Skin diseases in Norway and cutaneous squamous cell carcinoma in four Nordic countries: The role of occupation and occupational exposures. A population-based study

carcinoma in four Nordic countries:

The role of occupation and occupational exposures A population-based study

Jose Hernán Alfonso

Dep. of occupational Medicine and Epidemiology National Institute of Occupational Health

Oslo, Norway

2016

© Jose Hernán Alfonso, 2016

Series of dissertations submitted to the Faculty of Medicine, University of Oslo

ISBN 978-82-8333-279-7

All rights reserved. No part of this publication may be

reproduced or transmitted, in any form or by any means, without permission.

Cover: Hanne Baadsgaard Utigard.

Print production: Reprosentralen, University of Oslo.

“...Now and then I have noticed that bakers have swollen, aching hands. Everyone in this trade gets rough hands by kneading the dough. A baker just has to show his hands to reveal this trade. No other tradesman has similar hands".

“DeMorbisArtificum”

BernardoRamazzini(1633Ͳ1744)

Thisphotographyofabaker´shandwasacourtesyfromDr.M.N.Crepy.Availableat:

http://www.atlasdedermatologieprofessionnelle.com/index.php/Boulanger

Committeemembers

1. Opponent:ProfessorÅkeSvensson

DepartmentofOccupationalandEnvironmentalDermatology.

FacultyofMedicine,UniversityofLund,Sweden͘

2. Opponent:ProfessorMariaAlbin

DepartmentofOccupationalandEnvironmentalMedicineFaculty ofMedicine,UniversityofLund,Sweden͘

InstituteofEnvironmentalMedicine.KarolinskaInstitutet,Sweden.

Committeeadministrator:AssociateprofessorAnneOlaugOlsen

DepartmentofRheumatology,DermatologyandInfectiousDiseases.OsloUniversity Hospital.

InstituteofClinicalMedicine,FacultyofMedicine,UniversityofOslo,Norway͘

CONTENTS

ACKNOWLEDGEMENTS...11

Agradecimientos...13

PREFACE... ...15

LISTOFPAPERS...17

SUMMARY... ....19

Resumen... ...23

LISTOFABBREVIATIONS...27

CHAPTERI:INTRODUCTION...29

1.1NorwegianstudiesonthetopicofworkͲrelatedskindiseases...29

Thefirststudies... ...29

Systematicliteraturesearch...30

1.2PopulationͲbasedstudiesonoccupationandskindiseases...33

1.3Conclusionofthesystematicliteraturesearch...40

1.4Thesisoutline...40

CHAPTERII:AIMS...43

2.1Researchquestions...43

2.2.Aims... ...44

CHAPTERIII:THEORETICALBACKGROUND...45

3.1Thehealthyskin...45

3.2DefinitionofworkͲrelated/occupationalskindisease...48

3.3ClassificationofworkͲrelatedskindiseases...48

3.4Irritantcontactdermatitis...50

Pathogenesis... ...51

Cumulativeirritativecontactdermatitis...51

Hardeningphenomenon...52

3.5Allergiccontactdermatitis...52

3.6Skincancer... ....53

Definitionandnomenclature...53

Latencyperiod... ...53

Recognitionasanoccupationaldisease...54

Associationsbetweenoccupation,occupationalexposures,andskincancer...54

Cutaneoussquamouscellcarcinoma...56

RegistrationofcutaneoussquamouscellcarcinomainFinland,Iceland,Sweden,andNorway...56

IncidenceofcutaneoussquamouscellcarcinomaintheNordiccountries...57

3.7DeterminantsofworkͲrelatedskinproblems,diseases,andcutaneoussquamouscell carcinoma... ...59

3.7.1Endogenousfactors...59

Atopicdermatitis... ..59

Filaggrinmutations...60

Othergeneticandindividualsusceptibilityfactors...61

Age... ...61

Sex... ...62

Ethnicity... ...62

3.7.2Exogenousfactors:Occupationalexposures...62

Wetwork... ...62

Gloveocclusion... ...63

Skinexposurewithchemicalproducts...63

Skinexposuretobiologicalagents...65

Skinexposuretomechanicalfactors...66

Skinexposuretophysicalfactors...66

Someremarks... ...68

3.8SkinexposuresandskinproblemsinthegeneralworkingpopulationofNorway...69

3.9SocioeconomicimpactofworkͲrelatedskindiseases...71

SickleaveduetoworkͲrelatedskindiseasesͲmainlycontactdermatitisͲ...72

PhysicianͲcertifiedsickleaveinNorway...73

CHAPTERIV:MATERIALANDMETHODS...77

4.1Studydesign... ..78

4.2.Datasourcesandpopulation...78

4.3Poweranalyse...82

4.4.Exposureandoutcomevariables...82

4.5Covariates... ...88

4.6Statisticalmethods...89

StudyI... ...89

StudyII... ...89

StudyIII... ...89

StudyIV... ...90

4.7Directedacyclicgraphs...90

4.8Adjustmentforpotentialconfounding...92

4.9Populationattributablerisk...93

4.10Reportingandsubmissionofresults...94

4.11Additionalanalysis...94

4.12Ethicalconsiderations...95

CHAPTERV:SUMMARYOFRESULTS...99

5.1.NotifiedworkͲrelatedskindiseasesinNorway,2000–2013...99

5.2.NotifiedworkͲrelatedskindiseasesintheoffshoresector2000–2014.....101

5.3.AssociationbetweenselfͲreportedoccupationalexposuresandskinproblems...102

5.4.Attritionanalysis...103

5.5.AssociationbetweenoccupationalskinexposureandlongͲtermsickleave...105

5.6Occupationandrelativeriskofcutaneoussquamouscellcarcinoma infourNordiccountries...106

CHAPTERVI:DISCUSSION...111

6.1Themainfindingsandcomparisonswithotherstudies...111

StudyI... ...111

StudyII... ...112

StudyIII... ...114

StudyIV... ...115

6.2Advantagesandlimitations...116

6.3Methodologicalconsiderations...118

Validityofoccupationalepidemiologystudies...118

Studydesign... ...118

DurationoffollowͲup...119

6.4Internalvalidity...120

6.4.1SELECTIONBIAS...121

Samplingbias... ...121

NonͲresponsebias...121

LosstofollowͲup... .121

Healthyworkereffect...122

6.4.2INFORMATIONBIAS...123

Differentialmisclassification...124

NonͲdifferentialmisclassification...124

SelfͲreportofoccupationalskinexposureandskinproblems...125

ClassificationofoccupationalcategoriesinStudyIV...126

6.4.3CONFOUNDING...127

Controllingforconfoundinginthedesignofthestudy...128

Controllingforconfoundinginthedataanalysis...128

6.5Randomerrorandprecision...129

6.6ExternalValidity...130

StudyI... ...131

StudyII&III... ...132

StudyIV... ...132

6.7Sexdifferences...132

6.8Causationorassociation?...133

AustinBradfordHill:“viewpointsforcausation”...134

KennethRothman:“modelofsufficientͲcomponentcauses”...137

MiguelHernan:“counterfactualperspective”...137

Causaldiagrams:directedacyclicgraphs...138

Weneedapluralisticviewofcausalityinepidemiology...138

Finalremarks... ...138

CHAPTERVII:CONCLUSIONANDIMPLICATIONS...143

7.1.Conclusion...143

7.2Implications...143

Implicationsforprevention...143

7.3Perspectivesforfutureresearch...145

REFERENCELIST...149

APPENDIX1... ....167

APPENDIX2... ....169

APPENDIX3... ....172

APPENDIX4... ....174

APPENDIX5... ....176

APPENDIX6... ....180

APPENDIX7... ....181

STUDYItoIV...185

ACKNOWLEDGEMENTS

WhenIwasa6ͲyearͲoldboy,IdreamtaboutbecomingaƌĞƐĞĂƌĐŚĞƌ.Iwasluckytohave beeninspiredbymydedicatedandhardworkingparentsͲMirtha&JoséͲwhonotonlytaught mehowtocountredandwhitecellsintheopticalmicroscope,butalsomadeanenormous efforttoaffordmyeducation.

Severalyearslater,attheageof21,IstartedtovolunteerasaresearchassistantattheInstitute ofImmunology,FacultyofMedicine,UniversidadNacionaldeRosario,Argentina.Isolatingwhite cellsfrompatientswithrheumatoidarthritisandlungtuberculosis, ”exposing”thecellsto differenthormoneconcentrations,andcheckingcellgrowthandmeasuringcytokinesweremy maintasks.IamdeeplyindebtedtoDrMaríaLuisaBayandDrOscarBottassoforinitiatingme intothefascinatingworldofresearch.AlthoughIlovedworkingwithcellculture,partofmy dreamwastocombineresearchwithclinicalwork,somethingthatwasnotfeasibleinmy belovedArgentina.

Dream,dream,dream.ReachforthestarstoldmeĞƐŵŽŶĚdƵƚƵinFebruary2009,whenI representedArgentinaattheworld´slargeststudentfestivalinTrondheim.Fromthatmoment on,itwascleartomethatIwillbewillingtoworkhardtomaketheƌĞƐĞĂƌĐŚĞƌdreamareality.

Severalmonthslater,IwentbacktoNorway,learnedNorwegianandstartedmyspecialisation intoOccupationalandEnvironmentalMedicine.Iwouldliketoexpressmydeepestgratitudeto TorErikDanielsenwhonotonlysharedhiscontagiouscommitmentforOccupationalMedicine, butalsointroducedmetoSTANDERM,aninternationalresearchnetworkaimedatdeveloping standardsforahealthyskinathealthyworkplaces.MyspecialthanksgotoProf.JeanneDuus Johansen,Prof.SwenMalteJohn,andmycolleaguesfromSTANDERMwhoencouragedmeto reͲactivateresearchwithinoccupationaldermatologyinNorway.

It has been challenging, but also extremely exciting to do research within occupational dermatologyinacountrywherethisdisciplinewasnotgivenenoughpriority.

IwillthereforeneverforgetwhenmygoodcolleaguesMaritSkogstadandToreTynestoldme:

“IfyouwanttotakeaPh.D.withinoccupationaldermatology,thenyouwilldoit.Wewill supportyou.”

Somanywonderfulthingshavebeengoingonwhileworkingon thisPh.D.:theopportunity giventometoresearchinatopicIamveryfondofrightfromthedesignphase,writingthe researchprotocol,conformingtheprojectteam forinternationalandnationalcooperation, Ͳ justtonameafew.

TheabsolutebestthingabouttheprojectwillalwaysbemymainsupervisorHåkon Johannessen,ĂŶĚcoͲsupervisorsJanͲØivindHolm,KristinaKjærheim,andJacobP.Thyssen.

Youhavegenerouslyprovidedmewithmotivation,knowledge,newskills,support,quickand effectiveresponse,constructivecriticism,andrespectformydecisionsanddeadlines.

IamgratefultoKarlͲChristianNordbyandSteinarAasnesforbelievinginthisprojectfromthe beginningandtotheNationalInstituteofOccupationalHealthofNorwayforsupportingit.

Overthelastyears,I'veworkedwithsomeofthehighestskilledcolleaguesattheNational InstituteofOccupationalHealth. I'msogratefultohavebeenpartoftheDepartmentof OccupationalMedicineandEpidemiology,cooperationwithNOAandtheNordicOccupational CancerStudy.SpecialthanksgotoEvaK.Løvsethforassistingmetomakeprofessionalgraphs, KarinaCorbettforhelpingmetoimprovemywrittenEnglish,andtoØivindSkareandJanͲIvar Martinsenforexplainingmedifficultstatisticstopics.

Iwanttoextendmythankfulnesstoallmyfriendsaroundtheglobe,mysisters(Karina&

Mirthi)andmylargefamilyformakingmehappyeverysingletimeImeetyou.Lookingatyour picturesonmy deskisalways a goodsourceof inspiring energy. Mybeloved “abuela”

(grandmother)Felipahasalwaysbeenmygreatestinspirationasherenormouscourageisrare inthisworld.

NatyOreiro,despitedifferencesinourprofessions,youtaughtmetobeenthusiastic,to improvedayafterday,andtonevergiveup.Thankyousomuchforalwaysmeetingmewhile youareinEuropeduetoyourmusicaltours,orinthemiddleoffilminginArgentina.

WordswillneverbeenoughtoexpressmyimmensegratitudetoStigHvideSmith:notonlyfor thedreamsweshare,butalsoforbringingyourwholehearttosupportmeduringthisprocess, tobepatienteverydayandallowingmetodothesame. Tomy“little”dogStorm,thankyou foryourcompanionshipduringallthelatenightͲhours. :ŽŶĂƐ͕ / ǁŝƐŚ LJŽƵ ĨƵůĨŝůů LJŽƵƌ ĚƌĞĂŵ ĂďŽƵƚƐƚƵĚLJŝŶŐĂƚƚŚĞhŶŝǀĞƌƐŝƚLJŽĨKƐůŽ͘

MakingthisdreamcometruemakesmefeelthatIreachedthestars.Thankyousomuchtoall ofyouwhohavecontributedtomakeitreal.

dƵƐĞŶŚũĞƌƚĞůŝŐƚĂŬŬ͊

DƵĐŚĂƐŐƌĂĐŝĂƐĚĞĐŽƌĂnjſŶ͊

AGRADECIMIENTOS

Fuecuandoteníaseisañosqueempecéasoñarconconvertirmeencientífico.Fuímuy afortunadoaltenerpadresdedicadosylaboriososͲDŝƌƚŚĂLJ:ŽƐĠͲquenosólomeenseñarona contarglóbulosrojosyblancosenelmicroscopioóptico,sinoquetambiénhicieronunesfuerzo enormeparapoderafrontarmieducación.

Añosmastardes,cuandotenía21años,comencéatrabajarvoluntariamentecomoasistentede investigaciónenelInstitutodeInmunologíadelaFacultaddeCienciasMédicasde laUniversidadNacionaldeRosario.Eltrabajoconsistíaenaislamientodeglóbulosblancos depacientes con artritis reumatoidea y tuberculosis, para luego exponerlos a diferentesconcentraciones de hormonas y finalmente chequear el crecimiento de las célulasymedircitoquinas.EstoyprofundamenteagradecidoalaDra.MaríaLuisaBayyalDr.

OscarBottassoporiniciarmeenelfascinantemundodelainvestigación.Apesardequeme encantabatrabajarconcultivoscelulares,partedemisueñofuecombinarinvestigacióncon trabajoclínico,algoquenoeraposiblerealizarenmiamadaArgentina.

Ͳ“^ƵĞŹĂ͕ƐƵĞŹĂ͕ƐƵĞŹĂ LJĂůĐĂŶnjĂůĂƐĞƐƚƌĞůůĂƐ͟ͲmedijoelPremioNobeldelaPaz, DesmondTutuenel2009,cuandorepresentabaaArgentinaenelEncuentroMundial deestudiantesuniversitariosmasgrandedelmundo,enTrondheim.Paramífueclaro desdeesemomento,queestabadispuestoatrabajarduroparaconvertirelsueñodeser científicoenrealidad.

Algunos

meses

despues,

regresé a

Noruega,

aprendí

Noruego e

inicié mi

especialización en MedicinaOcupacionalyAmbiental.DeseoexpresarmiprofundagratitudaTorErikDanielsen, quien

no sólo

compartió su

contagioso

compromiso por

esta

disciplina, sino

quetambién me introdujóaSTANDERM.STANDERMesunaaccióninternacionaldeinvestigaciónconelobjetivo decrearestándaresparaunapielsanaenlugaresdetrabajosaludables.Misagradecimientos especiales

a la

Prof.

Jeanne Duus

Johansen, al

Prof.

Swen

Malte John

y mis

colegas de STANDERM por alentarme a reͲactivar la investigación en el campo de la dermatologíaŽĐƵƉĂĐŝŽŶĂůĞŶEŽƌƵĞŐĂ͘

Hasidodesafíante,perotambiénextremedamenteapasionantepoderrealizarinvestigación sobreenfermedades cutáneas profesionales, en un país donde la disciplina recibió poca atención.Porestarazón,nuncavoyaolvidaraqueldíaenelquemisbuenoscolegasMarit SkogstadyToreTynesmedijeron:“SiquereshacertuPhDsobredermatologíaocupacional, debeshacerlo.Nosotrosestáremoscontigoparaapoyarte”.

Hahabidomuchosaspectosgratificantesaltrabajarconestedoctorado:laoportunidadde trabajar en un tema que adoro, desde la fase de diseño, escribiendo el protocolo de investigaciónyconformandoelequipodetrabajoconcooperaciónnacionaleinternacional.

Missupervisoreshansido,sindudaalguna,unodelosmejorescomponentesdeesteproyecto.

MisupervisorprincipalHåkonJohannessenymiscoͲsupervisores:JanͲØivindHolm,Kristina

KjærheimyJacobP.Thyssenhansidogenerososalbrindarmemotivación,conocimientos, nuevashabilidades,apoyo,respuestasrápidasyefectivas,criticismoconstructivoyrespetopor misdecisionesyplazosdetiempoestablecidos.

EstoyagradecidoaKarlͲChristianNordbyySteinarAasnesporhabercreídoenesteproyecto desdeelinicioyalInstitutoNacionalNoruegodeSaludOcupacionalporhaberlofinanciado.

Alolargodelosúltimosaños,hetrabajadoconcolegasmuytalentososenelInstitutoNacional NoruegodeSaludOcupacional.EstoyagradecidodepoderserpartedelDepartamentode MedicinaOcupacionalyEpidemiología,porlacooperaciónconelDepartamentoNacionalde VigilanciadeSaludLaboral,yconelEstudiodeCancerOcupacionaldelospaísesNórdicos.

GraciasespecialesaEvaK.Løvsethporayudarmeahacergráficosprofesionales,aKarina Corbettforayudaramejorarmiinglésescrito,aØivind SkareyJanͲIvarMartinsenfor explicarmetemasdifícilesdeestadística.

Miagradecimientodecorazónparatodosmisamig@salrededordelmundo,mishermanas (KarinayMirthi)ymigranfamiliaporhacermefelizcadavezquelosveo.Tenersusfotosenmi escritoriosiempreesunabuenafuentedeenergíainspiradora.MiadoradaabuelaFelipa siemprehasidomimayorinspiraciónanodarmeporvencidoyaquesugrancorajeesalgo pocofrequenteenestemundo.

NatyOreiro,apesardelasdiferenciasennuestrasprofesiones,vosmeenseñasteahacerlas cosasconentusiasmo,amejorarmecontinuamenteyaseguiradelante.Muchasgraciaspor siempre hacer tiempo para encontrarnos cuando vos esƚĄs en Europa debido a tus girasmusicales,ocuandoestasfilmandoenArgentina.

LaspalabrasnuncaseránsuficientesparaexpresarmigratitudinmensaaStig,ǀŝĚĞ^ŵŝƚŚ:no sóloporlossueñosquecompartimos,sinotambiénportupacienciaysoportediario.Para mi“pequeño”ƉĞƌƌŽ^ƚŽƌŵ͗ŐƌĂĐŝĂƐƉŽƌƚƵĨŝĞůĐŽŵƉĂŹŝĂĚƵƌĂŶƚĞůĂƐůĂƌŐĂƐŚŽƌĂƐĚĞůĂŶŽĐŚĞ͘

:ŽŶĂƐ͕ƚĞĚĞƐĞŽƐƵĞƌƚĞĞŶĐƵŵƉůŝƌƚƵƐƵĞŹŽĚĞĞƐƚƵĚŝĂƌĞŶůĂhŶŝǀĞƌƐŝĚĂĚĚĞKƐůŽ͘

Cumplirestesueñomehacesentirquepuedotocarlasestrellasconlasmanos.Muchasgracias atodosquehancontribuidoahacerloposible.

'ƌĂĐŝĂƐĚĞĐŽƌĂnjſŶ͊

PREFACE

Inclinicalmedicine,preventionisoftenlinkedtoearlydiagnosis,forinstanceby highsensitiveandspecificbiomarkers.Ontheotherhand,fromtheperspectiveof occupational medicine, the conception of prevention is probably larger, and includespreventiveactionsthatcantakeplaceatanearlierpointwherethemain goalisnottoreducethedamageofthediseasebyanearlierdiagnosis,butrather to preclude the onset of disease by avoiding the exposure that causes it.

Epidemiologyisconcernedwiththis:conductingresearchatthepopulationlevel toprovideevidenceonwhetherexposuresareassociatedwithhealthproblems anddisease.Afterresearchisconductedandevidencecollected,identificationof exposuresassociatedtodiseasecanbeutilizedtosuggestpreventiveactionswith impactonpublichealth.

This is truly the case for dermatologists, occupational physicians, and epidemiologists.Therefore,thisthesisattemptstogatherapproachesfromthese threedisciplinesforthepurposesofcomprehensivepreventionofworkͲrelated affectionsoftheskin.

JoseHernánAlfonso

LISTOFPAPERS

Theworkofthepresentdoctoralthesisincludesthefollowingstudies,whicharereferredtoin thetextbyRomannumeralsfromItoIV:

I. Alfonso,J.H.,Løvseth,E.K.,Samant,Y.,Holm,J.Ø.(2015).WorkͲrelatedskin diseasesinNorwaymaybeunderreported:datafrom2000to2013.Contact Dermatitis,72,409Ͳ412.Doi:10.1111/cod.12355.

II. Alfonso,J.H.,Thyssen,J.P.,Tynes,T.,Mehlum,I.S.,Johannessen,H.A.(2015).

SelfͲreportedoccupationalexposuretochemicalandphysicalfactorsandriskof skinproblems:a3ͲyearfollowͲupstudyofthegeneralworkingpopulationof Norway.ActaDermVenereol,95,959Ͳ62.Doi:10.2340/00015555Ͳ2135.

III. Alfonso,J.H.,Tynes,T.,Thyssen,J.P.,Holm,J.Ø.,Johannessen,H.A(2016).SelfͲ reportedoccupationalskinexposureandriskofphysicianͲcertifiedlongͲterm sickleave:aprospectivestudyofthegeneralworkingpopulationofNorway.

ActaDermVenereol,96,336Ͳ40.Doi:10.2340/00015555Ͳ2253.

IV. Alfonso,J.H.,Martinsen,J.I.,Pukkala,E.,Weiderpass,E.,Tryggvadottir,L., Nordby,K.C.,Kjærheim,K.(2016).Occupationandrelativeriskofcutaneous squamouscellcarcinoma:a45ͲyearfollowͲupstudyinfourNordiccountries.J AmAcadDermatol,Inpress.Doi:10.1016/j.jaad.2016.03.033.

SUMMARY

Background

Skindiseasescausedorworsenedbyoccupationalexposures–workͲrelatedskindiseasesͲ representupto30%ofoccupationaldiseasesinEurope.ThechroniccourseofworkͲ relatedskindiseases,mostlyirritantandallergiccontactdermatitisofthehands,is associatedwithfrequentuseofhealthcareservices,highoccurrenceofsickleave,job loss,andjobchange.Therefore,theyconstituteatopprioritypublichealthproblem (EuropeanAgencyforSafetyandHealthatWork,EU.25report,2008).

Furthermore,agrowingbodyofresearchlinksexposuretosolarUVradiationinoutdoor workerstotherapidlyincreasingincidenceofcutaneoussquamouscellcarcinomain Europe,whichisnowrecognizedasanoccupationaldiseaseinseveralEuropean countries.

WorkͲrelatedskindiseaseshaveacommonfeature:theyare,infact,highlypreventable byreducingexposuretooccupationalhazards.Forinstance,preventionstrategiesare showntoreduceonsetandachronicandrelapsingcourseoftheseconditions.

Whilstepidemiologicalstudiesatthepopulationlevelareanimportanttooltodetermine etiologicandcontributingfactorsofthedisease,littleisknownaboutthecontributionof occupationalexposurestotheburdenofskinproblemsanddiseasesinNorway.

Moreover,thevariationintherelativeriskofcutaneoussquamouscellcarcinoma betweenoccupationalcategoriesoftheNordiccountrieshasnotyetbeendescribed.

Therefore,epidemiologicalstudiesareneededtoidentifytargetsforpreventionatthe populationlevel.

Mainaims

Thisthesissoughtto:

1. DescribethenotificationtrendsforworkͲrelatedskindiseasesinNorwayfortheperiod 2000Ͳ2013.

2. Investigatethecontributionofoccupationalchemicalandphysicalexposurestothe burdenofskinproblemsand physicianͲcertifiedlongͲtermsickleave inthegeneral workingpopulationofNorway.

3. Identify the occupational variation in the relative risk of cutaneous squamous cell carcinomabetweenoccupationalcategoriesinFinland,Iceland,Sweden,andNorway.

Studypopulation

ThefirststudywasbasedondatafromtheNorwegianLabourInspectorate`sRegistryof workͲrelateddiseasesfortheperiod2000Ͳ2013(n=41,181).Thesecondstudywasbased onSurveyinformationfromarandompanelsampleofthegeneralworkingͲage

population(n=6,745)(SurveyofLivingConditions–WorkEnvironment2006&2009, conductedbyStatisticsNorway).ThethirdstudywasbasedonthepreviousSurveyfor 2009mergedwithdatafromtheNorwegianLabourandWelfareAdministration’ssickness benefitRegistry2009and2010(n=6,182).Finally,thelaststudywasbasedondatafrom theNordicOccupationalCancerstudy,whichlinkeddemographiccensusdatatodiagnosis datafromtheNordicCancerRegistries(n=12.9million).

Design

Thisthesisusedtwodifferentdesigns:

First,acaseͲseriesdesignbasedonretrospectivedatainStudyI.

Second,aprospectivecohortͲdesigninStudyII,III,andIVwithafollowͲupuptothreeͲ yearinStudyII,oneͲyearinStudyIII,and45ͲyearinStudyIV.

Statisticalmethods

ThenotificationtrendsofworkͲrelatedskindiseases,occupations,andoccupational exposuresforthenotifiedworkͲrelatedskindiseasesweredescribedbyfrequency statisticsandcrossͲtabulations(StudyI).

TheassociationsbetweenselfͲreportedoccupationalexposureswithselfͲreportedskin problems(StudyII),andphysicianͲcertifiedlongͲtermsickleave(StudyIII)wereestimated byunconditionallogisticregression.Statisticaladjustmentforotherexplanatoryvariables wasperformedindifferentmodels:age,sex,occupation,andotherconcomitantskin exposuresinStudyII;andage,education,psychosocial,andmechanicalexposuresatwork inStudyIII.Thepopulationattributableriskpercentattributabletooccupational

exposureswascalculatedforbothskinproblems,andlongͲtermsickleave.

Thevariationintherelativeriskofcutaneoussquamouscellcarcinomabetween

occupationalcategoriesoffourNordiccountrieswasdescribedbystandardisedincidence ratioswiththeincidenceratesofcutaneoussquamouscellcarcinomaforthenational populationofeachcountryusedasreference.Occupationalcategorieswereclassified accordingtooccupationalsolarexposureandsocioeconomicstatus.

Mainresults

StudyIreportedadeclineinthenotificationofworkͲrelatedskindiseasesfrom487in 2000to91in2013.Contactdermatitisaccountedfor94%ofthecases(41%allergic,43%

irritant,10%unspecified).ThefivemostcommonoccupationswithnotifiedworkͲrelated skindiseaseweremechanics,weldersandplateͲ/workshopworkers,healthpersonnel, hairdressers,plumber,chefsandkitchenassistant.Thefivemostcommonoccupational exposuresconsistedofcleaningproducts,otherchemicalsubstances,oils,fuelsand solvents,metals,andadhesiveandepoxysubstances.

StudyIIreportedanassociationbetweenselfͲreportedoccupationalexposuretophysical factorssuchasindoordryair,andskincontactwithwaterandcleaningproductswithskin problemsatfollowͲup.Thepopulationattributablepercentriskattributedtothese occupationalexposureswas15.8%.

Inlinewiththepreviousfindings,StudyIIIreportedthatselfͲreportedoccupationalskin exposuretocleaningproductsandwasteamongmen,andoccupationalskinexposureto wateramongwomenpredictedphysicianͲcertifiedlongͲtermsickleave.Thepopulation attributablepercentriskattributedtotheseoccupationalexposureswas14.5%.

Finally,StudyIVreportedamoderatevariationoftherelativeriskofcutaneoussquamous cellcarcinomabetweenoccupationalcategories.Excessriskofcutaneoussquamouscell carcinomawasfoundamongoccupationalcategorieswithhighsocioeconomicstatussuch asphysiciansandadministrators;somewithoutdoorworksuchasseamen,publicsafety workers,Swedishfishermen;andsomewithpotentialexposuretochemicalsubstances suchastechnicalworkers,printers,publicsafetyworkers,andseamen.

Conclusion

WhilstworkͲrelatedskindiseasesseemtobegreatlyunderreportedinNorway,thisthesis provideƐevidenceofthecontributionofoccupationalskinexposurestotheburdenof skinproblemsandphysicianͲcertifiedlongͲtermsickleaveinthegeneralworking populationofNorway.

Apotentialforprimarypreventionatthepopulationlevelisfurthersupportedbythe populationriskattributabletooccupationalexposuresthatpredictedskinproblemsand longͲtermsickleave.

Socioeconomicfactorsand,tosomeextent,occupationalexposuresseemtoexplainthe moderatevariationoftherelativeriskofcutaneoussquamouscellcarcinomabetween occupationalcategoriesinFinland,Iceland,Sweden,andNorway.

Overall,thisthesishascontributedtotheidentificationoftargetsforpreventiveactions andfutureresearchwithinoccupationaldermatology.

RESUMEN

Antecedentes

Lasenfermedadescutáneascausadasoempeoradasporexposicioneslaborales

(dermatosisprofesionales)representanhastael30%delasenfermedadesocupacionales enEuropa.Porlotanto,constituyenunconsiderableproblemaenelmarcodesalud pública(EuropeanAgencyforSafetyandHealthatWork,EU.25report,2008).

Lasdermatosisprofesionalessonfundamentalmentedermatitisdecontacto,detipo irritativoyalérgicoconlocalizaciónfrequenteenlasmanosquepuedenresultaren consequenciassocioeconómicasypsicológicasperjudicialesparaelindividuoyla sociedad.

Adicionalmente,laincidenciadelcarcinomaespinocelulardelapielsehaincrementado considerablementedurantelasultimasdecadas,comprometiendofundamentalmentea trabajadoresalairelibreexpuestosalaradiaciónultravioletasolar,comoasítambiena aquellosexpuestosasustanciasquimicascancerigenasparalapielcomoelarsénicoylos hidrocarbonosaromáticospolicíclicos.Envariospaíseseuropeoselcarcinoma

espinocelulardelapielesreconocidocomounaenfermedadprofesional.

Lasdermatosisprofesionalessonevitablessiseimplementanmedidasdeprevención adecuadasparareducirlasexposicionesocupacionalesquelasocasionan.

EnNoruega,pocoseconoceacercadelroldelasexposicionesocupacionalesenel

desarollodelasdermatosisprofesionales.Mundialmente,hastaeldíadelafecha,ningún estudiopoblacionalconunlargoseguimientohadescriptolavariaciónocupacionalenel riesgodedesarrollarcarcinomaespinocelulardelapiel.

Esasíqueestudiosepidemiológicosanivelpoblacionalconstituyenunaherramienta fundamentalparadeterminarlosfactoresetiológicosdelasdermatosisprofesionales,e identificardeestamaneraprioridadesparalaprevención.

Objetivosprincipales

1. DescribirlatendenciadenotificacióndelasdermatosisprofesionalesenNoruegaporel periodo2000Ͳ2013.

2. Investigarlasasociacionesentreexposicioneslaboralesyelriesgodedesarrollar

problemascutáneos,comoasítambien,surelaciónconlaausencialaboralprolongadaen lapoblaciónenedadactivadeNoruega.

3. Identificarlavariaciónoccupacionalenelriesgorelativodelcarcinomaespinocelulardela pielencuatropaísesNórdicos(Finlandia,Islandia,SueciayNoruega)

Poblacióndeestudio

ElprimerestudiosehallabasadoeninformacióndelRegistrodeenfermedades

profesionalesdelMinisterioNoruegodeTrabajo(n=41.181).Elsegundo,enunamuestra randomizadadelapoblaciónenedadactivadeNoruega,elEstudiodeCondicionesde VidayLaborales2006y2009.CentroNacionaldeEstadisticasdeNoruega(n=6.745).El terceroenunenlaceentrelabasedeinformacióndelsegundoestudioconinformación delRegistrodeAusenciaLaboral2009Ͳ2010delaAdministraciónNoruegadeTrabajoy BienestarSocial(n=6.182).Finalmente,elcuartoestudiosehallabasadoeninformación deEstudiodeCancerOcupacionaldelospaísesNórdicos,quehaconectadoinformación demográficarecolectadaporcensosnacionalesainformacióndiagnósticadelosRegistros deCancerdelosrespectivospaíses(n=12.900.000).

Diseñoymétodosestadistícos

Estatésishautilizadodostiposdediseño:

Primero,unaseriedecasosfueutilizadoenelprimerestudioparadescribirdeforma retrospectivalastendenciasenlanotificacióndedermatosisprofesionales.

Undiseñolongititudinalfueutilizadoparaelresto,conunperiododeseguimientodetres añosparaelsegundoestudio,unañoparaelterceroy45añosparaelcuarto.

Modelosderegresiónlogisticaincondicionalfueronutilizadosenelsegundoytercer estudio.Tambiénseestimóelriesgoatribuiblepoblacionalparalasexposiciones ocupacionalesasociadasalosproblemascutáneosyausencialaboralprolongada.

Elriesgorelativodecarcinomaespinocelularentrecategoríasocupacionalesdecuatro paísesNórdicosfueestimadopormediodelcálculodetasasestandarizadosdeincidencia, conlaincidenciaespecíficadecarcinomaespinocelulardecadapaíscomoreferencia.

Resultadosprincipales

Elnúmerodenotificacionesdedermatosisprofesionalesdeclinóde487enel2000a91en el2013.Dermatitisporcontactorepresentaronel94%deloscasos(4ϭ%dermatitispor contactoalérgica,4ϯ%irritativa,10%inespecifica).Lascincoocupacionesmás

comunmentenotificadasfueronmecánicos,soldadoresytalleristas,personaldelasalud, peluqueros,plomeros,yempleadosdecocina.Lascincoexposicioneslaboralesmás frequentementereportadasfueronproductosdelimpieza,sustanciasquimicas,aceites mineralesysolventes,metales,adhesivosysustanciasepoxys.

Elsegundoestudio,revelóqueexposicionesocupacionalesafactoresfisícoscomoaire seco,trabajohúmedo,yproductosdelimpiezaestanasociadasalriesgodereportar problemascutáneosduranteseguimiento.Elporcentajederiesgopoblacionalatribuiblea estosfactoresfuedel15,8%.

Eneltercerestudio,laexposicióncutáneaocupacionalaproductosdelimpiezay

desechosenloshombres;yaltrabajohúmedoenlasmujeresestuvieronasociadosaun mayorriesgodeausencialaboralprolongada.

Elporcentajederiesgopoblacionalatribuibleaestosfactoresfuedel14,5%.

Enelcuartoestudio,elriesgorelativodecarcinomaespinocelularfueelevadoen ocupacionesdegrupossocioeconómicoaltocomoporejemplomédicosy

administradores;algunasocupacionescontrabajoalairelibrecomoporejemplo,

marineros,empleadospúblicosdeseguridad,pescadoresSuecos,jardineras;yenalgunos conpotencialexposiciónlaboralasustanciasquímicascomoporejemploempleados técnicos,trabajadoresdeimprenta,empleadospúblicosdeseguridadymarineros.

Conclusión

ApesardequelasdermatosisprofesionalespareceríanestarsubnotificadasenNoruega, estatésisdoctoralbrindaevidenciasobrelacontribucióndeexposicioneslaboralesal riesgodedesarrollarproblemascutáneos,comoasítambienalriesgodelaausencia laboralprolongada,enlapoblacióngeneralenedadactivadeNoruega.Adicionalmente, laestimacióndelriesgoatribuiblepoblacionalindicaríaunpotencialparalaprevencióna nivelpoblacional.

Factoressocioeconómicosy,hastaciertopunto,exposicionesocupacionalesexplicaríanla variaciónmoderadaenelriesgorelativodedesarrollarcarcinomaespinocelulardelapiel entrecategorşasocupacionalesdeFinlandia,Islandia,SueciayNoruega.

Engeneral,estatésishacontribuidoconlaidentificacióndeprioridadesparala prevencióndedermatosisprofesionalesyfuturainvestigaciónenelcampodela dermatologíaocupacional.

LISTOFABBREVIATIONS

OSD Occupationalskindiseases UVR Ultravioletradiation ICD Irritantcontactdermatitis ACD Allergiccontactdermatitis CD Contactdermatitis

AD Atopicdermatitis

cSCC Cutaneoussquamouscellcarcinoma BCC Basalcellcarcinoma

PAH Polycyclicaromatichydrocarbons LTSL PhysicianͲcertifiedlongͲtermsickleave SES Socioeconomicstatus

DAGs Directedacyclicgraphs

OR Oddsratios

95%CI 95%Confidenceinterval PAR Populationattributablerisk SIR Standardisedincidenceratio

CHAPTERI:INTRODUCTION

Skindiseasesareassociatedtoasubstantialburdenintheglobalcontextofhealth:they arebothwidespreadandamongthemostprevalentanddisablingdiseases,representinga sourceofconsiderablelossofhealthylife.Collectively,skindiseaseswerethe4^thleading causeofnonͲfatalburdenexpressedasyearslostduetodisabilityin2010.¹

Asanexample,workͲrelatedskindiseases,mostofthempreventablebyreductionof occupationalexposures,imposeasignificantburdentothesociety.Accordingtothe WorldHealthOrganization,theyrepresentachallengeforallworkers;andtheEU Commissionhasdefinedinsufficientpreventionatoppriorityproblem.²Moreover,the increasingincidenceofcutaneoussquamouscellcarcinoma³anditsassociationto occupationalexposuresisamatterofbigconcern.^4Ͳ5

Therefore,epidemiologicalstudiesatthepopulationlevelcancontributetoidentify potentialtargetsforpreventionofworkͲrelatedskindiseases.

Tobeginwith,thisintroductionwilldisplaythemainfindingsoftwosystematicliterature searchesperformedforthepurposesofthisthesis:thefirstaimedtoidentifyNorwegian studiesfocusingonworkͲrelatedskindiseasesforthelast35years,andthesecondaimed toidentifypopulationͲbasedstudieswithaprospectivecohortdesignfocusingon

occupationalexposuresandskindiseases.

1.1NORWEGIANSTUDIESONTHETOPICOFWORKͲRELATEDSKINDISEASES Thefirststudies

EpidemiologicalstudiesonworkͲrelatedskindiseaseshavebeenuncommoninNorway.⁶ ThefirstreportedNorwegianpublicationseemstobeonereportonpetroleumacnefrom 1921.⁷ThefirstgeneraloverviewofdermatitisasaworkͲrelateddiseasewasaleaflet madebyProfessorNielsDanboltin1942(Figure1,left).⁸Thesameyear,occupationwas acknowledged,intheJournaloftheNorwegianMedicalAssociation,asacommoncause fordermatitis.⁷

Overall,onlytwoPh.D.studiesaboutoccupationaldermatologywereperformed.Gunnar Høvding(1970)performedthefirstone,focusingoncementdermatitiscausedby

chromates(Figure1,right).⁹Fromthatpoint,cementdermatitishasbeenidentifiedas oneofthemostseriousoccupationalhealthproblemsinbuildingtradesandindustries.¹⁰ In1986,PetterKristensendescribedtheoccurrenceofhanddermatitisamongagroupof Norwegianhairdresserapprentices.¹¹Severalyearslater,JanͲØivindHolm(1994)

performedanepidemiologicalstudyofhanddermatitisandatopyamonghairdressersand trainees.¹²

ThesinglepopulationͲbasedstudythattookintoaccountoccupationasariskfactorfor handdermatosesandsickleavewasperformedformorethan30yearsinthecountyof Troms.¹³

Figure1.FirstNorwegianstudiesonworkͲrelatedskindiseases.

Ontheleft:pictureofthefirstNorwegianleafletaboutdermatitisasaworkͲrelateddiseasepreparedby ProfN.C.GauslaaDanbolt(1900–1984).⁸Ontheright:thefirstNorwegianPh.D.aboutoccupational dermatologybyG.Høvding(1970).⁹Source:NationalLibraryofNorway.Freetousewithoutrestriction.

Systematicliteraturesearch

AsystematicliteraturesearchwasconductedinthedatabaseOVIDMedlinetoinvestigate thenumberofNorwegianstudiesonworkͲrelatedskindiseases,thestudydesignand populationsamplefortheperiod1980Ͳ2015,withthelastsearchon19November2015.

Thissearchyielded49articles.Additionally,5additionalarticlesknownbytheauthor,but notretrievedbythesearchwereincluded.Thealreadypublishedarticlesofthisthesis wereexcluded.Allarticleswerefullread,andclassifiedaccordingtothedesign, populationsample,andlevelofevidence(Table1).

Table1.OverviewofNorwegianstudiesonworkͲrelatedskindiseases(1980–2015).

Observationalstudies Studydesign

(number)

Population(Author/sandyear/s) Levelof

evidence¹ Cohort(3) Industrialpainters: Romyhretal.2006.¹⁴Farmers: Nordbyetal.2004.¹⁵

Hairdressers:Holm,studyVI1994.¹²

IIͲ2

CrossͲ sectional (24)

Aquaculturefarm: Gransloetal.2009.¹⁶

Seafoodindustry:Aasmoetal.2005,¹⁷Bangetal.2005,¹⁸Kavli&Moseng1987,¹⁹Becket al.1983.²⁰

Dentalhealthpersonnel:Jacobsenetal.2003,²¹Morkenetal.1999,²²Jacobsen&HenstenͲ Pettersen1995,²³Jacobsen&Pettersen1993,²⁴Jacobsenetal.1991,²⁵Jacobsen&

Pettersen1989.²⁶

Healthpersonnel:Holteretal.2002,²⁷Holm1995,²⁸Kavlietal.1987.²⁹ Ship’sengineers:Svendsen&Hilt1997.³⁰

Mechanics:Moenetal.1995.³¹ Carpainters:Grønbergetal.1994.³²

Hairdressers:Holm&Veierød,studyItoV,1994.¹² Generalpopulation:Kavli1984.¹³

Shrimppeelers:Kavli1985.³³ Woodworkers:Efskind1980.³⁴

IIͲ2

CaseͲseries (14)

IncidenceofoccupationalskindiseasesascomparedtootherEuropeancountries2000–

2012Stocksetal.2015.³⁵

Healthpersonnel:Dahlinetal.2014,³⁶Steinkjer1998.³⁷

ReportingofworkͲrelateddiseasesin2006:Samantetal.2008.³⁸ Divers:Ahlénetal.2003.³⁹

GenotypesofPseudomonasaeruginosaonskininfectionsinoccupationalsaturationdiving systems:Ahlénetal.2001.⁴⁰

RegistrationofpatientswithworkͲrelatedcontactdermatitis:Holm&Engesland(1994)⁴¹ Militarypersonnel:Selvaag2000.⁴²

Beauticians:Selvaag&Holm1995.⁴³

Constructionworkers:Skogstad&Levy1994.⁴⁴ Electromechanicworkers:Leiraetal.1992.⁴⁵ Electricalworkers:Skyberg&Ronneberg1986.⁴⁶ Woodworkers:Johnssonetal.1983.⁴⁷

Officeworkers:Nilsen1982.⁴⁸

IIͲ3

CaseͲreport (2)

Constructionworkers:Tindholdt et al. 2005.⁴⁹ Beauticians:Selvaagetal.1995.⁵⁰

III

Review(3) Chemicalhazardsinoffshorework:Moen etal.2004.⁵¹ PreventionofworkͲrelatedlatexallergy:Mehlum1998.⁵²

Delayedallergyagainstrubbergloves.Anoccupationaldermatitisamonghealthpersonnel Holmetal.1993.⁵³

Letter to editor(2)

LittleresearchactivityinoccupationaldermatologyinNorway: Alfonsoetal. 2015.⁶Healthpersonnel:Holm 1992.⁵⁴

Unclassified (3)

Surveysinoccupationaldermatology: Nyfors 1994.⁵⁵ Occupationaldermatitisamongfishermen:Tellnes1997.⁵⁶

Occupationaleczema:diagnosisandtreatment:Kavli&Kristensen1985.⁵⁷

1.USPreventiveServicesTaskForce(1989).GuidetoclinicalpreventiveservicesreportoftheU.S.PreventiveServicesTask Force.Washington,DC:TheTaskForce.

AsTable1shows,themostfrequentstudydesignwascrossͲsectional,followedbycaseͲ series,bothfocusingonspecificriskgroupsandoninformationfromreportingsystems.

Dentalhealthpersonnelandhairdressersweretheriskgroupsinvestigatedmost frequently.However,mostofthesestudieswereperformedduringthe1990and exposurescenariosmaybedifferenttoday.

Thestudieswithaprospectivecohortdesignwereperformedamonghairdressers,¹² industrialpainters,¹⁴andmalefarmers.¹⁵

WhilstNorwayhasagreatpartoftheworkingpopulationemployedintheoffshore sector,thissearchdidnotretrievemanystudywithspecialfocusonthisgroup.For instance,onlyonereviewdescribedthatskinproblemsduetooccupationalexposureto chemicalhazardsarefrequentamongoffshoreworkers.⁵¹

Inbrief,mostofthestudiesfocusedoncontactdermatitis,twoonskininfectionscaused byPseudomonasaeruginosaamongdivers,^39,40andoneoncutaneoussquamouscell carcinomaofthelipsamongfarmers.¹⁴

Thissearchdidnotretrieveanyinterventionstudy.

1.2POPULATIONͲBASEDSTUDIESONOCCUPATIONANDSKINDISEASES AsystematicliteraturesearchaimedtoidentifypopulationͲbasedstudieswitha prospectivecohortdesignfocusingonoccupationalexposuresandskindiseaseswas conductedinthedatabaseOVIDMedline,withthelastsearchon10October2015.

Keratinocytecarcinomaswerenotincluded,asmetanalysesfocusingonassociations betweenoccupationalexposuretosolarUVRandcutaneoussquamouscellcarcinoma (SCC)andbasalcellcarcinoma(BCC)areavailable.^4,58

Thesearchstrategyincludedacombinationoffreetexttermsindexedbyahierarchical controlledvocabulary(MeSHandEmtree)adaptedforOVIDMedline(AppendixI).

Table2showstheinclusioncriteria.

Table2.Inclusioncriteriaforthesystematicliteraturesearch.

Studysubjects PopulationͲbased

Design Prospectivecohort

Exposure Occupationalexposures

Outcome WorkͲrelated/Occupationaldermatitis,skindisease,skinproblems,skin complaints,skinconditions,dermatoses

Language English,Norwegian,Danish,Swedish,Spanish

Period 1980–10/10/2015

Thesearchyielded297articles.Alltitlesandabstractswereassessedagainsttheinclusion criteriaforpossiblerelevance(Table2).

Atthispoint,onlypopulationͲbasedstudiesdealingwithoccupationalexposuresandskin diseaseswereincluded.Threeadditionalarticlesidentifiedinreferenceslists,butnot retrievedbythesearchwerealsoincluded.

From26eligiblearticles,whichwerereviewedtwotimes,15studiesstilllackeda populationͲbasedsample(Figure2).

Afterthequalitativeassessment,twostudieswithaprospectivecohortdesign^59,61were identifiedfromthe11populationͲbasedstudies(Figure2).

Inbrief,mostofthepopulationͲbasedstudieshadacrossͲsectionaldesign.Amongthe studieswithaprospectivedesign,onesinglestudyassessedassociationsbetween occupationalexposureandriskofhanddermatitis.However,thefocuswasmerelyon frequenthandwashingatwork.⁶¹

Table3showsanoverviewofthe11populationͲbasedstudiesincludedinthequalitative synthesis.

Figure2.Prismaflowdiagram.

Table3.OverviewofpopulationͲbasedstudiesregardingoccupationandskindiseases. FirstauthorYearCountryStudypopulationStudydesignMethods Wei592015Germany2,051subjectsaged 19Ͳ24yearswere followedͲupfrom childhood.

Prospective cohortstudy.Surveydata. Exposurevariable:atopic dermatitis.Jobcounselling Adjustmentforpotential confounders:parentalhistory ofasthma,allergicrhinitis, atopicdermatitis. Socioeconomicstatus Smoking. Outcomevariable:typeof occupation(highriskjobfor handeczemavs.lowriskjobfor handeczema).Useof protectivemeasuresandskin care. Onlycompletecases (participantswithnomissing dataonexposures,outcomes, andconfounderswereincluded fordescriptiveanalyses) Univariatelogisticregression models. Multiplelogisticregression models. (Imputationmethodswere usedformissingdata)

Conclusions YoungadultswithpreͲhireADdidnotbehavedifferently fromthosewithoutADintermsofchoosingtheirfirstjob. SubjectswithADwerenotsignificantlymorelikelytouse secondarypreventivemeasuresthanhealthysubjectswhen theywereunderhighͲriskexposuresforhandeczema. SubjectswithparentalhistoryofADorpreͲemployment counsellingseemedtohaveincreaseduseofsecondary preventivemeasures. Mainlimitation: Theoutcomemeasurewasbasedonthefirstjobchoiceat theverybeginningandthesubject´scareersandmight representonlytemporaryorshortͲtermparttimejobs. St.Louis602014USAArandomsampleof thegeneraladult populationofthree states:Connecticut, Kentucky,and Michigan.

CrossͲsectional population basedstudy

OneͲyearprevalencefor selfͲreporteddermatitis. ReceivedmedicalattenͲ tionduetoskinconditions. WorkͲrelateddermatitisdiagͲ nosedbyamedicaldoctor. PersonalperceptionsofworkͲ relatedness, Jobchangesassociatedwith dermatitis.

TheoveralloneͲyearprevalencefordermatitiswasbetween7.9 15.6%. Femalerespondersweremorelikelytoreportdermatitis. Between13to18%ofalldermatitiswererelatedtoworkbyusing adefinitionofworkͲrelateddermatitisthatincludedbothclinician supportedopinions,andtheopinionsofindividualsthemselves. Includingpatient´sperceptionsofworkͲrelatednessproduceda largerprevalenceestimateforworkͲrelateddermatitisthanthe previouslypublishedestimateof5.6%whichincludedonlythose casesofdermatitisattributedtoworkbyhealthcareprofession