professionals (OR 2.28 (2.23 to 2.34)) and allied health professionals (OR 1.94 (1.88 to 2.01)) and intermediate in doctors and dentists (OR 1.55 (1.50 to 1.61)). Differences in risk were higher after the employing trust had started to care for documented patients with COVID-19, and were reduced, but not eliminated, following additional adjustment for exposure to infected patients or materials, assessed by a job-exposure matrix. For prolonged COVID-19 sickness absence (episodes lasting >14 days), the variation in risk by staff group was somewhat greater., Conclusions: After allowance for possible bias and confounding by non-occupational exposures, we estimated that relative risks for COVID-19 among most patient-facing occupations were between 1.5 and 2.5. The highest risks were in those working in additional clinical services, nursing and midwifery and in allied health professions. Better protective measures for these staff groups should be a priority. COVID-19 may meet criteria for compensation as an occupational disease in some healthcare occupations., Trial Registration Number: ISRCTN36352994., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To explore the extent to which asbestos-exposed jobs vary in the ratio of excess mortality from lung cancer to deaths from pleural cancer., Design: Using data on underlying cause of death and last full-time occupation for 3 688 916 deaths among men aged 20-74 years in England and Wales during 1979-2010, we calculated proportional mortality ratios (PMRs), standardised for age and social class, with all occupations combined as reference. For each of 22 asbestos-exposed job groups with significantly elevated PMRs for pleural cancer, we calculated excess mortality from lung cancer (observed minus expected deaths) and its ratio to number of deaths from pleural cancer. To reduce confounding effects of smoking, we adjusted expected deaths from lung cancer in each job group, according to a formula based on its PMR for chronic obstructive pulmonary disease., Setting: England and Wales., Participants: 3 688 916 men who died aged 20-74 years during 1979-2010., Outcome Measures: Ratios of excess mortality from lung cancer to deaths from pleural cancer by job group., Results: Adjusted PMRs for lung cancer were elevated in all but 4 of the 22 asbestos-exposed job groups, but the ratio of excess lung cancer to deaths from pleural cancer varied widely between job groups, being significantly greater than the overall ratio in six, and significantly less in seven. Analysis for 2001-2010, when (because of changes in coding) ascertainment of pleural tumours was more reliable, showed similar variation between job groups, and indicated an overall ratio of 0.28., Conclusions: Excess lung cancer in asbestos-exposed jobs is not in a simple proportion to deaths from pleural cancer, and the ratio may vary importantly according to intensity of exposure to different types of asbestos and concomitant smoking habits. The current burden of lung cancer from occupational exposure to asbestos in Britain may not be so high as previously thought., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: The UK National Institute for Health and Clinical Excellence (NICE) has published guidance for employers on promoting mental wellbeing. A national audit in 2011 found wide variation between English National Health Service (NHS) trusts (organizations providing health care) in the implementation of this guidance, but it is not known whether fuller compliance with the guidance results in improved mental wellbeing of staff., Aims: To explore whether there is an association between implementation of NICE guidance on mental wellbeing by NHS trusts in England and mental health outcomes as reported by staff., Methods: A cross-sectional analysis relating mental health outcomes by trust from the NHS staff surveys in 2009 and 2010 to findings from the 2011 audit of compliance with NICE guidelines., Results: NHS staff survey scores for mental health were significantly poorer in mental health and ambulance trusts than in acute trusts and mental health problems were significantly more frequent in London than in most other areas of England. Mental health scores tended to be better in trusts where the audit showed that staff health and wellbeing was a regular board agenda item, although not significantly so. There was no indication of better scores in trusts with policies on mental wellbeing or those that provided psychological therapies for staff., Conclusions: No clear relationship was found between implementation of the NICE guidance and self-reported mental health outcomes. There are several possible explanations for this finding which require further exploration., (© The Author 2015. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objectives: To provide further information on the risks of lymphohaematopoietic (LH) and other cancers associated with styrene., Methods: We extended follow-up to December 2012 for 7970 workers at eight companies in England which used styrene in the manufacture of glass-reinforced plastics. Mortality was compared with that for England and Wales by the person-years method, and summarised by SMRs with 95% CIs. A supplementary nested case-control analysis compared styrene exposures, lagged by 5 years, in 122 incident or fatal cases of LH cancer and 1138 matched controls., Results: A total of 3121 cohort members had died (2022 since the last follow-up). No elevation of mortality was observed for LH cancer, either in the full cohort (62 deaths, SMR 0.90, 95% CI 0.69 to 1.15), or in those with more than background exposure to styrene (38 deaths, SMR 0.82, 95% CI 0.58 to 1.14). Nor did the case-control analysis suggest any association with LH cancer. In comparison with background exposure, the OR for non-Hodgkin's lymphoma/chronic lymphocytic leukaemia in workers with high exposure (estimated 8-h time-weighted average of 40-100 ppm) for ≥1 year was 0.54 (95% CI 0.23 to 1.27). Mortality from lung cancer was significantly elevated, and risk increased progressively across exposure categories, with an SMR of 1.44 (95% CI 1.10 to 1.86) in workers highly exposed for ≥1 year., Conclusions: We found no evidence that styrene causes LH cancer. An association with lung cancer is not consistently supported by other studies. It may have been confounded by smoking, but would be worth checking further., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

The International Agency for Research on Cancer controversially has classified formaldehyde as causing nasopharyngeal carcinoma and myeloid leukemia. To provide further information on this question, we extended follow-up of a cohort of 14,008 chemical workers at 6 factories in England and Wales, covering the period 1941-2012. Mortality was compared with national death rates for England and Wales, and associations with incident upper airway cancer and leukemia were explored in nested case-control analyses. We observed excess deaths from cancers of the esophagus (100 observed vs. 93.1 expected), stomach (182 vs. 141.4), rectum (107 vs. 86.8), liver (35 vs. 26.9), and lung (813 vs. 645.8), but none of these tumors exhibited a clear exposure-response relationship. Nested case-control analyses of 115 men with upper airway cancer (including 1 nasopharyngeal cancer), 92 men with leukemia, and 45 men with myeloid leukemia indicated no elevations of risk in the highest exposure category (high exposure for ≥1 year). When the 2 highest exposure categories were combined, the odds ratio for myeloid leukemia was 1.26 (95% confidence interval: 0.39, 4.08). Our results provide no support for an increased hazard of myeloid leukemia, nasopharyngeal carcinoma, or other upper airway tumors from formaldehyde exposure. These results indicate that any excess risk of these cancers, even from relatively high exposures, is at most small., (© The Author 2014. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: An unusual inflammation of the pinna has been reported to occur in some sheep farmers at the time of lambing., Aims: To explore the prevalence of this disorder and its possible causal associations., Methods: While on attachment to sheep farms during lambing, veterinary students used a standardized questionnaire to interview a sample of farmers about their work and about symptoms of skin inflammation in their hands, face and ears., Results: Interviews were completed by 76 (67%) of the farmers approached. Among 74 farmers who had carried out lambing, 3 (4%, 95% CI 1-11%) had experienced temporally related ear symptoms, all on multiple occasions. No farmers with ear symptoms had ever been involved in calving or farrowing, and no ear symptoms were reported in relation to shearing or dipping sheep. There was also an excess of hand symptoms related to lambing outdoors (24% of those who had done such work) and indoors (also 24%) compared with other farming activities., Conclusions: Our findings suggest that temporally related ear inflammation occurs in at least 1% of farmers who carry out lambing but not in association with the other farming activities investigated. Lambing appears to be associated also with hand inflammation, but the pathology may differ from that in the pinna.

Background: To explore explanations for elevated mortality from diabetes among male garment manufacturers and repairers in England and Wales during 1979-1990, analysis was extended by 10 years, looking also at other textile workers and at deaths from ischaemic heart disease (IHD)., Methods: Data on some 3.5 million deaths were used to compute proportional mortality ratios (PMRs) for diabetes and IHD, standardised for age and social class, in 10 textile-associated job groups, with additional analyses by place of birth for 1993-2000., Results: Male mortality from diabetes was elevated in nine of the 10 textile jobs, with overall PMRs of 147 (95% CI 131 to 165) during 1979-90 and 170 (95% CI 144 to 199) during 1991-2000. Proportional mortality from IHD was also consistently high. Female mortality from both diseases was close to that for other occupations. In both sexes, mortality from diabetes and IHD was increased among people born in the Indian subcontinent (PMRs 353 and 139 in men; 262 and 130 in women). In men, the proportion of deceased textile workers born in the Indian subcontinent (11.4%) was much higher than for all occupations (1.8%), but not in women (1.1% vs 0.7%). PMRs for male textile workers standardised for place of birth were lower but still significantly elevated (133, 95% CI 110 to 159 for diabetes; 109, 95% CI 105 to 114 for IHD)., Conclusions: No obvious occupational hazard explains the increased risk specific to men across a wide range of textile occupations. One possible explanation is uncontrolled residual confounding related to place of birth. This could be tested through suitably designed morbidity surveys.

Background: To explore time trends in deaths attributable to work in England and Wales, and identify priorities for prevention, we conducted a proportional analysis of mortality by occupation over a 22-year period., Methods: Analysis was based on deaths in men aged 20-74 years during 1979-1980 and 1982-2000 with a recorded occupation. Proportional mortality ratios, standardised for age and social class, were calculated for pre-specified combinations of occupation and cause of death, for which excess mortality could reasonably be attributed to work. Differences between observed and expected numbers of deaths by cause and occupation were expressed as annual excess death rates., Results: Mortality attributable to work declined substantially over the period of study, with total excess death rates of 733.2 per year during 1979-1990 and 471.7 per year during 1991-2000. The largest contributing hazards were chronic obstructive pulmonary disease and pneumoconiosis in coal miners, pleural cancer from asbestos, and motor vehicle accidents in lorry drivers. In contrast to most other hazards, there was no clear decline in excess mortality attributable to asbestos, or in deaths from sino-nasal cancer associated with exposure to wood dust., Conclusions: The overall decline in mortality attributable to work is likely to reflect reduced employment in more hazardous occupations, as well as improvements in working conditions. It is imperative to ensure that occupational exposures to asbestos and wood dust are now adequately controlled. Further research is needed on accidents involving lorries with the aim of developing more effective strategies for the prevention of injury.

Background: To identify opportunities for targeted prevention, we explored differences in occupational mortality from diseases and injuries related to alcohol consumption, sexual habits and drug abuse., Methods: Using data on all deaths among men and women aged 16-74 years in England and Wales during 1991-2000, we derived age- and social class-standardized proportional mortality ratios (PMRs) by occupation for cause of death categories defined a priori as potentially related to alcohol consumption, sexual habits or drug abuse., Results: The highest mortality from alcohol-related diseases and injuries was observed in publicans and bar staff (both sexes) and in male caterers, cooks and kitchen porters and seafarers. Male seafarers had significantly elevated PMRs for cirrhosis (179), 'other alcohol-related diseases' (275), cancers of the liver (155), oral cavity (275) and pharynx (267) and injury by fall on the stairs (187). PMRs for human immunodeficiency virus infection (HIV)/acquired immunodeficiency syndrome (AIDS) were particularly high in tailors and dressmakers (918, 95% CI: 369-1890, in men; 804, 95% CI: 219-2060, in women) and male hairdressers (918, 95% CI: 717-1160). Most jobs with high mortality from HIV/AIDS also had more deaths than expected from viral hepatitis. Of seven jobs with significantly high PMRs for both drug dependence and accidental poisoning by drugs, four were in the construction industry (male painters and decorators, bricklayers and masons, plasterers, and roofers and glaziers)., Conclusions: Our findings highlight major differences between occupations in mortality from diseases and injuries caused by alcohol, sexual habits and drug abuse. Priorities for preventive action include alcohol-related disorders in male seafarers and drug abuse in construction workers.

Background: Work in commercial fishing is physically demanding and hazardous, but unlike merchant seamen, fishermen are not required to hold a certificate of medical fitness., Aims: To investigate the case for regulatory medical standards for commercial fishermen and to identify priorities for the prevention and management of occupational injuries at sea., Methods: We surveyed a convenience sample of fishermen at three major fishing ports in South West England using a standardized interview-administered questionnaire., Results: Interviews were completed by 210 (68%) of 307 fishermen approached. Over their careers, 56 subjects (27%) had been returned to shore as an emergency for medical reasons, a rate of 14.6 (95% confidence interval 11.5-18.2) per 1000 man-years. Most emergency evacuations were for acute injuries, and only five were for illness. A few participants suffered from chronic disease that would call into question their fitness to go to sea. Fifty-five fishermen had suffered injuries in the past 12 months, including 12 that had caused loss of more than 3 days from work. Subjects had self-stitched 4 of 15 reported hand lacerations, while others had been bound with 'gaffer' tape., Conclusions: Prevention of hand lacerations should be a high priority, with first-aid training and equipment for fishing crews to improve their care when prevention fails. No firm conclusions can be drawn about the value of regular medical screening for commercial fishermen, but such screening should be considered a lower priority than accident prevention.

Background: National analyses of mortality in England and Wales have repeatedly shown excess deaths from pneumonia in welders. During 1979-90 the excess was attributable largely to deaths from lobar pneumonia and pneumonias other than bronchopneumonia, limited to men of working age and apparent in other occupations with exposure to metal fumes. The findings for 1991-2000 were assessed and compared with the mortality pattern from asthma in occupations exposed to known respiratory sensitisers., Methods: The Office of National Statistics supplied data on deaths by underlying cause among men aged 16-74 years in England and Wales during 1991-2000, including age and last held occupation. Data were abstracted on pneumonia for occupations with exposure to metal fumes and on asthma for occupations commonly reported to surveillance schemes as at risk of occupational asthma. The expected numbers of deaths were estimated by applying age-specific proportions of deaths by cause in the population to the total deaths by age in each occupational group. Observed and expected numbers were compared for each cause of death., Results: Among men of working age in occupations with exposure to metal fumes there was excess mortality from pneumococcal and lobar pneumonia (54 deaths vs 27.3 expected) and from pneumonias other than bronchopneumonia (71 vs 52.4), but no excess from these causes at older ages or from bronchopneumonia at any age. The attributable mortality from metal fume exposure was 45.3 excess deaths compared with an estimated 62.6 deaths from occupational asthma., Conclusion: Exposure to metal fumes is a material cause of occupational mortality. The hazard deserves far more attention than it presently receives.

Objectives: To investigate risks of physical activity at work by pregnancy trimester, including the effects on head and abdominal circumference., Method: At 34 weeks of gestation we interviewed 1327 mothers from the prospective Southampton Women's Survey (SWS); we asked about their activities (working hours, standing/walking, kneeling/squatting, trunk bending, lifting and night shifts) in jobs held at each of 11, 19 and 34 weeks of gestation, and subsequently ascertained four birth outcomes (preterm delivery, small for gestational age (SGA) and reduced head or abdominal circumference) blinded to employment history., Results: Risk of preterm delivery was elevated nearly threefold in women whose work at 34 weeks entailed trunk bending for >1 h/day. Small head circumference was more common in babies born to women who worked for >40 h/week. However, no statistically significant associations were found with SGA or small abdominal circumference, and preterm delivery showed little association with long working hours, lifting, standing or shift work., Conclusions: There is a need for more research on trunk bending late in pregnancy, and on the relationship of work to reduced head circumference. Our findings on several other occupational exposures common among pregnant workers are reassuring.

Background: Serious accidental poisoning by pesticides is rare in the UK, but more minor pesticide-related illness may be under-reported. Anecdotally, use of sheep dip has been linked with flu-like symptoms., Aim: To explore the frequency, nature and determinants of acute symptoms following work with pesticides., Methods: A postal survey of men in three rural areas of England and Wales provided data on occupational use of five categories of pesticide, occurrence of 12 specified symptoms within 48 h of using pesticides and tendency to somatize. Risk factors for pesticide-related symptoms were assessed by modified Cox regression., Results: Of 10 765 responders (response rate = 31%), 4108 had at some time used pesticides occupationally, including 935 (23%) who reported symptoms following such work on at least one occasion. In two areas, acute symptoms were most frequent following use of sheep dip (29 and 32% of users), but in the third area the rate was significantly lower (13% of users). The relative frequency of symptoms was similar for all five categories of pesticide, and flu-like symptoms did not cluster unusually among users of sheep dip. Risk of pesticide-related symptoms increased with somatizing tendency (prevalence ratio for highest versus lowest category 2.4, 95% confidence interval 2.0-3.0) and was higher in men who had used pesticides most often or handled concentrate., Conclusion: Acute symptoms are common following work with pesticides, but in many cases the illness may arise through psychological rather than toxic mechanisms.

Aims: To explore the circumstances associated with hospital admission of adults of working age for accidental pesticide poisoning in England., Methods: From Hospital Episode Statistics we identified all adults aged 16-69 years who completed hospital admissions nationally for accidental pesticide poisoning during April 1998 to March 2003. Further information was obtained through a postal questionnaire completed by the treating consultant., Results: Questionnaires were returned for 62% of 237 identified admissions, including 89 in which definite or possible accidental pesticide poisoning was confirmed. Fifty-four percent of episodes arose from an identifiable mishap, and 26% from unsatisfactory storage or transport of pesticides. Only two incidents resulted from exposure to spray drift. Three patients needed intensive care, but none died., Discussion: Serious accidental pesticide poisoning is rare among adults in England. There is an important contribution from poor storage of pesticides. Non-occupational acute poisoning by spray drift is seldom if ever a cause of hospital admission.

Objectives: To explore the prevalence and pattern of neuropsychiatric symptoms in past users of sheep dip and other pesticides., Methods: From a postal survey of men born between 1933 and 1977 and resident in three rural areas of England and Wales (response rate 31%), data were obtained on lifetime history of work with pesticides, neurological symptoms in the past month, current mental health and tendency to be troubled by non-neurological somatic symptoms (summarised as a somatising tendency score). Risk factors for current neuropsychiatric symptoms were assessed by modified Cox regression., Results: Data were available for 9844 men, including 1913 who had worked with sheep dip, 832 with other insecticides but not sheep dip and 990 with other pesticides but never with sheep dip or insecticides. Neurological symptoms were consistently 20-60% more common in past users of sheep dip than in men who had never worked with pesticides, but their prevalence was also higher in men who had worked only with pesticides other than sheep dip or insecticides. They clustered strongly within individuals, but this clustering was not specific to men who had worked with sheep dip. Reporting of three or more neurological symptoms was associated with somatising tendency (prevalence ratio (PR) 15.0, 95% CI 11.4 to 19.5, for the highest vs the lowest category of somatisation) and was more common in users of sheep dip (PR 1.3, 95% CI 1.0 to 1.6), other insecticides (PR 1.4, 95% CI 1.0 to 1.8) and other pesticides (PR 1.3, 95% CI 1.0 to 1.7) than in non-users. Among users of sheep dip, prevalence was higher in men who had dipped most often, but not in those who had worked with sheep dip concentrate. Past use of pesticides was not associated with current anxiety or depression., Conclusion: Neurological symptoms are more common in men who have worked with sheep dip, but the association is not specific to sheep dip or insecticides. A toxic cause for the excess cannot be ruled out, but several features of our observations suggest that psychological mechanisms have a role.

Objective: To investigate outcome and prognostic determinants for arm pain presenting to primary care and physiotherapy services., Methods: Patients with arm pain were recruited as they presented to primary care and physiotherapy services, and were followed for 12 months. At baseline, they were classified by diagnosis using a validated examination schedule. Depression, somatizing tendency, health anxiety, fear-avoidance beliefs and chronic pain outside the arm were ascertained using standard definitions. Three outcomes were considered: same-site pain during the final month of follow-up (continuing pain); pain present on most days of that month; and pain present without a break of 7 days over follow-up ('unremitting' pain). Associations were explored in multi-level logistic regression models and summarized as odds ratios (ORs) with 95% confidence intervals (95% CIs)., Results: Altogether, 313 (83%) of 375 subjects completed follow-up, including 53% with 'continuing' and 24% with 'unremitting' pain. 'Continuing' pain was predicted most strongly by male sex (OR 1.9, 95% CI 1.2-3.2) (this association was restricted largely to the elbow), higher frequency of pain in the past month at baseline (OR 2.5, 95% CI 1.1-5.6), chronic pain at sites outside the arm (ORs 1.6-2.4 for different sites) and current smoking (OR 3.3, 95% CI 1.6-6.6). There were also indications that mental health and fear-avoidance beliefs influenced prognosis. Predictors for the other two adverse outcomes were similar., Conclusion: Arm pain often persists in patients who consult medical services. Predictors of persistence include male sex (elbow only), frequency of pain at baseline, chronic pain at other sites and smoking.

Aims: To explore the frequency, nature, determinants and outcome of health-related job loss (HRJL) in men sampled from the general population of three rural areas., Methods: Data on lifetime occupational history, including any HRJL, were obtained as part of a postal survey of men aged 24-70 years in three rural areas of England and Wales. Incidence rates were calculated for first health-related loss of a job that had been held for >or=1 year. Associations with risk factors were examined by Poisson regression, and by application of conditional logistic regression in a nested case-control study., Results: HRJL was reported by 1408 (13%) of the 10 559 men who had held long-term jobs. The incidence rose steeply with age for cardiorespiratory and neurological disorders, but for accidents and poisoning the trend was, if anything, in the reverse direction. An increase in incidence over time was most marked for musculoskeletal disorders and mental illness, and much less prominent for cardiorespiratory and neurological disease. In comparison with other occupations, the risk was lower in agricultural workers (odds ratio (OR) 0.6, 95% CI 0.5 to 0.8), and higher in policemen (OR 2.4, 95% CI 1.6 to 3.7) and teachers (OR 2.0, 95% CI 1.5 to 2.7), this differential being even greater for HRJL caused by mental illness. Risk was also increased in employees relative to the self-employed (OR 2.0, 95% CI 1.7 to 2.3). Shift work was associated with a higher incidence of job loss caused by mental illness (OR 1.5, 95%CI 1.1-2.2), and heavy lifting with HRJL caused by musculoskeletal disorders (OR 2.6, 95% CI 2.0 to 3.5). After HRJL, 61% of subjects had subsequently obtained further long-term employment, usually within 1 year., Conclusions: In the population studied, HRJL has become increasingly common, especially in relation to musculoskeletal disorders and mental illness. In addition to being associated with ergonomic stresses in the workplace, it may be importantly influenced by cultural and economic factors. Future research should focus on the minority of workers who leave a job for health reasons and do not rapidly return to further work.

Objectives: To investigate the incidence, nature and determinants of non-fatal occupational injuries in British agriculture., Methods: As part of a postal survey, data on lifetime histories of work in agriculture and occupational accidents were obtained from men born between 1933 and 1977 and residing in three rural areas of England and Wales. Incidence rates for different categories of accident were compared with those derived from statutory reporting. Associations with risk factors were explored by Poisson regression, and summarised by incidence rate ratios (IRRs)., Results: Of the 10 765 responders (response rate = 31%), 3238 (30%) reported at least one occupational accident at the ages of 14-64 years, leading to absence from work for >or=3 days, including 1492 accidents that could be linked to a specific job listed in the history of agricultural work. The reported incidence of injuries in agriculture was markedly higher than that derived from statutory reporting, particularly for self-employed farmers. During 1996-2003, the highest rates of agricultural accidents were from handling, lifting or carrying (4.9/1000 person-years), falls from a height (4.6/1000 person-years) and injury by animals (3.4/1000 person-years). After adjustment for calendar period and age, the risk of accidents was elevated in men who had only recently entered agricultural work (IRR 3.7, 95% CI 2.7 to 5.1 for men who had worked in agriculture for up to 1 year relative to those who had entered the industry >25 years earlier), and in those who carried out forestry (IRR 1.7, 95% CI 1.5 to 1.9)., Conclusion: Our findings confirm the substantial underascertainment of serious accidental injuries in agriculture through statutory reporting, particularly for the self-employed. The risk of accidents is highest in new recruits to the industry and in those undertaking forestry, and these groups should be a target for further preventive action.

Background: Few community-based epidemiological investigations of upper limb disorders (ULDs) have classified cases by validated procedures involving a structured clinical examination., Aim: To compare risk factor profiles for different diagnostic categories of ULD using one such examination scheme., Methods: A questionnaire about upper limb pain and demographic, occupational and psychosocial risk factors was mailed to 10,264 adults from two English general practices, followed by standardized physical examination in those with arm or neck pain. Logistic regression was used to compare those with specific ULDs and non-specific arm pain with those who had no neck or arm symptoms., Results: There was a 59% response rate. A total of 1,197 subjects with arm or neck pain underwent standardized physical examination and were classified as having one or more of 11 specific ULDs or non-specific regional pain. Among these, 250 subjects with specific ULDs and 176 with only non-specific arm pain were compared with 2,248 subjects who had no neck or arm symptoms. Certain physical risk factors were more strongly associated with specific disorders than with non-specific pain. In comparison with pain-free subjects, the odds ratios (ORs) in keyboard users (>or=1 h versus <1 h/day) were 3.1 (95% CI 1.3, 7.8) for hand-wrist tendonitis but 1.3 (0.8, 2.1) for non-specific hand-wrist pain. Other differential associations were found with age, sex, manual versus non-manual employment and smoking. Unexpectedly, low vitality was similarly associated with both specific disorders and non-specific pain., Conclusion: These findings suggest that the schedule may usefully distinguish disorders that differ in their association with physical risk factors.

Background: Somatization (a tendency to report distress from somatic symptoms) is a little studied, but potentially important, confounder and effect modifier in occupational studies of musculoskeletal disease., Aims: To assess the role of somatization as a risk factor for disabling regional pain., Methods: A questionnaire was mailed to 4998 subjects of working age. Questions were asked about chronic and disabling pain in the past 12 months affecting the arm, low back, knee or combinations of these sites. Distress from physical symptoms was assessed using elements of the Brief Symptom Inventory and mental well-being was assessed using the short-form 36 (SF-36). Associations were examined by modified Cox regression and expressed as hazard ratios (HRs) with 95% confidence intervals (CI)., Results: Among 2632 responders, 24% reported chronic pain and 25% disabling pain at one or several sites. Risk of chronic or disabling pain increased strongly according to the number of somatic symptoms reported as bothersome. For example, the HR for chronic upper limb pain in those distressed by > or =2 somatic symptoms in the past 7 days versus none was 3.9 (95% CI 2.9-5.3), and that of disabling upper limb pain was 5.8 (95% CI 4.1-8.3). Similar patterns were found for the low back and knee, and there was a gradient of increasing risk according to the number of sites with disabling pain. In comparison, associations with SF-36 mental well-being score were weaker., Conclusion: Somatizing tendency should be evaluated as a possible confounder or effect modifier in studies of occupational risk factors for musculoskeletal pain.

Objective: To explore possible differences in risk factors for low back pain according to its speed of onset., Methods: We analyzed longitudinal data from 1366 hospital nurses in England who initially had been free from low back pain for at least one month. Risk factors were ascertained from a self-administered baseline questionnaire, and outcomes from serial followup questionnaires. Hazard ratios (HR) for developing a first new episode of low back pain during followup were derived by Cox regression., Results: Low back pain with gradual onset was significantly associated with psychological symptoms measured at baseline [HR 1.7 (95% CI 1.2, 2.4) and higher], but no such association was seen for sudden pain. Low back pain with sudden onset while at work was associated with exposure to specific patient-handling tasks [HR 1.8 (95% CI 1.1, 3.0) to 2.8 (95% CI 1.4, 5.5)]. However, symptoms that came on suddenly elsewhere were not related to occupational activity, and low back pain of gradual onset showed little relation to patient-handling., Conclusion: These findings suggest that a useful distinction can be made according to the speed and circumstances of onset of low back pain. If confirmed, they have important implications for the evaluation of ergonomic interventions aimed at reducing back pain.

Aims: To obtain further information about the risks of cancer associated with occupational exposure to ethylene oxide, Methods: Follow up was extended by 13 years for a cohort of 2876 men and women with definite or potential exposure to ethylene oxide in the chemical industry or in hospital sterilising units. Subjects were traced through National Health Service and social security records, and their mortality was compared with that expected from rates in the national population by the person-years method., Results: Analysis was based on 565 deaths, of which 339 had occurred during the additional period of follow up. Mortality was close to or below expectation for all causes (565 deaths v 607.6 expected), all cancers (188 v 184.2), and for all specific categories of malignancy including stomach cancer (10 v 11.6), breast cancer (11 v 13.2), non-Hodgkin's lymphoma (7 v 4.8), and leukaemia (5 v 4.6). All five deaths from leukaemia occurred in the subset of subjects with greatest potential for exposure to ethylene oxide, but even in this group the excess of deaths was small (2.6 expected)., Conclusions: The balance of evidence from this and other epidemiological investigations indicates that any risk of human cancer from ethylene oxide is low, particularly at the levels of occupational exposure that have occurred in Britain over recent decades. This may reflect the capacity of human cells to repair DNA damage caused by the chemical, which is a potent genotoxin and animal carcinogen.

Aim: To assess the incidence and risk factors for neck and shoulder pain in nurses., Methods: A longitudinal study of neck and shoulder pain was carried out in female nurses at two hospitals in England. Personal and occupational risk factors were assessed at baseline. The self reported incidence of symptoms in the neck and shoulder region was ascertained at three-monthly intervals over two years. A Cox regression model was used to estimate hazard ratios (HRs) for incident neck/shoulder pain during follow up in nurses who had been pain free for at least one month at baseline., Results: The baseline response rate was 56%. Of 903 women who were pain free at baseline, 587 (65%) completed at least one follow up while still in the same job. During an average of 13 months, 34% of these (202 women) reported at least one episode of neck/shoulder pain. The strongest predictor of pain in the neck/shoulder was previous history of the symptom (HRs up to 3.3). For physical exposures at work, the highest risks (HRs up to 1.7) were associated with specific patient handling tasks that involved reaching, pushing, and pulling. Nurses who reported low mood or stress at baseline were more likely to develop neck/shoulder pain later (HR 1.5). Workplace psychosocial factors (including job demands, satisfaction, and control) were not associated with incident neck/shoulder symptoms., Conclusions: Neck/shoulder pain is common among hospital nurses, and patient handling tasks that involve reaching and pulling are the most important target for risk reduction strategies.

To explore whether different distributions of numbness and tingling in the hand can be usefully distinguished in epidemiologic studies of disorders such as carpal tunnel syndrome, the authors used a postal questionnaire, an interview, and a physical examination to collect information about risk factors, symptoms, and signs from a general population sample of 2,142 adults in Southampton, England, during 1998-2000. The authors distinguished six distributions of numbness and tingling and compared their associations with other clinical findings and with known risk factors for upper limb disorders. Distinctive relations were found for symptoms that involved most of the palmar surface of the first three digits but not the dorsum of the hand or the little finger. Such symptoms were more often associated with positive Phalen's and Tinel's tests and, unlike other categories of sensory disturbance, were not related to neck pain or restriction of neck movement. They also differed in showing no association with lower vitality or poorer mental health but an association with repeated wrist and finger movements at work. These findings suggest that, in the classification of numbness and tingling of the hand, it may be useful to distinguish symptoms that involve most of the sensory distribution of the median nerve but not other parts of the hand.

To test the hypothesis that inhalation of metal fume reversibly increases susceptibility to pneumonia, the authors conducted a case-control study. Men aged 20-64 years, admitted to 11 hospitals in West Midlands, England, with community-acquired pneumonia during 1996-1999 were interviewed about their lifetime occupational history, exposure to metal fume, and potential confounding factors. Similar information was collected from controls admitted to the same hospitals with nonrespiratory illness. For cases, exposures were timed relative to the onset of their illness (on average, 6 months before interview). Exposure histories for controls were censored 6 months before interview. Interviews were completed by 525 cases and 1,122 controls (response rates of 74% and 99%). Pneumonia was associated with reported occupational exposure to metal fume in the previous year (adjusted odds ratio (OR) = 1.6, 95% confidence interval (CI): 1.1, 2.4) but not in earlier periods (OR = 1.1). The risk was highest for lobar pneumonia and recent exposure to ferrous fume (OR = 2.3, 95% CI: 1.2, 4.3). The association was not specific to any one microorganism. These findings support the hypothesis that ferrous and possibly other metal fumes reversibly predispose to infectious pneumonia. Research should now focus on the underlying mechanisms and prevention.

Objectives: To investigate whether occupational exposure to organic solvents increases the risk of dementia., Methods: Cases of dementia were identified from the computed tomography records of eight neuroradiology centres in England and Wales, and were compared with two sets of controls investigated at the same centres. The first set of controls were patients with brain cancer and the second set were patients with other disorders that were not chronically disabling. Lifetime occupational histories were obtained through a postal questionnaire completed by the subjects or their next of kin. Associations between dementia and occupation were examined by logistic regression., Results: Usable questionnaires were returned for 204 (61%) of the cases, 225 (51%) of the controls with brain cancer, and 441 (61%) of the other controls. The findings with each of the two sets of controls were similar. In comparison with all controls combined, cases had less often worked ever as a painter or printer (odds ratio (OR) 0.6, 95% confidence interval (95% CI) 0.3 to 1.2), and were less likely to have worked for > 1 year as a printer, painter, or launderer or dry cleaner (OR 0.6, 95% CI 0.3 to 1.4)., Conclusions: These findings provide no support for the hypothesis that occupational exposure to solvents is a cause of dementia. An excess risk in subsets of workers with extremes of exposure cannot be discounted, but the data indicate that any influence of exposure to solvents on the overall incidence of severe dementia in the general population of England and Wales is small.

To test the hypothesis that occupational lifting is a cause of hip osteoarthritis, the authors examined associations with lifting and other occupational activities in a case-control study. The study was performed in two English health districts (Portsmouth and North Staffordshire) from 1993 to 1995. A total of 611 patients (210 men and 401 women) listed for hip replacement because of osteoarthritis over an 18-month period were compared with an equal number of controls selected from the general population and individually matched for age, sex, and general practice. Information about suspected risk factors was obtained by a questionnaire administered at interview and a short physical examination. Analysis was by conditional logistic regression. After adjustment for potential confounders, the risk in men increased progressively with the duration and heaviness of occupational lifting. Relative to those with low exposure, men who had regularly lifted weights in excess of 50 kg for 10 years or longer had an odds ratio of 3.2 (95% confidence interval 1.6-6.5). No comparable association was found in women. Of the other occupational activities examined, only frequent climbing of stairs showed a pattern suggestive of a causal relation. These findings are consistent with the results of other studies, and there is now a strong case for regarding hip osteoarthritis as an occupational disease in men whose work has involved prolonged and frequent heavy lifting.

Hip osteoarthritis is a major cause of pain and disability. The authors explored individual risk factors for hip osteoarthritis in a population-based case-control study. The study was performed in two English health districts (Portsmouth and North Staffordshire) from 1993 to 1995. A total of 611 patients (210 men and 401 women) listed for hip replacement because of osteoarthritis over an 18-month period were compared with an equal number of controls selected from the general population and individually matched for age, sex, and family practitioner. Information about suspected risk factors was obtained by a questionnaire administered at interview and a short physical examination. Obesity (odds ratio (OR) = 1.7, 95% confidence interval (CI) 1.3-2.4; highest vs. lowest third of body mass index), previous hip injury (OR = 4.3, 95% CI 2.2-8.4), and the presence of Heberden's nodes (OR = 1.6, 95% CI 1.2-2.2) were independent risk factors for hip osteoarthritis among men and women. Hip injury was more closely related to unilateral as compared with bilateral disease. There were a negative association between cigarette smoking and osteoarthritis among men and a weak positive association with prolonged regular sporting activity. Obesity and hip injury are important independent risk factors for hip osteoarthritis, which might be amenable to primary prevention. Hip osteoarthritis may also arise as part of the polyarticular involvement found in generalized osteoarthritis.

The objective of this work was to address the relationship between physical activity in the workplace and subsequent musculoskeletal pain syndromes. We performed a survey of 5,042 men and women aged 70-75 years, selected from the retirement population of a large national employer (the post office). Subjects were sent a short postal questionnaire enquiring about all occupations held for at least 1 year, the physical activities performed in those jobs, and about recent rheumatic symptoms. The 1-month period prevalence of rheumatic symptoms ranged from 19.9% for hip pain or stiffness in men to 50% for knee pain or stiffness in women. Symptoms were more common in women than men at all sites and there were significant (P < 0.001) associations between symptoms at different sites. Obesity was significantly (P < 0.001) associated with the risk of pain or stiffness at the knee and hip. Prolonged occupational exposure (20+ years) to heavy lifting was associated with hip pain (RR = 1.5; 95% CI = 1.2-1.8); and prolonged exposure to working with arms elevated was associated with an increased risk of shoulder pain (RR = 1.4; 95% CI = 1.2-1.6). Tall stature (P = 0.003) and heavy lifting (P < 0.001) were both associated with increased risks of low back pain among men. This survey confirms the high prevalence of musculoskeletal symptoms observed in previous population-based studies. Associations between occupational activities and musculoskeletal symptoms were specific for activity type and skeletal site involved. Our results imply that the adverse effects of these occupational activities can be found many years after cessation of exposure.

To investigate the relation of aluminum and silicon in drinking water to risk of Alzheimer's disease, we carried out a case-control study in eight regions of England and Wales. Subjects were identified from the records of neuroradiology centers, and diagnoses were confirmed by a review of hospital case-notes. Exposure to aluminum and silicon in drinking water was estimated from residential histories of 106 men with Alzheimer's disease, 99 men with other dementing illnesses, 226 men with brain cancer, and 441 men with other diseases of the nervous system. All subjects in the study were between 42 and 75 years of age. There was little association between Alzheimer's disease and higher aluminum or lower silicon concentrations in drinking water when cases were compared with any of the control groups. The results indicate that any risk of Alzheimer's disease from aluminum in drinking water at concentrations below 0.2 mg per liter is small, and they give no support for a protective role of silicon.

We assessed whether the causes of aortic aneurysm underlying its distinctive geographical distribution in England and Wales act early or later in life from the OPCS data on deaths in England and Wales during April 1969-December 1972. From these data, we calculated proportional mortality ratios (PMRs) for aortic aneurysm by county of birth and county of death, for men and women aged 45-74. Among people resident in the county of their birth, PMRs for aortic aneurysm by county ranged from 31 in Pembrokeshire to 194 in Surrey. Among 'migrants', who died in a different county from that in which they were born, PMRs by place of death varied from 85 in the group of counties which had the lowest mortality in non-migrants to 111 in those with the highest mortality in non-migrants, and PMRs by place of birth varied from 74 in counties with lowest mortality in non-migrants to 113 in those with highest mortality in non-migrants. After adjustment for place of residence at death, the relation of mortality to place of birth was highly significant statistically (P < < 0.001). These findings indicate important causes of aortic aneurysm acting early in life, perhaps related to the formation of elastin in the arterial wall.

Objectives: To examine the mortality patterns of male and female farmers and farmers' wives in England and Wales., Methods: Information on all deaths in England and Wales at ages 20-74 during the periods 1979-80 and 1982-90 was obtained from the Office of Population Censuses and Surveys. Proportional mortality ratios (PMRs) and proportional cancer mortality ratios (PCMRs) were used to compare the mortality of farmers with that of the general working population, and of farmers' wives with wives of all working men., Results: Farmers and farmers' wives had high mortality from accidents and suicide and from certain respiratory diseases. Mortality from hernia was also raised. Deaths from cancer were generally below expectations, but the PMR for prostatic cancer was 112 (95%CI 106-118). The PMRs and PCMRs for oesophageal cancer were significantly increased in male farmers from two counties where cider is produced., Conclusions: The occupational hazards of farming continue to be associated with excess mortality, and most of the risks extend also to farmers' wives. Action is needed to reduce deaths, particularly from accidents and suicide.

To assess the frequency of bites by the Blandford fly, a postal survey was carried out at the end of the 1993 biting season. Questionnaires were sent to a random sample of 1,500 people, selected from the lists of the two general practices in Blandford Forum, and satisfactory replies were obtained from 1203 (80%). Altogether, 194 (16%) of subjects reported one or more insect bites, during the 2-month season, that had led to skin swelling more than 2.5 cm across. Of these, more than a quarter had suffered associated systemic symptoms, in the form of fever or joint pain. One hundred and forty-nine had used medications for bites, 20 had consulted a doctor, and seven had taken time off work or school. Bites were more common in females (22%) than males (9%). This difference was due largely to a higher frequency of bites on the legs. Risk might be reduced substantially in women by wearing trousers, especially in those who spend a lot of time outdoors.

Objectives: To assess the distribution of personal exposures to nitrogen dioxide (NO2) in school children, and to investigate factors that might influence personal exposure., Methods: NO2 exposures were assessed by use of passive diffusion tubes for 46 children aged 9-11 years, selected from two Southampton schools. The tubes were worn for seven days, and parallel measurements were made with static samplers in the child's kitchen, living room, classroom, and playground. Information about potential exposures was collected by questionnaire., Results: Personal exposures to NO2, averaged over seven days, ranged from 11 to 257 micrograms/m3 (6 to 137 ppb) with a geometric mean of 36 micrograms/m3 (19 ppb). Exposures correlated with concentrations of NO2 recorded in the home, but the relation was far from exact. Factors associated with increased personal exposure included the use of gas appliances in the home, living with one or more smokers, and travel to school by means other than a car. However, together these variables only explained a small part of the variation in personal exposures., Conclusions: These findings reinforce the need for personal monitoring of exposure in studies investigating potential health effects of NO2 in children.

Objective: To assess whether the increased risk of disease related to asbestos in occupations from the construction and engineering industries applies equally to pleural cancer, peritoneal cancer, and asbestosis., Methods: Analysis was based on deaths among men aged 20-74 in England and Wales during 1979-80 and 1982-90. (n = 1,656,096). Information about cause of death and the last full time occupation of decedents was derived from death certificates. Proportional mortality ratios (PMRs) by occupation were calculated for each of pleural cancer, peritoneal cancer, and asbestosis., Results: Altogether, 2848 deaths were attributed to cancer of the pleura, 362 to cancer of the peritoneum, and 281 to asbestosis. When occupations were ranked according to PMRs from these diseases, striking differences were found. The category of construction workers which included laggers had the highest mortality from peritoneal cancer (PMR 990, 64 deaths), but a PMR of only 160 (77 deaths) for pleural cancer. In contrast, several occupations with much higher mortality from pleural tumours had no excess of peritoneal cancer. PMRs for asbestosis related more closely to those for peritoneal than pleural cancer., Conclusions: These findings suggest that the exposure-response relations for diseases related to asbestos are not all linear, and that risks of pleural mesothelioma may be underestimated by simple extrapolation from observations in cohorts with heavy exposure.

Fifteen NHS occupational health departments from the Wessex and Oxford regions took part in an audit of the management of sharps injuries and contamination incidents. Data were collected prospectively for a series of 1102 incidents notified over a nine-month period. The rates of notified incidents for each department ranged from 9 to 44 incidents per 1000 staff members per year. The proportion of injured employees who were naturally immune to hepatitis B or had completed a full course of vaccination against the infection ranged from 57 to 83%, with the main shortfall occurring in ancillary workers. Some departments rarely stored source serum, while others did so in the majority of cases. The proportion of cases where the injured person was known to have had hepatitis B antibody levels > 100 IU/l within the past 12 months, or underwent immediate antibody assessment or had an immediate vaccination against hepatitis B varied from 26 to 97%, with a median of 68%. On the basis of these findings, the audit group has set targets against which performance will be re-assessed in a follow-up exercise.

Objectives: To explore a suspected hazard of lung cancer in butchers and cooks., Methods: 4018 male butchers and 2062 male cooks were identified from the 1961 census of England and Wales. 4857 (79.9%) of these men were traced through the National Health Service Central Register, and 3518 deaths were recorded during follow up to the end of 1992. Mortality from lung cancer and other causes was compared with that of the general population by the person-years method., Results: Mortality from all causes was significantly below that of the national population in both butchers (standardized mortality ratio (SMR) 0.94, 95% confidence interval (95% CI) 0.90-0.98) and cooks (SMR 0.89, 95% CI 0.84-0.95). When allowance was made for a latency of 20 years from entry to follow up, the deficit in butchers was reduced, but that in cooks persisted, and was largely explained by a shortfall of deaths from cancer and circulatory disease. Mortality from lung cancer was close to expectation in the butchers (SMR 1.01, 95% CI 0.90-1.13) and below expectation in the cooks (SMR 0.93, 95% CI 0.75-1.13). Cooks had increased mortality from cancers of the oral cavity (SMR 5.57) and pharynx (SMR 2.66)., Conclusions: The findings provide no support for an occupational hazard of lung cancer in either butchers or cooks. The possibility of excess risk in sub-groups of these occupations cannot be discounted. The high rates of oral and pharyngeal cancer in cooks are probably a consequence of high alcohol consumption.

We have used data from three analyses of occupational mortality for England and Wales to investigate a suspected hazard of pneumonia in welders. Mortality from the disease was consistently raised in welders aged 15-64, with standardised mortality ratios of 184 (95% CI 150-224) in 1959-63 and 157 (121-200) in 1970-72. Analysis of data for 1979-80 and 1982-90 showed that the increased risk is attributable mainly to an excess of pneumococcal and unspecified lobar pneumonia (proportional mortality ratio 255, 95% CI 192-332). No excess occurred in men above retirement age (65). A possible explanation of these findings is that welding fume reversibly increases the susceptibility of the lung to pneumonic infection. The observation of a similar mortality pattern in moulders and coremakers points to the metallic component of the fume as a possible culprit, but ozone or oxides of nitrogen could also be implicated. There are grounds for lobar pneumonia to be considered an occupational disease in welders.

Study Objectives: The aim was to examine the influence of domestic crowding and household amenities in early life on later mortality from all causes and specifically from stomach cancer, chronic obstructive pulmonary disease, and rheumatic heart disease., Design: This was a retrospective cohort study of people whose houses had been surveyed in 1936 and whose household size was known from the 1939 census. Subjects were followed through the National Health Service Central Register from 1951 to 1989., Setting: The housing survey had been carried out in the midland town of Chesterfield., Subjects: Subjects comprised 8138 men and women born after 1900., Results: A total of 2929 deaths were observed during the follow up period. All causes mortality in the full cohort was not consistently related to any of the housing variables examined, but among subjects who were still children at the time of the housing survey, death rates were higher in those whose houses were crowded or lacked a hot water tap. No associations could be shown between stomach cancer and domestic crowding or food storage facilities; chronic obstructive pulmonary disease and domestic crowding or use of gas for cooking; or rheumatic heart disease and domestic crowding. There were few deaths from these causes, however, in subjects who were children at the time of housing survey., Conclusions: The findings suggest that the housing of young adults in Chesterfield during the 1930s had little effect on their later mortality. Further follow up of the cohort is needed before firm conclusions can be drawn about the influence of housing at younger ages.

The possible hazard of lung cancer among cooks was studied in a cohort of 1798 cooks who had retired from the Army Catering Corps and 1310 referents retired from the Royal Army Pay Corps. During the follow-up from 1974 to 1989 the mortality of the referents was similar to that of the national population, apart from a moderate increase in lung cancer [standardized mortality ratio (SMR) 1.38]. Mortality from lung cancer among the cooks was significantly higher than among the national population [SMR 1.82, 95% confidence interval (95% CI) 1.25-2.57], as was mortality from cancer of the large intestine (SMR 3.03), ischemic heart disease (SMR 1.42), cerebrovascular disease (SMR 2.05), and digestive disease (SMR 2.27). The high rate of lung cancer among the cooks supports the hypothesis of an occupational hazard, although at least part of the excess was probably due to smoking. Possible explanations for the elevated mortality from other diseases include poor nutrition in early life, smoking, and high consumption of alcohol.