Occupational Medicine 2015;65:638–641 Advance Access publication 14 May 2015 doi:10.1093/occmed/kqv061
Online reporting and assessing new occupational health risks in SIGNAAL A. F. Lenderink1, S. Keirsbilck2,3, H. F. van der Molen1 and L. Godderis2,3 Netherlands Center for Occupational Diseases, Coronel Institute on Work and Health, AMC/University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands, 2Centre for Environment and Health, Katholieke Universiteit Leuven, 3000 Leuven, Belgium, 3IDEWE, External Service for Prevention and Protection at Work, 3001 Heverlee, Belgium. 1
Background Changes in work and working conditions continuously give rise to new work-related health risks. Without sufficient knowledge of these, opportunities for prevention and intervention may be missed. Aims
To develop, implement and evaluate an online tool called SIGNAAL for reporting and assessment of new work-related health risks by occupational health physicians and experts in the Netherlands and Belgium.
Methods
Development and implementation of SIGNAAL to allow both easy and sufficient detailed reporting by occupational health physicians and structured and transparent assessment by occupational health experts. A new work-related health risk is defined as a work-related disease due to specific exposure in a specific work setting not described in the literature before.
Results
The online reporting and assessment tool proved to be a feasible means of reporting possible new combinations of health problems and exposures in the work situation. Eleven of the 15 cases reported until October 2014 were fully assessed: one was an entirely new work-related disease, four were known but uncommon work-related diseases, five were known but new in the reported work situation and one was a well-known work-related disease.
Conclusions An online reporting system used in an occupational health setting can provide insight into new workrelated health risks by creating a structured way to gather, report and assess new combinations of health problems and exposure in the workplace. Key words
Aetiology; new and emerging risks; online reporting; work-relatedness.
Introduction Continuous changes in work and working conditions give rise to new work-related health risks and possibly to new work-related diseases. If there is insufficient knowledge of these, opportunities for intervention and prevention may be missed [1]. In occupational health and safety considerable effort goes into risk assessment in order to manage hazards and risks. Risk assessment is essentially a deductive method starting with premises, but for new risks, these premises are not known and consequently an inductive method might be more appropriate to discover previously unknown risks, e.g. by studying new work-related diseases [2]. In this art icle, we use the broader concept of work-related disease
rather than occupational disease, which is often interpreted as a more legal concept used for compensation [3]. We define a new work-related health risk as a workrelated disease due to specific exposure in a specific work setting not described in the literature before. There are several approaches to identify new occupational health risks, e.g. sentinel event notification systems [4] or data mining in existing databases [5]. The choice of approach may depend on the type of disease and the prevalence in the (at risk) population: health surveillance and epidemiological research in case of frequently occurring diseases with a low aetiological fraction and spontaneous reporting of cases for less prevalent diseases with a moderate to high aetiological fraction [6]. Our objective was to develop an online tool for reporting new work-related
© The Author 2015. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: [email protected]
Downloaded from http://occmed.oxfordjournals.org/ at Deakin University Library on October 29, 2015
Correspondence to: A. F. Lenderink, Netherlands Center for Occupational Diseases, Coronel Institute on Work and Health, AMC/University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands. Tel: +31 6 54932325/+31 20 5665387; e-mail: [email protected]
A. F. LENDERINK ET AL.: NEW OCCUPATIONAL HEALTH RISKS IN SIGNAAL 639
health risks by occupational physicians (OPs) and assessment of the reports by occupational health experts (OHEs) in the Netherlands and Belgium.
literature search on aetiology was performed using search strings developed for evidence-based occupational medicine [7]. The final assessment was taken in concert.
Methods Results Between 2 July 2013 and 1 October 2014, SIGNAAL received 15 reports (Table 1). The assessment of 11 cases was fully finalized; in four more cases, it is still underway. One case was assessed as a well-known workrelated health problem and this was communicated with the reporter with additional documentation on the case. For 10 cases, a preliminary literature search was performed on aetiology. In five cases, some evidence for a relationship between health problems and exposure was found, although the evidence level was low compared with international criteria (mainly case reports or small case–control studies). In five other cases, evidence was found of a possible relation between health problems and exposure, but in different work situations. Finally, one case was considered an entirely new work-related disease, four cases were ‘known, but uncommon’, five cases were ‘known, but new in the reported work situation’ and one was an established work-related disease (Table 2).
Table 1. SIGNAAL reported health problems in the first 15 months (2 July 2013 until 1 October 2014) Health problem
Occupation/task
Open angle glaucoma Achilles tendon rupture
Playing saxophone (teacher) Assembly, dismantling and maintenance of cranes Formaldehyde exposure in aluminium production Exposure to amorphous and crystalline silica in cylinder sharpener Exposure to hairspray in a hairdresser Care of dementia patients without lifting aids Cleaning a polluted drain with high pressure spray Operators coffee production
Nosebleeds Sarcoidosis Pulmonary alveolar proteinosis Back pain Endotoxin fever Heart problems (myocardial infarction, angina pectoris) Repeated respiratory infections Subclavian vein thrombosis (Paget Schrötter) Vertigo Sewage workers’ syndrome Bladder cancer Extrinsic allergic alveolitis Respiratory disease and cognitive problems NL = The Netherlands; B = Belgium.
Frequent intercontinental flying Repetitive work with hyperextension and lateral rotation of the arm Train drivers Wastewater treatment Exposure to methylene chloride and acetone in yarn production Exposure to metalworking fluids Exposure to manure gases (H2S, ammonia, etc.) in a new procedure for manure processing
Number of workers involved 1 1
Reporting country NL NL
>1
B
>1
B
1 3
B NL
1
NL
2
NL
1 1
NL NL
4 17 1 2 2
B B B NL NL
Downloaded from http://occmed.oxfordjournals.org/ at Deakin University Library on October 29, 2015
The project was initiated by the Netherlands Center for Occupational Diseases as part of a current programme to enhance reporting of occupational diseases by Dutch OPs. From the start, a collaboration was established with IDEWE (a Belgian non-profit occupational health and safety provider) and the Centre of Environment and Health (KU Leuven). Ethical approval was not required for this project. After launching the online tool, OPs in the Netherlands and Belgium were invited to report new work-related health problems through an online form on the SIGNAAL website. Upon receipt, the report was reviewed by a moderator who decided which OHE(s) should be involved in assessment based on the type of health problem presented. Each case was assessed by at least one but preferably two or more OHEs, i.e. occupational health specialists knowledgeable through study, training or experience in the area or topic reported. They independently assessed the reported case online to determine work-relatedness, newness and necessary follow-up. A preliminary
640 OCCUPATIONAL MEDICINE
Table 2. Assessment outcomes of the 11 fully assessed SIGNAAL reported health problems Work related
New
Health problem
Relation to exposure
In this work setting
Glaucoma and playing saxophone Achilles tendon rupture during assembly, dismantling and maintenance of cranes Nosebleeds and formaldehyde exposure in aluminium production Pulmonary alveolar proteinosis and exposure to hairspray in a hairdresser Back pain and care of dementia patients without lifting aids Endotoxin fever and cleaning a polluted drain with high pressure spray Heart problems (myocardial infarction, angina pectoris) and long-term exposure to carbon monoxide in coffee production Repeated respiratory infections and frequent intercontinental flying Subclavian vein thrombosis (Paget Schrötter) and repetitive work with hyperextension and lateral rotation of the arm Vertigo in train drivers Sewage workers’ syndrome in wastewater treatment
Y Y
RN RN
++ ++
± ±
± ±
Y
N
++
?
?
Y
RN
±
?
?
Y
NN
++
++
++
Y
N[WS]
++
±
?
Y
N[WS]
++
++
?
Y
RN
++
++
±
Y
N[WS]
±
±
±
Y Y
N[WS] RN
± ++
± ±
? ±
Y = yes; N = new; NN = not new; RN = not really new, but relatively unknown; N[WS] = never described in the current work situation; ++ = already known and regularly described in the literature; ± = relatively unknown and seldom described in the literature; ? = unknown, not described before in the literature.
Discussion Use of SIGNAAL proved to be feasible for reporting and assessment of possible new combinations of health problems and exposure in the work situation in the Netherlands and Belgium. Through SIGNAAL, it is possible to collect sufficient information to provide a preliminary assessment of both the novelty and work-relatedness of the reported combination of health problems, exposure and work situation. Although the assessment procedure is structured and transparent, it is usually not possible to demonstrate causality from expert assessment. In evidence-based medicine, expert opinion is considered the lowest level of evidence, although studies underline that a literature search may improve this considerably [8]. Nevertheless, the new reported disease-exposure combinations should be looked upon as signals, a first step to generate hypotheses, which need further strengthening and validation, e.g. by follow-up epidemiological and/or experimental research. This can be considered part of a more comprehensive approach to detecting new and emerging risks in occupational health in line with the EU Occupational Safety and Health Strategic Framework 2014–20 [9]. SIGNAAL relies on spontaneous reporting of unusual cases by vigilant OPs. Common criticisms of comparable spontaneous reporting systems such as those concerned with infectious diseases or new adverse drug reactions are that they suffer from under-reporting, too many reports
on already well-known reactions and false causality attribution. But although the numbers of reports are a poor indication of the incidence or prevalence of potential new health risks, they are important indicators of clinical concern among reporting physicians [10]. So SIGNAAL reports indicate OPs’ concerns and perceptions about work-relatedness of encountered health problems as well as possible blind spots in their knowledge and may thus guide knowledge transfer and education. We conclude that a specifically designed online reporting system is feasible for gathering reports from OPs on new combinations of health problems, exposure and work setting of sufficient quality for assessment. Assessment of the reported cases can generate hypo theses on new or relatively unknown occupational health risks, resulting in further research, transfer of knowledge and early intervention as well as preventive measures in the workplace.
Key points
•• Changes in work and working conditions may give
rise to new work-related health risks. work-related health risks can be detected through spontaneous reporting by occupational health physicians. •• An online tool is feasible for reporting and assessment of new work-related health risks.
•• New
Downloaded from http://occmed.oxfordjournals.org/ at Deakin University Library on October 29, 2015
Reported health problems, exposure/work situation
A. F. LENDERINK ET AL.: NEW OCCUPATIONAL HEALTH RISKS IN SIGNAAL 641
Funding Dutch Ministry of Social Affairs and Employment.
Acknowledgements We wish to thank the members of the project team who developed SIGNAAL with a special thanks to Amin Khan, webmaster of the Netherlands Center for Occupational Diseases, who built and tested the online tool in Drupal. We also want to thank the occupational health physicians who reported a case in SIGNAAL and the occupational health experts who took part in the assessment process.
Conflicts of interest
References 1. Harremoes P, Gee D, MacGarvin M et al. Late Lessons From Early Warnings: The Precautionary Principle 1896– 2000. Luxemburg: Office for Official Publications of the European Communities, 2001. 2. Vandenbroucke JP. Observational research, randomised trials, and two views of medical science. PLoS Med 2008;5:e67. 3. ILO. World Day for Safety and Health at Work: A Background. Geneva: International Labour Organization, 2005.
Stay alert to the latest content Sign up to any of the following free alerts to receive the latest content straight to your inbox: w eTOCs Receive alerts via email each time an issue is published online w &LWH7UDFNDOHUWV 5HFHLYHDOHUWVZKHQDVSHFLȷFDUWLFOHLVFLWHGRUFRUUHFWHG Track topics / authors / articles w 566IHHGV Receive alerts with the ‘headlines’ from the latest journal content w $GYDQFH$FFHVV View papers online weeks ahead of print
Visit www.oxfordjournals.org/register ‘View alerting preferences’
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None declared.
4. Halperin WE, Ordin DL. Closing the surveillance gap. Am J Ind Med 1996;29:223–224. 5. Bonneterre V, Bicout DJ, Larabi L et al. Detection of emerging diseases in occupational health: usefulness and limitations of the application of pharmacosurveillance methods to the database of the French National Occupational Disease Surveillance and Prevention network (RNV3P). Occup Environ Med 2008;65:32–37. 6. Lenderink AF, van der Laan G, Spreeuwers D, van der Molen HF, Pal T. Signals of New Occupational Health Risks: An Impetus for Health and Safety Vigilance—Theme Publication of Netherlands Center for Occupational Diseases. Amsterdam: Netherlands Center for Occupational Diseases, 2009. 7. Mattioli S, Zanardi F, Baldasseroni A et al. Search strings for the study of putative occupational determinants of disease. Occup Environ Med 2010;67:436–443. 8. Schaafsma F, Hulshof C, de Boer A, van Dijk F. Effectiveness and efficiency of a literature search strategy to answer questions on the etiology of occupational diseases: a controlled trial. Int Arch Occup Environ Health 2007;80:239–247. 9. EU Occupational Safety and Health (OSH). Strategic Framework 2014–2020. Internet site European Commission, Employment, Social Affairs & Inclusion. http://ec.europa.eu/social/main.jsp?catId=151 (16 February 2015, date last accessed). 10. Edwards IR. Spontaneous reporting—of what? Clinical concerns about drugs. Br J Clin Pharmacol 1999;48:138–141.
Online reporting and assessing new occupational health risks in SIGNAAL A. F. Lenderink1, S. Keirsbilck2,3, H. F. van der Molen1 and L. Godderis2,3 Netherlands Center for Occupational Diseases, Coronel Institute on Work and Health, AMC/University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands, 2Centre for Environment and Health, Katholieke Universiteit Leuven, 3000 Leuven, Belgium, 3IDEWE, External Service for Prevention and Protection at Work, 3001 Heverlee, Belgium. 1
Background Changes in work and working conditions continuously give rise to new work-related health risks. Without sufficient knowledge of these, opportunities for prevention and intervention may be missed. Aims
To develop, implement and evaluate an online tool called SIGNAAL for reporting and assessment of new work-related health risks by occupational health physicians and experts in the Netherlands and Belgium.
Methods
Development and implementation of SIGNAAL to allow both easy and sufficient detailed reporting by occupational health physicians and structured and transparent assessment by occupational health experts. A new work-related health risk is defined as a work-related disease due to specific exposure in a specific work setting not described in the literature before.
Results
The online reporting and assessment tool proved to be a feasible means of reporting possible new combinations of health problems and exposures in the work situation. Eleven of the 15 cases reported until October 2014 were fully assessed: one was an entirely new work-related disease, four were known but uncommon work-related diseases, five were known but new in the reported work situation and one was a well-known work-related disease.
Conclusions An online reporting system used in an occupational health setting can provide insight into new workrelated health risks by creating a structured way to gather, report and assess new combinations of health problems and exposure in the workplace. Key words
Aetiology; new and emerging risks; online reporting; work-relatedness.
Introduction Continuous changes in work and working conditions give rise to new work-related health risks and possibly to new work-related diseases. If there is insufficient knowledge of these, opportunities for intervention and prevention may be missed [1]. In occupational health and safety considerable effort goes into risk assessment in order to manage hazards and risks. Risk assessment is essentially a deductive method starting with premises, but for new risks, these premises are not known and consequently an inductive method might be more appropriate to discover previously unknown risks, e.g. by studying new work-related diseases [2]. In this art icle, we use the broader concept of work-related disease
rather than occupational disease, which is often interpreted as a more legal concept used for compensation [3]. We define a new work-related health risk as a workrelated disease due to specific exposure in a specific work setting not described in the literature before. There are several approaches to identify new occupational health risks, e.g. sentinel event notification systems [4] or data mining in existing databases [5]. The choice of approach may depend on the type of disease and the prevalence in the (at risk) population: health surveillance and epidemiological research in case of frequently occurring diseases with a low aetiological fraction and spontaneous reporting of cases for less prevalent diseases with a moderate to high aetiological fraction [6]. Our objective was to develop an online tool for reporting new work-related
© The Author 2015. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: [email protected]
Downloaded from http://occmed.oxfordjournals.org/ at Deakin University Library on October 29, 2015
Correspondence to: A. F. Lenderink, Netherlands Center for Occupational Diseases, Coronel Institute on Work and Health, AMC/University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands. Tel: +31 6 54932325/+31 20 5665387; e-mail: [email protected]
A. F. LENDERINK ET AL.: NEW OCCUPATIONAL HEALTH RISKS IN SIGNAAL 639
health risks by occupational physicians (OPs) and assessment of the reports by occupational health experts (OHEs) in the Netherlands and Belgium.
literature search on aetiology was performed using search strings developed for evidence-based occupational medicine [7]. The final assessment was taken in concert.
Methods Results Between 2 July 2013 and 1 October 2014, SIGNAAL received 15 reports (Table 1). The assessment of 11 cases was fully finalized; in four more cases, it is still underway. One case was assessed as a well-known workrelated health problem and this was communicated with the reporter with additional documentation on the case. For 10 cases, a preliminary literature search was performed on aetiology. In five cases, some evidence for a relationship between health problems and exposure was found, although the evidence level was low compared with international criteria (mainly case reports or small case–control studies). In five other cases, evidence was found of a possible relation between health problems and exposure, but in different work situations. Finally, one case was considered an entirely new work-related disease, four cases were ‘known, but uncommon’, five cases were ‘known, but new in the reported work situation’ and one was an established work-related disease (Table 2).
Table 1. SIGNAAL reported health problems in the first 15 months (2 July 2013 until 1 October 2014) Health problem
Occupation/task
Open angle glaucoma Achilles tendon rupture
Playing saxophone (teacher) Assembly, dismantling and maintenance of cranes Formaldehyde exposure in aluminium production Exposure to amorphous and crystalline silica in cylinder sharpener Exposure to hairspray in a hairdresser Care of dementia patients without lifting aids Cleaning a polluted drain with high pressure spray Operators coffee production
Nosebleeds Sarcoidosis Pulmonary alveolar proteinosis Back pain Endotoxin fever Heart problems (myocardial infarction, angina pectoris) Repeated respiratory infections Subclavian vein thrombosis (Paget Schrötter) Vertigo Sewage workers’ syndrome Bladder cancer Extrinsic allergic alveolitis Respiratory disease and cognitive problems NL = The Netherlands; B = Belgium.
Frequent intercontinental flying Repetitive work with hyperextension and lateral rotation of the arm Train drivers Wastewater treatment Exposure to methylene chloride and acetone in yarn production Exposure to metalworking fluids Exposure to manure gases (H2S, ammonia, etc.) in a new procedure for manure processing
Number of workers involved 1 1
Reporting country NL NL
>1
B
>1
B
1 3
B NL
1
NL
2
NL
1 1
NL NL
4 17 1 2 2
B B B NL NL
Downloaded from http://occmed.oxfordjournals.org/ at Deakin University Library on October 29, 2015
The project was initiated by the Netherlands Center for Occupational Diseases as part of a current programme to enhance reporting of occupational diseases by Dutch OPs. From the start, a collaboration was established with IDEWE (a Belgian non-profit occupational health and safety provider) and the Centre of Environment and Health (KU Leuven). Ethical approval was not required for this project. After launching the online tool, OPs in the Netherlands and Belgium were invited to report new work-related health problems through an online form on the SIGNAAL website. Upon receipt, the report was reviewed by a moderator who decided which OHE(s) should be involved in assessment based on the type of health problem presented. Each case was assessed by at least one but preferably two or more OHEs, i.e. occupational health specialists knowledgeable through study, training or experience in the area or topic reported. They independently assessed the reported case online to determine work-relatedness, newness and necessary follow-up. A preliminary
640 OCCUPATIONAL MEDICINE
Table 2. Assessment outcomes of the 11 fully assessed SIGNAAL reported health problems Work related
New
Health problem
Relation to exposure
In this work setting
Glaucoma and playing saxophone Achilles tendon rupture during assembly, dismantling and maintenance of cranes Nosebleeds and formaldehyde exposure in aluminium production Pulmonary alveolar proteinosis and exposure to hairspray in a hairdresser Back pain and care of dementia patients without lifting aids Endotoxin fever and cleaning a polluted drain with high pressure spray Heart problems (myocardial infarction, angina pectoris) and long-term exposure to carbon monoxide in coffee production Repeated respiratory infections and frequent intercontinental flying Subclavian vein thrombosis (Paget Schrötter) and repetitive work with hyperextension and lateral rotation of the arm Vertigo in train drivers Sewage workers’ syndrome in wastewater treatment
Y Y
RN RN
++ ++
± ±
± ±
Y
N
++
?
?
Y
RN
±
?
?
Y
NN
++
++
++
Y
N[WS]
++
±
?
Y
N[WS]
++
++
?
Y
RN
++
++
±
Y
N[WS]
±
±
±
Y Y
N[WS] RN
± ++
± ±
? ±
Y = yes; N = new; NN = not new; RN = not really new, but relatively unknown; N[WS] = never described in the current work situation; ++ = already known and regularly described in the literature; ± = relatively unknown and seldom described in the literature; ? = unknown, not described before in the literature.
Discussion Use of SIGNAAL proved to be feasible for reporting and assessment of possible new combinations of health problems and exposure in the work situation in the Netherlands and Belgium. Through SIGNAAL, it is possible to collect sufficient information to provide a preliminary assessment of both the novelty and work-relatedness of the reported combination of health problems, exposure and work situation. Although the assessment procedure is structured and transparent, it is usually not possible to demonstrate causality from expert assessment. In evidence-based medicine, expert opinion is considered the lowest level of evidence, although studies underline that a literature search may improve this considerably [8]. Nevertheless, the new reported disease-exposure combinations should be looked upon as signals, a first step to generate hypotheses, which need further strengthening and validation, e.g. by follow-up epidemiological and/or experimental research. This can be considered part of a more comprehensive approach to detecting new and emerging risks in occupational health in line with the EU Occupational Safety and Health Strategic Framework 2014–20 [9]. SIGNAAL relies on spontaneous reporting of unusual cases by vigilant OPs. Common criticisms of comparable spontaneous reporting systems such as those concerned with infectious diseases or new adverse drug reactions are that they suffer from under-reporting, too many reports
on already well-known reactions and false causality attribution. But although the numbers of reports are a poor indication of the incidence or prevalence of potential new health risks, they are important indicators of clinical concern among reporting physicians [10]. So SIGNAAL reports indicate OPs’ concerns and perceptions about work-relatedness of encountered health problems as well as possible blind spots in their knowledge and may thus guide knowledge transfer and education. We conclude that a specifically designed online reporting system is feasible for gathering reports from OPs on new combinations of health problems, exposure and work setting of sufficient quality for assessment. Assessment of the reported cases can generate hypo theses on new or relatively unknown occupational health risks, resulting in further research, transfer of knowledge and early intervention as well as preventive measures in the workplace.
Key points
•• Changes in work and working conditions may give
rise to new work-related health risks. work-related health risks can be detected through spontaneous reporting by occupational health physicians. •• An online tool is feasible for reporting and assessment of new work-related health risks.
•• New
Downloaded from http://occmed.oxfordjournals.org/ at Deakin University Library on October 29, 2015
Reported health problems, exposure/work situation
A. F. LENDERINK ET AL.: NEW OCCUPATIONAL HEALTH RISKS IN SIGNAAL 641
Funding Dutch Ministry of Social Affairs and Employment.
Acknowledgements We wish to thank the members of the project team who developed SIGNAAL with a special thanks to Amin Khan, webmaster of the Netherlands Center for Occupational Diseases, who built and tested the online tool in Drupal. We also want to thank the occupational health physicians who reported a case in SIGNAAL and the occupational health experts who took part in the assessment process.
Conflicts of interest
References 1. Harremoes P, Gee D, MacGarvin M et al. Late Lessons From Early Warnings: The Precautionary Principle 1896– 2000. Luxemburg: Office for Official Publications of the European Communities, 2001. 2. Vandenbroucke JP. Observational research, randomised trials, and two views of medical science. PLoS Med 2008;5:e67. 3. ILO. World Day for Safety and Health at Work: A Background. Geneva: International Labour Organization, 2005.
Stay alert to the latest content Sign up to any of the following free alerts to receive the latest content straight to your inbox: w eTOCs Receive alerts via email each time an issue is published online w &LWH7UDFNDOHUWV 5HFHLYHDOHUWVZKHQDVSHFLȷFDUWLFOHLVFLWHGRUFRUUHFWHG Track topics / authors / articles w 566IHHGV Receive alerts with the ‘headlines’ from the latest journal content w $GYDQFH$FFHVV View papers online weeks ahead of print
Visit www.oxfordjournals.org/register ‘View alerting preferences’
Downloaded from http://occmed.oxfordjournals.org/ at Deakin University Library on October 29, 2015
None declared.
4. Halperin WE, Ordin DL. Closing the surveillance gap. Am J Ind Med 1996;29:223–224. 5. Bonneterre V, Bicout DJ, Larabi L et al. Detection of emerging diseases in occupational health: usefulness and limitations of the application of pharmacosurveillance methods to the database of the French National Occupational Disease Surveillance and Prevention network (RNV3P). Occup Environ Med 2008;65:32–37. 6. Lenderink AF, van der Laan G, Spreeuwers D, van der Molen HF, Pal T. Signals of New Occupational Health Risks: An Impetus for Health and Safety Vigilance—Theme Publication of Netherlands Center for Occupational Diseases. Amsterdam: Netherlands Center for Occupational Diseases, 2009. 7. Mattioli S, Zanardi F, Baldasseroni A et al. Search strings for the study of putative occupational determinants of disease. Occup Environ Med 2010;67:436–443. 8. Schaafsma F, Hulshof C, de Boer A, van Dijk F. Effectiveness and efficiency of a literature search strategy to answer questions on the etiology of occupational diseases: a controlled trial. Int Arch Occup Environ Health 2007;80:239–247. 9. EU Occupational Safety and Health (OSH). Strategic Framework 2014–2020. Internet site European Commission, Employment, Social Affairs & Inclusion. http://ec.europa.eu/social/main.jsp?catId=151 (16 February 2015, date last accessed). 10. Edwards IR. Spontaneous reporting—of what? Clinical concerns about drugs. Br J Clin Pharmacol 1999;48:138–141.
