Mesothelioma: most famous occupational disease on the internet

It’s pretty easy to notice while browsing on the internet that one of the best known occupational diseases is mesothelioma, the cancer of the pleura or the peritoneum, caused in most cases by asbestos exposure, in occupational or environmental settings.

Mesothelioma has become a main target for law firms in the United States as the compensations are high (could easily reach 1 million dollars as the disease is deadly) and the cause-effect relationship is quite clear, as well as there is a certain dose-effect relationship. For instance Selikoff’s report indicated that 8% of 17,800 asbestos insulation workers in the United States and Canada followed from 1967 to 1976 died from malignant mesothelioma. Asbestos is still very present in many construction materials, so this disease still remains of high interest even after the asbestos ban in the US in 1989.

As part of their online marketing efforts to reach new patients, law firms offer high pay-per-click rates for keyword searches including “mesothelioma” and “asbestos”, up to $70 or even more.

The mirage of a quick buck has therefore attracted hoards of home-made webmasters who quickly designed lots of websites containing a few keyword-rich pages. A search for “mesothelioma” on Google gives 11,300,000 results (more than 11 millions!), which is a huge number for a however rare disease, compared for instance to “occupational asthma” (300,000 results) or “silicosis” (667,000 results) or even “contact dermatitis” (885,000 results).

This means that probably the extra 10.5 millions results for “mesothelioma” are just from websites created by webmasters with no medical background whatsoever trying to get rich overnight.

So I wondered what they could possibly have to say about mesothelioma…

And here are some quite funny quotes from such website…

  • Mesothelioma is a type of cancer. It is a cancer of mesothelial cells. These cells cover the outer surface of most of our internal body organs, forming a lining that is sometimes called the mesothelium. So this is where this type of cancer gets its name.

Pretty clear, uh?

  • Mesothelioma cancer can develop in the tissues covering the lungs, abdomen, the pleura.

No kidding, the tissue covering the pleura?!

  • It is unusual for mesothelioma to spread to other parts of the body. But if it does, it does not usually cause troublesome symptoms.

Probably just an itchy sensation, but that’s it, not troublesome at all… :)

Comparison between the French and the Romanian occupational medicine system

  • Overall population: France has 3 times more inhabitants than Romania (62 millions compared to 21 millions)
  • Working population: France has 4 times more workers than Romania (16 millions compared to about 4 millions) – possible explanation: several millions of young/middle age Romanians went to work abroad in the last 15 years
  • Occupational physicians: in France there are about 6500-7000 occupational physicians, in Romania there are only about 330 and some 2000 general practitioners with limited competence in occupational medicine
  • Young occupational physicians: currently, in both countries, about 60 young specialists start working in occupational medicine every year – this will help overcome the lack of professionals in Romania within the following years. In France the prospects are however dramatic: about 1500 occupational physicians are expected to retire in the next 5 years, while only 300 young physicians will replace them and there is already a serious penury of such physicians.
  • Occupational health system: in France, employers organize an internal occupational health & safety service (“services autonomes”) or associate with hundreds/thousands of other employers (“services interentreprises”) in order to better manage the health and safety aspects of work. These medical services employ occupational physicians, auxiliary staff, other health and safety personnel (industrial hygienists, ergonomists, organizational psychologists, toxicologists). In Romania, occupational medicine is mainly a liberal profession, the occupational physicians work under a direct contract with the employer. In large industrial units, however, internal occupational medicine services are set up. In both countries, there are some occupational physicians employed by governmental agencies supervising the functioning of the occupational health and safety system.
  • Workplace activity of physicians: in France, a third of the entire working time of an occupational physician is regulated to take place in the workplace (ergonomic studies, risk identification and evaluation, employers and workers counseling, health promotion, other activities). In Romania, there is not a regulated time, although this is a normal part of an occupational physician’s job; however it depends on the contract with the employer.
  • Numerus clausus of workers under medical surveillance / occupational physician: 3300 in France, not regulated in Romania. Due to the lack of occupational physicians in France, in many medical services, occupational physicians are assigned the maximum number of workers. In Romania, occupational physicians supervise the activity of general practitioners with restricted competence in occupational medicine, so being assigned an unspecified number of workers, possibly several thousands.
  • Medical examinations required by the law: pretty much the same, yet different procedures – pre-employment examinations, periodic examinations, other examinations, better regulated by the law in France. For instance, certain low-risk professional categories in France are examined every two years, in order to save time and medical resources. In Romania, periodic examinations are to take place yearly, however, many small unit employers choose to send new employees only to pre-employment examinations and not to have them followed on a regular basis, given that the enforcement governmental agencies are rather weak.
  • Hospital-based services of occupational medicine: somehow similar as organization, they are assigned to help diagnose difficult cases of suspected occupational diseases.
  • Risk evaluation: mandatory in every enterprise, in both countries. The occupational physician in France maintains an overall risk evaluation document (“fiche d’entreprise”) which may be used by the employer in the elaboration of the official risk evaluation document (“document unique”). In Romania, occupational physicians may be part of the team evaluating health&safety risks, but this is generally not the rule.
  • Occupational diseases: thought to be underreported in both countries, yet much more in Romania. There is a determined list of occupational diseases which may be reported in both countries. In France, the table also specifies the maximum time interval between the end of exposure and the diagnostic/reporting of an occupational disease. In Romania, except for occupational cancer and pneumoconiosis, the worker must be employed at the respective firm, so that the occupational disease might be reported and acknowledged. The reporting is performed by the worker himself in France, by the occupational physician in Romania (or any other physician).
  • Number of occupational diseases in 2006: 42306 in France, 910 in Romania, the huge difference results mainly from the massive underreporting of occupational musculoskeletal diseases (31639 reported in France in 2006, compared to only 47 in Romania). Other figures are closer, take for instance – silicosis: 315 cases reported in France, 268 cases in Romania.
  • Last but not least, the gross salary of an occupational physician: 4000-6500 euros monthly in France, compared to 700 to 1500 euros in Romania

Training in occupational medicine

Recently, as I was reading Joseph LaDou’s book titled “Current occupational and environmental medicine”, I was struck by the similarities between the situation in the US described and the situation of occupational medicine practice in Romania.

In absence of laws to the contrary, industry continues to hire the most compliant and the most cost-effective health care providers and safety specialists. Occupational health nurses in the US (or the general practitioners with a short training in occupational medicine in Romania) are viewed by industry as professional peers of occupational physicians and preferred due the higher compliance and lower costs.
Short-courses designed for physicians with a general medicine practice (200 hours of instruction) are available in Romania, just as in the US (where they are conducted at the University of Cincinnati and the University of California, San Francisco).

Failure to diagnose occupational diseases and consequently eventually compensate workers is due partly to the lack of training of physicians in charge of workers’ health and partly due to interests of the industries. The books’ authors recognize this situation in the US, and it is also the case in Romania.

The shortage of formally trained occupational physicians is about to be corrected in Romania, about 60 young physicians were enrolled to a 4 years residency training in occupational medicine, which compared to about 100 physicians per year in the US represents a huge number.

But there is also a shortage of other professionals in Romania, also representing key players in the process of occupational health.

For instance there are very few industrial hygienists, which greatly impairs the control over workplace chemical and physical hazards. I have knowledge of only one training course in industrial hygiene in Romania, offered by the University of Bucharest, Faculty of Chemistry.
As an occupational physician confronted with a huge number of workplace chemicals, with possible effect on people’s health, it is easy to feel overwhelmed. The medical residency curriculum is deficient in specific training in toxicology and industrial hygiene, so that this course would make a perfect addition, but unfortunately it was discontinued for some reason this year.

Importance of prevention

During the years following the graduation of the medical school, I noticed that there is something very particular with the kind of medicine we’re practicing. Hypertension cannot be cured, but only controlled under medication; it’s the same with diabetes, asthma, and most other diseases, this is the limit of medical knowledge. In general, drugs used currently usually inhibit something, either an enzyme, a specific receptor, a biochemical reaction, there’re very few which actually help build something in the organism and these are used only a secondary line of treatment.

Relatives and friends told me often of various herbal remedies which allegedly could help cure such diseases, and I used to rebuke them, as not scientifically proven and inefficient

Recently, I was drawn attention to this article in Spanish, an 2006 interview with Nobel prize winner Richard J. Roberts, a British biochemist and molecular biologist.

In this interview, he states that in the pharmaceutical industry, as researchers are financed from private sources, they follow lines of research oriented towards finding new drugs that don’t cure diseases, only alleviate its symptoms, so that the end users, the patients, keep buying and using the respective products. This is logical from an economical point of view, but obviously it’s totally unacceptable from an ethical or medical point of view.
Given the aging tendency of the population on one hand and the increasing environmental pollution and altering of healthy life habits, I can foresee that the market for the pharmaceutical companies will expand, further increasing their profits.

Suddenly, I found myself in a privileged medical specialty, one of the few which take action to prevent diseases, rather than treat them for as long as the patient lives.

For instance, I was reading recently some statistics about the guarded prognosis of the occupational skin diseases: despite proper treatment, only 25% of the patients have clearance of the dermatitis, even with a change in jobs, 50% of the cases improve with treatment, but the remaining 25% are the same or worse. This is just an example of how hard it is to actually treat and completely cure a disease once it’s there. Prevention is therefore of paramount importance, and occupational medicine has its well-established role here.

Hand-arm vibration syndrome

Hand-arm vibration syndrome, or vibration white finger, is a complex condition associated with vibration exposure and the use of hand-held vibrating tools.

Symptoms include:

  • white fingers
  • sensory disturbances
  • reduced hand dexterity
  • diminished grip strenght

Additional symptoms:

  • cold intolerance
  • wrist and hand pain
  • muscle cramps

Vibration exposure has a cummulative effect on both vessels and nerves.

The diagnosis of hand-arm vibration syndrome is based on a history of vibration exposure and presence of symptoms. The Stockholm workshop scales are widely used in assessing the severity of this condition in affected individuals.

Electrodiagnostic and vascular flow studies are helpful in excluding other etiologies such as an arterial thrombosis or peripherial nerve compression lesion, although these separate lesions may coexist.

Diagnosed early, this condition is reversible, in in case of long-term exposure, blanching of fingers may persist indefinitely despite avoidance of vibration exposure.

Prevention of hand-arm vibration syndrome includes:

  • Use of well-padded antivibration gloves
  • Frequent breaks from operatring vibratory machinery

Treatement is based on

  • Interruption of exposure to vibration
  • Discontinuation of smoking
  • Oral vasodilators (calcium blockers)
  • Limitation of cold exposure

Aspects of occupational health and safety in Romania

Romania, a former Communist country (1948-1989), joined the European Union on January 1, 2007.
For this purpose, it completed a process of harmonizing the entire legislation on occupational health and safety with that of the European Union, but the application of this legislation in practice lags well behind. It is said that the current situation is similar to that of the developed countries some years ago. But there is a big difference: then most practitioners, industrialists and decision-makers were genuinely ignorant about occupational health risks. Currently the information systems and the communication infrastructure are so well developed that ignorance is no longer an excuse for anyone.

Therefore what lacks now in Romania’s occupational health system is not the information, nor the legislation, but rather more pressure from the government, the worker organizations, the community advocacy groups, as well as more trained occupational health and safety specialists, to help reinforce the modern sound principles of occupational health and safety in workplaces.

Romania’s government is confused: under the pressure from the European Union, it adopted in 2006 a set of Decisions that translate EU Directives on occupational health and safety, which is great. But for instance currently, under political pressure from certain giant economic units, looking forward to cut off costs and preserve the current situation, the government is about to back off, to allow workers medical surveillance to be conducted by physicians with only a 200 hours course training in occupational medicine, instead of occupational physicians trained by a 4-year long residency.

Worker organizations seem to be little interested in occupational health and safety, focusing on getting higher wages rather than on having working conditions improved, preferring a bonus for risky working conditions instead of elimination of those risks.

Due to hard economic conditions, most large industrial complexes broke down to smaller units, with fewer workers and older technology, where occupational health and safety principles are hard to impose and follow.

Occupational health specialists are few, currently there are about 350 occupational physicians in Romania and very few industrial hygienists, employed both in the public and private sectors, which is obviously insufficient for a population of 21.6 million inhabitants. It was estimated that about 1,300 occupational physicians would be required. In order to fill in this lack of specialists, some 2,500 physicians (GPs) received a short-term training in occupational medicine (200 hours course), but their activity was predictably suboptimal. Other several hundreds physicians are currently in training in occupational medicine by residency and expected to start working within a few years.

The results of this situation are well visible: a low prevalence of occupational diseases, well beyond the EU average, due to non-identification and under-reporting of these diseases, even in the context of more hazardous working conditions.

Noise induced hearing loss

In this post, I’ll highlight just a few aspects of this occupational disease.

Legislation

In Romania, the health and safety aspects of occupational exposure to noise is regulated by Government’s Decision no.493, issued 12 April 2006 (link), which accurately translates Directive 2003/10/EC of the European Parliament and of the Council of 6 February 2003 on the minimum health and safety requirements regarding the exposure of workers to the risks arising from physical agents – noise (link).

Noise exposure action and limit values

Lower exposure action value: 80 db(A)
Workers should be offered hearing protection.

Upper exposure action value: 85 db(A)

  • Prevention program: technical and administrative measures to reduce noise below the 87 dB threshold
  • Hearing protectors
  • Medical surveillance

Noise exposure limit value: 87 db(A)

Special mentions on audiometry and hearing loss

Guidelines on performing pure tone air and bone conduction threshold audiometry, by the British Society of Audiology: http://www.thebsa.org.uk/docs/RecPro/PTA.pdf

Audiometry is afterall a subjective assessment. Even if a trained audiometric technician, audiologist or physician can do a lot to obtain accurate results, the level of patient intelligence, cooperation, or good will is still of paramount importance. An electrophysiologic measurement such as brainstem auditory evoked potentials (BAEPs, also known as auditory brainstem response, ABR) can help in determining the general degree of hearing loss without requiring a subjective response from the individual.

Interpretation of periodic audiograms should take in account age correction.

There may be asymmetric occupational noise induced hearing loss in certain cases, such as truck drivers exposed to greater noise to the ear closer to the engine exhaust.

Noise induced hearing loss may be accelerated by synergic risk factors such as cigarette smoking, noisy hobbies (recreational shooting, listening to loud music, motorcycle riding, metalworking), exposure to industrial organic solvents.

NIHL treatment

First measure to be taken is obviously discontinuing worker’s exposure to noise, to prevent further damage to the internal ear.

As for the medical treatment, although no specific treatment is available to cure, as the sensorineural hearing impairment is mainly irreversible, there are some non-specific substances which can be of help to alleviate accompanying tinnitus and to some small degree the hearing loss: vitamins, antioxidants, vasodilators.

Drugs that are currently used to this purpose are:

  • Ginkgo Biloba: 2x120mg/day [commercial products Bilobil, Tanakan]
  • B Vitamins (B-12 and B-3 in particular) –over 25 µg of B-12, over 25 mg for the rest daily for 6 months [commercial product Mega B Complex]
  • N-acetyl cysteine: 3x200mg/day [commercial product ACC]
  • Vinpocetine: 3x10mg/day [commercial product Cavinton]

There are many other suplements to help with both tinnitus and hearing loss: vitamins A, C, E, zinc, magnesium, choline, melatonin, ipriflavone, arginine, resveratrol, lecithin, L carnitine, co-enzyme q10, alpha lipoic acid, Chinese herbs, garlic. Eliminating coffeine intake could help with tinnitus in certain patients.

For instance, a March 28, 2007 in press release, University of Michigan researchers report that in a new study in animals a combination of high doses of vitamins A, C, and E and magnesium, taken one hour before noise exposure and continued as a once-daily treatment for five days, was very effective at preventing permanent noise-induced hearing loss.

This is an interesting observation and I think it could have immediate practical applications in decreasing workers sensitivity to noise in industrial settings.

A smart tool converting pascals into decibels

Sound pressure [Pascal]
Pa = N/m2
Sound pressure level[dB] dB (SPL)

Occupational cancer in Romania

Estimate of occupational cancer rate

Currently, the best estimate of the proportion of cancer deaths due to occupational exposures over the last few decades is 4%, with an associated uncertainty range of 2% to 8%, based on an estimate by Doll and Peto in 1981 in a report to the US Congress, which is nowadays also used by the Health and Safety Executive (HSE) of Great Britain (source).

Situation in Romania

A WHO document indicates that occupational carcinogens cause 0.4% of the cancer cases in Romania, which is 10 times less than the internationally acknowledged estimate of 4% (source).

Given the average incidence of 50,000 new cancer cases per year (source, Romania’s National Institute of Statistics), the 4% estimate points out to about 2,000 of them to be caused by occupational factors, while the 0,4% estimate refers only to 200 such cases.

Do you know how many occupational cancer cases were officially registered in Romania last year (2006)? Only 3 !

France’s example is very telling: for its population 3 times more numerous than Romania’s, there were 371 registered occupational cancer cases in 1995 and 1925 such cases in 1995.

So, what happened to the rest of the cases? Why were they not reported and registered?

There is only one possible explanation, as highlighted by the PHARE occupational medicine expert Herman Spaanjard, who helped conduct a national study in Romania during 2005-2006: „Romanians are genetically resistent to occupational diseases” ! ;)

Subacute lead poisoning

A case I just saw, quite impressive from a medical point of view:

A 35-year old man presented with abdominal colicative pain with acute onset, at his workplace, one hour after starting the night shift. At hospital presentation, about 30 hours later, the pain not only persisted but increased in intensity and symptoms also included nausea, vomiting, loss of appetite or intestinal transit in the last few days.

He has been working for only two months as a foundry worker in the (primary) smelting industry of raw lead ore, in the most polluted town in Europe, Copsa Mica, Sibiu county, Romania. At his workplace, he was was exposed to molten metal fumes (lead and zinc), of high concentration. He said he was given a respirator and the filters/cartridges were changed every few days.

Physical examination was little remarkable: except for epigastric and periombilical pain, Burton’s line (a black line on the gums) and an antialgic body posture, there were no other signs.

As weird as it sounds, in this occupational medicine clinic there is no way to perform atomic absorption spectrophotometry which provides accurate quantitative analyzes for blood lead, so the lab diagnostic use to be based only on urinary lead excretion as indicator of exposure. However, the laboratory technician is in vacation, so not even this analysis could be performed. Urinary delta-aminolevulinic acid, ALA-U, [>25 mg/l] and coproporphyrins, CP-U [1230 ug/l] used as indicators of biological effect were well above normal values, therefore indicating a string inhibition of heme synthesis.

Laboratory findings also showed anemia [hemoglobin 10,6 g/dl] due to increased erythrocyte destruction [urinary urobilinogen 30mg/l, urinary bilirubin 3mg/l]. Other findings: microproteinuria [initially 30mg/l, a few days later 100mg/l]. All other analysis were within normal limits.

The textbook says that lead-induced hemolysis is caused by increased membrane fragility produced by the inhibition of sodium/potassium adenosine triphosphatase and pyrimidine 5′-nucleotidase.

Basophilic stippling of erythrocytes This inhibition of pyrimidine 5′-nucleotidase also impairs elimination of degrading RNA, which can manifest as basophilic stippling of erythrocites. And this patient does have basophilic stippling…

He was given chlorpromazine 25 mg bid im [commercial product Plegomazin] which controlled well the saturnine colic, but also induced sleeping, which was actually quite a good idea, given patient’s initial state of exhaustion. He underwent chelation therapy with d-penicillamine 250 mg po qid [commercial product Cuprenil], the only currently chelator available in Romania [EDTA used to be the first choice, but its production has been discontinued in Romania, for it being too cheap to produce and commercially uneffective.

The clinical evolution is favorable, the patient became completely asymptomatic within a few days, just that today, 8 days after ingression his ALA-U level is still 23.5 mg/l [normal range u to 10mg/l]. This indicates a massive inhibition of heme synthesis enzymes, due to massive exposure and absorption of lead.

But then what? He’ll probably return to his workplace, even against medical advise, hopefully moved to a workstation with lower exposure, just to become intoxicated again and again over the years and watch his health deteriorating. Some of his work colleagues were already intoxicated 20 times… But more on the chronic lead intoxication in another post.

First post

stethoscopeIt’s blogging time! I have some experience in the past with webmastering, published a few websites, but never tried blogging. This website will testimony some of my web ramblings, gathering here some of the best online resources I stumble upon, spiced up with short articles on the theory and the practice of occupational medicine in Romania and some other topics related to the medical field in general. I hope you’ll like it. Please feel free to comment my articles, it’s always getting some feedback.