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PubMed2006

Occupational acrylonitrile exposure and lung cancer: a meta-analysis.

The present work summarizes the currently available published studies on lung cancer and occupational acrylonitrile exposure. Meta-analytic methods were used to estimate the overall risk. To adjust for the healthy worker effect, rate ratio estimates based on regression analyses and ratios of standard mortality ratios were aggregated. Overall effect estimates were 0.95 (95% CI 0.86 to 1.06) and 1.25 (95% CI 1.10 to 1.43) before and after adjustment for the healthy worker effect, respectively. Therefore, a 25% increase in lung cancer risk attributable to occupational acrylonitrile exposure is suggested. Possible contribution of smoking confounding the increased risk cannot be fully excluded.

Acrylonitrile↗
PubMed2005

Differential respirable dust related lung function effects between current and former South African coal miners.

Dust-related dose-response decrements in lung function among coal miners have been reported in several studies, with varying magnitudes across populations. Few studies have compared differences between current and former coal miners. No studies on dose response relationships with lung function have been conducted in South African coal mines, one of the top three producers of coal internationally. The objectives of this study were (1) to describe the relationship between respirable dust exposure and lung function among current and former South African coal miners and to determine whether differential dust related effects were present between these employment categories; (2) to examine dust related dose response relationships, controlling for potential confounding by smoking and a history of tuberculosis (TB). Six hundred and eighty-four current and 188 ex-miners from three bituminous coal mines in Mpumalanga Province were studied. Interviews assessing work histories, smoking profiles and other risk factors were conducted. Work histories were also obtained from company records. Standardised spirometry was performed by trained technicians. Cumulative respirable dust exposure (CDE) estimates were constructed from company-collected sampling and measurements conducted by the researchers. Regression models examined the associations of CDE with per cent predicted FEV(1) and FVC, controlling for smoking, past history of TB and employment status. A statistically significant decline in FEV(1) of 1.1 and 2.2 ml/mg-year/m(3) was found in representative 40-year-old, 1.7-m tall current and former miners, respectively. Significant differences were found between the highest and medium exposure categories. Ex-miners had a lower mean per cent predicted lung function than current miners for each cumulative exposure category, suggesting a "healthy worker" effect. Past history of TB contributed to 21 and 14% declines in per cent predicted FEV(1) and FVC, respectively. Thus, in this cohort, a dose-related decline in lung function was associated with respirable dust exposure, with a magnitude of effect similar to that seen in other studies and important differences between current and former employees. A "healthy worker" effect may have attenuated the magnitude of this relationship. TB was a significant contributor to lung function loss.

Adult↗
PubMed1985

An investigation of bias in a study of nuclear shipyard workers.

The authors examined discrepant findings between a 1978 proportional mortality study and a 1981 cohort study of workers at the Portsmouth, New Hampshire, Naval Shipyard to determine whether the healthy worker effect, selection bias, or measurement bias could explain why only the proportional mortality study found excess cancer deaths among nuclear workers. Lower mortality from noncancer causes in nuclear workers (the healthy worker effect) partly accounted for the observed elevated cancer proportional mortality. More important, however, was measurement bias which occurred in the proportional mortality study when nuclear workers who had not died of cancer were misclassified as not being nuclear workers based on information from their next of kin, thereby creating a spurious association. Although the proportional mortality study was based on a small sample of all deaths occurring in the cohort, selection bias did not contribute materially to the discrepant results for total cancer deaths. With regard to leukemia, misclassification of occupation in the proportional mortality study and disagreement about cause of death accounted for some of the reported excess deaths.

Epidemiologic Methods↗
PubMed1991

Mortality of employed men and women.

This paper presents mortality data for a 1% sample of men and women in England and Wales who were employed at the time of the 1971 Census of Population. It provides background information on the "healthy worker effect" by age, social class (as determined by occupation), cause of death, and length of follow-up. As expected, relative mortality of those employed at census rose with subsequent follow-up. This effect was strongly age-related, apparently as a consequence of the development (and increasing predominance) of chronic diseases with age. This suggests a unified explanation for some of the variation described in the literature. Statistical modelling of the relationship between mortality and length of follow-up confirmed that the healthy worker effect did not entirely disappear as follow-up progressed in this study. We examined social background as an explanation for this persistently low mortality, but found no evidence to suggest that it was an important factor.

Adult↗
PubMed1985

An epidemiological application of Popper's method.

The strong logicodeductive method of science is applied in an investigation of the mortality of a large population of communications workers (338 306 white men) to explain the mortality deficits so often observed in occupational studies. A theory for the healthy worker effect is proposed, and its predictions are tested in comparisons of mortality curves fitted to Weibull functions using regression techniques. The theory, based on the effect of selection on prevalent chronic disease, successfully predicts that as age increases the mortality rates of an employed population soon after hire will diverge from those of a general population. This new finding was observed for mortality from all causes, all causes minus accidents, cardiovascular diseases, and cancers. The theory successfully predicts the rate of decrease of the healthy worker effect as duration of service increases and the relative magnitudes of the effect by cause. Having survived initial empirical testing, this explanation for the effects of selection on occupational mortality meets at least two criteria (only one being sufficient) for deciding whether an explanation is to be preferred: it has made more precise predictions, and it has made new predictions not previously suggested.

Adult↗
PubMed1994

Occupational exposures estimated by a population specific job exposure matrix and 25 year incidence rate of chronic nonspecific lung disease (CNSLD): the Zutphen Study.

The influence of occupational exposures on total mortality and respiratory mortality and morbidity was examined, employing a population specific Job Exposure Matrix (JEM). Moreover, the relationship between time-related variables of exposure to dust and chronic nonspecific lung disease (CNSLD) incidence was analysed, using time since first exposure and duration of exposure. Occupational exposures in the Zutphen cohort were assessed by application of a JEM, arbitrarily considering jobs as exposed when at least 10% of men who had held the job of interest reported an exposure to one or more from a list of 27 chemical agents. None of the exposures was related to mortality due to CNSLD, although results were influenced by the healthy-worker effect and low mortality rates. Exposure to wood dust and a high probability of exposure to dust were associated with total mortality. Exposures to dust and solvents were statistically significantly related to CNSLD incidence. An exposure-response relationship was found for the probability of exposure to dust with CNSLD incidence. Time-related estimates of exposure to dust based on work history were negatively related to CNSLD incidence. The results suggest the presence of a healthy-worker effect, in a general population study, resulting in an underestimation of the relationship between occupational exposures and respiratory diseases based on the evidence published so far. The use of the full work history to determine exposure to dust leads to stronger relationships with CNSLD incidence, compared to conventional analyses using exposure at the start of follow-up.

Age Factors↗
PubMed2006

Mortality and life expectancy of professional fire fighters in Hamburg, Germany: a cohort study 1950-2000.

BACKGROUND: The healthy worker effect may hide adverse health effects in hazardous jobs, especially those where physical fitness is required. Fire fighters may serve as a good example because they sometimes are severely exposed to hazardous substances while on the other hand their physical fitness and their strong health surveillance by far exceeds that of comparable persons from the general population. METHODS: To study this effect a historic cohort study was conducted to assess mortality and life expectancy of professional fire fighters of the City of Hamburg, Germany. Fire departments and trade unions questioned the validity of existing studies from outside Germany because of specific differences in the professional career. No mortality study had been conducted so far in Germany and only few in Europe. Information on all active and retired fire fighters was extracted from personnel records. To assure completeness of data the cohort was restricted to all fire fighters being active on January 1, 1950 or later. Follow up of the cohort ended on June 30th 2000. Vital status was assessed by personnel records, pension fund records and the German residence registries. Mortality of fire fighters was compared to mortality of the Hamburg and German male population by means of standardized mortality ratios. Life expectancy was calculated using life table analysis. Multivariate proportional hazard models were used to assess the effect of seniority, time from first employment, and other occupational characteristics on mortality. RESULTS: The cohort consists of 4640 fire fighters accumulating 111,796 person years. Vital status could be determined for 98.2% of the cohort. By the end of follow up 1052 person were deceased. Standardized Mortality Ratio (SMR) for the total cohort was 0.79 (95% CI, 0.74-0.84) compared to Hamburg reference data and 0.78 (95% CI, 0.74-0.83) compared to National German reference data. Conditional life expectancy of a 30 year old fire fighter was 45.3 years as compared to 42.9 year of a German male in normal population. Job tasks, rank status and early retirement negatively influenced mortality. For fire fighters with comparably short duration of employment the mortality advantage diminished with longer time since first employment. SMR of persons who retired early was 1.25 (95% CI, 1.13-1.60) in reference to the general German population and the SMR of 1.71 (1.18-2.50) in the multivariate regression model. CONCLUSION: A strong healthy worker effect was observed for the cohort, which diminished with longer time since first employment for fire fighters with shorter duration of employment, as expected. The negative effects on mortality of job tasks, rank status and in particular early retirement indicate the presence of undetermined and specific risks related to occupational hazards of fire fighters.

Adolescent↗
PubMed1986

Long-term mortality study of oil refinery workers: V. Comparison of workers hired before, during, and after World War II (1940-1945) with a discussion of the impact of study designs on cohort results.

The mortality experience of a large refinery cohort (1937-1978) was examined by dividing it into three subcohorts according to hire dates: those hired before 1940, those hired during the period 1940-1945, and those hired after 1945. These three periods are approximately equivalent to before, during, and after World War II and span a total hiring period of more than 75 years. The results showed that a substantial portion of the cohort (3,330 or 27%) had been recruited during 1940-1945, and they contributed 980 or 28% of the total deaths. However, their mortality experience was quite different from the rest. A series of significant increases were seen among the external causes for accidents, suicide, and homicide. In terms of overall mortality and in contrast to the rest of the cohort, no "healthy worker effect" was seen (SMR = 1.00). They also showed increases in several types of cancer including cancers of the pancreas and prostate and leukemia. These unusual experiences cannot be explained either on the basis of their war-related deaths or on their period of employment (one-half were terminated within 1 year from date of hire), and data is insufficient to separate the role of hiring practices or their socioeconomic status. However, their life-styles were probably quite different judged from the fact that alcoholism-related deaths were increased as much as fivefold. Almost two-thirds of the total deaths occurred among 4,080 workers in the before 1940 subcohort. Further, the 5,117 workers of the after-1945 subcohort contributed only 5% of the total deaths. Thus, the results of the original refinery cohort (1937-1978) primarily reflect the experience of those employees hired before 1940. Given the same cohort method (historical prospective), cohort results vary widely according to different study designs, and this has implications for "generalizable" risk assessment or risk projections. A prospective study of new hires with 30 years of follow-up is rather inefficient because it would yield only a small number of deaths, with a strong healthy worker effect. The same is true for studies based on active workers with a short period of follow-up. Studies based on time of hire, however, provide a means for controlling time-related occupational exposures.

Accidents↗
PubMed1996

Negative bias in exposure-response trends in occupational studies: modeling the healthy workers survivor effect.

Many occupational studies analyze trends between cumulative exposure and mortality. The authors show that such trends are, in general, negatively confounded by employment status. Mortality rates for workers who leave work ("inactive" workers) are higher than for active workers because some workers leave because they are ill. The percentage of inactive relative to active person-time is higher in low categories of cumulative exposure, causing employment status to act as a negative confounder of exposure-response trends (the opposite occurs for time-since-hire). We illustrate these phenomena using 10 "negative" mortality studies, in which adjustment for employment status removes false trends. However, adjustment for employment status will lead to biased estimates when it acts as an intermediate variable between cumulative exposure and death, as occurs directly when exposure causes a disabling disease that, in turn, causes death or indirectly when exposure causes workers to leave work. The authors illustrate this problem using simulated follow-up data for leaving, disease incidence, and mortality. In the null case in which cumulative exposure affects neither disease incidence (or mortality) nor leaving rates, employment status indeed acts as a negative confounder of exposure-response trends, and traditional adjustment eliminates this confounding. However, when cumulative exposure affects disease incidence or rates of leaving, adjustment for employment status will not be adequate. Employment status falls under the general rubric of variables that are simultaneously confounders and intermediate variables.

Bias↗
PubMedDate not supplied

[Reanalysis of mortality in a petrochemical plant producing vinyl chloride and polyvinyl chloride].

OBJECTIVE: To study cancer mortality among main subgroups of workers employed in VC/PVC production potentially exposed to toxics and carcinogens. MATERIALS AND METHODS: We reanalyzed the mortality of 1,658 males (follow up 1972-1995; 35,626 person years; 170 deaths) by Poisson regression, adjusting for age, age at hiring, calendar period, length of exposure and latency. We calculated the relative risks (RR) and the 95% confidence intervals (CI) for PVC baggers (n. = 197), PVC compound (n. = 403) and autoclave (n. = 209) workers. As an internal reference we used two groups of workers: technicians and employees (main reference: n. = 202 subjects), with the group of other blue collar workers (n. = 639) added for statistical purposes only (minor reference: n. = 841 subjects). RESULTS: Pooling the four subgroups of exposed workers, the comparison with the main reference group allowed us to detect increased mortality from all causes of death (RR = 2.09; CI = 1.09-4.00; 160 deaths), all tumours (RR = 1.53; ns; 81 deaths), lung cancer (RR = 2.05; ns; 29 deaths) and cardiovascular diseases (RR = 3.57; ns; 29 deaths). The analysis for each specific subgroup revealed increased mortality from all causes of death among both PVC baggers (RR = 2.66; CI = 1.27-5.59) and PVC compound workers (RR = 2.68; CI = 1.36-5.27). Comparison of the minor reference group with the overall population of exposed workers showed increased RRs for other diseases, namely, liver tumour (RR = 4.08; ns; 9 deaths), lymphomas and leukaemia (RR = 2.97; ns; 7 deaths) and liver cirrhosis (RR = 3.30; ns; 11 deaths). The analysis for each specific subgroup revealed significantly increased RR for all tumours among PVC compound workers (RR = 1.74; CI = 1.06-2.85), for lung cancer among PVC baggers workers (RR = 3.04; CI = 1.15-7.99) and for liver cancer (RR = 9.57; CI = 1.69-54.1) and liver cirrhosis (RR = 6.32; CI = 1.37-29.07) among autoclave workers. In addition, the two deaths from brain tumour were observed among PVC compound workers. CONCLUSIONS: To highlight the risk previously reported in the literature and to reduce the possible dilution effect (due to comparison bias, healthy worker effect), it proved methodologically pivotal to separate exposed and probably unexposed workers (considered as an internal reference group).

Adult↗
PubMed1993

The effect of occupational type of household on mortality in Japan.

The mortality of the Japanese population was examined focusing on the effect of household head occupation rather than individual occupations. The 'healthy worker effect' (HWE) which implies lower mortality observed in a working than in a non-working populations has been successively observed in comparative studies on mortality in different occupation populations. In this study we report quite similar results analysing the effect of household head occupation. We point out the possibility that HWE should have a component which is shared with the household members if the worker is a household head. We call this component the 'indirect effect'. The results obtained in this study are as follows. The employee household had the lowest mortality followed by self-employed, agriculture and 'others' households. The self-employed household also had a low standardized mortality ratio (SMR) except for diabetes in male. The SMR of the agriculture household was significantly high especially for those above 65 years of age and for suicide in both male and female of age 45 years old and over but low for cirrhosis of liver in male and tuberculosis in both male and female. The SMR of 'Others' household was the highest among the occupational type of households especially between 20-64 years. The similarity in SMR trend among male and female rather than in occupational type of household, despite the fact that males are more likely to be working than females, suggests the presence of indirect effect. Though it is difficult to distinguish direct and the indirect effects completely, we also discuss a method that enables us to distinguish the two effects more effectively.

Adolescent↗
PubMed1995

Mortality from cardiovascular diseases among potash miners exposed to heat.

We assessed mortality rates in a cohort of French potash miners between 1977 and 1987. The cohort comprised all workers of a potash mine active on January 1, 1977, or subsequently hired, with at least 3 years of employment. We compared the mortality of the subcohort exposed to heat from underground work (U) with the mortality of those who had never worked underground (D). The overall mortality was low [standardized mortality ratio (SMR) = 0.89, based on 570 deaths] and was lower among underground workers (age-standardized mortality rate = 660 per 100,000 person-years, 266 deaths) than among daylight workers (age-standardized mortality rate = 710 per 100,000 person-years, 304 deaths). Mortality from ischemic heart diseases (IHD) was higher for underground workers than for daylight workers (relative risk = 1.6). As exposure to heat decreased over time, we analyzed the mortality according to period of hire: within underground workers, we observed a downward trend for mortality from IHD which contrasted with a stable mortality from IHD among daylight workers. Among subjects who left for medical reasons, IHD mortality was five times greater in the heat-exposed group compared with daylight workers. The data are consistent with an increased risk of ischemic heart diseases from a hot environment that is offset by a strong healthy worker effect.

Cardiovascular Diseases↗
PubMed1990

The 'healthy smoker': a phenomenon of health selection?

The detrimental effects of smoking on lung function have been recognized for several decades. Evidence comes from cross-sectional studies which emphasize that damage, certainly at the level of the small airways, may be detectable after a relatively short smoking history, and from longitudinal studies which show that smoking is associated with an increased rate of function loss over time. Implicit in most published evaluations of the evidence has been the concept that smoking is a habit taken up at random by the general population, and that those who do and do not take up the habit start out with similar levels of lung function. Published material was reviewed for evidence to the contrary, consistent with a health selection process similar to that shown in relation to workplace exposures and labeled the 'healthy worker' effect. Despite the wealth of published data on the topic of lung function in relation to the smoking habit, much is presented in a way which does not permit the concept of the 'healthy smoker' to be addressed. Nevertheless, this review revealed sufficient evidence from cross-sectional studies, as well as evidence from one longitudinal study to support the concept of the 'healthy smoker' as an individual who takes up the habit because his/her lungs are relatively resistant to the effects of smoking. If correct, this means that previous studies, particularly those which were cross-sectional in design and focussed on younger persons, are likely to have underestimated the consequences of smoking on lung function. The concept of the 'healthy smoker' may also throw light on characteristics which identify the 'susceptible smoker'.

Adolescent↗
PubMedDate not supplied

[General and oncologic morbidity in Moscow municipal transport drivers].

A case study was undertaken to examine general and cancer mortality rates and cancer morbidity among municipal transport drivers in Moscow. The mortality and cancer morbidity in 1969 to 1988 were followed up among 2528 men and 212 women. In this period, male mortality rates due to malignant neoplasms, cardiovascular diseases and all causes taken together were statistically lower than the expected rates. Male cancer morbidity rates were also lower the expected ones. In the past decade 42 cases of gastric cancer were revealed in the cohort, which was statistically greater than the expected figures (29.8). In the first decade, prostatic cancer mortality was statistically significantly higher in bus drivers with length of service of over 20 years. Among women, there were only 12 deaths, with significantly decreased mortality rates. Esophageal cancer was detected in women who had worked as drivers for 20-29 years. The lower morbidity and mortality rates may be associated with the "healthy worker effect", i.e. with the fact that staff is strictly selected for this job.

Automobile Driving↗
PubMed1990

Mortality from circulatory diseases, especially ischaemic heart disease in sea pilots and boatmen in Sweden 1951-84: a retrospective cohort study.

A cohort of 1455 sea pilots and boatmen employed after 1921 was established. Those identified and alive in 1951 (n = 1323) were linked to the Swedish cause of death register 1951-84. In 21 352 person-years 383 deaths were observed among sea pilots compared with 379.3 expected (SMR = 101;95% CI between 99 and 112) and in 12,127 person-years the observed number of deaths among boatmen was 136, expected 135.9 (SMR = 100) when Swedish men were used as a reference population. For ischaemic heart disease (IHD) (ICD-8: 410-414) the SMR was equal to 96 (obs = 131, exp = 137.2) for sea pilots and 91 (obs = 44, exp = 48.4) for boatmen. No trend over time or geographical differences could be observed. A healthy worker effect could not explain why there was no excess mortality from IHD.

Aged↗
PubMed2003

[Chronic back pain: more than pain in the back. Findings of a regional survey among insurees of a workers pension insurance fund].

BACKGROUND: Surveys with a main focus on back pain tend to isolate the complaint from possibly concomitant pains, other symptoms and disorders. Severe chronic back pain is assumed here to imply more than pain in the back. PARTICIPANTS AND METHODS: We report results from a two stage survey conducted in 1998 - 2000. The initial postal questionnaire addressed all 10,000 actively employed blue collar workers from a regional pension fund (Landesversicherungsanstalt Schleswig-Holstein) aged 40 - 54 and residing in or around Luebeck/Germany (68 % males). Subjects reporting severe and disabling back pain were invited to a socio-medical examination. The response and participation rates were 58 % and 65 % respectively. Non-response and non-participation seem to result in minor though opposite, effects. RESULTS: The prevalence of current back pain (back pain of any severity within the past 7 days) is high (68 %; including 16 % with severe, disabling back pain) despite the preponderance of males and a probable healthy worker effect. 82 % of subjects participating in the second round reported recurrent or persisting back pain on the day of examination, in the majority with a chronic fluctuating and overall deteriorating course pattern. 18 % reported no current back pain and hence gave prospective (and additionally retrospective) evidence of an episodic-intermittent course of the disorder. The former group showed significantly more pains, bodily complaints, dysfunctional cognitions, emotional distress and concomitant disorders. 35 % of them indicated back pain as their dominant health problem; 49 % identified back pain and another disorder as dominant, and 16 % reported other prominent health problems. More than 70 % of "other" disorders originated from the musculoskeletal system often involving the extremities. SUMMARY AND CONCLUSION: Back pain is very common among blue collar workers. Severe disabling back pain is usually associated with numerous other pains, bodily complaints, disorders, and indicators of psychological distress ("amplified back pain"). However, even amplified back pain is not always the sole or dominant health problem. Assessing the degree of "amplification" seems helpful in splitting a previously homogeneous group of severely affected back pain sufferers-with possible prognostic and therapeutic consequences.

Adult↗
PubMed1996

Socioeconomic differences in 'avoidable' mortality in Sweden 1986-1990.

BACKGROUND: 'Avoidable' mortality is commonly studied as an indicator of the outcome of health care. In this study socioeconomic differences in avoidable mortality in Sweden from 1986 to 1990 are analysed and related methodological issues discussed. METHODS: The 1985 Swedish Population and Housing Census was linked to the National Cause of Death Register 1986-1990. Mortality from potentially 'avoidable' causes of death was analysed for the age group 21-64 years. Analyses were performed for different socioeconomic groups, blue-collar workers, white-collar workers and the self-employed as well as for individuals outside the labour market. Standardized Mortality Ratios were calculated using standardization by age and sex. RESULTS: For all indicators studied, the death rates for those not in work were higher than for people at work. The largest differences were found for chronic bronchitis, diabetes, bacterial meningitis, ulcer of the stomach and duodenum, chronic rheumatic heart disease, asthma and hypertensive and cerebrovascular disease. For these causes of death the risk of dying was between 3.1 and 7.5 times greater in the non-working population than in the work-force. The differences in avoidable mortality between blue-collar workers and white-collar workers and the self-employed were, however, much smaller. For most of the indicators no significant differences were found. For ulcers of the stomach and duodenum, however the death rate for blue-collar workers was 2.8 times higher than those for other categories in work. CONCLUSIONS: The small difference in mortality outcome for different socioeconomic groups within the work-force indicates an equal quality of care for these groups. The greatly increased risk among the non-working population, however, is a warning sign. These results may be due to a 'healthy worker' effect. The measurement of socioeconomic differences in mortality may be dependent on the time-period chosen between occupational exposure and mortality outcome.

Adult↗
PubMed2004

[Patterns of mortality in a cohort of workers followed during 28 years: the Manresa study].

INTRODUCTION AND OBJECTIVES: To describe mortality patterns in a cohort of workers followed for 28 years, to estimate possible trends, and to compare the findings with those for the general population. SUBJECTS AND METHOD: The cohort included 1059 healthy male workers aged 30 to 59 years and followed for 28 years. Physical examinations and structured interviews were carried out every 5 years. Deaths were recorded from death certificates. The standardized mortality ratio (SMR) was calculated using sex- and age-specific mortality rates for the Catalan population as a reference for the same time period. RESULTS: The number of observed deaths in this cohort was 259 (24%). The main causes of death were cardiovascular diseases (n = 90, 35%) and cancer (n = 90, 35%). No excess mortality was observed in the cohort in comparison to the general population. All-cause mortality was lower, and cause-specific mortality was lower than or similar to rates in the general population. Overall, 382 deaths were expected, resulting in a significantly lower standardized mortality ratio of 67.7% (95% CI: 59.7%-76.5%). CONCLUSIONS: The patterns of mortality in this cohort of male workers were similar to those in the general population. Total mortality was lower than expected--evidence of the "healthy worker effect" which was particularly strong during the early part of the follow-up period.

Adult↗