Introduction to occupational diseases

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Károly Nagy and Ferenc Kudász, National Labour Office - Department of Occupational Health, Hungary

Introduction

Occupational diseases span a broad range of human illnesses, many of which clinically and pathologically are not different from those of non-occupational origins. They are contracted as a result of exposure to risk factors resulting, at least partially, from work activities. The diagnosis of occupational diseases can rarely be established on clinical grounds alone. It is essential to reveal the link between occupation and disease because of the employers’ responsibility to prevent occupational diseases and the compensation of ill workers. However, the list of reportable occupational diseases, as well as the related compensation systems, differs from country to country, making comparisons considerably more difficult.

Definition of ‘occupational disease’

Several definitions of the term “occupational disease” exist. However, for the purpose of the Protocol of 2002 to the Occupational Safety and Health Convention of International Labour Organisation (ILO), the term ‘occupational disease’ covers any disease contracted as a result of an exposure to risk factors arising from work activity” (Article 1 (b)) [1]. The ILO Employment Injury Benefits Recommendation (1964, Article 6, (1)) defines occupational diseases more precisely in the following terms: “Each Member should, under prescribed conditions, regard diseases known to arise out of the exposure to substances and dangerous conditions in processes, trades or occupations as occupational diseases.” [2] The various definitions, however, have two main mandatory elements in common [3]

  1. the causal relationship between exposure in a specific working environment or work activity and a specific disease; and,
  2. the fact that the disease occurs among the group of exposed persons with a higher frequency rate than in the rest of the population, or in other worker populations.

The causal relationship is established on the basis of clinical and/or pathological data, occupational background and job analysis, identification and evaluation of occupational risk factors and of the role of other risk factors [4]. As a general rule, the symptoms are not sufficiently characteristic to allow an occupational disease to be diagnosed without the knowledge of the physical, chemical, biological and/or other risk factors encountered in the exercise of an occupation. The recognition of an occupational disease is a specific example of clinical decision-making or applied clinical epidemiology [4]. Deciding on the pathology of a disease is not an “exact science” but rather a question of judgement based on a critical review of all the available evidence. This should include the strength of association, consistency, specificity, time sequence or biological gradient (the greater the level and duration of the exposure, the greater the severity of the diseases or their incidence) [3][5]. The World Health Organisation will detail information (including diagnostic criteria) on disease with occupational origin in the 11th revision of its International Statistical Classification of Diseases and Related Health Problems (ICD11) to be released in 2015 [6].

Further definitions concerning occupational and work-related diseases

Reportable occupational diseases: Occupational diseases mentioned in national lists as part of national laws or administrative provisions liable for compensation and subject to prevention measures. Reported occupational diseases are reportable diseases already passed through the legally required reporting process.
Recognised occupational disease: A recognised case of an occupational disease is a case accepted as such by a competent national authority in an administrative proceeding [7] [8].
Work-related diseases: All illnesses that can be caused, worsened or jointly caused by working conditions. A case of work-related illness does not necessarily refer to recognition by an authority whereas occupational diseases have a specific or a strong relation to the occupation, generally with only one causal agent while work-related diseases have a complex aetiology. Among their multiple causal agents, factors arising from the work and/or working environment play a role in the development of such diseases. A more precise distinction between occupational diseases and work-related diseases can be made by evaluating their attributable fractions. It is suggested that the attributable fraction of occupational diseases is more than 50% and less than 50% for work-related diseases [9].

Historical overview

The history of occupational diseases is as old as organised economic activity. Back pain resulting from strain at work is described in an Egyptian papyrus and a case of severe lead colic was recounted by Hippocrates. Other early writers like Pliny also recognised the association between certain disorders and occupations (e.g., mercury poisoning of slaves working as miners).
During the Middle Ages, where primitive methods of ventilation and personal protection were used in gold and silver mines, common mining accidents and miners’ occupational diseases caused by dust inhalation were studied and described. Ramazzini’s description of the diseases associated with 54 different occupations (e.g., the mercury poisoning of Venetian mirror makers) provides a comprehensive account of occupational disorders.
The rapid technological progress and growth during the era of Industrial Revolution of the 18th century led to unsanitary working and living conditions. This corresponded with a rise in the number of accidents and deaths among workers caused by new machinery and exposure to toxic materials.
Percivall Pott, a London surgeon, first described occupational cancer when finding links between the prevalence of scrotal cancer among chimney sweeps and the prolonged exposure to soot ingrained into their skin. In the 20th century, the incidence of classic occupational diseases such as lead poisoning and anthrax have declined, although none have been eradicated. Furthermore, new diseases have appeared as a result of advances in technology or of changes in work or working conditions. For example: occupational deaths among radiologists as a result of occupational X-ray exposures, asbestos-related diseases or hemangiosarcoma caused by vinyl chloride monomer [10] [11].
The turn of the third millennium is witnessing the emergence of a different set of challenges, including work-related musculoskeletal disorders, psychosocial issues, and work-related mental health disorders [12].

Workers’ compensation

History and general aspects

Statutory compensation for occupational (industrial) diseases was enacted first in Germany and then in the United Kingdom in the late nineteenth and early twentieth centuries. During the twentieth century this trend continued in the vast majority of countries in Western Europe and North America. The moral basis or social philosophy underlying workers' compensation is the efficient and dignified provision of financial and medical benefits to those suffering from a disease caused by their work or injured on the job; and the allocation of the expenses to an appropriate source, i.e. the consumer. The cost of insurance is reflected in the cost of goods or services produced by the employer; thus the cost of workers' compensation liability is passed ultimately to consumers. This system is meant to preserve the injured worker's dignity and well-being by providing an income and medical care, benefits for physical and mental disablement and by keeping them off welfare. Broader coverage can also include prevention and rehabilitation as it already does in some countries.

Workers' compensation is a no-fault law: in case of an occupational accident or disease, the policyholder is to collect compensation for any loss of worker (death, ill-health) without a determination of liability. The current schemes in each country provide compensation for accidents and diseases attributed to work. However, there are important differences in coverage and funding between the different countries. Which diseases are compensated can in principle be decided by attributing the disease to an occupational exposure-effect relationship in the individual case (“individual proof’) or from a list of occupational diseases, where scientific evidence of an exposure-effect relationship in particular circumstances is sufficient to allow the “benefit of presumption”. In practice, a combination of these principles is found in the various schemes.

Compensation schemes in Europe

European compensation systems are generally based on two methods. One is modelled after the German approach, with self-governed sectoral insurance associations funded by employers' contributions. This provides a comprehensive prevention, rehabilitation and compensation service. In the second form, the state administers the system for compensating occupational diseases as part of its wider provision for social security and levies contributions from employers to finance it. In most countries these two approaches are mixed with participation of both the state and private insurance systems. In Belgium, for instance, there is a state system for occupational diseases for industrial and commercial sector workers. In Denmark, occupational diseases are insured by specific funds financed by contributions from employers. In Norway the private employers’ insurance system ‘tops up’ the funds provided by the state system. The United Kingdom Industrial Injuries scheme is a government-funded compensation scheme for employed earners providing benefits to those suffering from listed ‘prescribed diseases’. In many European countries, occupational disease insurance systems are now also involved in prevention and rehabilitation. In all European countries, compensated (reportable) diseases are covered in a list [13]. There is also a European Union list (European Schedule of Occupational Diseases = ESOD) [14]. In Sweden, only infectious diseases are listed; eligibility for other conditions is open and based on individual assessment. Finland has an indicative list, but its system does not exclude other conditions. France and the United Kingdom are, in general, more prescriptive and permit only listed diseases [13].

Legal aspects

ILO List of Occupational Diseases (revised 2010)

The 1996 ILO code of practice claims that each government should formulate, implement and periodically review a coherent national policy and principles on the recording, notification and investigation of occupational diseases [3]. As a part of this policy, a national list of occupational diseases should be established. This list should comprise, to the extent possible, the diseases appearing in the ILO list of occupational diseases. The ILO list is regularly reviewed and updated at tripartite meetings of experts convened by the Governing Body of the ILO. The national lists of occupational diseases should be reviewed and updated with due regard to the most up-to-date ILO list (most currently adopted in 2010). The list includes a range of internationally recognized occupational diseases, from illnesses caused by chemical, biological and physical agents to respiratory and skin diseases, musculoskeletal disorders and occupational cancer. Mental and behavioural disorders have also been specifically included in the ILO list. This list also has open items in all the sections dealing with all the aforementioned diseases. The open items allow the recognition of the occupational origin of diseases not specified in the list if a significant association is observed between exposure to risk factors arising from work activities and the disorders contracted by the worker. The sections and subsections of occupational diseases applied in the current list are as follows:

  1. Occupational diseases caused by exposure to agents arising from work activities
    1. Diseases caused by chemical agents
    2. Diseases caused by physical agents
    3. Biological agents and infectious or parasitic diseases
  2. Occupational diseases by target organ systems
    1. Respiratory diseases
    2. Skin diseases
    3. Musculoskeletal disorders
    4. Mental and behavioural disorders
  3. Occupational cancer
  4. Other diseases

The list is not exhaustive to include every occupational disease but rather specifies those considered common to many countries. The list should, therefore, be adapted to local circumstances, and used to help prioritise occupational diseases [15].

ILO Protocol of 2002 to the Occupational Safety and Health Convention, 1981

The provisions of the Protocol state that the competent national authorities shall establish and review requirements for the recording and notification of occupational diseases. The requirements shall determine among others [1]:

  • the responsibility of employers to keep records on occupational diseases;
  • the use of these records to establish preventive measures at the workplace;
  • the maintenance period of these records;
  • measures to ensure the confidentiality of personal and medical data;.
  • the responsibility of employers to notify the competent authorities;
  • to provide appropriate information to workers and their representatives concerning the notified cases.

The Protocol makes a recommendation concerning the data required for the notification, for example: on the enterprise, establishment and employer; the workplace, the circumstances of the exposure to health hazards. Each Member shall publish annual statistics concerning occupational diseases as well as the analyses thereof. The statistics shall be established following classification schemes that are compatible with the latest relevant international schemes.

Commission Recommendation concerning the European schedule of occupational diseases 2003/670/EC

It is recommended that the Member States of the EU introduce into their national laws the European schedule of occupational diseases, develop and improve effective preventive measures, draw up quantified national objectives with a view to reducing the rates of recognised occupational illnesses or progressively make their statistics on occupational diseases compatible with the European schedule. The prime aim of harmonising European statistics on occupational diseases, that at least information on the causative agent, the medical diagnosis and the sex of the patient should be available for each case of occupational diseases. The Member States should lay down workers´ rights to compensation in respect of all diseases which can be proved to be occupational in origin and nature. Prevention is supported, for instance, by promoting research or by target setting, which means formulating quantified targets for the reduction of the rates of recognised occupational diseases. The Recommendation highlights the meaning of research on ailments linked to an occupational activity, and of raising awareness among medical staff. Networking and information exchanging tasks are assigned to the European Agency for Safety and Health at Work concerning occupational illnesses. There are two annexes linked to the Recommendation. Annex 1 comprises 108 diseases divided in five groups according to their causative factors (chemical, physical, infectious, etc.) or the affected organs (e.g. the skin). This annex, the European schedule of occupational diseases, should be introduced into the national laws and regulations. The diseases mentioned in this schedule must be linked directly to the specific occupations, and, therefore, are liable for compensation and subject to prevention measures. Annex II of the Recommendation comprises 48 additional diseases that can be proved to be occupational in origin and nature and thereby granting the workers right to compensation [14]. The European Commission has published a guideline providing stakeholders key criteria for diagnosing occupational diseases listed in the Recommendation.[18] The impact of the Recommendation was reviewed in 2013 [13] [16]. The analysis produced several scenarios and suggestions for an EU-wide strategy [17]. In 2013 the European Commission organised a conference with European and international experts to discuss those findings [16]

Regulation No 1338/2008 of the European Parliament and of the Council

The Regulation No 1338/2008 of the European Parliament and of the Council establishes a common framework for the systematic production of community statistics on public health and health and safety at work [8]. According to the scope of the regulation a case of occupational disease is defined as such by the national authorities responsible for the recognition of occupational diseases. In contrast, a case of work-related illness does not necessarily require recognition by an authority. The occupational diseases dataset shall be established in the framework of the specifications laid down by the European Occupational Diseases Statistics (EODS) methodology, taking into consideration the circumstances and practices in EU Member States. This common dataset shall cover the following list of subjects: characteristics of the disease of the sick person (including, gender and age), characteristics of the enterprise and workplace, the causative agent or factor. The overall aim of EODS is to obtain gradually synchronised, comparable and reliable data and indicators (for example exposure, occupation at time of exposure, severity of disease) on occupational diseases in Europe [18]. After the revision and simplification of the EODS methodology, Eurostat envisages re-launching the collection of national data and the dissemination of aggregated data [19].

Current challenges

Developments in the national lists of occupational diseases: co-ordinating structure, wording and content of the lists

Most European countries have a national list of occupational diseases. These lists cover about the same content as the ESOD (European Schedule of Occupational Diseases, Annex I), although the number of specific diseases in the national lists varies from 32 to 141.Low back pain, for example, is not mentioned in the national list of Belgium or Hungary but it is in that of Denmark or France. Another example is that trachoma is specifically mentioned in Portugal but not in Austria. The different numbers are due to the different characteristics and structures of the lists, and to the different structures of the particular diseases or groups of diseases within the lists. Only a few countries report that their lists do not include a number of diseases in the ESOD. In countries with relatively small populations and limited fields of industrial production, the national lists probably do not need to adopt all the diseases in the EU list. In almost all European countries, there is growing public interest in the structure and content of the national lists of occupational diseases and they are under active discussion. Consequently, the originally created national lists were amended on a number of occasions with new occupational diseases added. In many countries, the ESOD had an impact on these national discussions and changes [13]. In addition, there is no general agreement on the diagnostic criteria of occupational diseases despite attempts to reach a consensus of the following items in relation to diseases listed in ESOD [5]:

  • Minimum intensity of exposure: the minimum level of exposure that is required to cause disease. Lower exposures are unlikely to lead to occupational disease. This concept is applicable especially to toxic agents. Usually no minimum threshold dose can be defined for carcinogenic or allergenic agents.
  • Minimum duration of exposure: the shortest exposure period for which a disease can occur. Periods of exposure less than this are unlikely to cause disease.
  • Maximum latent period: This refers to the period after the cessation of exposure, beyond which it is unlikely that any disease can be attributed to the exposure. For example, acute myocardial ischemia occurring a year after an acute exposure to carbon monoxide is not attributable to that exposure.
  • Minimum induction period: This is the shortest period from the beginning of an exposure to the beginning of a disease below which the exposure would have been unlikely to have caused the disease. For example, lung cancer developing within a year after the first exposure to asbestos is unlikely to be attributed to that exposure.

Priorities for prevention of occupational diseases at the European level

In addition to the priorities of stakeholders in the national socio-economic context, social partners also have to pay attention to the policy for the prevention of occupational disease at the EU level. For example, the European Trade Union Confederation has raised topics concerning the future EU Health and Safety Strategy along the following occupational disease-related themes [20]:

  • psychosocial factors: the integration of psychosocial aspects in general health and safety policies, and tools related to issues like stress and mental health;
  • the revision of the Carcinogens Directive including the potential improvement brought by the inclusion of the reprotoxic agents in the Directive;
  • proposal of a new directive on musculoskeletal disorders.
  • The issue of asbestos reached a European Parliament resolution [21].

For prevention of work-related musculoskeletal disorders priority should be given to the preparation of toolkits that are sector and workplace oriented. Furthermore, emphasis should be on efficient support measures for small and medium sized enterprises.

New work-related hazards

Definitions and typology of new work-related diseases

Changes in work and working conditions have resulted in new occupational health risks and new occupational diseases. The same is true for every new technology with potential new risks. These risks, if not assessed and managed properly, could have serious? potential consequences for human health. Proper risk assessment and health surveillance is needed to collect empirical and research data, and risk management to prevent new occupational diseases. ‘New risk’ or new work-related hazards as formulated by the European Agency for Safety and Health at Work are [22]:

  • Risks previously unknown and caused by new processes / technologies / types of workplaces, or social / organisational changes. For example, nanotechnology is a key technology of the 21st century with far-reaching implications for science, industrial development and new product design. However, despite the potential adverse effects on human health, the toxicology of these nanostructured materials (nanotoxicology) has not been investigated sufficiently. The Compendium in Projects in the European NanoSafety Cluster gives an overview of the topic [23].
  • Long-standing issues such as stress or bullying are now considered as risks due to a change in social or public perceptions. Work-related stress is recognised as a major obstacle to productivity in Europe. A European work-related public health report on Cardiovascular Diseases and Mental Ill Health (2007) has revealed that cardiovascular diseases (CVD) and mental ill health are interrelated, and that mental disorders can be risk factors for CVD and vice versa. The report states that 6% of all CVD cases among men and 14% in women can be attributed to job strain. Mental ill health is as much a risk factor for cardiovascular disease and mortality as the lack of physical activity or high cholesterol [24].
  • Long-standing issues, such as electromagnetic radiation, identified as a risks because of new scientific knowledge in the field. Although the occupational aspects of electromagnetic fields are undeniable, their health effects are much more debated in relation to public health policy [25].

Table 1. Categories of new work-related diseases, with examples.

Category Examples
New diseases due to changes in work and working conditions
  • Progressive Inflammatory Neuropathy (PIN) in swine slaughterhouse workers
  • Popcorn disease
  • Legionnaires' disease
  • Allergy to preservatives (paint, adhesive)
  • Allergy to biological pesticides ||
New risks from known agents
Consequences of parents’ occupational exposure on their offspring
  • Congenital abnormalities
  • Cancer in children
  • Delayed neuropsychological development

Source: van der Laan [23]

Methodology

Detecting new occupational health risks may require different instruments – and often several complimentary methods instead of using a single one – from those used for monitoring known occupational diseases.

  1. Sentinel case approach; in analogy with pharmacovigilance:

In the case of a rare disease with a high etiological fraction (when work is an important cause of the complaints), then a large group of sentinel physicians and others, who describe and report the cases in detail and reveal the likely occupational factors the disease is associated with, are more suitable than epidemiological research. A voluntary surveillance scheme with dermatologists in the Netherlands provides valuable data about the distribution of occupational skin diseases in risk professions and the causal agents [4]. The national network for monitoring and prevention of occupational diseases in France includes 32 consultation centres and a sample of occupational health services. This network aims to collect data on occupational diseases, to identify emerging and re-emerging risks in occupational health and to improve practices to diagnose work-related diseases [26]. Another example for the sentinel case approach, where the sentinels more effectively revealed causative occupational factors and associations between them and the disease, than an epidemiological research would have done, is the identification of the so-called “popcorn disease”: a severe lung disease with airway obstruction caused by inhalation of airborne diacetyl, a chemical used to produce artificial butter flavouring [27]. Pharmacovigilance is “the process and science of monitoring the safety of medicines and taking action to reduce risks and increase benefits from medicines” [24]. This approach is comparable to analysing and learning from occupational accidents or from experiences with identifying the adverse effects of drugs (e.g. side effects, congenital birth defects, congenital abnormalities).

  1. Epidemiological studies; health surveillance:

In the case of frequent illnesses with a low etiological fraction (when work is only one of the many causes), epidemiological research among large groups of workers is more valuable than individual reports. Epidemiological studies are facilitated by the fact that links are relatively easy to establish between records of health outcomes with past occupational exposure data. Therefore, health surveillance is to serve as an early warning system.

References

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  2. ILO - International Labour Organization, R121 - Employment Injury Benefits Recommendation, 1964. Available at: [2]
  3. 3.0 3.1 3.2 ILO - International Labour Organization, List of Occupational Diseases. Identification and recognition of occupational diseases: Criteria for incorporating diseases in the ILO list of occupational diseases, 2010. Retrieved 20 November 2013, from: [3]
  4. 4.0 4.1 4.2 ILO - International Labour Organization, National System for Recording and Notification of Occupational Diseases Practical Guide, 2013. Retrieved 20 November 2013, from: [4]
  5. 5.0 5.1 European Commission, Information notices on occupational diseases: a guide to diagnosis. Office for Official Publications of the European Communities, Luxembourg, 2009. Retrieved 20 November 2013, from: [5]
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  7. Nowak, D., Drexler, H., Kraus, T., Letzel, S. Berufskrankenheitenneute – Was muss der Nicht-Arbeitsmediziner wissen? Dtsch med Wochenschr, 138(01/02), 2013, pp. 479-484.
  8. 8.0 8.1 Regulation (EC) No 1338/2008 of the European Parliament and of the Council of 16 December 2008 on Community statistics on public health and health and safety at work (Text with EEA relevance). Available at: [7]
  9. FIOH - Finnish Institute of Occupational health, Concepts of occupational diseases, 2013. Retrieved 13 March, 2013, from: [8]
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  12. EU-OSHA – European Agency for Safety and Health at Work, ‘Occupational diseases’, Outlook 1 – New and emerging risks in occupational safety and health, 2009, pp. 16-18.
  13. 13.0 13.1 13.2 13.3 European Commission, Report on the current situation in relation to occupational diseases’ systems in EU Member States and EFTA/EEA countries, in particular relative to Commission Recommendation 2003/670/EC concerning the European Schedule of Occupational Diseases and gathering of data on relevant related aspects, 2013. Available at: [10]
  14. 14.0 14.1 Commission Recommendation of 19 September 2003 concerning the European schedule of occupational diseases (notified under document number C(2003) 3297). Available at: [11]
  15. Niu, S., The ILO Activities on Occupational Diseases, 2014. Retrieved 14 February 2014, from: [12]
  16. 16.0 16.1 European Commission, Occupational Diseases in the EU - The system(s) and their role / Way forward, 2014. Retrieved 14 February 2014, from: [13]
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  18. European Commission, Population and social conditions 3/2000/E/n°19 European Occupational Diseases Statistics (EODS) Phase 1 Methodology, 2000. Available at: [15]
  19. De Norre, B., Presentation – Session 2: diagnostic criteria, data and statistics, 2014. Retrieved 14 February 2014, from: [16]
  20. ETUC - European Trade Union Confederation, ETUC resolution on the EU Health and Safety Strategy 2013-2020, 2013. Retrieved 12 December 2013, from: [17]
  21. European Parliament resolution of 14 March 2013 on asbestos related occupational health threats and prospects for abolishing all existing asbestos (2012/2065(INI)) Available at: [18]
  22. Flaspöler, E., Reinert, D, & Brun, E., EU-OSHA, ‘Expert forecast on emerging physical risks related to occupational safety and health’, Office for Official Publications of the European Communities, Luxembourg, 2005. Available at: [19]
  23. 23.0 23.1 van der Laan, G., ‘New Occupational Diseases, a typology’, presentation at 30th ICOH Congress 2012.
  24. 24.0 24.1 European Commission, The EU pharmacovigilance system, 2013. Retrieved 12 December 2013, from: [20]
  25. EU NanoSafety Cluster, European NanoSafety Cluster Compendium, 2013. Retrieved 12 December 2013, from: [21]
  26. ANSES – Agence nationale de sécurité sanitaire de l’alimentation, de l’environnement et du travail. RNV3P: National Network for Monitoring and Prevention of Occupational Diseases. Retrieved 14 February 2014, from: [22]
  27. Centers for Disease Control and Prevention – CDC (2011). Flavorings-Related Lung Disease. Retrieved 31 March 2014, from: [23]


Links for further reading

Clapp, R.W, Jacobs, M.M., Loechler, E.L. Environmental and Occupational Causes of Cancer New Evidence, 2005–2007. Rev Environ Health. 23, 1, 2008, pp. 1-37.

Eurogip, Les maladies professionnelles en Europe - Statistiques 1990-2006 et actualité juridique, 2009. Retrieved 20 November 2013, from: [24]

Eurogip, Cancers d’origine professionnelle: quelle reconnaissance en Europe? Réf. Eurogip - 49/F, 2010. Retrieved 20 November 2013, from: [25]

Eurogip, Series ‘Point statistique AT/MP’, 2013. Available at: [26]

Eurostat, Health and safety at work in Europe, 2010. Retrieved 20 November 2013, from: [27]

Franco, G., ‘A tribute to Bernardino Ramazzini (1633–1714) on the tercentenary of his death’, Occupational Medicine, Vol. 64, No. 1, Oxford University Press, London, 2014, pp. 2-4. Available at: [28]

ILO - International Labour Organization, List of Occupational Diseases (revised 2010), 2010. Retrieved 20 November 2013, from: [29]

ILO - International Labour Organization, Prevention of occupational diseases, 2013. Retrieved 20 November 2013, from: [30]

Kim, E-A., Kang, S-K., ‘Historical review of the List of Occupational Diseases recommended by the International Labour organization (ILO)’ Annals of Occupational and Environmental Medicine 2013, 25:14. Retrieved 12 December 2013, from: [31]

Karjalinen, A., International Statistical Classification of Diseases and related Health Problems (ICD-10) in Occupational Health. Protection of the Human Environment Occupational and Envirnomental Health Series. WHO & FIOH, Geneva, 1999.

Karvonen, M., Mikheev, M.I. (Eds.), Epidemiology of Occupational Health, WHO Regional Office for Europe, Copenhagen, 1986. Available at: [www.euro.who.int/__data/assets/pdf_file/0020/156071/WA400.pdf‎]

Mahmud N, Schonstein E, Schaafsma F, Lehtola MM, Fassier JB, Reneman MF, Verbeek JH. Pre-employment examinations for preventing occupational injury and disease in workers. Cochrane Database of Systematic Reviews 2010, Issue 12. Available at: [32]

Spreeuwers, D., de Boer, A. G. E. M. , Verbeek,J. H. A. M., van Dijk, F. J. H. Evaluation of occupational disease surveillance in six EU countries. Occupational Medicine 2010; 60 :509–516.

Spreeuwers, D., de Boer, A. G. E. M. ,Verbeek,J. H. A. M., van Beurden, M. M., van Dijk, F. J. H. Diagnosing and reporting of occupational diseases: a quality improvement study. Occupational Medicine 2008; 58 :115-121.

Walters, D., ‘An International Comparison of Occupational Disease and Injury Compensation Schemes’, Industrial Injuries Advisory Council, 2007. Available at: [33]