Nursing management of patients with

occupational and industrial disorders

 INTRODUCTION

 Industries use chemicals for making products in large quantity. The

effluents from the industrial processes have compounds with
capacity to produce certain ill effects among the exposed individuals.
Occupational centres are extracting work from the workers beyond
their physical and mental capacities. This may cause certain diseases
among the workers.
 Occupational disease and occupational pathology, a
subspecialty of clinical medicine is the study of occupational
disease that have appeared as a result of harmful factors in the
manufacturing environment or work process.
 Nurse should know about the causes, symptoms, diagnostic
measures. management and prevention of occupation and
industry related health disorders.
Definition

 Occupational health is defined as the highest level of

physical, mental and social well being of workers in all
occupations. It is the branch of health care that deals with
all aspects of workplace health and safety. It place a strong
emphasis on hazard prevention at the primary level.
What is occupational health nursing ?

 Application of nursing principles in conserving the health

of workers at the workplace.
 Based on principles of recognition prevention and
treatment of illness, injuries.
Objectives of occupational health
 Maintenance and promotion of workers' health and working
capacity (health monitoring)
 Improvement of working environment and work to become
conducive to safety and health (worksite visits)
 Development of work organizations and working cultures in a
direction, which supports health and safety at work (health
education).
 OCCUPATIONAL HEALTH
STATISTICS
 There are 100 million occupational injuries causing 0.1 million deaths in
the world according to WHO. It is also estimated that in India 17 million
occupational non-fatal injuries (17% of the world) and 45,000 fatal
injuries (45% of the total deaths due to occupational injuries in world)
occur each year. Out of 11 million cases of occupational diseases in the
world 1.9 million cases (17%) are contributed by India and out of 0.7
million deaths in the world 0.12 (17%) is contributed by India.
 The adverse occupational factors have been estimated to cost 2-14% of
the gross national products for various countries. As the incidence of
occupational related morbidity and mortality is very high in India it is
false to say that out of total of one million crore of rupee of GNP in the
year 1999, occupational diseases has caused a loss of around 70,000
crore. The amount paid as compensation for death and disablement
resulting from work related injuries in India has increased more from Rs.
8 million in 1961 to 186 million in 1997.
 India reported 1,109 deaths and more than 4,000 injuries
in registered factories, on average, each year between 2017
and 2020. In 2021, it is said that average 7 accidents were
reported in every month in Indian manufacturing
industries, killing more than 162 workers.
 Enormous burden of poor working
condition
 The ILO estimates that some 2.3 million women and men around the
world succumb to work-related accidents or diseases every year, this
corresponds to over 6000 deaths every single day. Worldwide, there are
around 340 million occupational accidents and 160 million victims of
work-related illnesses annually. The ILO updates these estimates at
intervals, and the updates indicate an increase of accidents and ill health.
Some of the major findings in the ILO's latest statistical data on
occupational accidents and diseases, and work-related deaths world-wide
level include the following:
 Diseases related to work cause the most deaths among workers
Hazardous substances alone are estimated to cause 651,279 deaths a
year. The construction industry has a disproportionately high rate of
recorded accidents.
 Younger and older workers are particularly vulnerable. The ageing
population in developed countries means that an increasing number
of older persons are working and need special consideration.
 The concept of occupational health nursing is new to India. It is
non-existent in unorganized sectors. Even the public sector and
private employers have not yet realized its importance. There is a
need to create awareness about this issue amongst all stakeholders.
 National Institute of Occupational Safety & Health (NIOSH) has developed
a priority list of leading work-related illnesses and injuries. Three criteria
were used to develop the list:

a) The frequency of occurrence of the illness or injury

b) Its severity in individual cases

c) Its potential for prevention.

d) Occupational lung disease is first on the list Silicosis, asbestosis are still
prevalent in many parts of the world
 The prevalence of Occupational Asthma varies from 10% to
nearly all of the workers in certain high-risk occupations,
NISOH considers occupational cancer to be the second
leading work-related disease, followed by cardio-vascular
diseases, disorder of reproduction, neurotoxicity, noise
induced hearing loss, dermatological conditions, and
psychological disorders.
Major occupational diseases can be
divided in following categories for better
understanding:
A. Occupational injuries
B. Occupational lung diseases
C. Occupational cancers
D. Occupational dermatoses
E. Occupational Infections
F. Occupation toxicology
G. Occupational mental disorders
Occupational disorders can be grouped according the etiological factors:
 Occupational injuries: ergonomic related
 Chemical occupational factors: dust, gases, acid, alkali, metals etc.
 Physical occupational factors: noise, heat, radiation
 Biological occupational factors
 Behavioral occupational factors
 Social occupational factors
 Occupational health was one of the components of the National Health
Policy 1983 and now also included in National Health Policy 2002 but
very little attention has been paid to mitigate the effect of occupational
disease through proper programme. Ministry of Health & Family
Welfare, Govt. of India has launched a scheme entitled "National
Programme for Control & Treatment of Occupational Diseases" in
1998-99, The National Institute of Occupational Health, Ahmedabad
(ICMR- Indian council of medical research) has been identified as the
nodal agency for the same.
• Capacity building to promote research, education, training at
National Institute of Occupational Disease

• Health Risk Assessment and development of intervention

programme in cottage industries with high risk of silicosis

• Prevention and control of Occupational Health Hazards among

salt workers in the remote desert areas of Gujarat and Western
Rajasthan.
Occupational diseases in India

 Estimated 17 million occupational non fatal injuries (17%of the

world) and 45,000 fatal injuries (45% of the total deaths due to
occupational injuries in world) occur each year.
Global strategy for occupational health

 The global strategy for achieving occupational health for all

(WHO-1999) includes the following ten major areas for
action:
 Strengthening of International and national policies for health
at work and development of policy tools.
 Developing healthy work environments.
 Establishing registration and data system including
development of information services for experts, effective
transmission of data, and raising pubic awareness through
strengthened public information system.
 Strengthening research.
 Developing collaboration in occupational health services and
organizations.
Occupational injuries

 Wet floors, spills, and clutter may cause slips, trips and
falls. Poor vehicle maintenance, inadequate operator
training and lack of safety restraint contribute to
ambulance crashes. Unsafe electric work practices may
cause electric shock, electrocutions, fire and explosions.
Occupational infections

 Needlestick injuries contribute to 39%, 37% and 4.4% of

hepatitis C, hepatitis B and HIV infections respectively.
The prevalence of acute hepatitis B infection among health
workers. globally is 5.3%.About 54% of health workers in
low- and middle-income countries have latent TB
infection.
Occupational diseases
 Occupational disease, any illness associated with a particular
occupation or industry. Such diseases result from a variety of
biological, chemical, physical, and psychological factors that
are present in the work environment or are otherwise
encountered in the course of employment. Occupational
medicine is concerned with the effect of all kinds of work on
health and the effect of health on a worker's ability.
 Occupational diseases are essentially preventable and can be
caused by faulty working conditions. The control of
occupational health hazards decreases the incidence of work-
related diseases and accidents and improves the health and
morale of the forces, leading to decreased absenteeism and
increased worker efficiency.
Common occupational diseases in India

 Respiratory diseases- Diseases of the respiratory system are

frequent in professions where workers are exposed to
hazardous substances. Daily exposure to hazardous chemicals
among industrial and construction workers causes allergies
and significant respiratory conditions.
These are typical among them:
 Mesothelioma-Mesothelioma is a rare and aggressive cancer
that affects the mesothelium, a thin layer of tissue that covers
the internal organs.
 Pneumonitis

 Tuberculosis

 Occupational asthma
 Silicosis- Silicosis is a chronic lung condition brought on by
exposure to hazardous quantities of silica dust, typically over a
lengthy period of time. Those who handle specific materials
have the risk of inhaling tiny silica dust. The dust particles
might leave lung scarring after entering the lungs.
 Pharyngitis

 Chronic obstructive pulmonary disease (COPD)

 Hearing issues- Those who spend their days around loud
machines and a lot of noise run the risk of losing their hearing.
 Heavy lifting
 Workers who are required to lift and carry big goods, such as
porters, labourers, and construction workers, may become
exhausted.
Overexertion is frequently linked to the following injuries:
 Hernias
 Leg wounds
 Sprained ankles
 Back and shoulder injuries
 Joint abrasions
Contemporary occupational disease

 As a result of the difficulties in today's workplace, mental health issues and

stress-related illnesses are on the rise. The employees are under excessive

pressure due to the employment expectations of the profit-driven economy.

 Workplace stress is caused by a shortage of time , a mismatch between the

skills needed and those that are accessible, isolation at the office, and a lack

of appreciation.
 Many musculoskeletal disorders are also brought on by
prolonged computer use, a sedentary workplace culture, and a
lack of mobility.
 High Blood Pressure
 Muscle pain, headache
 Cardiovascular diseases
 Gastrointestinal disorders
 Weakened immune system
 Increased cholesterol
 Depression

 Anxiety, anger, restlessness

Common occupational diseases in India
 Chrome ulceration: Chrome ulcers, also known as chrome holes. are
generally crusted lesions that are painless and reveal a 2.5 mm pitted ulcer
covered with exudate.
 The hands, forearms, and feet are the areas of the body where ulcers most
frequently develop.
 Anthracosis: It is caused by inhaling coal dust for an extended
period of time, which turns the lungs black. When continuous
exposure to coal dust particles causes anthracosis.
 Skin cancer :The abnormal growth of skin cells most
often develops on skin exposed to the sun. There are
common skin cancers are squamous cell carcinoma,
basal cell skin cancer.
 Toxicanemia: When anemia is diagnosed, the body doesn't
produce enough healthy red blood cells to supply enough
oxygen to tissues.
 Dermatitis due to mineral oils: When essential oils
come into contact with the skin, a delayed
hypersensitivity reaction can cause dermatitis (eczema)
known as allergic contact dermatitis.

 Contact dermatitis: Skin irritation is brought on by

coming into contact with certain things. that causes
rashes, dry skin, and itching.
 Byssinosis: Byssinosis is a lung condition that develops over
time with repetitive exposure to cotton or jute dust in working
situations with poor ventilation.
 Asbestosis: A lung condition brought on by inhaling
asbestos fibre, a fibrous hydrated magnesium silicate.
Asbestos fibres are utilised in the construction of
insulation and roofs Long-term asbestos exposure results
in lung fibrosis, which shortens breath.
 Noise-induced hearing loss: The hearing impairment known
as noise-induced hearing loss (NIHL) is brought on by
exposure to loud noise. Individuals may lose their ability to
perceive a specific frequency range or have poor hearing,
including increased sensitivity to sound or ringing in the
ears.
Coal miners' pneumoconiosis: The occupational pneumoconiosis
known as black lung illness, sometimes referred to as coal workers
pneumoconiosis (CWP) or simply black lung, is brought on by
prolonged exposure to coal dust.
 Occupational cancer: Occupational cancer has been linked
to exposure to chemicals, dusts, radiation, and particular
industrial processes. Cancer may develop as a result of
mutations brought on by carcinogens, which are
substances that cause cells to grow out of control.
 Toxic nephritis: The inflammation of the kidneys is known as
nephritis. The ability of the kidneys to remove extra water and
waste from the blood can be affected by exposure to toxins
and cause inflammation to the kidneys.
Disorders due to chemical agents

Hazardous chemicals can act directly on the skin, resulting in

local irritation or an allergic reaction, or they may be
absorbed through the skin, ingested, or inhaled. In the
workplace ingestion of toxic chemicals is usually accidental
and most commonly results from handling contaminated
food, drink, or cigarettes.
 Substances that occur as gases, vapours, aerosols, and
dusts are the most difficult to control, and most hazardous
chemicals are therefore absorbed through the respiratory
Tract. If inhaled, airborne contaminants act as irritants to
the respiratory tract or as systemic poisons.
 Toxicity in such cases depends on the contaminant's
concentration, particle size, and physicochemical properties,
particularly its solubility in body fluids. An individual's reaction
to any hazard depends primarily on the length, pattern, and
concentration of exposure but is also affected by such factors as
age, sex, ethnic group. genetic background, nutritional status.
coexistent disease, exposure to other toxic agents, life-style,
and history of previous exposure to the agent in question
Organic compounds

 The organic compounds that pose the greatest occupational

hazards are various aromatic, aliphatic, and halogenated
hydrocarbons and the organophosphates, carbamates,
organochlorine compounds, and bipyridinium compounds
used as pesticides.
 Pesticides are used the worldwide, and, even though
precautionary measures (such as using protective clothing and
respirators, monitoring contamination of equipment and
clothing, keeping workers out of recently sprayed areas, and
requiring workers to wash thoroughly after exposure), this
causes symptoms related to parasympathetic overactivity, such
as chest tightness, wheezing, blurring of vision, vomiting,
diarrhea, abdominal pain, and in severe cases respiratory
paralysis.
Gasoline

 Gasoline is a human-made substance that people use primarily to fuel

vehicles and other machines that use an engine.

 Gasoline is not just toxic when people ingest it. A person can also
sustain damage to the skin, eyes, and lungs, when they come into
contact with gasoline liquid or the fumes or vapors of gasoline
 Temperature
 When working in a hot in, humans maintain normal body temperature by
perspiring and by increasing the blood flow to the surface of the body.
Heatstroke is characterized by thirst, fatigue, giddiness, and often muscle
cramps, fainting can also occur, a more serious and sometimes lethal
condition, results when prolonged exposure to heat and high humidity. If
victims are not quickly cooled down, coma, convulsions, and death.
 Cold
 Work in cold environment may also have serious adverse effects.
Tissue damage that does not involve freezing can cause
inflammatory swelling known as frost bite, or the freezing of
tissue, can lead to gangrene and the loss of fingers or toes. If
exposure is prolonged and conditions (such as wet or tight
clothing) encourage heat loss, may result, a critical fall in body
temperature.
 Mercury poisoning, one of the classic occupational diseases,
is a representative example of metal poisoning Exposure to
mercury can occur in many situations, including the
manufacture of thermometers, explosives, fungicides,
batteries, and various electrical products. The disorders it
can vary depending on the type of mercury compound and
the method of exposure.
 Noise
 Exposure to excessive noise can be unpleasant and can impair working
efficiency. Temporary or permanent hearing loss may also occur,
depending on the loudness or intensity of the noise, its pitch or
frequency, the length and pattern of exposure, and the vulnerability of
the individual. Prolonged exposure to sound energy of intensity above
80 to 90 decibels is likely to result in noise- induced hearing loss,
developing first for high frequencies and progressing downward.
 Vibration
 Whole-body vibration is experienced in surface and air transport, with motion
sickness its most familiar effect. A more serious disorder, known as Raynaud's
syndrome or vibration white finger (VWF), the extensive use of vibratory hand
tools, especially in cold weather. The condition is seen mostly among workers
who handle chain saws, grinders, pneumatic drills, hammers, initial signs of
VWF are tingling and numbness of the fingers, followed by redness and pain
occur in the recovery stage. In some cases the tissues, bones, and joints affected
by the vibration may develop abnormalities; even gangrene may develop.
Other mechanical stresses
 Muscle cramps often afflict workers engaged in
heavy manual labour as well as typists, pianists, and
others who frequently use rapid, repetitive
movements of the hand or forearm. Tenosynovitis, a
condition in which the sheath enclosing a tendon to
the wrist or to one of the fingers becomes inflamed,
causing pain and temporary disability. It can also
result from prolonged repetitive movement.
Ionizing radiation
 Ionizing radiation damages or destroys body tissues by breaking
down the molecules in the tissues into positively or negatively
charged particles called ions. Delayed effects of exposure to
radiation include the development of leukemia and other cancers.
Examples skin cancers that killed many of the pioneering
scientists who worked in radioactive department.
Disorders due to psychological factors
 There are two psychological and commonly encountered at work are
boredom and mental stress. Workers who perform simple, repetitious
tasks for prolonged periods are subject to boredom.
 Boredom can cause frustration, unhappiness, inattentiveness, and other
detriments to mental well-being it can play a major role in Job
dissatisfaction, increased responsibility.
 Disinterest, competition, feelings of inadequacy, and bad
working relationships can also contribute to mental stress.
 Stress affects both mental and physical health, causing anger,
irritation, aches, nausea, ulcers, migraine, asthma, colitis, or
even breakdown and Moderate exercise, meditation,
relaxation, and therapy can help workers to cope with stress.
 Pneumoconiosis
 Pneumoconiosis is one of a group of interstitial lung disease
caused by breathing in certain kinds of dust particles that damage
lungs. As most often these dusts can absorbed only in the
workplace, pneumoconiosis is called an occupational lung disease.
 Pneumoconiosis usually take years to develop, Because lungs can't
get rid of all these dust particles, they cause inflammation in lungs
that can eventually lead to scar tissue.
Causes

 Mineral dusts (asbestos, silica, coal), metal dusts,

biological dusts manufactured fibers (glass or ceramic
fibers), and toxic fumes (nitrogen dioxide, sulfur
dioxide, chlorine, ammonia).
Clinical manifestations

• Long-term cough

• Coughing up large amounts of mucus

• Shortness of breath

• Prolonged illness culminating in respiratory failure

Risk factors

 Coal miners
 Exposed to long term dust
 Smoking
 Age
Treatment

 As it is an uncurable disease, the treatment is planned as

controlling symptoms from worsen the condition.
 Avoid smoking
 Avoid dust exposure
 Medication
 Bronchodilators
 Corticosteroids
 Oxygen therapy
Prevention
 Wearing masks
 Washing areas of skin that come in contact with dust
 Regular health check ups
 Physical examinations
 Home care
 Health education to the patient and their families about working in
hazardous areas
Anthracosis

 Carbon dust (coal mine dust); coal miners pneumoconiosis

 Two phases in coal miners pneumoconiosis
1. Simple pneumoconiosis- little ventilatory impairment
caused by 12 yr. of exposure
2. Progressive massive fibrosis – severe respiratory
disability and frequently results in premature death
Byssinosis

 Byssinosis is a disease of the lungs. It is caused by

breathing in cotton dust or dusts from other vegetable
fibers such as flax, hemp, or sisal while at work
Causes
 Breathing in (inhaling) the dust produced by raw cotton can cause
byssinosis.
 It is most common in people who work in the textile industry. Those who
are sensitive to the dust can have an atom-like condition after being
exposed.
 Byssinosis is still common in developing countries. Smoking increases risk
of developing this disease.
 Being exposed to the dust many times can lead to long-term (chronic) lung
disease.
Clinical manifestations
 Symptoms May include any of the following.
 Chest tightness
 Cough
 Shortness of breath
 Symptoms are worse at the beginning of the work week and
improve later in the week.
 Symptoms are also less severe when the person is away
from the workplace.
Diagnostic evaluation

Detailed medical history (ask for certain exposures or times

of exposure)
Physical examination, paying special attention to the lungs.
 Chest X-ray
 CT- chest
 Pulmonary function test
 Biopsy of lung tissue
Risk factors

 Exposure to an agent known to cause an occupational

disorder
 Length of time from exposure of agent to onset of
symptoms
Treatment
 As it is an uncurable disease, the treatment is planned as controlling
symptoms from worsen the condition.
 Avoid smoking
 Avoid dust exposure
 Medication
 Bronchodilators
 Corticosteroids
 Oxygen therapy
Prevention

 Wearing masks
 Washing areas of skin that come in contact with dust
 Washing face and hands thoroughly before eating, drinking or
taking any medications
 Regular health check ups
 Physical examinations
Silicosis
 Silicosis is a chronic fibrotic pulmonary disease caused by
inhalation of silica dust (crystalline silicon dioxide particles).
 Exposure to silica and silicates occur in almost all mining,
quarrying and tunnelling operations.
 Glass manufacturing, stone cutting, manufacturing of
abrasives and pottery work occupations with exposure of
hazards.
Pathophysiology
Inhalation of the silica particles, which have fibrogenic properties

Interact with epithelial cells and macrophages (nodular lesions are

produced)

Nodules enlarges and coalesce(in large group)

Fibrosis

Resulting in loss of pulmonary volume

Diagnostic evaluation
 History
 Physical examination
 Chest X-ray: findings nodes in upper lobe of the lung
 CT- chest
 Pulmonary function test
 Biopsy of lung tissue
 Tuberculosis test
Clinical manifestations

 Patients with acute silicosis present with:

 Dyspnoea
 Fever cough
 Weight loss
 Symptoms are more severe in patients whose disease is
complicated by progressive massive fibrosis.
 Chronic in long latency period
Risk factor

 Workers at risk in
 Mining industries
 Pottery and ceramic industries
 Metal grinding
 sand blasting
 Building and construction workers glass manufacture
 Slowly progressive symptoms;
 Hypoxemia
 Severe air flow obstruction
 And right sided heart failure
 Edema because of cardiac failure
Treatment
 There is no specific treatment for silicosis, because the
fibrotic process in the lung is irreversible.
 Supportive therapy is ordered for managing complications
and preventing infection
 Other test are done such as, tuberculosis, lung cancer.
 If tuberculosis is present, it is aggressively treated.
 Additional therapy
 Oxygen therapy
 Diuretics

 Inhaled beta- adrenergic agonists

 Anticholinergic

 bronchodilators
Prevention

 Avoid silica exposure

 Wearing masks
 Routine health check ups
 Health education to family members
 Avoid smoking
 Avoid dust exposure
Bagassosis

 It is a occupational lung disease caused by inhalation of

bagasse or sugarcane dust.
 Sugarcane fiber is utilized in manufacturing of paper,
cardboard and ray on.
 It is caused by Thermophilic actinomycete which is known
as thermoactinomyces sacchari.
Clinical manifestation
 Breathlessness

 Cough

 Hemoptysis

 Slight fever
 Bronchiolitis

 Skiagram: Mottling in lungs or shadow

 Impairment in pulmonary functions
Treatment

 Acute inflammatory condition can be treatable if

diagnosed early
 If it is untreated, there is diffuse in fibrosis, emphysema
and bronchiectasis
Prevention
 Dust control: suppression of dust control e.g wet process,
enclosed apparatus, exhaust ventilation.
 Personal protection
 Masks or respirators with mechanical filters or with oxygen
supply
 Medical control
 Initial medical examination
 Periodical checkups of the workers
Asbestosis

 It is a chronic lung disease caused by asbestos fibres.

Prolonged exposure to these fibers can cause lung tissue
scarring and shortness of breath.
 Asbestos used in manufacture of asbestos cement, fire proof
textiles, roof tiling, brake lining.
 Asbestos enters in the body by inhalation and fine dust may
be deposited in the alveoli
 Fibroids
 Respiratory insufficiency
 Bronchus carcinoma
 Pleural mesothelioma
Risk factors
 Buildings construction workers
 Electricians
 Railroad personnel
 Aircraft or automobile workers
 Workers in mills and refineries
 Shipyard personnel
Clinical manifestation

 Initial exposure of 10-40 years to asbestos

 Breathing difficulty
 Continuous dry cough
 Chest discomfort or stiffness
 Crackling sound on physical examination
Treatment
 There is no specific treatment for asbestos because the fibrotic
process in the lung is irreversible.
 Supportive therapy is ordered for managing complications and
preventing infection such as, oxygen administration
 Pulmonary rehabilitation
 Enhancing physical activities, health education on breathing and
relaxation techniques
Surgical management

 Thoracocentesis

 Lung transplantation
 Integrative care

 Prevention is a key strategy for all occupational lung diseases.

Containing dust and wearing personal protective devices that limit the
amount of inhaled particles are essential for people who work in
industries with known risks.
 Chest x-ray, pulmonary function studies, bronchoscopy, and possibly
lung biopsy are used to establish for early diagnosis.
 Pulmonary function testing shows restrictive impairment of lung
ventilation, with reduced vital capacity and reduced total lung
capacity. Blood gas analysis reveals hypoxemia, especially with
exercise.
 Bronchoscopy may be performed to obtain tissue for biopsy.
Specialized lung scans may be used to deter- mine the extent of
fibrosis
 Eliminating further exposure to the offending agent is an
important part of disease management.
 There is no specific therapy. Anti-inflammatory drugs,
such as corticosteroids, may reduce the inflammatory
response and slow the progression of the disease.
 Preventing exposure to other damaging substances such
as cigarette smoke and pollution.
 Pneumococcal vaccine and annual influenza
immunizations are recommended to reduce the risk of
lower respiratory infections. Supportive care, similar to
COPD.
Nursing diagnosis
 Activity intolerance related to diseased condition
 Severe dyspnoea
 Ineffective breathing pattern related to restrictive lung disease
 Anticipatory grieving related to potential loss of employment and
income
 Nutritional imbalance
 Anxiety
 Following research projects has been proposed to initiate by
the Government:

• Prevention, control and treatment of silicosis and tuberculosis

in Industries

• Occupational health problems of tobacco harvesters and their

prevention

• Hazardous process and chemicals, database generation,

documentation and information
 Developing healthy work practices and promoting health at
work.
 Strengthening occupational health services.
 Establishing support services for occupational health.
 Developing occupational health standards based on scientific
risk assessment.
 Developing human resources for occupational health.