Asian-Pacific Newsletter 2/2015, Infectious diseases

Asian-Pacific Newsletter O N O C C U PAT I O N A L H E A LT H A N D S A F E T Y Volume 22, number 2, September 2015

Infectio us disease s

Asian-Pacific Newsletter on Occupational Health and Safety

Contents

Volume 22, number 2, September 2015 Infectious diseases

Published by Finnish Institute of Occupational Health PO Box 18 FI-00391 Helsinki, Finland Editor-in-Chief Suvi Lehtinen Editor Inkeri Haataja Linguistic Editing Alice Lehtinen Layout Kirjapaino Uusimaa, Studio Printing SLY-Lehtipainot Oy /Kirjapaino Uusimaa The Editorial Board is listed (as of 1 August 2015) on the back page.

This publication enjoys copyright under Protocol 2 of the Universal Copyright Convention. Nevertheless, short excerpts of the articles may be reproduced without authorization, on condition that the source is indicated. For rights of reproduction or translation, application should be made to the Finnish Institute of Occupational Health, International Affairs, PO Box 18, FI-00391 Helsinki, Finland.

The electronic version of the Asian-Pacific Newsletter on Occupational Health and Safety on the Internet can be accessed at the following address: http://www.ttl.fi/Asian-PacificNewsletter The issue 3/2015 of the Asian-Pacific Newsletter deals with textile sector.

Photograph on the cover page: © World Health Organization / Jonathan Perugia

27 Editorial David Koh, Singapore 28 Governance and leadership at the heart of preventing health emergencies Marie-Paule Kieny, WHO 29 Workplace Programme to Prevent and Control Transmission of Infectious Diseases: The Philippines’ Response Ma. Teresita S. Cucueco, Maria Beatriz G. Villanueva, the Philippines 31 Outbreaks of H5N1 and H7N9 Avian Influenza in China Shicheng Yu, Lijun Jia, Hongyan Yao, P.R. China 34 Middle East Respiratory Syndrome (MERS) outbreak in Korea Soo-Geun Kim, Hyun-Sul Lim, Republic of Korea 37 Emerging infectious diseases from the workplace perspective Jeff Hwang, Kenneth Choy, Siok-Lin Gan, Singapore 40 Instructor training for protection against respiratory diseases among health care workers in Japan Koji Wada, Toru Yoshikawa, Japan 42 Use of blunt suture needles halves the risk of needle stick injuries among surgeons Jani Ruotsalainen, Jos Verbeek, Cochrane Work 43 WHO Collaborating Centres Meeting in Jeju, Republic of Korea Suvi Lehtinen, Finland 44 ICOH2015 in Seoul Suvi Lehtinen, Finland 46 Seoul Statement on the Development of Occupational Health Services for All

Avian influenza in Indonesia. A health official prepares the vaccine.

Printed publication: ISSN 1237-0843 On-line publication: ISSN 1458-5944 © Finnish Institute of Occupational Health, 2015 The Asian-Pacific Newsletter is financially supported in 2015 by the International Labour Organization (ILO).

The responsibility for opinions expressed in signed articles, studies and other contributions rests solely with their authors, and publication does not constitute an endorsement by the International Labour Office, the World Health Organization or the Finnish Institute of Occupational Health of the opinions expressed in them.

A

n emerging disease is one that has appeared in a population for the first time, or that may have existed previously but is rapidly increasing in incidence or geographic range. [1] During the last decade, several emerging infectious diseases (EID) have been the focus of worldwide attention. In 2009, swine flu, which is caused by the H1N1 influenza virus, first appeared in Mexico. This spread swiftly and resulted in a worldwide pandemic. It was the first Public Health Emergency of International Concern (PHEIC) declared by the World Health Organization. The pandemic was confirmed as over in 2010, but was estimated to have killed over 200 000 people during its course [2], in particular younger patients aged under 65 years. In addition to swine flu, other influenza viruses have also been born from the mixing and re-assortment of the genetic material of human and animal viruses. Two types of avian influenza, namely H5N1, which was first observed in Hong Kong in 1997, and H7N9, which appeared in Shanghai in 2013, have fatality rates of over 30% [3].

Other viruses, such as coronaviruses are also the cause of infections that have never before been encountered in humans. In 2003, the Severe Acute Respiratory Syndrome coronavirus (SARS-CoV) caused global furore by rapidly spreading across many countries, beginning with a few cases in South China and Hong Kong.

Slightly over 8000 SARS cases were confirmed, with a death rate of almost 10% among infected patients. More recently in 2012, another novel coronavirus was identified as being responsible for the Middle

East Respiratory Syndrome (MERS). Of the 1000 plus reported cases of MERSCoV infected patients, about one third died from the illness [4]. As its name suggests, the MERS outbreak originated in Saudi Arabia in the Middle East. It subsequently spread as far as Korea in 2015.

Hospital-associated infections were rife in several countries, including Korea [5].

The Ebola virus was first identified in 1976 in Africa. The disease is initially spread from wild animals to humans and then subsequently via human to human transmission. From 1976 to 2013, over 20 outbreaks occurred, resulting in a total of approximately 200 cases of Ebola in humans. All these outbreaks were contained in a matter of months. However, the latest Ebola epidemic in West Africa, the first cases of which are believed to have actually emerged in 2013, is unprecedented.

It has lasted much longer and has resulted in many more cases than all previous outbreaks. By 23 August 2015, over 28 000 Ebola cases had been reported, with over 11 000 deaths. [6] The international response to the current Ebola outbreak has unfortunately been woefully inadequate. As the cases of Ebola in the affected countries of Guinea, Liberia, and Sierra Leone exploded, all responders to this crisis, including the World Health Organization, were overwhelmed [7]. To make matters worse, the Ebola epidemic has had a huge impact on decimating an already sparse West African health workforce. In the current outbreak, health care workers have been about 20 to 30 times more likely to be infected than the general population, and about two thirds of those who have been infected have died [8]. The effect has also been psychological, and many health care workers have been traumatised. A painful lesson that was re-learnt from the Ebola outbreak was that health worker protection and support must be embedded in emergency preparedness, health response and health care delivery.

Given the above very recent and currently prevailing scenarios, it is extremely timely that this issue of the Asian-Pacific Newsletter on Occupational Health and Safety focuses on the important topic of emerging infectious diseases. We should all be prepared for the next EID – internationally and nationally, at all workplaces,

in our communities, and also at the personal level. The question is not whether an EID will occur again, but rather, when and where the next one will strike.

David Koh Assistant Vice Chancellor and VicePresident (Research and Innovation) Distinguished Professor, PAPRSB Institute of Health Sciences Universiti Brunei Darussalam david.koh@ubd.edu.bn Professor, SSH School of Public Health National University of Singapore david_koh@nuhs.edu.sg

References 1. WHO. Emerging diseases. http://www. who.int/topics/emerging_diseases/en/ accessed 27 Aug 2015.

2. Dawood FS, Iuliano AD, Reed C et al. Estimated global mortality associated with the first 12 months of 2009 pandemic influenza A H1N1 virus circulation: a modelling study.

Lancet Infect Dis 2012;12(9):687–95.

3. Yu S, Jia L, Yao H. Outbreaks of H5N1 and H7N9 Avian Influenza in China. AsianPacific Newsletter on Occupational Health and Safety 2015;22:31-3.

4. Zumla A, Hui DS, Perlman S. Middle East respiratory syndrome. Lancet. 2015 Jun 3. pii: S0140-6736(15)60454-8. doi: 10.1016/ S0140-6736(15)60454-8. [Epub ahead of print] 5. Kim SG, Lim HS. Middle East Respiratory Syndrome (MERS) outbreak in Korea.

Asian-Pacific Newsletter on Occupational Health and Safety 2015;22:34-6.

6. WHO. Ebola Situation Report – 26 August 2015. http://apps.who.int/ebola/currentsituation/ebola-situation-report-26-august-2015 accessed 27 Aug 2015.

7. WHO Director-General addresses the Review Committee of the International Health Regulations focused on the Ebola response. Opening remarks at the Review Committee on the role of the International Health Regulations in the Ebola outbreak and response. Geneva, Switzerland, 24 August 2015. http://www.who.int/dg/ speeches/2015/review-committee-ihrebola/en/ accessed 27 Aug 2015.

8. WHO. Health worker Ebola infections in Guinea, Liberia and Sierra Leone. Preliminary report. http://www.who.int/csr/resources/publications/ebola/health-workerinfections/en/ accessed 27 Aug 2015.

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Marie-Paule Kieny, WHO

Governance and leadership at the heart of preventing health emergencies In a world where people, goods and information are constantly on the move, infectious disease outbreaks in one country can easily become terrifying global threats. However, health emergencies due to infectious disease outbreaks are not inevitable events. The recipe for epidemic or pandemic prevention, nationally and globally, is a mix of ingredients we know well and have promoted for many years. These include surveillance and response capacity in all countries, effective health systems, and the ability to identify potential problems and solutions to stimulate the necessary research and development. However, there are two elements the global community has often left out of some of the conversation – governance and leadership.

In addition, collaboration between countries, both at regional and global levels, must be strengthened.

In the 2014–2015 Ebola outbreak in West Africa we saw the culmination of a situation that had long been incubating. The catalyst happened to be Ebola, a fierce virus that engenders great anxiety and which, until now, was unknown to the populations of West Africa. But the conditions of the health sector in the three stricken coun-

© World Health Organization / Garry Smith

Vaccination campaign against yellow fever in villages.

A woman receives the shot.

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tries, and the lack of an efficient regional and global alert and response mechanism, meant that any other disease epidemic would have wreaked similar panic and tragedy.

The fact that these systems were extremely fragile not only caused thousands of avoidable deaths, but also made it difficult for international teams to assess the extent of the epidemic and intervene in a timely way to stop it from spiralling out of control.

In order to have functioning health systems in place, including surveillance and response capacity, and the ability to identify imminent outbreaks and potential solutions, governments must have legitimacy with their populations and the leadership capacity to mobilize health staff, resources and communities towards the resolution of a common problem. However, when the outbreak started in West Africa, the limited public health services available were already struggling to deal with routine health conditions, let alone have the capacity to address a vicious virus.

For many years the populations of Guinea, Liberia and Sierra Leone have relied on themselves to look after their health problems – either by going to traditional healers or, for those who could afford it, by turning to the private sector, where healthcare is more available but paid for out of pocket. Years of war, but also subsequent neglect of the health sector, had already corroded people’s confidence in the system and driven them away from the hospitals and health facilities. Even the medical profession itself had abandoned ship for better futures abroad. And those few who remained worked in dire conditions and were rarely remunerated.

Professor Cheikh Ibrahima Niang, a Senegalese socioanthropologist who has assisted WHO in understanding the behaviour and attitudes of communities in West Africa, argues that trust and confidence are the strategic tools for ending the epidemic and rebuilding the countries. To achieve that, governments, which are best placed to understand their populations’ needs and reactions, must take leadership and initiate open and fruitful dialogue with their communities in order to regain their trust and the legitimacy to finally close the Ebola chapter and enact effective reforms.

The Ebola outbreak placed an unconscionable burden on the already fragile health systems of Guinea, Liberia and Sierra Leone, but also on their economies and on the very fibre of social life, reversing small but hard-earned de-

velopment achievements of recent years.

What Ebola has shown most of all is that a top-down approach is not the optimal way to go. Even now, after more than a year of efforts, we see that many people in West Africa are still resisting medical help and are hiding infected loved ones, opening the door to more transmissions.

In the words of Professor Niang, “Many of these people may be illiterate, but they are not stupid. They do not want to be passive recipients, they want to be actors in their own response to the crisis.” Ending the Ebola epidemic, reconstructing the health systems and preventing another such crisis from occurring will demand an ownership on the part of communities and a gradual improvement in the governance of the health sector.

But good governance is not just the duty of the Ebola stricken countries. Because of increased connectedness between states, ensuring that all national health systems are adequate and prepared for health crises is an international concern, and not just the concern of low-resourced countries. The international community has an interest in directing funds and development assistance where they will have a lasting effect. The challenge for global health now – beyond Ebola – is to ensure that international health aid and strategies work to achieve sustainable health systems, equitable access to health products and services and collaborative approaches to epidemic prevention, including R&D into diseases for which no modern line of defence exists. In parallel, countries needing to reform or strengthen their systems must invest in the task financially and through effective reform, including by establishing a well trained and remunerated health workforce, functioning health infrastructure, social security schemes and processes to ensure that populations have a stake in their health system, and a say in the health decisionmaking process.

Dr Marie-Paule Kieny Assistant Director-General Health Systems and Innovation World Health Organization

Ma. Teresita S. Cucueco, Maria Beatriz G. Villanueva, the Philippines

Workplace Programme to Prevent and Control Transmission of Infectious Diseases: The Philippines’ Response During the last decade of the previous century, the threat of another global pandemic kept health experts worldwide at heightened alert. Previous experiences of the devastation caused by the Spanish Flu and the Asian Influenza pandemics have increased international surveillance of infectious diseases, in order to mitigate and control the spread of the disease and reduce its effect on populations.

The start of the new millennium saw the outbreak of the Severe Acute Respiratory Syndrome (SARS) in 2002 in Asia.

Since then, there has been a rise in emerging and re-emerging infectious disease epidemics that have affected not only Asian countries, but countries on almost all continents, as increasing international travel facilitates the transmission of infectious diseases when contaminated people enter a country.

Noting the threat of these biological epidemics/pandemics to the health and security of its population, the Philippines prepared a comprehensive programme in response to SARS in 2002, influenza A (H1N1) in 2009, and the Middle East respiratory syndrome (MERS-CoV) in 2012, by establishing and implementing an outbreak response mechanism at national and regional levels. The Philippine Department of Health (DOH) [1] manages emerging infectious diseases in the country in co-operation with other government agencies and the private sector.

They efficiently implement measures of surveillance, risk communication, capa-

bility and capacity building, and prevention and control in order to minimize the impact of these diseases on public health.

Because many of the emerging infectious diseases originated beyond the borders of the Philippines, an important component in the framework of response is to prevent and/or minimize the entry of the disease into the country. Mechanisms for the prevention and management of local spread and public education on the nature of the diseases were also included in the response and preparedness system.

Workplace response The Department of Labor and Employment (DOLE), as one of the members of the task force, is in charge of providing guidance to enterprises and businesses in the development and implementation of workplace policies and programmes to ensure the protection of workers in the face of these threats. Under the Department’s leadership and through multisectoral co-operation, National Guidelines on precautionary measures to prevent a possible outbreak of SARS and influenza A (H1N1) were issued in 2004 [2] and 2009 [3].

The key principle of the Guidelines is to ascertain that all employers are aware of their roles and responsibilities in promoting good hygiene and good healthseeking behaviours among the general working population. All workers are reminded of everyday actions to maintain their health. Frequently washing one’s

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hands with soap and water or disinfecting them with alcohol-based hand sanitizers; covering one’s mouth when sneezing or coughing; spitting in proper places; getting adequate rest, proper diet and regular physical exercise; cleaning the work area with household disinfectant; and making sure that water, soap and disinfectants are available in all washrooms and toilets are simple actions that workers can take.

Workers in the health care setting face high-risk exposure and need more stringent measures for protection. These include strict hygiene and the use of appropriate personal protective equipment (PPEs) such as N95 respirators, overalls and gloves. It must also be ensured that workers wear PPE properly while at work and dispose of it accordingly after use.

Provisions on benefits for sick workers have been included in the Guidelines. For workers who are requested by their employers to stay at home or who are served a quarantine order for reasons related to SARS, A (H1N1) or any of the emerging infectious diseases, employers are urged to exercise flexibility and compassion in 30

granting additional leaves beyond allowed absences, with pay. Hospitalization benefits that workers are entitled to under the health insurance system have been reiterated in the guidelines. Workers infected during the performance of their duties are entitled to benefits under the employees’ compensation law.

Agencies that cater to the large population of Overseas Filipino Workers (OFWs) are put on alert to ensure that information on the prevention and control of emerging infectious diseases are provided during pre-departure orientation seminars, especially for OFWs who are stationed in affected regions. Returning OFWs must also be made aware of the quarantine and isolation protocol for suspected or confirmed cases of emerging infectious diseases.

Integral to the Guidelines is the dissemination of information to all workers.

Information campaigns can be integrated into existing information drives at the workplace. During periods of heightened concern, employers are directed to provide timely, appropriate facts from competent sources such as the Health Department, World Health Organization and the

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US Centers for Disease Control. The Department of Labor and Employment website also offers important information to facilitate access and dissemination.

The preventive approach is the domain of the Occupational Safety and Health Center (OSHC), an agency attached to DOLE. Through the OSHC, enterprises and businesses that need support in implementing the national guidelines are provided with technical assistance in the form of risk assessment, respiratory protection programme design, and workplace improvements to reduce the likelihood of droplet infection and contamination by materials possibly infected by the biological agents. Building focal persons’ capabilities is also part of the menu of support extended to enterprises.

Through advocacy activities and collaboration with the regional offices of DOLE and DOH, the OSHC disseminates guidance for employers in different national regions regarding care of workers who are ill, following the procedure defined by the Health Department.

Sustaining measures Specific to safety and health, the govern-

ment has been taking actions to safeguard workers, more so those working under increasingly precarious conditions, from threats of emerging diseases. A broad range of programmes on prevention, diagnosis, treatment and compensation, hinged on basic compliances with occupational safety and health standards, is being implemented to cover not only Philippine-based workers but also OFWs. Preparedness and response systems institutionalized through the Executive Order of the Philippine President guarantee that government measures are comprehensive and sustained, and will trickle down to all workplaces. These are policies and practices that promote “decent work” for all Filipinos, even in times of threat from both perennial and new workplace hazards and risks.

Ma. Teresita S. Cucueco, MD, CESO III Executive Director Occupational Safety and Health Center (OSHC) Department of Labor and Employment (DOLE) North Avenue corner Agham Road Diliman, Quezon City, Philippines 1104 Email: oshc_dole@yahoo.com Maria Beatriz G. Villanueva, MD Division Chief, Health Control Division Occupational Safety and Health Center (OSHC)

References 1. Executive Order No. 168 (2014), Creating the Inter-Agency Task Force for the management of emerging infectious diseases in the Philippines, Office of the President of the Philippines, Manila, Philippines.

2. Department Order No. 47 (Series of 2003), Guidelines on SARS Prevention and Control, Department of Labor and Employment (DOLE), Manila, Philippines.

3. Department Advisory No. 4 (Series of 2009), guidelines on Influenza A (H1N1) Prevention and Control at the Workplace, Department of Labor and Employment (DOLE), Manila, Philippines.

Shicheng Yu, Lijun Jia, Hongyan Yao, P.R. China

Outbreaks of H5N1 and H7N9 Avian Influenza in China Introduction Three types of influenza viruses have been identified: A, B, and C, of which the A virus has a variety of subtypes due to its hemagglutinin antigen (HA) and neuraminidase (NA). Sixteen HAs and 9 NAs subtypes have been found so far [1]. Avian influenza virus (AIV) is an influenza A virus, circulates in poultry, and causes most poultry and wild waterfowl infection.

Human beings can be infected with AIV through accidents, and suffer from avian influenza (AI). Only a few AIVs can infect people and lead to a severe disease, such as H5N1, H7N9, H9N2, H7N2, H7N3, and H7N7. Of these, H5N1 and H7N9 have gained attention due to their severity, high case fatality rate (CFR), and the economic loss caused to relevant industries. This report summarizes the history of H5N1 and H7N9 in China, including incidence, deaths, economic burden, and a strategy for dealing with outbreaks of the disease.

Outbreaks in China In May 1997, Hong Kong of China was the first to report human H5N1infection, also called highly pathogenic avian influenza.

Eighteen human cases were confirmed, and of these, six patients died during the year. In February and March 2003, the first identified human cases of H5N1 infection emerged in eastern China during the SARS (Severe Acute Respiratory Syndromes) outbreak, but these cases were only diagnosed retrospectively in 2006.

Worldwide, 16 countries reported 842 human H5N1 cases between 1 February 2003 and 23 June 2015. Of these, 447 cases were fatal, resulting in a CFR of 53.09% [2]. In the Western Pacific region, 237 cases of human infection with H5N1 were reported in Cambodia, China, Lao PDR,

and Viet Nam between February 2003 and 23 June 2015. Of these, 134 cases were fatal, resulting in a CFR of 56.54%. Since the first human case of H5N1 infection was confirmed in mainland China, the number of incident cases of AIV has risen to 52, and 31 people had died as of 23 June 2015, resulting in a CFR of 59.62% [3]. A recent study demonstrated that the H5N1 cases occurred in the winter and spring, accounting for 74.42% of total cases [4].

The first human case of H7N9 infection emerged on 19 February 2013 in Shanghai, eastern China. Until then, worldwide, H7N9 had not been observed in either animals or human beings. As of 9 March 2015, there were 631 confirmed cases of human infection with H7N9 across the world [3], most of which were in mainland China (611 cases). Four occurred in Taipei of China; 13 in Hong Kong of China; one was a Chinese traveller, reported in Malaysia; and two cases were travellers who had returned from China, reported in Canada. A Chinese study [5] showed that confirmed cases of H7N9 totalled 148 in 2013, and that of these, 48 cases were fatal, resulting in a CFR of 32.43%. H7N9 infections occurred from March to May, especially in April; the occurrence of cases was sporadic and most cases were located in Jiangsu, Zhejiang, and Shanghai of eastern China.

The avian influenza A H5N1 and H7N9 viruses are thought to be mainly zoonotic and do not seem to be transmitted from human to human [6]. Both infections have demonstrated an association with live poultry markets or potentially contaminated environments. A few risk factors for contracting H5N1 and H7N9 AIV have been identified, including exposure to live poultry, occupational expo-

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Table 1. Incidence, death, and culling of poultry due to AI epidemics in poultry from 2004 to 2014 by regions in China* Regions

Outbreaks

Due to H5N1

Incidence

Deaths

Slaughtered poultry

Eastern China

23

21

45 887

139 969

21 215 107

Central China

40

38

142 619

95 688

4 189 557

Western China

52

49

174 230

155 844

7 939 072

Total

115

108

362 736

391 501

33 343 736

AI: avian influenza; AIV: avian influenza virus. *Source: Veterinary Bulletin between Jan, 2004 and July 2014.

sure to live poultry, visiting live poultry markets, exposure to sick or dead poultry, exposure to backyard poultry, or handling slaughtered poultry. Saliva and secretions from the nasal cavity and faeces of infected poultry and birds may carry AIV. Most of the cases were H5N1 and H7N9 infections through direct contact or close contact with poultry (chicken, duck, and turkey), or indirect contact with materials polluted by waste from infected swine or poultry.

The H7N9 virus exhibits low pathogenicity in birds, but is a severe disease for human beings; whereas the H5N1 virus is highly pathogenic in both birds and people. Cases of H5N1 were spread across most of the regions in China, whereas the occurrence of H7N9 was mainly in the Yangtze River delta in eastern China.

According to data gathered up until 24 May 2013, about 72.0% of those infected with H7N9 resided in urban areas. In contrast, according to 2006 data, approximately 56.0% of those infected with H5N1 dwelled in rural areas, with the highest incidence rate across years. One study indicated a male-to-female ratio of 2.9:1 for H7N9, and 2.8:1 for H5N1 in urban areas; and a ratio of 1.6:1 for H7N9 and 0.5:1 for H5N1 in rural areas [6]. The male-tofemale ratio was higher in urban areas than in rural areas for both AIV infections. H5N1 and H7N9 can affect people of all age groups; more than half of the H7N9 cases occurred in people aged 60 years or over, with a median age of 62 years. However, the H5N1 cases mainly occurred in young adults, with a median age of 26 years. Anecdotally, a study

@ World Health Organization / Jonathan Perugia

Routine disinfection of a chicken house in Sadamukti Village, West Java 32

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indicated that urban males aged 45 or over were more likely to be infected with H7N9, due to increasing exposure to retail live poultry.

Avian influenza A viruses have been epidemic in poultry for 10 years in China since 2004, and have not so far been eradicated [7]. A total of 115 outbreaks in poultry (chickens, ducks, geese, quails, migratory birds, and wild birds, etc.) were reported between 1 January 2004 and 31 December 2014, in 23 provinces in China. Of these, 108 were caused

by H5N1, accounting for 93.91% of total outbreaks. The figures for incidence, and the deaths and culling of poultry were at least 362 736, 391 501, and 33 343 736, respectively. Once avian influenza A viruses were epidemic in poultry, the affected birds in the poultry farm or surrounding poultry farms had to be culled, so deaths due to culling were much higher than those due to the disease. The number of outbreaks and affected poultry was higher in western China than in eastern and central China, but the numbers of slaughtered poultry and deaths of poultry were the highest in eastern China, as shown in Table 1 [7].

Outbreaks of H5N1 and H7N9 not only cause great harm to human beings, but also affect the poultry trade, breeding industry, and tourism industry. They become a global health problem. They can, however, be prevented, and the experiences gained from fighting AI outbreaks in China could be used to treat the disease. Health and agricultural authorities have set up an emergency response plan and guidelines for dealing with outbreaks of AI infections to manage them among

@ World Health Organization / Jonathan Perugia

people as well as among poultry. Usually a work mechanism of joint prevention and control is established under unified co-ordination of governments at all levels. The health authorities guide all relevant departments to implement prevention and control measures, including the supervision and inspection of field work, the development and distribution of the protocol for patient diagnosis and treatment, the treatment of patients, the establishment of expert medical treatment groups, the implementation of training for health care workers, the investigation of infection sources and situation analysis, epidemic surveillance, and the timely release of information. Control measures include providing protection for poultry breeding workers, poultry slaughter workers, and sales staff of live poultry.

At the same time, to reduce the risk of contamination, health professionals offer knowledge regarding avian influenza and self-protection techniques to people who often visit live poultry markets. The implementation of control measures at live poultry markets, such as market disinfection, a ban on the selling of live poultry at market stalls, market closure, and poultry culling, is considered useful for controlling the potential transmission of AIV infections to humans. With respect to the agricultural sector, epidemic monitoring has been strengthened by local centres for animal disease control and prevention during outbreaks, such as AIV detections in poultry (chickens, ducks, geese, and pigeons, etc.), migrating birds, and in environmental samples.

Information systems crucial All cases of AIV infection are reported to the Chinese Center for Disease Control and Prevention (China CDC) through a national real-time online system for reporting notifiable infectious diseases, established in 2004. China CDC and provincial CDCs release the epidemic information in a timely manner to the public. Local CDCs carry out investigations of cases or suspected cases, prompt the isolation of patients, implement medical quarantine, and actively monitor close contacts on the basis of recommended national guidelines, disseminate extensive knowledge regarding epidemic prevention and treatment, inform people not to kill or eat

A public health officer injects a goose as part of an extensive vaccination campaign in Cibuaya sub-district, West Java.

wild animals or dead poultry or scientifically raise poultry, advertise the health hotline, and settle people’s concerns. It is also their task to strengthen research on AIV, the development of diagnostic reagents and vaccines, and the protection of the environment.

Concluding remarks Depending on the scope and degree of the outbreak, the government will decide whether or not to close down live poultry markets, standardize poultry dispatching, or cull poultry. It will also provide poultry producers with financial subsidies for culling. The health authority maintains close communication and co-operation with the World Health Organization (WHO), Food and Agriculture Organiza-

tion (FAO), and International Epizootic Office (IEO), and reports outbreaks to the relevant countries or regions in order to strengthen international co-operation and communication regarding information about and appraisal of an epidemic situation.

Current epidemiological trends indicate that a 1arge-scale human H7N9 avian influenza epidemic is unlikely; however, it is likely that sporadic cases will continue to emerge in China [8].

Shicheng Yu, Lijun Jia, Hongyan Yao Chinese Center for Disease Control and Prevention (China CDC) Email: shicheng_yu@163.com

References 1. Tong SX, Li Y, Rivailler PR, et al. A distinct lineage influenza A virus from bats. PNAS 2012;109:426–74.

2. http://www.who.int/mediacentre/factsheets/avian_influenza/en/.

3. http://www.wpro.who.int/emerging_disease/AvianInfluenza/en/.

4. Jianjun Mo, Yi Tan. Epidemic characteristics of the Chinese people infected with highly pathogenic avian influenza. Applied Preventive Medicine 2013;19(4):211–3.

5. Jiang Hui-fen, Bao Ye-jiang, Xu Xiao-hong, et al. Epidemiology analysis of human infection with avian influenza A (H7N9) virus in 2013. Chinese Journal of General Practice 2015;13(4):650–2.

6. Benjamin J Cowling, Lianmei Jin, Eric HY, et al. Comparative epidemiology of human infections with avian influenza A H7N9 and H5N1 viruses in China: a population-based study of laboratory-confirmed cases. Published Online June 24, 2013 http://dx.doi.org/10.1016/S0140–6736 (13) 61171-X. 7. Huang Ze-ying, Wang Ji-min. Analysis on occurrence and characteristics of avian influenza in China during 2004–2014. Guangdong Agricultural Sciences, 2015;4:93–8.

8. Lei Zhou, Ruiqi Ren, Yanping Zhang, et al. Epidemiology of human infection with avian influenza A (H7N9) virus in China, September–Decmber 2014. Disease Surveillance, 2015:30(4):265–8.

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Soo-Geun Kim, Hyun-Sul Lim, Republic of Korea

Middle East Respiratory Syndrome (MERS) outbreak in Korea Introduction The Middle East Respiratory Syndrome (MERS) is an infectious disease and was discovered in 2012 [1]. Originating from the Arabian Peninsula, the disease has spread to many different countries via travellers. The disease-causing pathogen is the MERS-Coronavirus (MERS-COV) [2], which has an average incubation period of 6.5 days (2~14 days) [3]. The majority of MERS patients suffer from high fever, coughingal and dyspnoea. Some patients also experience digestive problems, such as diarrhoea and vomiting.

The first MERS patient in South Korea was reported on 20 May 2015. The Korean Centers for Disease Control and Prevention (KCDC) report patient incidences daily on the basis of the results of epidemiologic investigations.

This paper is based on the data from KCDC’s public press releases up to 2 August 2015 [4].

Primary case The primary MERS case was reported on 20 May 2015.

The patient was a 68-year-old man, who had travelled in the Middle East region from 18 April to 3 May of the same year. On 11 May, suffering from fever and a cough, he visited four different local clinics and hospitals. A total of 30 people were initially infected by the primary patient, and 37 more were infected in the hospital in which he stayed for 3 days, [5]. He did not initially report recent travel in the Middle East, although he had travelled to Bahrain, Qatar, and Saudi Arabia. At the fourth medical centre he visited, he requested to be examined by KCDC, and was ThinkstockPhotos

then diagnosed with MERS [6]. At this medical centre, the people who came into contact with the patient went into self-imposed quarantines, and the disease did not spread any further at that medical centre.

Outbreak of MERS There were 185 confirmed MERS cases in South Korea.

One more MERS diagnosis was made in China; a traveller from South Korea who had been to Huizhou. The last case was diagnosed on 4 July. On 27 July, the government announced that no new person would be isolated due to close contact [7]. After the diagnosis of patient zero, the MERS outbreak in South Korea came to an end. It lasted 69 days.

Beginning from the primary case and his wife on 20 May, the number of diagnosed cases was 22 by 6 June, and 23 by 7 June. The last confirmed case was diagnosed on 4 July (Fig. 1). The total of confirmed cases, according to the order of infection, consisted of 1 primary case, 30 secondary cases, 124 tertiary cases, 22 quaternary cases, and 9 unconfirmed cases.

By 4 July, with the last confirmed case, there were a total of 186 cases. Of these, 82 cases were people who had visited a hospital and/or were hospitalized (44.1%), 65 were family/visitors of the patients (34.9%), and 39 were health care personnel (21.0%) (Table 1).

One hundred and eleven cases were men (59.7%), 75 cases women (40.3%). As regards age groups, 42 cases were in their 50s (22.6%), 36 in their 60s (19.4%), 30 in their 70s (16.1%), 29 in their 40s (15.6%), and 26 in their 30s (14.0%) (Table 2).

The number of fatalities, according to gender, was 24 males (66.7%) and 12 females (33.3%). The fatalities belonged to the following age groups: 11 cases in their 60s and 70s (30.6%), 7 cases in their 80s (19.4%), 6 cases in their 50s (16.7%), and 1 case in his 40s (2.8%) (Table 3).

Among the deceased, 33 were of old age, high risk, and patients with a variety of chronic diseases (cancer, cardiac disease, kidney disease, diabetes, immunodeficiency conditions, and other underlying diseases) (91.7%).

Hospital associated infection The locations in which the MERS patients were exposed to the pathogen were mostly health care facilities: 178 patients, or 95.7% of total confirmed cases, were infected at 15 different health care facilities. There were 90 cases at the Samsung Medical Center (48.9%), 36 at the

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• Asian-Pacific Newslett on Occup Health and Safety 2015;22:34–36

There are no confirmed cases in local communities.

Figure 1. Epidemic curve: Confirmed cases of MERS-CoV by time Source: KBS Digital News Division. Current state of MERS infection http://news.kbs.co.kr/news/view.do?ncd=3087507 Table 1. Distribution of confirmed cases in regards to infectious type Total

Patients

Families/ Visitors

Healthcare personnel Sub total

Doctors

Nurses

Care givers

Others

186

82

65

39

8

15

8

8

%

(44.1)

(34.9)

(21.0)

(4.3)

(8.1)

(4.3)

(4.3)

Table 2. Gender and age distribution of confirmed cases Gender Total 186 %

Age

M

F

0~9

111

75

-

1

-

(0.5)

(59.7) (40.3)

10~19 20~29 30~39 40~49 50~59 60~69 70~79 80~89 90~99 13

26

29

42

36

30

(7.0) (14.0) (15.6) (22.6) (19.4) (16.1)

9

-

(4.8)

-

Table 3. Gender and age distribution of deaths due to MERS-CoV Gender Total

36 %

Age

M

F

0~9

24

12

-

-

-

-

-

-

-

-

(66.7) (33.3)

10~19 20~29 30~39 40~49 50~59 60~69 70~79 80~89 90~99

Pyeongtaek St. Mary’s Hospital (19.4%), 14 at the Dae-Chung Hospital (7.5%), and 11 cases at the Konyang University Hospital (5.9%). These four hospitals were the major outbreak locations (Table 4).

The primary case went to Pyeongtaek St. Mary’s, the 14th case infected by the pri-

1

6

11

11

7

(2.8) (16.7) (30.6) (30.6) (19.4)

-

mary case went to the Samsung Medical Center, and the 16th patient went to the Dae-Chung and Konyang Hospitals.

The disease was mostly spread through close contact in health care facilities and via droplets. There is some controversy regarding spread through bio-aerosols.

Health care personnel infected by MERS-CoV Thirty nine health care workers became infected in health care facilities, making up 21.0% of the total infected. Their occupational categories were as follows: 8 doctors (20.5%), 15 nurses (38.5%), 8 caregivers (20.5%), and 8 others including a radiological technologist, security guards, emergency transporter, rescuer, ambulance driver, and an IT specialist at the health care facilities (Table 1) (20.5%).

Health care personnel were not infected in the local community, but directly by a MERS patient or suspected patients.

Among the 39 infected health care personnel, 30 cases (76.93%) were infected by visiting patients, 30 (83.3) were infected not knowing that their patient had MERS, while 9 (16.7%) were aware of their patient’s illness. In nine cases, the personnel were infected despite wearing personal protective equipment (PPE).

Mutation of the Virus The MERS outbreak in South Korea has led to suspicions that the virus has mutated. However, on 5 June 2015, test results from China on the DNA of the MERS virus from the infected South Korean patient showed no significant mutation. On 6 June KCDC also tested the virus from a second patient and later reported that the South Korean sample matched the original MERS virus by up to 99.55% [8].

Discussion and conclusion The South Korean MERS outbreak was the largest incidence of the disease spreading outside the Arabian Peninsula. It showed that MERS is not a problem limited to the Middle East, but that it can occur in any country, at any time. All nations will have to strengthen their medical surveillance systems and preventive controls.

The South Korean MERS outbreak also showed that MERS is controllable, even though we still know little about how the infection spreads.

The reason why MERS spread so quickly and vastly in South Korea is because of the delayed diagnosis of the first patient (signs of infection began on the 11 May, but diagnosis and quarantine did

Asian-Pacific Newslett on Occup Health and Safety 2015;22:34–36 •

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not take place until 20 May), and also because of incomplete understanding of the significance of prohibiting close contact and enacting early quarantine to prevent the virus spreading. This led to secondary cases freely visiting many different hospitals in hope of finding a cure for their sickness without knowing the cause of their disease. Crowded emergency rooms, multiple-bed wards, and free access for patient visitors led to tertiary and quaternary cases. There were also cases in medical facilities of patients being treated with febrile respiratory problems in the same way as regular patients; they were not made to wear masks.

We still do not know enough about the forms of transmission of MERS in order to prevent it. Therefore, health care personnel must adhere to the precautionary principle when they treat patients, until scientific research determines how the virus spreads. The management of infection is essential for stopping MERS transmission in any hospital. Entire hospital wards need to be quarantined; the possibility of quarantine for those who come in to close contact with confirmed cases, and for all personnel and patients of the hospital needs to be considered. Patients with febrile respiratory problems must be treated separately from regular patients in emergency rooms and must wear masks.

As MERS is difficult to distinguish from other acute respiratory diseases, health care personnel must take standard precautions. Droplets during close contact must be avoided, and protection of the eyes is necessary when treating confirmed case patients. Caution regarding airborne contamination is a must during aerosol production operations.

Soo-Geun Kim, MD Department of Occupational Medicine Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine 29, Saemunan-Ro, Jongno-Gu Seoul, Korea 110-746 Email: ksg6201@empal.com Hyun-Sul Lim, MD Department of Preventive Medicine College of Medicine, Dongguk University Gyeongju, Korea

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Table 4. Laboratory-confirmed Middle East respiratory syndrome coronavirus infection in health care personnel in regards to health care facilities. % in parentheses

Health Care Facilities

All Confirmed Cases

Infected HCP**

Primary case

1 (0.5)

-

Within Family

2 (1.1)

-

Samsung Medical Center

90 (48.4)

15 (16.5)

Pyeongtaek St. Mary’s Hospital

36 (19.4)

3 (8.1)

Dae-Chung Hospital

14 (7.5)

6 (42.9)

Konyang Univ. Hospital

11 (5.9)

2 (18.2)

Hallym Univ. Dongtan Sacred Heart Hospital

6 (3.2)

2 (33.3)

Kunkuk Univ. Medical Center

4 (2.2)

1 (25.0)

Kyung Hee Univ. Hospital at Gangdong

5 (2.7)

2 (50.0)

Pyeongtaek Good Morning Hospital

4 (2.2)

1 (25.0)

Asan Medical Center

1 (0.5)

1 (100)

Catholic Univ. Yeoudo St. Mary’s Hospital

1 (0.5)

-

Asan Chungmu Hospital

1 (0.5)

1 (100)

Good Gang-An Hospital

1 (0.5)

-

Local clinic (Song’s Internal Medicine)

1 (0.5)

-

Local clinic (365 Medical)

1 (0.5)

1 (100)

Local clinic (Seoul clinic at Asan)

1 (0.5)

1 (100)

Local clinic (Yangji Seoul Samsung)

1 (0.5)

-

Ambulance

3 (1.6)

3 (100)

Unknown

2 (1.1)

-

186 (100.0)

39 (21.0)

Total ** HCP: Healthcare personnel

References 1. Hijawi B, Abdallat M, Sayaydeh A, et al. Novel coronavirus infections in Jordan, April 2012: epidemiological findings from a retrospective investigation. East Mediterr Health J 2013;19(suppl 1):S12–8.

2. Zaki AM, van Boheemen S, Bestebroer TM, Osterhaus AD, Fouchier RA. Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia. N Engl J Med 2012;367:1814–20.

3. Assiri A, McGeer A, Perl TM, Price CS, Al Rabeeah AA, Cummings DA, Alabdullatif ZN, Assad M, Almulhim A, Makhdoom H, et al.; KSA MERS-CoV Investigation Team. Hospital outbreak of Middle East respiratory syndrome coronavirus. N Engl J Med 2013;369:407–16.

4. Korea Ministry of Health and Welfare (MoH) and Center for Disease Control and Prevention.

MERS portal. Available online: http://www.mers.go.kr/mers/html/jsp/main.jsp 5. Park HY, Lee EJ, Ryu YW, Kim Y, Kim H, Lee H, Yi SJ. Epidemiological investigation of MERS-CoV spread in a single hospital in South Korea, May to June 2015. Euro Surveill 2015;20(25):pii=21169.

Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=21169 6. World Health Organization (WHO). Middle East respiratory syndrome coronavirus (MERS-CoV) – Republic of Korea. Geneva: WHO; 24 May 2015. Available from: http://www.who.int/csr/don/24-may2015-mers-korea/en/.

7. KBS Digital News Division. Current state of MERS infection [Internet]. Seoul: KBS Digital News Division; 2015 [cited 2015 July 30]. Available from: http://dj.kbs.co.kr/resources/2015-06-08/.

8. World Health Organization (WHO). Preliminary data from sequencing of viruses in the Republic of Korea and the People’s Republic of China. Geneva: WHO; 9 June 2015. Available from: http://www.who.int/csr/disease/coronavirus_infections/risk-assessment-9june2015/en/

• Asian-Pacific Newslett on Occup Health and Safety 2015;22:34–36

Jeff Hwang, Kenneth Choy, Siok-Lin Gan, Singapore

Emerging infectious diseases from the workplace perspective Workplace safety and health has been an increasing priority in many countries for the past few decades. Increased awareness and implementation of preventive measures have led to a decrease in various traditional occupational diseases such as silicosis in Germany [1], and chemicalrelated diseases in South Korea [2]. Much is known about many of these traditional occupational diseases – the agent that causes the disease, the routes of exposure, and the appropriate control measures.

Among these occupational diseases, infectious diseases such as blood-borne infections and zoonotic diseases are known to pose a higher risk in certain occupational groups such as health care [3] and farm workers, respectively [4]. The reasons for the increased risk of infections in certain occupations are summarized in Table 1 below:

Photo by Tan Tock Seng Hospital, Singapore

Table 1. Factors contributing to increased risk of infections at the workplace Factors contributing to increased risk of infections at the workplace 1. Work processes that increase the risk of exposure E.g. venepuncture, animal handling 2. Work environment - Congregation of workers - Hygiene factors at work - Immunological changes caused by environmental conditions, psychological stress [5] - Presenteeism [6] 3. Overseas travel

In recent years, emerging infectious diseases such as SARS in 2003, influenza A(H1N1) in 2009 and MERS in the past two years have threatened the maintenance of workplace health. During the H1N1 pandemic in 2009, employees who attended work while infected with H1N1 spread the disease to an estimated seven million co-workers [7]. As well as affecting employees and their co-workers directly, these infectious diseases have the potential to cause work disruptions and affect business operations through sickness absence, as seen in countries such as Norway [8] and Catalonia [9] during the H1N1 pandemic.

Health care workers undergo regular training exercises on simulated emerging infectious disease scenarios, wearing personal protective equipment.

Critical work such as security and maintenance need to manage the threat from the infectious agent, while simultaneously maintaining the functioning of essential services.

Emerging infectious diseases pose many unique challenges. Firstly, knowledge regarding the emerging infectious disease may be lacking at the initial phase of any outbreak; we may not know the route of transmission or the appropriate personal protective equipment (PPE) to use. It was initially uncertain whether the transmission of MERS was human to human, or whether it came from exposure to a common source [10]. Information on the effectiveness of facemasks and respirators on reducing the risk of H1N1 infection during the 2009 influenza H1N1 outbreak was also limited at first [11]. A lack of knowledge will pose a challenge for workplaces when deciding which control measures to implement.

Asian-Pacific Newslett on Occup Health and Safety 2015;22:37–39 •

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A lack of knowledge may also lead to uncertainty or even fear among employers and employees. This can hinder preventive efforts as, doubts regarding the information available and the effectiveness of the control measures may grow, leading to reduced buy-in. Such a situation was

38

noted during the 2015 MERS outbreak in South Korea, when schools were closed even though they had not been linked to the transmission of MERS-CoV [12].

Workplaces may react in a similar way.

Vaccinations are also unlikely to be available in the initial phase of an out-

• Asian-Pacific Newslett on Occup Health and Safety 2015;22:37–39

break. This highlights the importance of preventive measures, including strategies such as deferring non-essential travel, providing isolation facilities, and providing and properly using personal protective equipment. Risk assessment is important in order to identify employees likely to be exposed to the infectious agent towards which control measures should be targeted. These workers will also need to undergo training on how to correctly don PPE and fit-test respirators.

Managing emerging infectious diseases at the workplace involves the participation of multiple stakeholders. On a governmental level, the labour ministry will have to work closely with the health authority, which is the expert in terms of scientific information and infectious control measures for the infectious agent. It is important to ensure that the information that the labour ministry distributes at workplaces is aligned to that of the health authority and other governmental sources, but it is also crucial that it be disseminated to employers and employees in a timely manner. The labour ministry may also work with labour unions and employers in promulgating and disseminating advisories, such as the MERS advisories, disseminated in Singapore in 2015 [13], which address any labour union and employers’ concerns.

Employers have a duty to protect their employees from emerging infectious disease, not least because of legislative requirements in various countries such as Brunei [14], Hong Kong [15] and Singapore [16], which demand employers to protect the health of their workers, but also because business operations may be affected by employees’ sickness absences. As discussed earlier, workplace factors may make it more likely for workers to suffer from infectious diseases, and thus employers may also be morally obligated to safeguard their employees.

Employers first need to obtain upto-date information on the emerging infectious disease and the recommended control measures from local authorities.

Preparation will then include developing business continuity plans and enabling the use of personal protective equipment through training, fit-testing and maintaining adequate stock. Risk assessment should include the identification of work-

ers at highest risk, and the formulation of risk control measures in accordance with the hierarchy of controls [17], for example, deferring non-essential travel overseas and monitoring personnel who have gone overseas for any illness.

Employers may also be obligated to notify governmental agencies about employees who have been diagnosed with an emerging infectious disease, in order to enable early detection of localized outbreaks at a workplace. For these employees, the issue of medical leave and expenses will also need to be considered at an early stage by both employers and the labour department. For workers who are given quarantine orders, employers need to consider work-at-home policies, as well as granting medical leave for the quarantine period, with guidance from the labour ministry.

We shall now discuss emerging infectious diseases in the health care context.

Health care institutions are at a significant risk of infectious diseases, as both suspected and confirmed cases are referred there for treatment. Health care workers accounted for 21% of all the SARS cases globally [18], while transmission of MERS was confined to health care facilities in South Korea [19]. In addition to the biological risk, health care workers may also experience psychological stress working in a health care institution in the event of an outbreak. A survey in Hong Kong among frontline staff during the SARS outbreak in 2003 found that 68% of the respondents reported a high level of stress [20].

Thus, health care institutions need to be ever-ready to manage emerging infectious agents. Infection control policies and practices should be reinforced at all times, not only when there is a threat from emerging infectious agents. Mask fitting should be updated regularly, along with staff training on donning personal protective equipment Once the threat of an emerging infectious disease has been detected, preparation will include formulating a case definition for suspect cases (often the role of the health ministry), resource planning and allocation such as isolation rooms or wards, personal protective equipment, manpower to manage the cases, and screening of patients and visitors for

symptoms related to the infectious disease. On a national level, there may even be designated hospitals to assess suspect cases, as recommended by WHO for the MERS outbreak in South Korea [12].

In the event of any outbreak, in addition to devoting resources to managing the infectious disease itself, health care institutions will need to maintain normal operations to look after other patients.

Allaying any fears is also important, and this can be done through strong leadership support, timely dissemination of information, and training health care staff on infection control measures.

In conclusion, emerging infectious diseases will continue to be a significant threat for workplaces, and preventive

measures involving multiple stakeholders are key for safeguarding employees and upholding workplace health.

Dr Jeff Hwang, Medical Officer Ministry of Manpower, Singapore Email: Jeff_hwang@mom.gov.sg Dr Kenneth Choy, Deputy Director (Occupational Medicine) Ministry of Manpower, Singapore Dr Siok-Lin Gan, Executive Director Workplace Safety and Health Institute, Singapore

References 1. van Kampen V, Merget R, Butz M, Taeger D, Bruning T. Trends in suspected and recognized occupational respiratory diseases in Germany between 1970 and 2005. American journal of industrial medicine 2008;51(7):492–502.

2. Kang SK, Kim EA. Occupational diseases in Korea. Journal of Korean medical science 2010;25(Suppl):S4–12.

3. Fry DE. Occupational risks of blood exposure in the operating room. The American surgeon 2007;73(7):637–46.

4. Lim VK. Occupational infections. The Malaysian journal of pathology 2009:31(1):1–9.

5. Korzeniewski K, Nitsch-Osuch A, Chcialowski A, Korsak J. Environmental factors, immune changes and respiratory diseases in troops during military activities. Respiratory physiology & neurobiology 2013;187(1):118–22.

6. Zakrzewska K. Presenteeism – unhealthy extra presence in the workplace. Przeglad epidemiologiczny 2014;68(1):77–80, 157–9.

7. Miller RDK. Sick at Work: Infected Employees in the Workplace During the H1N1 Pandemic. Institute for Women’s Policy Research 2010, No. B264.

8. de Blasio BF, Xue Y, Iversen B, Gran JM. Estimating influenza-related sick leave in Norway: was work absenteeism higher during the 2009 A(H1N1) pandemic compared to seasonal epidemics? Euro surveillance: bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin 2012;17(33).

9. Tora-Rocamora I, Delclos GL, Martinez JM, Jardi J, Alberti C, Manzanera R, Yasui Y, Cleries R, Tobias A, Benavides FG. Occupational health impact of the 2009 H1N1 flu pandemic: surveillance of sickness absence. Occupational and environmental medicine 2012; 69(3):205–10.

10. Background and summary of novel coronavirus infection – as of 30 November 2012 [http://www.who.int/csr/disease/coronavirus_infections/update_20121130/en/] 11. Interim Recommendations for Facemask and Respirator Use to Reduce 2009 Influenza A (H1N1) Virus Transmission [http://www.cdc.gov/h1n1flu/masks.htm] 12. Summary and risk assessment of current situation in Republic of Korea and China [http://www.who.int/csr/disease/coronavirus_infections/risk-assessment-19june2015/en/] 13. Tripartite advisory on workplace measures to tackle MERS-CoV [http://www.mom.gov.sg/mers] 14. Workplace Safety and Health Order. Brunei Darussalam; 2009:635–704.

15. Occupational Safety and Health Ordinance. Hong Kong; 1997.

16. Workplace Safety and Health Act. Singapore; 2006.

17. Hierarchy of Controls [http://www.cdc.gov/niosh/topics/hierarchy/] 18. Summary of probable SARS cases with onset of illness from 1 November 2002 to 31 July 2003 [http://www.who.int/csr/sars/country/table2003_09_23/en/] 19. Intensified public health measures help control MERS-CoV outbreak in the Republic of Korea [http://www.wpro.who.int/mediacentre/releases/2015/20150728/en/] 20. Tam CW, Pang EP, Lam LC, Chiu HF. Severe acute respiratory syndrome (SARS) in Hong Kong in 2003: stress and psychological impact among frontline health care workers. Psychological medicine 2004;34(7):1197–204.

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Koji Wada, Toru Yoshikawa, Japan

Instructor training for protection against respiratory diseases among health care workers in Japan Introduction Protecting health care workers against respiratory diseases is an essential occupational health measure, particularly in a globalized world in which regional disease outbreaks can become major global pandemics in a short space of time.

Following the severe acute respiratory syndrome (SARS) outbreak in the early 2000s, respiratory protection became Photo by Hitoshi Nagase

widely available in countries such as Canada, where health care workers lost their lives (1). Although no Japanese guidelines or policies on respiratory protection for health care workers existed at that time, hospitals and local governments began providing health care workers with N95 respirators from around 2007 onwards in order to enhance preparedness for future pandemic flu outbreaks, on the basis of guidelines published in other countries, such as the United States. In 2007, we launched the “Fit-test Instructor”, a project aimed at developing a train-the-trainer programme on respiratory protection in hospitals. (2)

Why should health care workers wear N95 respirators?

The N95 respirator, which filters out at least 95% of airborne particles, is one type of particulate filtering facepiece respirator approved by the National Institute for Occupational Safety and Health (NIOSH) in the USA. According to CDC guidelines, although it is not required by all staff involved in an outbreak response, respiratory protection is particularly recommended for staff working with high-risk patients infected by Mycobacterium tuberculosis or SARS (3).

Fit-testing during training

Newly-qualified fit-test instructors, 6 June 2015

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• Asian-Pacific Newslett on Occup Health and Safety 2015;22:40–42

What are the regulatory requirements for respiratory protection among health care workers?

In Japan, the Industrial Safety and Health Act requires employers to provide all necessary individual personal protective equipment for all their employees. In turn, employees must use all the personal protective equipment provided. However, these regulations and other guidelines do not specifically mention that health care workers are obligated to wear N95 respiratory protection. Although the Japanese Society for Infection Prevention and Control has released guidelines relating to pandemic influenza, no comprehensive guidelines exist for other respiratory infections.

What is the role of a fit-testing instructor?

A fit-testing instructor’s task is to instruct health care workers on the correct use of respiratory personal protective equipment and to instil in them the importance of self-protection in a hospital setting. They also promote the development of occupational health services within hospitals to safeguard the health of the staff while striving to provide the best possible standard of care for patients during infectious disease outbreaks. A fittesting instructor’s duties also include the following.

1) Selecting the most appropriate N95 respirators A wide range of N95 respirators have been authorized by NIOSH and are currently available on the market. In some hospitals, the departments that purchase medical devices often select N95 respirators based on “the price”, and retailers may offer competitive deals on bulk purchases.

It should be noted, however, that devices often have different characteristics ? especially in relation to mask size, comfort, product lifespan and appearance. Moreover, McMahon et al. have recommended that hospitals stock at least three different types or sizes of respirator to ensure all frontline staff are fully protected (1).

Fit-test instructors can also play a key role in assessing the risk of infection among colleagues, selecting the appropriate number and type of respirators according to

Table 1. Fit-test instructor training course (13:00–17:30) 13:00–13:15

Orientation

13:15–13:25

Lecture 1. Disease characteristics and modes of transmission of respiratory infections

13:25–13:55

Lecture 2. Types of respirators

13:55–14:20

Lecture 3. Instructions for wearing N95 respirators and fit-testing

14:30–14:50

Demonstration on wearing respirators

14:50–15:15

Demonstration of qualitative fit-testing

15:15–15:30

Demonstration of quantitative fit-testing

15:30–16:45

Practical session on wearing and fit-testing respirators

16:45–17:00

Examination for certificate

17:00–17:10

Demonstration of newly developed devices: powered air-purifying respirators

17:10–17:30

Q&A session

their specific needs, assessing their quality, and educating frontline staff on their proper use.

2) Conducting fit-testing on staff Fit-test instructors must take the initiative when conducting fit-testing on staff, and ensure the commitment of hospital management, administration and occupational health to implementing fit-testing for all at-risk staff members and to overcoming barriers to respirator use. Fit-test instructors are also expected to train colleagues to conduct fit-testing. The quality of fittesting is important, as often, staff without the correct training do not realize when respirators are improperly fitted. Instructors must also keep a log of which respirators have been fitted for each staff member. Although there are no clear guidelines on how often fit-testing should take place, continuous training may be necessary, either annually or bi-annually, based on the risk of an outbreak occurring.

What is the training curriculum for fit-test instructors?

We have developed a 4.5-hour training session for fit-test instructors. The timetable, as shown in Table 1, includes 75 minutes of lectures on infectious disease transmission and types of respirator, demonstrations on how to wear and use N95 respirators, and guidance on how to conduct qualitative and quantitative fit-testing based on OSHA’s Respiratory Protection Standard (29 CFR 1910. 134). We

then give participants the opportunity to learn to wear N95 respirators properly, according to the instructions of the manufacturing company and to conduct fit-testing in practice in groups of three during the practical session, supported by qualified instructors. The programme also enables participants to acquire the skills to train others through role play exercises, to instruct others on how to wear the N95 respirators, and to conduct fit-testing (both qualitative and quantitative).

Participants receive a certificate after successfully completing a short examination.

Finally, we also demonstrate new devices for respiratory protection such as powered air-purifying respirators, PAPRs, which may be used in the near future in health care settings.

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How we conduct the training sessions Given the breadth and detail of the course content and the emphasis on interaction between participants, we can only accept a maximum of 30 attendees per session.

Both retailers and manufacturers of N95 respirators, including Koken Ltd., 3M Japan Health Care, Shigematsu Works Co. Ltd., Moraine Corporation, and Halyard Health endorse this programme. Although participants can test a range of their products for themselves, we do not allow the retailers and manufacturers to directly market their products during the session.

can learn more about the needs of health care workers and compare the characteristics of their products with those of other companies. It is hoped that this type of exchange could stimulate future product development.

with wide-ranging expertise to deal with a whole host of scenarios, and be able to ensure the health and safety of staff working on the frontline during an outbreak of emerging diseases.

How often do we provide training?

All lectures are provided by volunteers who have already completed the training, and so far we have been able to run training sessions around four times a year; both in Tokyo and elsewhere in Japan. Since 2009, we have delivered 15 sessions nationwide, and as of June 2015 have trained more than 500 fit-test instructors.

Koji Wada, Medical Officer International Health Cooperation National Center for Global Health and Medicine 1-21-1 Toyama, Shinjuku-ku Tokyo, 162-8655, Japan Email: k-wada@it.ncgm.go.jp

What are the benefits of these training sessions?

The sessions allow participants to share their experiences on respiratory protection with other hospitals and receive updates on best practices, both by joining a mailing list and attending ad-hoc meetings on specific topics, such as the Ebola Virus and the Middle East Respiratory Syndrome (MERS) after the programme.

Participants can also collaborate with device manufacturers to conduct fit-testing in their hospitals. Meanwhile, representatives from device manufacturers

Conclusions Fit-test instructors must be equipped

Toru Yoshikawa, Senior Researcher National Institute of Occupational Safety and Health Japan

References 1. McMahon E, Wada K, Dufresne A. Implementing fit-testing for N95 filtering face piece respirators: Practical information from a large cohort of hospital workers. Am J Infect Control 2008;36:298–300.

2. Wada K, Yoshikawa T, Kurosu K, Nagase J. Personal protective equipment for respiratory protection – the text of fittest instructor training program. [Online] 2014. Available from: http://rouken.sakura.ne.jp/ fittest/. (in Japanese only) [Accessed on 17th June 2015] 3. CDC. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. [Online] Available from: http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions. html.

Jani Ruotsalainen, Jos Verbeek, Cochrane Work

Use of blunt suture needles halves the risk of needle stick injuries among surgeons Surgeons are exposed to the risk of needle stick injuries at work, which may lead to infection by blood borne viruses. According to a recent Cochrane review (1), the use of blunt suture needles instead of sharp needles reduces the risk of needle stick injury by over 50%.

Health care workers are at risk of acquiring infectious diseases through exposure to needle stick and cut injuries at work. Exposure to blood or bodily fluids from infected patients can lead to, for example, Hepatitis B (HBV), Hepatitis C (HCV) and HIV infection. These are 42

serious viral infections that may cause a chronic disease process and eventually lead to death. Infections or suspicions of infection also cause stress and absenteeism from work. A significant proportion of these injuries and close calls remain unreported. Worldwide it is estimated that nearly three million health care workers suffer from needle stick injuries annually.

Surgeons and their assistants are especially at risk of exposure to blood due to glove perforations and needle stick injuries during operations. The use of blunt needles can reduce this risk because they

• Asian-Pacific Newslett on Occup Health and Safety 2015;22:42–43

do not penetrate the skin so easily, but still sufficiently penetrate other tissues.

This hypothesis was tested in a Cochrane review (1) by summarizing the results of ten different studies. The total number of operations in these studies was 2961. Six of the studies concentrated on abdominal surgery, two on hip replacement, and two on vaginal repair. On average, a surgeon who used sharp needles sustained one glove perforation per three operations. The use of blunt needles reduced the perforation rate by 54%. The surgeons mainly rated blunt needles as acceptable

Figure 1. Forest plot of meta-analysis summarising results of ten studies comparing blunt versus sharp suture needles (on glove perforations).

A forest plot describes the results of all included studies (little red boxes) relative to the line of no effect. The horizontal position of the box indicates the magnitude of effect, whereas the size of the box refers to the weight ascribed to the study in the meta-analysis due to its size. The horizontal lines through the boxes show the 95% confidence intervals around the means, which in this case are rate ratios. At the bottom, the little diamond figure is the result of meta-analysis, i.e. the pooled result obtained by combining all the individual rate ratios.

The I² test is a way to quantify how much the individual studies differ from one another statistically. Here the result is zero, meaning no difference, so we can be sure that the summary effect is truly meaningful.

for use even though the force needed in their use was higher. It is unlikely that future research will change this conclusion.

In conclusion, we can say there is high quality evidence that blunt suture needles lead to fewer perforations of surgical gloves than sharp needles. There is also moderate quality evidence that blunt needles reduce the number of needle stick injuries. The results were not influenced by the quality of the studies, albeit that in abdominal closure, the effect may be more noticeable than in vaginal repair operations.

Jani Ruotsalainen, Managing Editor Cochrane Work Finnish Institute of Occupational Health PO Box 310, FI-70101 Kuopio, Finland Email: jani.ruotsalainen@ttl.fi

Jos Verbeek, Coordinating Editor Cochrane Work Finnish Institute of Occupational Health PO Box 310, FI-70101 Kuopio, Finland Email: jos.verbeek@ttl.fi

References 1. Parantainen A, Verbeek JH, Lavoie M-C, Pahwa M. Blunt versus sharp suture needles for preventing percutaneous exposure incidents in surgical staff. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD009170. DOI: 10.1002/14651858.CD009170.

Suvi Lehtinen, Finland

WHO Collaborating Centres Meeting in Jeju, Republic of Korea This year, the WHO Global Network of Collaborating Centres for Occupational Health celebrated its 25th Anniversary.

The Network was established in 1990 to support the WHO Occupational Health Programme. Over the years, it has grown from a small meeting of occupational

health and safety experts to an extensive gathering of experts and institutes that implement the WHO Global Plan of Action on Workers’ Health (Resolution 60.26). The 10th meeting of the Network was held on 27‒29 May 2015 in Jeju, the Republic of Korea, back-to-back with

the 31st ICOH Congress on Occupational Health.

The global workforce is 3.3 billion, and roughly only 10‒15% have access to any kind of occupational health services. This speaks for the huge need to improve workers’ health everywhere. The most impor-

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Photo by Suvi Lehtinen

tant topic on the agenda of the Meeting was how to further develop the Global Master Plan for 2015‒2017 and beyond.

This is a joint work plan of the WHO/ HQ Occupational Health Programme, the WHO Regional Offices, and the Network of the Collaborating Centres.

The work of the two and a half day meeting was organized in the form of introductory lectures and world cafés, in which all participants had the opportunity to have their say regarding the modifying of the contents of the GMP and the collaborative programme for the years 2015‒2017. The discussions in the world cafés were lively, and although a large number of needs for development were recognized, an equally rich number of contributions by the CCs to implement the Plan were also noted.

A total of 39 CCs were represented, as were the International Labour Office (ILO), and NGOs such as the International Commission on Occupational Health (ICOH), the International Ergonomics

Association (IEA), and the International Occupational Hygiene Association (IOHA). The total number of participants exceeded 100.

Before the Network meeting, a Planning Committee meeting was also held as a half-day discussion. The Ways of Working of the Network are currently under revision. In order to maintain the strong, active support of the CCs, a clear defini-

tion of the goals and the roles of each actor still need further thought.

Suvi Lehtinen Chief, International Affairs Finnish Institute of Occupational Health Helsinki, Finland Email: suvi.lehtinen@ttl.fi

Suvi Lehtinen, Finland

ICOH2015 in Seoul Photos by Suvi Lehtinen

Children’s choir performs at the closing ceremony.

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The 31st International Congress on Occupational Health was held on 31 May‒5 June 2015 in Seoul, the Republic of Korea. A total of 3535 participants attended and contributed to its success. The largest group of attending professionals were physicians, but hygienists, safety officers and nurses were also well represented in the audience.

The Congress programme accommodated 10 keynote lectures and one special lecture in the opening session. In addition, 30 semiplenary lectures were held.

For the first time in ICOH Congress history, a Global Policy Forum was arranged, the aim of which was to discuss the future of occupational health and the current challenges in the development of occupational health services for all working people. The Forum’s programme consisted of introductory policy overviews by International Organizations, followed by

Professor Ken Takahashi

comments from experts from different continents.

In the Closing Session, Dr. LEE Young Soon presented a summary of the Congress topics, highlighting the differences in the occupational health and safety priorities of different continents.

The Congress programme was rich in topics and presentations. Parallel sessions catered to all interests. There was an abundance of interesting presentations. Professor Ken Takahashi held his Keynote Lecture on how we can best prevent asbestosrelated diseases in all the countries of the world. Several Semiplenary lectures and Special Sessions discussed topics of special interest to Asian countries: in his semiplenary lecture Dr. Shyam Pingle of India talked about Achieving Occupational Health through Workplace Wellness, and Dr. Somkiat Siriruttanapruk of Thailand in turn discussed the Policy-Maker Using Good Correlations between Community Health and Occupational Health.

In the closing session of the ICOH Congress, a Seoul Statement on the Development of Occupational Health Services for All was approved and signed by the President of the 31st International Congress and President of KOSHA (Korea Occupational Safety and Health Agency), Dr. LEE Young Soon, and the ICOH President, Dr. Kazutaka Kogi.

ILO’s Turin Centre offered two ICOH members a partial fellowship for the ILO Master in Occupational Health. The winners of the ILO Master Partial Fellowship awards at the ICOH 2015 Congress were Dr. Victor Hoe, Malaysia; and Dr. Gloria Villalobos, Colombia, who received a partial fellowship for a 3-month residence

at the ILO’s international training centre in Turin, Italy; and a 3-month distancelearning course.

The next ICOH Congress will be held in 2018 in Dublin, Ireland. During the Seoul Congress, ICOH members voted Melbourne, Australia as the 2021 Congress site.

In addition to all the participants of ICOH2015, I would like to extend a special, warm thank-you to the Organizers:

all the events were excellently organized and their helpful attitude, friendliness and hospitality could be felt throughout the Congress. Our heartfelt thanks!

Suvi Lehtinen Chief, International Affairs Finnish Institute of Occupational Health Helsinki, Finland Email: suvi.lehtinen@ttl.fi

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Seoul Statement on the Development of Occupational Health Services for All The 31st International Congress on Occupational Health, ICOH 2015, was organized by the International Commission on Occupational Health, ICOH, the Korea Occupational Safety and Health Agency, KOSHA, and the Korean Society of Occupational and Environmental Medicine, KSOEM, from 31 May to 5 June 2015 in Seoul, Republic of Korea. The Congress approved a “Seoul Statement on the Development of Occupational Health Services for All”.

Recalling that decent conditions of work, occupational health and occupational safety constitute a basic human right of workers as declared by the UN International Covenant of Economic, Social and Cultural Rights of working people (1966), the ILO Declaration on Fundamental Principles and Rights at Work (1998), the Centennial Declaration of the International Commission on Occupational Health, ICOH (2006) and the Seoul Declaration on Safety and Health at Work adopted by the ILO, ISSA, KOSHA and ICOH together with a high number of other Non-Governmental and Professional Associations (2008),

Emphasizing that in spite of positive developments of occupational safety and health particularly in industrialized countries, over three quarters of workers of the world live and work in developing and transitory countries, often working in high risk occupations in both formal and informal sectors, without adequate protection by occupational health and safety law and lacking social protection and access to occupational health services. Such gaps in prevention and protection lead to 2.3 million deaths among the workers of the world every year, Keeping in mind that the ILO Convention No.161 on Occupational Health Services and the WHO Global Strategy on Occupational Health for All, as well as the Cancun Charter by the ICOH (2012), call for organization of occupational health services for all working individuals and all occupations, without exclusion of any group of workers, economic sectors, including the informal sector, or workers in contracted or self-employment, Taking into consideration that new challenges, risks and hazards continuously emerge, due to changes in economic structures, transfer of technologies, demographic changes, migration and social dynamics. The management of and adjustment to the continuous change need active sharing 46

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of information, the effective use of existing knowledge, and the generation of new research on occupational health.

Recognizing that a growing body of research evidence speaks for positive economic and productive impact of occupational health services, due to prevention of loss by accidents and diseases, sickness absenteeism and disabilities, and through facilitation of production processes, Reminding that according to the principles of the ICOH International Code of Ethics for Occupational Health Professionals, protection and promotion of workers’ health is a professional, ethical and social imperative for all occupational health professionals and for the international occupational health community, the 31s t ICOH Congress states the following: 1. Policies Every government in collaboration with social partners should, as a part of their stewardship, draw up necessary regulations, strategies and programmes for national policies on occupational health and occupational health services by using the international guidance provided by the ILO Convention No. 161, Recommendation No. 171 on Occupational Health Services and the WHO Global Strategy on Occupational Health for All. Such policy should aim at the provision of services for all, with full coverage without exclusion of any group or sector of work life.

2. Implementation Implementation of occupational health policies should be based on legislation, with appropriate governance structures, well-defined rights and responsibilities, establishment and strengthening of the occupational health system and respective infrastructures, and sufficient resources and financing for services. Special measures, multiple service provision models, including primary health care, and support should be developed for organization of

occupational health services for small-scale enterprises, the selfemployed and the informal sectors. Public occupational health services should be provided for the underserved sectors. Where front-line services are of limited scope, usually occupational medicine and nursing, they should be reinforced by secondary level support services.

3. Contents and activities The content and activities of occupational health services at the workplace level include prevention and management of physical, chemical, biological and ergonomic factors, prevention of occupational diseases and injuries, prevention of excessive work load, and work life constraints, promotion of health and work ability, rehabilitation and return to work, as well as first aid and curative services. Such services should be adjusted to the health needs of working people, by taking into consideration the existing hazards and responding to the needs of various groups of workers, including young, female, ageing, and migrant workers and various types of vulnerable groups.

4. Human resources, competence and expertise Governments should ensure the availability of sufficient human resources for the effective delivery of occupational health services. Where possible, the occupational service team should be multidisciplinary, covering several types of expertise, such as occupational medicine, occupational health nursing, ergonomics, occupational hygiene, psychology and accident prevention, rehabilitation and return to work. In cases, where multidisciplinary services may be difficult to organize and sustain, the basic occupational health service (BOSH) approach and proactive risk prevention and locally adjusted methods may be used.

5. Training and education In line with the ILO Convention No. 161, special competence and training are needed for provision of competent occupational health services. Governments should ensure appropriate and updated training and education curricula for occupational health personnel. International standards and model curricula should be developed for occupational health personnel. Depending on national conditions the training could be organized at universities or other relevant institutions.

6. Sharing information and good practices Effective exchange and dissemination of information on all aspects of occupational health should be promoted and encouraged, and good practices and guidelines should be shared via the international collaboration between occupational health professional bodies, International and Non-Governmental Organizations, WHO, ILO and ICOH and other relevant institutions and associations. Dissemination of this knowledge should be supported by international and national expert communities, employers, workers, and governmental organizations.

7. Research Appropriate and adequate research support should be structured for the production of evidence based information for the development of occupational health systems, methods and good practices,

training and education. Longstanding international experience has shown that research is best supported and sustained when it is nested in the National Institute of Occupational Health, or respective centre of excellence in the country.

8. Collaboration and networking National Collaboration To ensure sufficient coordination and exchange of information within countries, continuous dialogue should be maintained and close and regular collaboration between occupational health and general health services, with occupational safety and health, social security institutions, social partners (employers and workers) and academia should be encouraged. Networking between all involved in the development of occupational health, including occupational health service providers, is also recommended.

International Collaboration International Collaboration, including bilateral and multilateral networking, should be enhanced among all the key international professional associations in the field of occupational health and safety. Such networks should collaborate and provide scientific and professional support to the International Organizations, ILO and WHO. 9. Commitment The organizers and participants of the ICOH 2015 Congress declare commitment for collaboration and support for all parties, national and international, professional and governmental in their efforts for organization of competent occupational health services for all workers across the world.

10. Follow up It was agreed to follow up and evaluate the implementation of this Statement and results be presented to the forthcoming 32nd International Congress on Occupational Health, ICOH 2018, which will be organized in Dublin, Ireland.

On behalf of the 31st International Congress on Occupational Health In Seoul, Republic of Korea, 5 June 2015,

Dr. Kazutaka Kogi, MD, President of the International Commission of Occupational Health, ICOH

Dr. Lee, Young-Soon, PhD President of the ICOH 2015 Congress, President of the Korea Occupational Health and Safety, KOSHA

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Editorial Board

as of 1 August 2015

Chimi Dorji Licencing/Monitoring Industries Division Ministry of Trade and Industry Thimphu BHUTAN Nayake B.P. Balalla Senior Medical Officer (Occupational Health) Jerudong Park Medical Centre Jerudong BG 3122 BRUNEI DARUSSALAM Yang Nailian National ILO/CIS Centre for China China Academy of Safety Sciences and Technology 17 Huixin Xijie Chaoyang District Beijing 100029 PEOPLE’S REPUBLIC OF CHINA CHAN Cheung-hing, Thomas Deputy Chief Occupational Safety Officer Safety Management and Information Division Occupational Safety and Health Branch Labour Department 13/F., Harbour Building 38 Pier Road, Central HONG KONG, CHINA

K. Chandramouli Joint Secretary Ministry of Labour Room No. 115 Shram Shakti Bhawan Rafi Marg New Delhi-110001 INDIA Gan Siok Lin Executive Director Workplace Safety and Health Institute 1500 Bendemeer Road #04-01 Ministry of Manpower Services Centre Singapore 339946 SINGAPORE John Foteliwale Deputy Commissioner of Labour (Ag) Labour Division P.O. Box G26 Honiara SOLOMON ISLANDS Do Tran Hai Director General National Institute of Labour Protection 99 Tran Quoc Toan Str. Hoankiem, Hanoi VIETNAM

Nancy Leppink Chief of LABADMIN/OSH International Labour Office 4, route des Morillons CH-1211 Geneva 22 SWITZERLAND Evelyn Kortum Technical Officer, Occupational Health Interventions for Healthy Environments Department of Public Health and Environment World Health Organization 20, avenue Appia CH-1211 Geneva 27 SWITZERLAND Jorma Rantanen ICOH, Past President FINLAND Antti Koivula Director General Finnish Institute of Occupational Health PO Box 40 FI-00250 Helsinki FINLAND