Search

Hypertension is the foremost risk factor for cardiovascular disease (CVD), which is the leading cause of death globally. In some countries, such as the US, the prevalence of hypertension and working-age CVD mortality are increasing. CVD is also the most common work-related disease worldwide. Long working hours and other psychosocial stressors at work are important modifiable risk factors for hypertension and CVD. However, there has been inadequate attention paid to the primary prevention of work-related hypertension and CVD. The state-of-the art method for blood pressure (BP) measurement is 24-hour ambulatory BP (ABP), necessary for accurate clinical decision making and to assess risk factors for BP elevation. Thus, ABP should be used in workplace screening and surveillance programs (along with surveys) to identify occupational risk factors, high-risk job titles, worksites and shifts, and evaluate programs designed to improve work organization. For example, after 30 months of an organizational intervention designed to lower psychosocial stressors at work among >2000 public sector white-collar workers in Quebec, Canada, BP and prevalence of hypertension significantly decreased in the intervention group, with no change in the control group, and a significant difference between the intervention and control groups. Further research is also needed on mechanisms linking work-related factors to hypertension and CVD, the cardiovascular effects of understudied work stressors, high-CVD risk worker groups, potential “upstream” intervention points, and country differences in working conditions, hypertension and CVD. Important organizational interventions, such as collective bargaining, worker cooperatives, or legislative and regulatory-level interventions, need to be evaluated.

OBJECTIVES: This study aimed to develop and evaluate a job-exposure matrix (JEM) specific to healthcare workers, JEM Soignances, based on self-reported data. METHODS: The JEM was constructed using data from healthcare workers within the CONSTANCES cohort (N=12 489). Job titles and sectors of activity (eg, hospital activities) defined occupational groups. We assessed 24 exposures covering organizational, psychosocial, physical, chemical and biological factors. Several methods (group-based frequency, CART, random forest, extreme gradient boosting machine) were applied using a 70% training sample. Performance was evaluated on the remaining 30% using area under the ROC curve (AUC) and Cohen’s Kappa (κ). Two alternative JEM were proposed using only job titles or adding healthcare establishment size and type (public/private) to define occupational groups. RESULTS: All methods offered similar discriminatory power (AUC). We selected the group-based frequency method as it was the most understandable and easiest to implement. Of the 24 included exposures, 15 demonstrated satisfactory performance, with nine showing good discriminatory power and fair-to-moderate agreement, such as physical effort at work (AUC=0.861, κ=0.556), ionizing radiation exposure (AUC=0.865, κ=0.457), carrying heavy loads (AUC=0.840, κ=0.402), shift work (AUC=0.807, κ=0.383), and formaldehyde exposure (AUC=0.847, κ=0.289). The remaining nine exposures mainly showed poor-to-moderate discriminatory power and poor agreement. Compared to JEM Soignances, the job title-only JEM performed poorly, while the one incorporating healthcare establishment size and type showed similar results. CONCLUSIONS: JEM Soignances provides good internal performance and validity. Future research will assess its external validity by comparing it with existing JEM and examining its predictive validity regarding known associations between exposures and health outcomes (eg, long working hours and strokes).

Abstract Background The pathophysiology of toxico-nutritional optic neuropathies remains debated, with no clear understanding of the respective roles played by the direct alcohol toxicity, smoking and the often associated vitamin deficiencies, which are risk factors for optic neuropathy. Our aim was to investigate genetic susceptibility in patients with bilateral infraclinical optic neuropathy associated with chronic alcohol use disorder. Methods This retrospective cohort study included 102 visually asymptomatic patients with documented alcohol use disorder from a French reference center. Optic neuropathy was identified with optical coherence tomography (OCT), after which genetic susceptibility in the group of affected patients was investigated. Genetic testing was performed using panel sequencing of 87 nuclear genes and complete mitochondrial DNA sequencing. Results Optic neuropathy was detected in 36% (37/102) of the included patients. Genetic testing of affected patients disclosed two patients (2/30, 6.7%) with optic neuropathy associated with pathogenic variants affecting the SPG7 gene and five patients (5/30, 16.7%) who harbored variants of uncertain significance close to probable pathogenicity in the genes WFS1, LOXL1, MMP19, NR2F1 and PMPCA. No pathogenic mitochondrial DNA variants were found in this group. Conclusions OCT can detect presence of asymptomatic optic neuropathy in patients with chronic alcohol use disorder. Furthermore, genetic susceptibility to optic neuropathy in this setting is found in almost a quarter of affected patients. Further studies may clarify the role of preventative measures in patients who might be predisposed to avoidable visual loss and blindness.

Introduction: Biological risks are a major global problem in the workplace. The recent COVID-19 pandemic has highlighted the need for a more comprehensive understanding of the biological risks at work. This study presents data on both communicable infectious biological agents and noncommunicable factors leading to death and disability for the year 2021. Methods: We followed the methodology established by the International Labour Organization (ILO) in their past global estimates on occupational accidents and work-related diseases. We used relevant ILO estimates for hazardous substances and related population attributable fractions derived from literature, which were then applied to World Health Organization mortality data. The communicable diseases included in the estimates were tuberculosis, pneumococcal diseases, malaria, diarrheal diseases, other infectious diseases, neglected tropical diseases, influenza associated respiratory diseases and COVID-19. Noncommunicable diseases and injuries considered were Chronic Obstructive Diseases (COPD) due to organic dusts, asthma, allergic reactions and risks related to animal contact. We estimated death attributable to biological risk at work and disability in terms of disability adjusted life years (DALYs). Results: We estimated that in 2022, 550,819 deaths were caused by biological risk factors, with 476,000 deaths attributed to communicable infectious diseases and 74,000 deaths caused by noncommunicable factors. Among these, there were 223,650 deaths attributed to COVID-19 at work. We calculated the rate of 584 DALYs per 100,000 workers, representing an 11% increase from the previous estimate of the global burden of work-related disabilities measured by DALYs. Conclusion: This is a first update since previous 2007 ILO estimates, which has now increased by 74% and covers most biological risks factors. However, it is important to note that there may be other diseases and deaths are missing from the data, which need to be included when new information becomes available. It is also worth mentioning that while deaths caused by major communicable diseases including COVID-19 are relatively rare within the working population, absences from work due to these diseases are likely to be very common within the active workforce.

Introduction: The COVID-19 pandemic turned biological hazards in the working environment into a global concern. This systematized review of published reviews aimed to provide a comprehensive overview of the specific jobs and categories of workers exposed to biological hazards with the related prevention. Methods: We extracted reviews published in English and French in PubMed, Embase, and Web of Science. Two authors, working independently, subsequently screened the potentially relevant titles and abstracts recovered (step 1) and then examined relevant full texts (step 2). Disagreements were resolved by consensus. We built tables summarizing populations of exposed workers, types of hazards, types of outcomes (types of health issues, means of prevention), and routes of transmission. Results: Of 1426 studies initially identified, 79 studies by authors from every continent were selected, mostly published after 2010 (n = 63, 79.7%). About half of the reviews dealt with infectious hazards alone (n = 38, 48.1%). The industrial sectors identified involved healthcare alone (n = 16), laboratories (n = 10), agriculture (including the animal, vegetable, and grain sectors, n = 32), waste (n = 10), in addition of 11 studies without specific sectors. The results also highlighted a range of hazards (infectious and non-infectious agents, endotoxins, bioaerosols, organic dust, and emerging agents). Conclusion: This systematized overview allowed to list the populations of workers exposed to biological hazards and underlined how prevention measures in the healthcare and laboratory sectors were usually well defined and controlled, although this was not the case in the agriculture and waste sectors. Further studies are necessary to quantify these risks and implement prevention measures that can be applied in every country.

OBJECTIVES: This study aimed to construct and evaluate a gender-specific job exposure matrix (JEM) for 27 physical work exposures, based on self-report.METHODS: We constructed a JEM using questionnaire data on current physical exposures from 29 381 male and 35 900 female asymptomatic workers aged 18–69 years in the French CONSTANCES cohort study. We excluded workers with musculoskeletal pain to reduce potential reporting bias. We grouped 27 self-reported physical exposures using the French national job codes and stratified by gender. We compared individual and group-based exposures using the performance indicators Cohen’s kappa (κ), sensitivity, specificity, and area under the receiver operating curve (AUC).RESULTS: JEM validation showed fair-to-moderate agreement (κ 0.21–0.60) for most physical exposures for both genders except for ‘reach behind’ (poor), ‘bend neck’ (poor), ‘finger pinch‘ (poor), standing’ (good), ‘use computer screen’ (good), and ‘use keyboard or scanner’ (good). We found the highest AUC for ‘standing’ (men 0.85/ women 0.87), ‘kneel/squat’ (men 0.80/women 0.81), ‘use computer screen’ (men/women 0.81), and ‘use keyboard or scanner’ (men 0.82/ women 0.84). The AUC was

ObjectivesThough the rise of big data in the field of occupational health offers new opportunities especially for cross-cutting research, they raise the issue of privacy and security of data, especially when linking sensitive data from the field of insurance, occupational health or compensation claims. We aimed to validate a large, blinded synthesized database developed from the CONSTANCES cohort by comparing associations between three independently selected outcomes, and various exposures.MethodsFrom the CONSTANCES cohort, a large synthetic dataset was constructed using the avatar method (Octopize) that is agnostic to the data primary or secondary data uses. Three main analyses of interest were chosen to compare associations between the raw and avatar dataset: risk of stroke (any stroke, and subtypes of stroke), risk of knee pain and limitations associated with knee pain. Logistic models were computed, and a qualitative comparison of paired odds ratio (OR) was made.ResultsBoth raw and avatar datasets included 162,434 observations and 19 relevant variables. On the 172 paired raw/avatar OR that were computed, including stratified analyses on sex, more than 77% of the comparisons had a OR difference ≤0.5 and less than 7% had a discrepancy in the statistical significance of the associations, with a Cohen's Kappa coefficient of 0.80.ConclusionsThis study shows the flexibility and the multiple usage of a synthetic database created with the avatar method in the particular field of occupational health, which can be shared in open access without risking re-identification and privacy issues and help bring new insights for complex phenomenon like return to work.

Since the beginning of the COVID-19 pandemic, there has been a growing literature on COVID and work (1). Major editorials (2–4) and reports from international associations and agencies (5–8) have highlighted the importance of occupational health research in COVID-19 prevention and management. Occupational health research has focused on specific worker populations with high prevalence of COVID-19, particularly healthcare workers, and has studied the associations between different work exposures to SARS-CoV-2 and incidence of COVID-19. Some countries have also begun to provide workers’ compensation for occupationally-acquired COVID-19 (9–13). Return to work (RTW) following COVID-19 is another crucial topic that has been studied among patients with severe cases of SARS-CoV-2 infection in different countries (14–18). Clinicians have also observed patients who suffer from persistent symptoms following COVID-19, often called “long-COVID” (19). Through analyses of large health databases, a variety of post-acute sequelae among patients with COVID-19 have been identified, including malaise, fatigue, musculoskeletal pain, anemia, and other respiratory, neurocognitive, mental health, metabolic, cardiovascular, and gastrointestinal disorders (20). The World Health Organization defined a “post COVID-19 condition” among individuals with a history of probable or confirmed SARS-CoV-2 infection with symptoms continuing three months from the onset of COVID-19 infection, which last for at least two months, and which cannot be explained by an alternative diagnosis (21). Common symptoms include fatigue, shortness of breath, cognitive dysfunction, and generally have a significant impact on everyday functioning. Symptoms may be of new onset following initial recovery from an acute COVID-19 episode or persist from the initial illness. Symptoms may also fluctuate or relapse over time. The “Global Burden of Disease Long COVID Collaborators”, a worldwide collaboration, defined three main post-COVID condition symptoms: (i) persistent fatigue with bodily pain (myalgia) or mood swings; (ii) cognitive problems, often forgetfulness or concentration difficulties, commonly referred to as “brain fog;” and (iii) ongoing respiratory problems (shortness of breath and persistent cough as the main symptoms) (22). This task force showed that, in a pooled study of over one million subjects, the prevalence of post-COVID condition was 0.9% [95% confidence interval (CI) 0.3–2.0%] after one year, but was at as high as 15% for symptoms that were presents at three months. Different factors were associated with a post-COVID condition, including age 20–49 years, female sex, and initial severity of illness (including hospitalization, intensive care unit admission, and mechanical ventilation) (22–24). For example, 26.6% (95% CI 11.5-47.8) of women who needed intensive care support had a post-COVID condition after a year. In 2023 in the United Kingdom, it was estimated that 2.0 million people living in private households (3.0% of the population) were experiencing self-reported post-COVID conditions (defined as symptoms continuing for more than four weeks after the first confirmed or suspected COVID-19 infection that were not explained by something else) (25). In the sample, more than 85% were in the working age. The consequences of such unexpected persistence of disease on the health of the workforce are large. Most of the post-COVID symptoms found in the general population were similar for workers: in a recent review including 60 cohort studies of working age adults and 10 cases studies, the most frequently reported post-COVID-19 symptoms were fatigue (92%), shortness of breath (82%), muscle pain (44%) and joint pain (35%) (26). In a recent study with a 15-month follow-up of workers, similar symptoms were reported as well as cognitive symptoms and autonomic dysregulation (27). This study also assessed the Work Ability Index, and found that women had a larger self-reported reduction in work ability following COVID infection than men. RTW and work factors related to post-COVID condition have been examined in small samples of workers, and found that poorer work ability was related to previous comorbidities, symptoms of fatigue, and some occupational and work organizational factors (28–31). Previous comorbidities related to chronic disease (obesity, hypertension and respiratory disorders), were associated with slower RTW among healthcare workers hospitalized for COVID-19. Asthenia / reported loss of memory and sleep disorders were associated with the longest duration of work absence (>3 months) (29). Some type of work and activity sectors have also been related to RTW outcomes. For example, in a small Canadian descriptive study, among healthcare workers physicians had better improvement than nurses and healthcare assistants (28), and business, finance and management sectors had overall the RTW outcome though not significant (31). Modification of work duties improved RTW in this same study, whereas skeptical reactions from employers and colleagues and lack of support from the social welfare system complicated RTW in a qualitative study (30).Aben et al (32) conducted a study among employees who reported sick due to COVID-19 (N=30 396) or flu-like symptoms not due to COVID-19 (N=15,862), using routinely collected data from a national Dutch occupational health service. Even though there was a 100% RTW rate three months after a flu-like syndrome, the RTW rate after COVID-19 was only 92.8%. The authors were also able to determine important predictors contributing to later return to work in specific statistical models: older age [hazard ratio (HR) 0.99, 95% CI 0.99–0.99], female sex (HR 0.88, 95% CI 0.86–0.90), belonging to a risk group – including chronic illness, compromised immune system, diabetes, and obesity (HR 0.85, 95% CI 0.82–0.89), and some specific symptoms like shortness of breath and fatigue (HR for both symptoms 0.70, 95% CI 0.68–0.72) (32). However, other potential predictors (working conditions and workplace factors, economic context, resources, personal and lifestyle factors) were not exhaustively considered, and understanding causal relation between these factors and the RTW predictors identified is difficult. Aben et al (32) also highlighted that time-to-RTW was shortened as different virus variants became dominant over time. For example, 12.8% of employees who contracted COVID-19 were absent from work for >12 weeks during the alpha virus dominant period, but this number declined to 5.8% in the delta virus-dominant period and to 1.4% in the omicron virus dominant period (32). Strategies promoting return to work for those with post-COVID-19 conditions will need to be implemented and could be comparable to programs developed for other chronic conditions, since post-COVID conditions share some similarities to post-intensive care syndrome, fibromyalgia, and chronic fatigue syndrome (15, 33, 34). These patients have better outcomes following integrative health approach that combines traditional medical management, non-pharmacological treatments including physical therapy, and behavior and lifestyle changes (35, 36). As with RTW following other illnesses, RTW efforts post-COVID should look out for potential red flags or complications (19). Guidelines recommend that occupational practitioners should be included in the process as early as possible, and give importance to job accommodations for improving work ability of such workers (5, 8, 37). An observational study on a small sample of workers undergoing specific rehabilitation for post-COVID conditions reported significant but modest improvements on a variety of symptoms, though only half of the participants were able to return to work (31). Additional research in working populations is needed with larger observational cohorts, randomized controlled trials, and mixed approaches to evaluate the cost-effectiveness of integrative care and other approaches in preserving work ability for these patients (38–40).In conclusion, COVID-19 remains an important topic for the occupational health research agenda, including acute and post COVID conditions. Although there is still debate about the definition of what a `post-COVID condition` entails, the sheer number of patients who are not returning to work in a timely manner or returning to work with limitations, and the lack of research interventions available should lead occupational health practitioners and researchers to work not only to prevent infection but to prevent or reduce work disability resulting from the COVID-19 pandemic and future pandemics.Acknowledgements and conflict of interest. Authors are paid form their institutions. AD is editor in chief of Archives des maladies professionnelles et de l’environnement and received form a regional grant (TEC-TOP, Pays de la Loire Region, Angers Loire Metropole, University of Angers, CHU Angers). References 1. Burdorf A, Porru F, Rugulies R. The COVID-19 pandemic: one year later - an occupational perspective. Scand J Work Environ Health 2021;47:2457. https://doi.org/10.5271/sjweh.3956 2. Burdorf A, Porru F, Rugulies R. The COVID-19 (Coronavirus) pandemic: consequences for occupational health. Scand J Work Environ Health 2020;46:22930. https://doi.org/10.5271/sjweh.3893 3. Sim MR. The COVID-19 pandemic: major risks to healthcare and other workers on the front line. Occup Environ Med 2020;77:2812. https://doi.org/10.1136/oemed-2020-106567 4. Descatha, A. [COVID-19: Tribute to Health Care Warriors, to their occupational health units, and to their strategists]. Arch. Mal.Prof. Environ. 2020;3:1712. 5. Global impact and policy recommendations (COVID-19 and the world of work) [Internet]. [cited 17.2.2023]. Available from: https://www.ilo.org/global/topics/coronavirus/impacts-and-responses/lang--en/index.htm 6. COVID-19: Occupational health and safety for health workers: interim guidance, 2 February 2021 [Internet]. [cited 17.2.2023]. Available from: https://www.who.int/publications-detail-redirect/WHO-2019-nCoV-HCW_advice-2021-1 7. COVID-19 - Control and Prevention | Occupational Safety and Health Administration [Internet]. [cited 17.2.2023]. Available from: https://www.osha.gov/coronavirus/control-prevention 8. COVID-19: Back to the workplace - Adapting workplaces and protecting workers | Safety and health at work EU-OSHA [Internet]. [cited 17.2.2023]. Available from: https://osha.europa.eu/en/publications/covid-19-back-workplace-adapting-workplaces-and-protecting-workers 9. Descatha A, Fadel M, Pitet S, Verdun-Esquer C, Esquirol Y, Legeay C, et al. SARS-CoV-2 (COVID-19) Job Exposure Matrix: “Mat-O-Covid” Creation (COVID-Mate in French), accuracy study, and perspectives. Archives des Maladies Professionnelles et de l’Environnement 2021;82:48793. https://doi.org/10.1016/j.admp.2021.07.008 10. Oude Hengel KM, Burdorf A, Pronk A, Schlünssen V, Stokholm ZA, Kolstad HA, et al. Exposure to a SARS-CoV-2 infection at work: development of an international job exposure matrix (COVID-19-JEM). Scand J Work Environ Health 2022;48:6170. https://doi.org/10.5271/sjweh.3998 11. Descatha A, Sembajwe G, Gilbert F, Mat-O-Covid Investigation Group null, Fadel M. Mat-O-Covid: Validation of a SARS-CoV-2 Job Exposure Matrix (JEM) Using Data from a National Compensation System for Occupational COVID-19. Int J Environ Res Public Health 2022;19:5733. https://doi.org/10.3390/ijerph19095733 12. van der Feltz S, Peters S, Pronk A, Schlünssen V, Stokholm ZA, Kolstad HA, et al. Validation of a COVID-19 Job Exposure Matrix (COVID-19-JEM) for Occupational Risk of a SARS-CoV-2 Infection at Work: Using Data of Dutch Workers. Ann Work Expo Health 2023;67:920. https://doi.org/10.1093/annweh/wxac032 13. Fadel M, Gilbert F, Legeay C, Dubée V, Esquirol Y, Verdun-Esquer C, et al. Association between COVID-19 infection and work exposure assessed by the Mat-O-Covid job exposure matrix in the CONSTANCES cohort. Occup Environ Med 2022;79:7829. https://doi.org/10.1136/oemed-2022-108436 14. Hodgson CL, Higgins AM, Bailey MJ, Mather AM, Beach L, Bellomo R, et al. The impact of COVID-19 critical illness on new disability, functional outcomes and return to work at 6 months: a prospective cohort study. Crit Care 2021;25:382. https://doi.org/10.1186/s13054-021-03794-0 15. Godeau D, Petit A, Richard I, Roquelaure Y, Descatha A. Return-to-work, disabilities and occupational health in the age of COVID-19. Scand J Work Environ Health 2021;47:4089. https://doi.org/10.5271/sjweh.3960 16. Gualano MR, Rossi MF, Borrelli I, Santoro PE, Amantea C, Daniele A, et al. Returning to work and the impact of post COVID-19 condition: A systematic review. Work 2022;73:40513. https://doi.org/10.3233/WOR-220103 17. Griffiths D, Sheehan L, van Vreden C, Petrie D, Whiteford P, Sim MR, et al. Changes in work and health of Australians during the COVID-19 pandemic: a longitudinal cohort study. BMC Public Health 2022;22:487. https://doi.org/10.1186/s12889-022-12897-4 18. Fourie M, van Aswegen H. Outcome of survivors of COVID-19 in the intermediate phase of recovery: A case report. S Afr J Physiother 2022;78:1751. https://doi.org/10.4102/sajp.v78i1.1751 19. DeMars J, Brown DA, Angelidis I, Jones F, McGuire F, O’Brien KK, et al. What is Safe Long COVID Rehabilitation? J Occup Rehabil 2022;14. https://doi.org/10.1007/s10926-022-10075-2 20. Al-Aly Z, Xie Y, Bowe B. High-dimensional characterization of post-acute sequelae of COVID-19. Nature 2021;594:25964. https://doi.org/10.1038/s41586-021-03553-9 21. A clinical case definition of post COVID-19 condition by a Delphi consensus, 6 October 2021 [Internet]. [cited 17.2.2023]. Available from: https://www.who.int/publications-detail-redirect/WHO-2019-nCoV-Post_COVID-19_condition-Clinical_case_definition-2021.1 22. Global Burden of Disease Long COVID Collaborators, Wulf Hanson S, Abbafati C, Aerts JG, Al-Aly Z, Ashbaugh C, et al. Estimated Global Proportions of Individuals With Persistent Fatigue, Cognitive, and Respiratory Symptom Clusters Following Symptomatic COVID-19 in 2020 and 2021. JAMA 2022;328:160415. 23. Joshee S, Vatti N, Chang C. Long-Term Effects of COVID-19. Mayo Clin Proc 2022;97:57999. https://doi.org/10.1016/j.mayocp.2021.12.017 24. Wulf Hanson S, Abbafati C, Aerts JG, Al-Aly Z, Ashbaugh C, Ballouz T, et al. A global systematic analysis of the occurrence, severity, and recovery pattern of long COVID in 2020 and 2021. medRxiv 2022;2022.05.26.22275532. 25. Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK - Office for National Statistics [Internet]. [cited 17.2.2023]. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/prevalenceofongoingsymptomsfollowingcoronaviruscovid19infectionintheuk/2february2023 26. Kokolevich ZM, Crowe M, Mendez D, Biros E, Reznik JE. Most Common Long COVID Physical Symptoms in Working Age Adults Who Experienced Mild COVID-19 Infection: A Scoping Review. Healthcare (Basel) 2022;10:2577. https://doi.org/10.3390/healthcare10122577 27. Sansone D, Tassinari A, Valentinotti R, Kontogiannis D, Ronchese F, Centonze S, et al. Persistence of Symptoms 15 Months since COVID-19 Diagnosis: Prevalence, Risk Factors and Residual Work Ability. Life (Basel) 2022;13:97. https://doi.org/10.3390/life13010097 28. Grazzini M, Lulli LG, Mucci N, Paolini D, Baldassarre A, Gallinoro V, et al. Return to Work of Healthcare Workers after SARS-CoV-2 Infection: Determinants of Physical and Mental Health. Int J Environ Res Public Health 2022;19:6811. https://doi.org/10.3390/ijerph19116811 29. Mendola M, Leoni M, Cozzi Y, Manzari A, Tonelli F, Metruccio F, et al. Long-term COVID symptoms, work ability and fitness to work in healthcare workers hospitalized for Sars-CoV-2 infection. Med Lav 2022;113:e2022040. 30. Kohn L, Dauvrin M, Detollenaere J, Primus-de Jong C, Maertens de Noordhout C, Castanares-Zapatero D, et al. Long COVID and return to work: a qualitative study. Occup Med (Lond) 2022;kqac119. https://doi.org/10.1093/occmed/kqac119 31. Brehon K, Niemeläinen R, Hall M, Bostick GP, Brown CA, Wieler M, et al. Return-to-Work Following Occupational Rehabilitation for Long COVID: Descriptive Cohort Study. JMIR Rehabil Assist Technol 2022;9:e39883. https://doi.org/10.2196/39883 32. Aben B, Kok RN, de Wind A. Return-to-work rates and predictors of absence duration after COVID-19 over the course of the pandemic. Scand J Work Environ Health 2023;4077. https://doi.org/10.5271/sjweh.4077 33. Dotan A, David P, Arnheim D, Shoenfeld Y. The autonomic aspects of the post-COVID19 syndrome. Autoimmun Rev 2022;21:103071. https://doi.org/10.1016/j.autrev.2022.103071 34. Uchiyama Y, Sasanuma N, Nanto T, Fujita K, Takahashi M, Iwasa S, et al. COVID-19 Patient Returned to Work after Long Hospitalization and Follow-up: A Case Report. Prog Rehabil Med 2021;6:20210025. https://doi.org/10.2490/prm.20210025 35. Roth A, Chan PS, Jonas W. Addressing the Long COVID Crisis: Integrative Health and Long COVID. Glob Adv Health Med 2021;10:21649561211056596. https://doi.org/10.1177/21649561211056597 36. Paz LES, Bezerra BJ da S, Pereira TM de M, da Silva WE. COVID-19: the importance of physical therapy in the recovery of workers’ health. Rev Bras Med Trab 2021;19:94106. https://doi.org/10.47626/1679-4435-2021-709 37. Clin B, Esquirol Y, Gehanno JF, Letheux C, Gonzalez M, Pairon JC, et al. Rôle des services de santé au travail dans le repérage et l’accompagnement des personnes concernées par des symptômes persistants suite à la Covid-19. Recommandations de la Société française de médecine du travail (SFMT). Archives des Maladies Professionnelles et de l’Environnement 2021;82:395400. https://doi.org/10.1016/j.admp.2021.06.006 38. Müller K, Zwingmann K, Auerswald T, Berger I, Thomas A, Schultz AL, et al. Rehabilitation and Return-to-Work of Patients Acquiring COVID-19 in the Workplace: A Study Protocol for an Observational Cohort Study. Front Rehabil Sci 2021;2:754468. https://doi.org/10.3389/fresc.2021.754468 39. do Prado CB, Emerick GS, Cevolani Pires LB, Salaroli LB. Impact of long-term COVID on workers: A systematic review protocol. PLoS One 2022;17:e0265705. https://doi.org/10.1371/journal.pone.0265705 40. Sivan M, Greenhalgh T, Darbyshire JL, Mir G, O’Connor RJ, Dawes H, et al. LOng COvid Multidisciplinary consortium Optimising Treatments and servIces acrOss the NHS (LOCOMOTION): protocol for a mixed-methods study in the UK. BMJ Open 2022;12:e063505. https://doi.org/10.1136/bmjopen-2022-063505 41. Alkodaymi MS, Omrani OA, Fawzy NA, Shaar BA, Almamlouk R, Riaz M, et al. Prevalence of post-acute COVID-19 syndrome symptoms at different follow-up periods: a systematic review and meta-analysis. Clin Microbiol Infect 2022;28:65766. https://doi.org/10.1016/j.cmi.2022.01.014 42. Valter R, Sembajwe G, Descatha A, Fadel M. Comparison of different estimators of SARS-CoV-2 pandemic activity on geographical and temporal levels. Front Public Health 2022;10:871010. https://doi.org/10.3389/fpubh.2022.871010

Introduction: With recent higher awareness of the necessity of improving healthcare workers’ well-being, we aimed to overview systematic reviews dealing with interventions on well-being, occupational health, and aging of healthcare workers. Methods: From three databases (PubMed, Embase, and Web of Science), a scoping review of systematic reviews was carried out to determine current knowledge on interventions focused on the well-being or aging of healthcare workers. Only systematic reviews were considered, with appropriate extraction and quality evaluation. Results: Of the total of 445 references identified, 10 systematic reviews were included, mostly published since 2019. Nurses were the most frequent targets of interventions, and mental health was the main outcome described. The overall level of quality was also heterogenous, with high to low-quality reviews. Conclusions: Workers' mental health well-being was the major outcome targeted by intervention, with varying level of evidence. Further studies are needed with integrative approaches on global health and life course perspectives, with a focus on the plurality of settings, worker types, and women.

The aim was to describe out-of-hospital cardiac arrest (OHCA) occurring in the workplace of a large emergency network, and compare the evolution of their management in the last 15 years. A retrospective study based on data from the Northern Alps Emergency Network compared characteristics of OHCA between cases in and out the workplace, and between cases occurring from January 2004 to December 2010 and from January 2011 to December 2017. Among the 15,320 OHCA cases included, 320 occurred in the workplace (2.1%). They were more often in younger men, and happened more frequently in an area with access to public defibrillation, had more often a shockable rhythm, had a cardiopulmonary resuscitation started by a bystander more frequently, and had a better outcome. Cardiopulmonary resuscitation started by a bystander was the only chain of survival link that improved for cases occurring after December 2010. Workplace OHCA seems to be managed more effectively than others; however, only a slight survival improvement was observed, suggesting that progress is still needed.

Abstract Background This study examined prospective associations between atypical working hours with subsequent tobacco, cannabis and alcohol use as well as sugar and fat consumption. Methods In the French population-based CONSTANCES cohort, 47,288 men and 53,324 women currently employed included between 2012 and 2017 were annually followed for tobacco and cannabis use. Among them, 35,647 men and 39,767 women included between 2012 and 2016 were also followed for alcohol and sugar and fat consumption. Three indicators of atypical working hours were self-reported at baseline: working at night, weekend work and non-fixed working hours. Generalized linear models computed odds of substance use and sugar and fat consumption at follow-up according to atypical working hours at baseline while adjusting for sociodemographic factors, depression and baseline substance use when appropriate. Results Working at night was associated with decreased smoking cessation and increased relapse in women [odds ratios (ORs) of 0.81 and 1.25], increased cannabis use in men [ORs from 1.46 to 1.54] and increased alcohol use [ORs from 1.12 to 1.14] in both men and women. Weekend work was associated with decreased smoking cessation in women [ORs from 0.89 to 0.90] and increased alcohol use in both men and women [ORs from 1.09 to 1.14]. Non-fixed hours were associated with decreased smoking cessation in women and increased relapse in men [ORs of 0.89 and 1.13] and increased alcohol use in both men and women [ORs from 1.12 to 1.19]. Overall, atypical working hours were associated with decreased sugar and fat consumption. Conclusions The potential role of atypical working hours on substance use should be considered by public health policy makers and clinicians in information and prevention strategies.

Abstract Background Shoulder pain, which is a widespread condition, can lead to participation restrictions in daily and professional life. However, there are few studies focusing on the differences between daily life limitations and work limitations. This study aims at identifying the factors associated with limitations in personal and professional life in a population of working age suffering from shoulder pain. Methods A sample of working age job seekers and workers with shoulder pain was drawn from the last general population cross-sectional French study on disability. Limitations were categorized depending on whether they related to daily life and/or work. The variables assessed were age, sex, state of health, activity restrictions, need for accommodation, and aggravating living conditions or aggravating working conditions. Separate Quasi-Poisson regressions were performed for each type of limitation. Results The sample consisted of 795 individuals of which 33.7% had no limitation, 21.7% were limited in daily life, 6.0% at work, and 38.6% in both. Factors significantly associated with daily life limitations and work limitations and their computed Prevalence Ratios (PR) were the need for accommodation (PR = 2.16), activity restrictions (PR = 2.28), perceived poor health (PR = 2.42) and low income (PR = 1.64). Aggravating living conditions and aggravating working conditions were associated with daily life limitations (PR of 1.69 and 0.63 respectively). Conclusions The present study identifies factors associated with disability in a population with shoulder pain. Further research should be carried out in order to study health-related periods of cessation of work.

OBJECTIVES: Musculoskeletal disorders (MSD) represent a major public health issue, affecting more then 40 million European workers in 2017. The overall aging of the working population is expected to increase the burden of disease, but temporal changes in exposures or diagnosis may also drive the global trends in MSD. We therefore conducted a systematic review to summarize the evidence on the role of demographic and temporal changes in the occurrence of MSD. METHODS: We conducted a systematic review of articles reporting temporal trends in MSD in the general working-age population. Only articles controlling for age in the analysis were included. The risk of bias was assessed. The main indicators extracted were age-controlled time trends in MSD incidence or prevalence. RESULTS: Among 966 articles, 16 fulfilled the inclusion criteria, representing 23 results according to the indicators extracted. No study was found with a high risk of bias. Results presenting time trends in prevalence were found in 12 studies and incidence in 11. After controlling for age, the reported temporal trends varied, mostly between non-monotonic changes (N=12/23) and increases (N=10/23). One article also highlighted an increase among women and non-monotonic changes among men (N=1/23). Several factors other than aging were suggested to explain temporal trends in MSD, mainly trends in obesity, changing occupational exposures, and cultural factors regarding pain tolerance. CONCLUSION: This review shows that different kind of factors in addition to aging may contribute to varying or increasing trends in MSD. This review also highlighted the scarcity of evidence regarding time trends in the burden of MSD and their underlying causes.

Abstract We examined the prospective association of physical exertion at work with subsequent tobacco, cannabis, alcohol use, and sugar and fat consumption. Volunteers of the French population-based CONSTANCES cohort currently employed were included from 2012 to 2017 for tobacco and cannabis outcomes (n = 100,612), and from 2012 to 2016 for alcohol and sugar and fat outcomes (n = 75,414). High level of physical exertion at work was defined as a score ≥ 12 at the Rating Perceived Exertion Borg scale. Substance use was self-reported and diet rich in sugar and fat was obtained from principal component analysis and analyzed as quartiles. Generalized linear models computed odds of substance use and sugar and fat consumption at follow-up according to baseline physical exertion at work, while adjusting for sociodemographic factors, depressive symptoms and baseline level of consumption. High physical exertion was associated with tobacco use with dose-dependent relationships. It was also associated with increased odds of cannabis use at least once per month compared to no use in the past and with increased odds of diet rich in sugar and fat. Hence, the role of physical exertion at work on tobacco and cannabis use and diet rich in sugar and fat should be tackled for information and prevention strategies.

Background: The World Health Organization (WHO) and the International Labour Organization (ILO) are the producers of the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury (WHO/ILO Joint Estimates). Welding fumes have been classified as carcinogenic to humans (Group 1) by the WHO International Agency for Research on Cancer (IARC) in IARC Monograph 118; this assessment found sufficient evidence from studies in humans that welding fumes are a cause of lung cancer. In this article, we present a systematic review and meta-analysis of parameters for estimating the number of deaths and disability-adjusted life years from trachea, bronchus, and lung cancer attributable to occupational exposure to welding fumes, to inform the development of WHO/ILO Joint Estimates on this burden of disease (if considered feasible). Objectives: We aimed to systematically review and meta-analyse estimates of the effect of any (or high) occupational exposure to welding fumes, compared with no (or low) occupational exposure to welding fumes, on trachea, bronchus, and lung cancer (three outcomes: prevalence, incidence, and mortality). Data sources: We developed and published a protocol, applying the Navigation Guide as an organizing systematic review framework where feasible. We searched electronic databases for potentially relevant records from published and unpublished studies, including Medline, EMBASE, Web of Science, CENTRAL and CISDOC. We also searched grey literature databases, Internet search engines, and organizational websites; hand-searched reference lists of previous systematic reviews; and consulted additional experts. Study eligibility and criteria: We included working-age (≥15 years) workers in the formal and informal economy in any Member State of WHO and/or ILO but excluded children (

BackgroundStudies began investigating occupational exposures as a source of contamination to SARS-CoV-2, yet few considered the variation in SARS-Cov2 pandemic activity for these exposures. Several indicators were built to assess SARS-Cov2 activity though they usually serve a specific purpose and have limitations. The aim was to compare qualitatively different estimators of the SARS-CoV-2 pandemic activity and to create an estimator of pandemic activity level based on daily hospital admissions for job-exposure matrices (JEM) usage.MethodsFrom publicly available French databases, we retrieved all data from March 19, 2020 (first day available) to March 25, 2021 (day of data collection) on four different estimators: percentage of intensive care bed occupied, reproductive number, tests' positive rate and number positive tests. An indicator based on new daily hospital admissions was created for a COVID JEM. Due to the heterogeneity of the estimators, a qualitative comparison was carried out.ResultsDuring the study period, three major outbreaks took place. Though the number of positive tests was the first indicator to worsen during the 2nd outbreak, it failed to identify variation during the outbreak. Though each indicators behaved differently during the study period, the indicator based on new daily hospital admissions and the positive rate seemed to be the closest to one another.ConclusionThis study highlights the heterogeneity of the indicators used during the first and second SARS-Cov2 outbreaks in France. An indicator based on new daily hospital admissions seems to be a good candidate for estimating SARS-CoV-2 epidemic activity for COVID JEMs and is easily available in countries where usual indicators are not commonly accessible.

Objective Cold environments are a potential risk factor for stroke. The aim of this study was to investigate the association between performing work tasks in cold environments and the occurrence of a first stroke event.Methods From the French population-based cohort CONSTANCES (‘Cohorte des consultants des Centres d'examens de santé’ in French), we collected data from baseline questionnaires along with medical interviews on cardiovascular risk factors and reported exposure to cold temperatures (

OBJECTIVE: This study aimed to estimate the proportion and number of incident upper-extremity musculoskeletal disorders (UEMSD) cases attributable to occupational risk factors in a working population. METHODS: Between 2002−2005, occupational physicians randomly selected 3710 workers, aged 20–59, from the Pays de la Loire (PdL) region. All participants underwent a standardized clinical examination. Between 2007−2010, 1611 workers were re-examined. This study included 1246 workers who were free of six main clinically diagnosed UEMSD at baseline but were diagnosed with at least one of these UEMSD at follow-up [59% of men, mean age: 38 (standard deviation 8.6) years]. Relative risks and population-attributable fractions (PAF) were calculated using Cox multivariable models with equal follow-up time and robust variance. The total number of incident UEMSD in the PdL region was estimated after adjustment of the sample weights using 2007 census data. The estimated number of potentially avoidable UEMSD was calculated by multiplying PAF by the total number of incident UEMSD in PdL. RESULTS: At follow-up, 139 new cases of UEMSD (11% of the study sample) were diagnosed. This represented an estimated 129 320 incident cases in the PdL in 2007. Following adjustment for personal factors, 26 381 (20.4% of all incident UEMSD) were attributable to high physical exertion, 16 682 (12.9%) to low social support, and 8535 (6.6%) to working with arms above shoulder level. CONCLUSIONS: A large number and important proportion of incident UEMSD may be preventable by reducing work exposures to physical exertion and working with arms above shoulder level as well as improving social support from co-workers/supervisors.

OBJECTIVES: A job exposure matrix (JEM) is a tool to estimate workers’ exposure to occupational physical risk factors. We evaluated the performance of two general population JEM (CONSTANCES and O*NET) to detect known exposure–disease relationships in an American prospective cohort study. We compared exposure estimates from three data sources and explored whether combining exposures from these two JEM, or combining exposure from each JEM with individual-level measures, improved prediction of carpal tunnel syndrome (CTS). METHODS: Using Cox proportional hazard models, we evaluated relationships between physical work exposure and incident CTS of 2393 workers using JEM-assigned and individual-level measure exposure information. We compared exposure estimates using Spearman’s rank correlation and Cohen’s kappa. We compared combined exposure models to single source exposure models by using binomial logistic regression and examined differences based on model fit and performance. RESULTS: The O*NET JEM [hazard ratio (HR) range 1.3–2.01] demonstrated generally similar exposure–disease associations as individual-level measures (HR range 1.00–1.42); we found fewer associations with the CONSTANCES JEM (HR range 1.08–2.05). Comparisons between the three sources showed stronger correlations and agreement at the job versus worker level. Combined models improved goodness-of-fit and had lower Akaike information criterion (AIC) values compared to single-source models. CONCLUSIONS: JEM can be applied cross nationally and there is potential to combine complementary exposure methods to improve estimation of workplace physical exposures in the prediction of CTS. More investigations are needed to explore exposure-disease associations in other samples and combinations of exposure data from different methods.

Abstract Background Upper extremity musculoskeletal disorders (UEMSD) are one of the most common and costly occupational health problems. We aimed to assess the population-attributable fraction (PAF) of personal and occupational risk factors associated with incident UEMSD in a working population. Methods From 2002 to 2005, a random sample of 3710 workers from the Pays de la Loire region in France, aged 20–59 were included by occupational physicians (OPs). Between 2007 and 2010, 1611 workers were re-examined by their OPs. Subjects free from UEMSD at baseline were included in this study (1275 workers, mean age: 38.2 years). Cox regression models with equal follow-up time and robust variance estimates were used to estimate age-adjusted and multivariable-adjusted relative risks (RRs) and their 95% confidence intervals (CIs). Based on multivariable models, PAF associated with each factor included in the models was estimated. Results During the follow-up period, 143 (11%) cases of UEMSD were diagnosed. PAFs for factors associated with the incident UEMSD risk were 30% (7 to 51) for high physical exertion (RPE Borg scale ≥12), 12% (− 0.2 to 24) for low social support, 7% (− 3 to 17) for working with arms above shoulder level (≥2 h/day), 20% (12 to 28) for age group ≥45, 13% (3 to 22) for the age group 35–44, and 12% (0.3 to 24) for female gender. Conclusions Our study suggests that an important fraction of UEMSD can be attributed to occupational exposures after the contributions of personal and other work-related factors are considered. In terms of public health, our findings are in agreement with the ergonomic literature postulating that a high proportion of UEMSD are preventable through modifying workplace risk factors. Such information is useful to help public health practitioners and policy makers implement programs of prevention of UEMSD in the working population.

Background: The World Health Organization (WHO) and the International Labour Organization (ILO) have produced the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury (WHO/ILO Joint Estimates). For these, systematic reviews of studies estimating the prevalence of exposure to selected occupational risk factors have been conducted to provide input data for estimations of the number of exposed workers. A critical part of systematic review methodology is to assess the quality of evidence across studies. In this article, we present the approach applied in these WHO/ILO systematic reviews for performing such assessments on studies of prevalence of exposure. It is called the Quality of Evidence in Studies estimating Prevalence of Exposure to Occupational risk factors (QoE-SPEO) approach. We describe QoE-SPEO’s development to date, demonstrate its feasibility reporting results from pilot testing and case studies, note its strengths and limitations, and suggest how QoE-SPEO should be tested and developed further. Methods: Following a comprehensive literature review, and using expert opinion, selected existing quality of evidence assessment approaches used in environmental and occupational health were reviewed and analysed for their relevance to prevalence studies. Relevant steps and components from the existing approaches were adopted or adapted for QoE-SPEO. New steps and components were developed. We elicited feedback from other systematic review methodologists and exposure scientists and reached consensus on the QoE-SPEO approach. Ten individual experts pilot-tested QoE-SPEO. To assess inter-rater agreement, we counted ratings of expected (actual and non-spurious) heterogeneity and quality of evidence and calculated a raw measure of agreement (Pi) between individual raters and rater teams for the downgrade domains. Pi ranged between 0.00 (no two pilot testers selected the same rating) and 1.00 (all pilot testers selected the same rating). Case studies were conducted of experiences of QoE-SPEO’s use in two WHO/ILO systematic reviews. Results: We found no existing quality of evidence assessment approach for occupational exposure prevalence studies. We identified three relevant, existing approaches for environmental and occupational health studies of the effect of exposures. Assessments using QoE-SPEO comprise three steps: (1) judge the level of expected heterogeneity (defined as non-spurious variability that can be expected in exposure prevalence, within or between individual persons, because exposure may change over space and/or time), (2) assess downgrade domains, and (3) reach a final rating on the quality of evidence. Assessments are conducted using the same five downgrade domains as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach: (a) risk of bias, (b) indirectness, (c) inconsistency, (d) imprecision, and (e) publication bias. For downgrade domains (c) and (d), the assessment varies depending on the level of expected heterogeneity. There are no upgrade domains. The QoE-SPEO’s ratings are “very low”, “low”, “moderate”, and “high”. To arrive at a final decision on the overall quality of evidence, the assessor starts at “high” quality of evidence and for each domain downgrades by one or two levels for serious concerns or very serious concerns, respectively. In pilot tests, there was reasonable agreement in ratings for expected heterogeneity; 70% of raters selected the same rating. Inter-rater agreement ranged considerably between downgrade domains, both for individual rater pairs (range Pi: 0.36–1.00) and rater teams (0.20–1.00). Sparse data prevented rigorous assessment of inter-rater agreement in quality of evidence ratings. Conclusions: We present QoE-SPEO as an approach for assessing quality of evidence in prevalence studies of exposure to occupational risk factors. It has been developed to its current version (as presented here), has undergone pilot testing, and was applied in the systematic reviews for the WHO/ILO Joint Estimates. While the approach requires further testing and development, it makes steps towards filling an identified gap, and progress made so far can be used to inform future work in this area.

Background: As part of the development of the World Health Organization (WHO)/International Labour Organization (ILO) Joint Estimates of the Work-related Burden of Disease and Injury, WHO and ILO carried out several systematic reviews to determine the prevalence of exposure to selected occupational risk factors. Risk of bias assessment for individual studies is a critical step of a systematic review. No tool existed for assessing the risk of bias in prevalence studies of exposure to occupational risk factors, so WHO and ILO developed and pilot tested the RoB-SPEO tool for this purpose. Here, we investigate the assessor burden, inter-rater agreement, and user experience of this new instrument, based on the abovementioned WHO/ILO systematic reviews. Methods: Twenty-seven individual experts applied RoB-SPEO to assess risk of bias. Four systematic reviews provided a total of 283 individual assessments, carried out for 137 studies. For each study, two or more assessors independently assessed risk of bias across the eight RoB-SPEO domains selecting one of RoB-SPEO’s six ratings (i.e., “low”, “probably low”, “probably high”, “high”, “unclear” or “cannot be determined”). Assessors were asked to report time taken (i.e. indicator of assessor burden) to complete each assessment and describe their user experience. To gauge assessor burden, we calculated the median and inter-quartile range of times taken per individual risk of bias assessment. To assess inter-rater reliability, we calculated a raw measure of inter-rater agreement (Pi) for each RoB-SPEO domain, between Pi = 0.00, indicating no agreement and Pi = 1.00, indicating perfect agreement. As subgroup analyses, Pi was also disaggregated by systematic review, assessor experience with RoB-SPEO (≤10 assessments versus > 10 assessments), and assessment time (tertiles: ≤25 min versus 26–66 min versus ≥ 67 min). To describe user experience, we synthesised the assessors’ comments and recommendations. Results: Assessors reported a median of 40 min to complete one assessment (interquartile range 21–120 min). For all domains, raw inter-rater agreement ranged from 0.54 to 0.82. Agreement varied by systematic review and assessor experience with RoB-SPEO between domains, and increased with increasing assessment time. A small number of users recommended further development of instructions for selected RoB-SPEO domains, especially bias in selection of participants into the study (domain 1) and bias due to differences in numerator and denominator (domain 7). Discussion: Overall, our results indicated good agreement across the eight domains of the RoB-SPEO tool. The median assessment time was comparable to that of other risk of bias tools, indicating comparable assessor burden. However, there was considerable variation in time taken to complete assessments. Additional time spent on assessments may improve inter-rater agreement. Further development of the RoB-SPEO tool could focus on refining instructions for selected RoB-SPEO domains and additional testing to assess agreement for different topic areas and with a wider range of assessors from different research backgrounds.

Background: The World Health Organization (WHO) and the International Labour Organization (ILO) are developing the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury (WHO/ILO Joint Estimates), supported by a large number of individual experts. Evidence from previous reviews suggests that exposure to long working hours may cause depression. In this article, we present a systematic review and meta-analysis of parameters for estimating (if feasible) the number of deaths and disability-adjusted life years from depression that are attributable to exposure to long working hours, for the development of the WHO/ILO Joint Estimates. Objectives: We aimed to systematically review and meta-analyse estimates of the effect of exposure to long working hours (three categories: 41–48, 49–54 and ≥55 h/week), compared with exposure to standard working hours (35–40 h/week), on depression (three outcomes: prevalence, incidence and mortality). Data sources: We developed and published a protocol, applying the Navigation Guide as an organizing systematic review framework where feasible. We searched electronic academic databases for potentially relevant records from published and unpublished studies, including the WHO International Clinical Trial Registers Platform, Medline, PubMed, EMBASE, Web of Science, CISDOC and PsycInfo. We also searched grey literature databases, Internet search engines and organizational websites; hand-searched reference lists of previous systematic reviews; and consulted additional experts. Study eligibility and criteria: We included working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State but excluded children (aged

Background: Exploratory study to investigate whether co-exposure to physical wrist stressors and chemicals is associated with carpal tunnel syndrome (CTS) in French male farmers and agricultural workers. Methods: Cross-sectional study of 711 men aged 30–65 years and working as either farmers or agricultural workers in 2009–2010 within a cohort covered by the French Agricultural Workers' and Farmers' Mutual Benefit Fund. CTS and exposure to physical wrist stressors and chemicals were assessed using a self-administered questionnaire. Associations between CTS and personal/medical factors, exposure to physical wrist stressors, exposure to chemicals, and co-exposure to physical wrist stressors and chemicals were studied using multivariate logistic regression models. Results: Forty-four men {5.6% [95% confidence interval (CI) 4.0–7.7]} reported that they had suffered from unilateral/bilateral CTS during the last 12 months. CTS was associated with age, current smoking [odds ratio (OR) = 2.1 (1.0–4.5)], and exposure to physical wrist stressors [OR = 2.6 (1.1–5.9)]. An association was found between CTS and co-exposure to physical wrist stressors and chemicals [OR = 3.3 (0.8–14.3), p = 0.044] in comparison with the no-exposure group. Conclusions: This exploratory study shows an association of CTS with exposure to biomechanical wrist stressors in male farmers and agricultural workers and suggests an association of CTS with co-exposure to physical wrist stressors and chemicals. Owing to the limitations of the study, this result must be confirmed by a prospective study with objective assessments of the outcome and exposure before drawing conclusions on the possible synergistic effects of mechanical stressors and chemicals on the impairment of the median nerve. Keywords: Carpal tunnel syndrome, Chemicals, Co-exposure, Multiple exposure, Physical risk factors

Background: World Health Organization (WHO) and International Labour Organization (ILO) systematic reviews reported sufficient evidence for higher risks of ischemic heart disease and stroke amongst people working long hours (≥55 hours/week), compared with people working standard hours (35–40 hours/week). This article presents WHO/ILO Joint Estimates of global, regional, and national exposure to long working hours, for 194 countries, and the attributable burdens of ischemic heart disease and stroke, for 183 countries, by sex and age, for 2000, 2010, and 2016. Methods and Findings: We calculated population-attributable fractions from estimates of the population exposed to long working hours and relative risks of exposure on the diseases from the systematic reviews. The exposed population was modelled using data from 2324 cross-sectional surveys and 1742 quarterly survey datasets. Attributable disease burdens were estimated by applying the population-attributable fractions to WHO’s Global Health Estimates of total disease burdens. Results: In 2016, 488 million people (95% uncertainty range: 472–503 million), or 8.9% (8.6–9.1) of the global population, were exposed to working long hours (≥55 hours/week). An estimated 745,194 deaths (705,786–784,601) and 23.3 million disability-adjusted life years (22.2–24.4) from ischemic heart disease and stroke combined were attributable to this exposure. The population-attributable fractions for deaths were 3.7% (3.4–4.0) for ischemic heart disease and 6.9% for stroke (6.4–7.5); for disability-adjusted life years they were 5.3% (4.9–5.6) for ischemic heart disease and 9.3% (8.7–9.9) for stroke. Conclusions: WHO and ILO estimate exposure to long working hours (≥55 hours/week) is common and causes large attributable burdens of ischemic heart disease and stroke. Protecting and promoting occupational and workers’ safety and health requires interventions to reduce hazardous long working hours.

Introduction: Systematic reviews are routinely used to synthesize current science and evaluate the evidential strength and quality of resulting recommendations. For specific events, such as rare acute poisonings or preliminary reports of new drugs, we posit that case reports/studies and case series (human subjects research with no control group) may provide important evidence for systematic reviews. Our aim, therefore, is to present a protocol that uses rigorous selection criteria, to distinguish high quality case reports/studies and case series for inclusion in systematic reviews.Methods: This protocol will adapt the existing Navigation Guide methodology for specific inclusion of case studies. The usual procedure for systematic reviews will be followed. Case reports/studies and case series will be specified in the search strategy and included in separate sections. Data from these sources will be extracted and where possible, quantitatively synthesized. Criteria for integrating cases reports/studies and case series into the overall body of evidence are that these studies will need to be well-documented, scientifically rigorous, and follow ethical practices. The instructions and standards for evaluating risk of bias will be based on the Navigation Guide. The risk of bias, quality of evidence and the strength of recommendations will be assessed by two independent review teams that are blinded to each other.Conclusion: This is a protocol specified for systematic reviews that use case reports/studies and case series to evaluate the quality of evidence and strength of recommendations in disciplines like clinical toxicology, where case reports/studies are the norm.

We aimed to make an exhaustive assessment of circumstances of bites by exotic reptiles bred in France. A retrospective observational study was conducted in all the reported cases from 2000 to 2020 in French poison control centers (PCCs). Two hundred and eighteen cases of bites were recorded. The sex ratio (M/F) of the patients was 1.79 and the mean age of the patients was 29.0 ± 15.8 years. Twenty-two cases (10.1%) occurred during the deep night. One hundred and eighty-six bites (85.7%) occurred in a private context; however, there were more cases of high severity when it occurred in a professional setting (60.0% vs. 11.2%, p < 0.01). The feeding/nursing activity accounted for 54.7% cases. Forty-three species of snake were identified; 28 were considered venomous. There were no deaths among the patients in the study. Most of the cases (85.8%) were of mild severity. All of the patients bitten by a venomous reptile were hospitalized: 10 patients received an antivenom; and 2 required surgery. Bites occurred at home and by a small number of popular non-venomous reptile species (pythons and boas, colubrids). These occurred mainly when handling the animals. The rare envenomations were mainly by Asian and American crotalids, followed by elapids. One-third of them were treated with antivenom when available.

Background: The World Health Organization (WHO) and the International Labour Organization (ILO) are developing joint estimates of the work-related burden of disease and injury (WHO/ILO Joint Estimates), with contributions from a large network of experts. Evidence from mechanistic and human data suggests that occupational exposure to ergonomic (or physical) risk factors may cause osteoarthritis and other musculoskeletal diseases (excluding rheumatoid arthritis, gout, and back and neck pain). In this paper, we present a systematic review and meta-analysis of the prevalence of occupational exposure to physical ergonomic risk factors for estimating the number of disability-adjusted life years from these diseases that are attributable to exposure to this risk factor, for the development of the WHO/ILO Joint Estimates. Objectives: We aimed to systematically review and meta-analyse estimates of the prevalence of occupational exposure to ergonomic risk factors for osteoarthritis and other musculoskeletal diseases. Data sources: We searched electronic bibliographic databases for potentially relevant records from published and unpublished studies, including Ovid Medline, EMBASE, and CISDOC. We also searched electronic grey literature databases, Internet search engines and organizational websites; hand-searched reference list of previous systematic reviews and included study records; and consulted additional experts. Study eligibility and criteria: We included working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State but excluded children (

Background: The World Health Organization (WHO) and the International Labour Organization (ILO) are developing Joint Estimates of the work-related burden of disease and injury (WHO/ILO Joint Estimates), with contributions from a large network of experts. Evidence from mechanistic data suggests that exposure to long working hours may increase alcohol consumption and cause alcohol use disorder. In this paper, we present a systematic review and meta-analysis of parameters for estimating the number of deaths and disability-adjusted life years from alcohol consumption and alcohol use disorder that are attributable to exposure to long working hours, for the development of the WHO/ILO Joint Estimates. Objectives: We aimed to systematically review and meta-analyse estimates of the effect of exposure to long working hours (three categories: 41–48, 49–54 and ≥55 h/week), compared with exposure to standard working hours (35–40 h/week), on alcohol consumption, risky drinking (three outcomes: prevalence, incidence and mortality) and alcohol use disorder (three outcomes: prevalence, incidence and mortality). Data sources: We developed and published a protocol, applying the Navigation Guide as an organizing systematic review framework where feasible. We searched electronic bibliographic databases for potentially relevant records from published and unpublished studies, including the WHO International Clinical Trials Register, Ovid MEDLINE, PubMed, Embase, and CISDOC on 30 June 2018. Searches on PubMed were updated on 18 April 2020. We also searched electronic grey literature databases, Internet search engines and organizational websites; hand-searched reference list of previous systematic reviews and included study records; and consulted additional experts. Study eligibility and criteria: We included working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State but excluded children (

The study aimed to assess the proportion mediated by the duration of exposure to ergonomic factors at work on the relationship between socioeconomic position (SEP) and low walking speed. This cross-sectional study was performed on data collected at baseline on 19,704 men and 20,273 women 45–70 years old, currently or previously employed, enrolled in the Constances cohort. SEP was assigned through current or last occupation, categorized in three classes, based on the European Socioeconomic Classification. Walking speed was assessed through one measurement of normal walking for 3 m and dichotomized at the lowest quintile of the sex- and age- (5-year) specific distribution. Self-reported workplace exposure throughout working life to repetitive work, intense physical work, and lifting/carrying heavy loads was used to assess the duration of exposure to each factor, categorized in four classes. Through Poisson regression models, adjusted for BMI, smoking, alcohol intake, hypertension, physical activity, diabetes, cardiovascular diseases, and a cognitive score, the attenuation in the prevalence ratio (PR) of low walking speed by SEP produced by the inclusion of duration of exposure to each factor was evaluated. The mediating effect of work ergonomic exposures on the relationship between SEP and low walking speed was assessed using the weighted method by Vanderweele. In the fully adjusted model without ergonomic exposures, both men and women in the middle and the lowest SEP had a significantly increased risk of low walking speed compared with those in the highest SEP (men: PR = 1.30 and PR = 1.46, respectively; women: PR = 1.24 and PR = 1.45, respectively). The inclusion in separate regression models of exposure duration to repetitive work, intense physical work, and handling of heavy loads produced modest risk attenuations in both men and women, all smaller or around 10%. Mediation analysis revealed in both sexes significant mediation effects for most ergonomic exposures considered, although also with low mediation effects. Significant differences in walking speed by SEP were observed in this large sample, but the proportion of such differences explained by the duration of exposure to ergonomic factors at work was low using either the risk attenuation or the mediation analysis methods.

Background: The World Health Organization (WHO) and the International Labour Organization (ILO) are developing Joint Estimates of the work-related burden of disease and injury (WHO/ILO Joint Estimates), with contributions from a large network of experts. Evidence from mechanistic data suggests that exposure to long working hours may cause ischaemic heart disease (IHD). In this paper, we present a systematic review and meta-analysis of parameters for estimating the number of deaths and disability-adjusted life years from IHD that are attributable to exposure to long working hours, for the development of the WHO/ILO Joint Estimates. Objectives: We aimed to systematically review and meta-analyse estimates of the effect of exposure to long working hours (three categories: 41–48, 49–54 and ≥55 h/week), compared with exposure to standard working hours (35–40 h/week), on IHD (three outcomes: prevalence, incidence and mortality). Data sources: We developed and published a protocol, applying the Navigation Guide as an organizing systematic review framework where feasible. We searched electronic databases for potentially relevant records from published and unpublished studies, including MEDLINE, Scopus, Web of Science, CISDOC, PsycINFO, and WHO ICTRP. We also searched grey literature databases, Internet search engines and organizational websites; hand-searched reference lists of previous systematic reviews; and consulted additional experts. Study eligibility and criteria: We included working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State but excluded children (aged

Background: The World Health Organization (WHO) and the International Labour Organization (ILO) are developing joint estimates of the work-related burden of disease and injury (WHO/ILO Joint Estimates), with contributions from a large network of individual experts. Evidence from mechanistic data and prior studies suggests that exposure to long working hours may cause stroke. In this paper, we present a systematic review and meta-analysis of parameters for estimating the number of deaths and disability-adjusted life years from stroke that are attributable to exposure to long working hours, for the development of the WHO/ILO Joint Estimates. Objectives: We aimed to systematically review and meta-analyse estimates of the effect of exposure to long working hours (three categories: 41–48, 49–54 and ≥55 h/week), compared with exposure to standard working hours (35–40 h/week), on stroke (three outcomes: prevalence, incidence, and mortality). Data sources: A protocol was developed and published, applying the Navigation Guide to systematic reviews as an organizing framework where feasible. We searched electronic databases for potentially relevant records from published and unpublished studies, including Ovid MEDLINE, PubMed, EMBASE, Scopus, Web of Science, CISDOC, PsycINFO, and WHO ICTRP. We also searched grey literature databases, Internet search engines, and organizational websites; hand-searched reference lists of previous systematic reviews; and consulted additional experts. Study eligibility and criteria: We included working-age (≥15 years) individuals in the formal and informal economy in any WHO and/or ILO Member State but excluded children (aged

Background Long‐working hours (LWH) are a probable risk factor for ischemic heart diseases (IHD); however, no previous study has considered duration of exposure to LWH when addressing this topic. We aimed to determine the association between cumulative exposure to LWH and IHD while accounting for relevant confounders. Methods and Results In this retrospective study, we included all baseline participants from the French population‐based cohort CONSTANCES. Part‐time employees and those who reported a cardiac event in the 5 years before LWH exposure were excluded. From self‐administered questionnaires and clinical examinations, we obtained participants’ age, sex, body mass index, occupational status, smoking habits, high blood pressure, diabetes mellitus, familial history of cardiovascular disease, dyslipidemia, exposure to LWH, and its duration. We defined LWH as working for >10 hours daily for at least 50 days per year. The main outcome was reported history of IHD, ie, myocardial infarction or angina pectoris, during a clinical examination. Of 137 854 included participants, 69 774 were men. There were 1875 cases (1.36%) of IHD, and exposure to LWH was reported by 42 462 subjects (30.8%) among whom 14 474 (10.50%) reported exposure for at least 10 years. Overall, exposure to LWH for ≥10 years was associated with an increased risk of IHD, adjusted odds ratio (aOR) 1.24 (1.08–1.43), P=0.0021. In stratified analyses, this effect was not observed in women, but was significant amongst men, aOR 1.28 (1.11–1.48), P=0.0008. Conclusions This large population‐based study supports an association between cumulative exposure to LWH and IHD in men. Future research should consider relevant strategies for reducing LWH exposure and duration.

Abstract Background Infections caused by multidrug-resistant organisms (MDRO) are emerging worldwide. Physicians are increasingly faced with the question of whether patients need empiric antibiotic treatment covering these pathogens. This question is especially essential among MDRO carriers. We aim to determine the occurrence of MDRO bacteraemia among bacteraemic patients colonized with MDRO, and the associated factors with MDRO bacteraemia among this population. Methods We performed a retrospective monocentric study among MDRO carriers hospitalized with bacteraemia between January 2013 and August 2016 in a French hospital. We compared characteristics of patients with MDRO and non-MDRO bacteraemia. Results Overall, 368 episodes of bacteraemia were reviewed; 98/368 (26.6%) occurred among MDRO carriers. Main colonizing bacteria were extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (40/98; 40.8%), ESBL-producing Klebsiella pneumoniae (35/98; 35.7%); methicillin-resistant Staphylococcus aureus (26/98; 26.5%) and multidrug-resistant Pseudomonas aeruginosa (PA) (12/98; 12.2%). There was no significant difference considering population with MDRO bacteraemia vs. non-MDRO bacteraemia, except for immunosuppression [OR 2.86; p = 0.0207], severity of the episode [OR 3.13; p = 0.0232], carriage of PA [OR 5.24; p = 0.0395], and hospital-acquired infection [OR 2.49; p = 0.034]. In the multivariate analysis, factors significantly associated with MDRO bacteraemia among colonized patient were only immunosuppression [OR = 2.96; p = 0.0354] and the hospital-acquired origin of bacteraemia [OR = 2.62; p = 0.0427]. Conclusions According to our study, occurrence of bacteraemia due to MDRO among MDRO carriers was high. Factors associated with MDRO bacteraemia were severity of the episode and hospital-acquired origin of the bacteraemia. Thus, during bacteraemia among patients colonized with MDRO, if such characteristics are present, broad-spectrum antimicrobial treatment is recommended.

Among other purposes, companies and regulatory agencies from around the world often adopt International Standard Organization (ISO) standards to determine acceptable practices, equipment and criteria for preventing occupational injuries and illnesses. ISO standards are based on a consensus among individuals who participate in the process. This discussion paper examines the scientific process for the development of several ISO standards on biomechanical factors, comparing it with processes used by other professional organizations, including scientific committees working on the development of clinical guidelines. While the ISO process has value, it also has clear limitations when it comes to developing occupational health and safety standards that should be based on scientific principles.

Abstract Background Carpal tunnel syndrome (CTS) is the most common nerve entrapment neuropathy in the working-age population. The reduction of CTS incidence in the workforce is a priority for policy makers due to the human, social and economic costs. To assess the theoretical impact of workplace-based primary interventions designed to reduce exposure to personal and/or work-related risk factors for CTS. Methods Surgical CTS were assessed using regional hospital discharge records for persons aged 20–59 in 2009. Using work-related attributable fractions (AFEs), we estimated the number of work-related CTS (WR-CTS) in high-risk jobs. We simulated three theoretical scenarios of workplace-based primary prevention for jobs at risk: a mono-component work-centered intervention reducing the incidence of WR-CTS arbitrarily by 10% (10%-WI), and multicomponent global interventions reducing the incidence of all surgical CTS by 5% and 10% by targeting personal and work risk factors. Results A limited proportion of CTS were work-related in the region’s population. WR-CTS were concentrated in nine jobs at high risk of CTS, amounting to 1603 [1137–2212] CTS, of which 906 [450–1522] were WR-CTS. The 10%-WI, 5%-GI and 10%-GI hypothetically prevented 90 [46–153], 81 [58–111] and 159 [114–223] CTS, respectively. The 10%-GI had the greatest impact regardless of the job. The impact of the 10%-WI interventions was high only in jobs at highest risk and AFEs (e.g. food industry jobs). The 10%-WI and 5%-GI had a similar impact for moderate-risk jobs (e.g. healthcare jobs). Conclusion The impact of simulated workplace-based interventions suggests that prevention efforts to reduce exposure to work-related risk factors should focus on high-risk jobs. Reducing CTS rates will also require integrated strategies to reduce personal risk factors, particularly in jobs with low levels of work-related risk of CTS.

We have read with great interest the two editorials by Burdorf et al: “The COVID-19 pandemic: one year later – an occupational perspective” (1) and “The COVID-19 (Coronavirus) pandemic: consequences for occupational health” (2). The authors highlight the importance of the societal consequences of the outbreak and changes in the world of work to manage occupational health. The key points identified – such as individual socio­economic factors, psychological effects and occupations with highest risk of contamination – modify return-to-work approaches. It is estimated that around 800 million people of working age worldwide were living with disabilities before the SARS-CoV-2 pandemic. In early January 2021, the cumulative COVID-19 hospitalisation rate reached 207.4/100 000 (18–49-year-olds) and 505.7/100 000 (50–64-year-olds), respectively, in the United States (3). In France, the hospitalisation rate was 411.5/100 000 across all ages (4). A recent cohort study of working-age men who were hospitalised for COVID-19 highlighted the long-term health consequences of such a disease (5). The SARS-CoV-2 pandemic creates new challenges for occupational health, shifting attention away from return-to-work after health problems to resuming work during an outbreak, dealing with lockdown, and taking special account of workers with vulnerabilities (6, 7). We recommend considering three different aspects of occupational medicine during a pandemic. Firstly, for most workers at high-risk of severe COVID-19, the issues of work disability and resuming work had never occurred before the epidemic. Recommendations such as physical and social distancing and wearing a facemask are highly advisable to protect against infection but may not be enough to enable some individuals to resume work. Therefore, decision-making requires individual comprehensive assessments of the underlying medical condition, the SARS-CoV-2 contamination risk associated with either regular work or teleworking, and vaccination opportunities. The second situation concerns workers who have suffered from COVID-19. Preliminary studies suggest that long recovery duration is related to high severity (7), but this is still a matter of debate for patients suffering from “long COVID-19” (5, 8, 9), a condition for which the long-term effects remain unknown. Any long-running recovery must be considered to be a potential sign of long COVID-19. These long-lasting syndromes occur among patients with severe symptoms but have also been reported independently of acute phase severity, hospitalisation and receiving medical oxygen (8, 9). Researchers worldwide are currently investigating such syndromes. Strategies promoting return to work for these workers will need to be implemented and could be similar to programmes developed for other chronic conditions. Moreover, numerous more serious sequelae following critical illness suggest the need for enhanced support by rehabilitation and occupational health specialists. Finally, the consequences of the epidemic must be evaluated over time for people who suffered from functional limitations before COVID-19 as their physical and mental condition may be modified by the epidemic and, specifically, the consequences of lockdown (10). In all of these situations, medical, social, financial and working contexts are key elements. In addition to a medical assessment, the use of scales such as the Work Ability Index (WAI) (11) or the Work Productivity and Activity Impairment (WPAI) (12) can help perform long-term follow-up and provide information about work capacity and workload. It also gives a “back to basics” perspective, urging politicians to move towards a `decent-work-for-all` policy, as advocated by the United Nation`s Sustainable Development Goal (SDG) 8, which the WHO has endorsed (13). References 1. Burdorf A, Porru F, Rugulies R. The COVID-19 pandemic: one year later – an occupational perspective. Scand J Work Environ Health – online first. https://doi.org/10.5271/sjweh.3956 2. Burdorf A, Porru F, Rugulies R. The COVID-19 (Coronavirus) pandemic: consequences for occupational health. Scand J Work Environ Health. 2020;46(3):229–230. https://doi:org/10.5271/sjweh.3893. 3. COVID-19 Hospitalizations [Internet]. Available from: https://gis.cdc.gov/grasp/COVIDNet/COVID19_3.html 4. COVID-19 in France, vaccine and allergy management in occupational setting. Descatha A et al. Arch Mal Prof Environ 2021. Accepted for publication. 5. Huang C, Huang L, Wang Y, Li X, Ren L, Gu X, et al. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet 2021;397(10270):220-32 https://doi.org/10.1016/S0140-6736(20)32656-8 6. Shaw WS, Main CJ, Findley PA, Collie A, Kristman VL, Gross DP. Opening the Workplace After COVID-19: What Lessons Can be Learned from Return-to-Work Research? J Occup Rehabil. 2020;30(3):299–302. https://doi.org/10.1007/s10926-020-09908-9 7. Taylor T, Das R, Mueller K, Pransky G, Christian J, Orford R, et al. Safely Returning America to Work: Part I: General Guidance for Employers. J Occup Environ Med. 2020;62(9):771–9. https://doi.org/10.1097/JOM.0000000000001984 8. Carfì A, Bernabei R, Landi F, Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020;324(6):603–5. https://doi.org/10.1001/jama.2020.12603 9. Tenforde MW, Kim SS, Lindsell CJ, Billig Rose E, Shapiro NI, Files DC, et al. Symptom Duration and Risk Factors for Delayed Return to Usual Health Among Outpatients with COVID-19 in a Multistate Health Care Systems Network - United States, March-June 2020. MMWR Morb Mortal Wkly. 2020;69(30):993–8. https://doi.org/10.15585/mmwr.mm6930e1 10. Chudasama YV, Gillies CL, Zaccardi F, Coles B, Davies MJ, Seidu S, et al. Impact of COVID-19 on routine care for chronic diseases: A global survey of views from healthcare professionals. Diabetes Metab Syndr. 2020;14(5):965–7. https://doi.org/10.1016/j.dsx.2020.06.042 11. Tuomi K. Eleven-year follow-up of aging workers. Scand J Work Environ Health. 1997;23(1):1–71. 12. Reilly MC, Zbrozek AS, Dukes EM. The validity and reproducibility of a work productivity and activity impairment instrument. PharmacoEconomics. 1993;4(5):353–65. https://doi.org/10.2165/00019053-199304050-00006 13. Organization WH. Health in the 2030 agenda for sustainable development. Sixty-Ninth World Health Assembly. Document A. 2016, p69.