Chapter 10 Identifying Hazards

Identifying Hazards and Communicating Risks

After reading this chapter, you will be able to:

Linking these topics to the Medical Council exam objectives, especially sections 78-6 and 78-8.

Note: The colored boxes contain optional additional information; click on the box open it and to close it again.
Words in CAPITALS are defined in the Glossary

Thinking outside the box

Julie Richards consults Dr. Rao because she is concerned about her eyes which have been red and irritated ever since she spent a day cleaning out the basement last week. She heard radon gas is a problem in the area and that it accumulates in basements. She wonders if her eye problem may be related to radon gas. Dr. Rao is well aware that the environment can cause health problems, but he very much doubts that radon can cause eye irritation. For him, the notion of environment includes the combination of natural, built and social environments. Glancing through his records, he notices that this is not the first time someone in the Richards family has experienced such problems, so rather than merely dismiss the radon idea he decides to take a broader-ranging history.

Identifying Environmental Problems

Environmental hazards (see Definition box below: Hazards and risks) contribute to cause a wide range of diseases and environmental factors are involved in the aetiology of virtually every illness. Environmental hazards are often complicated by how ubiquitous they can be and the scale of remediation that may be required to address them, as with soil contamination by effluents, or air pollution. In other instances, a disease caused by specific environmental hazards may respond to a simple solution such as cleaning or wearing protective equipment. Moreover, many patients worry about elements of their environment that have little or no effect on health, so physicians need to be able to distinguish those that are hazardous from those that are not. To diagnose an illness as predominantly environmental in origin, physicians have to include a thorough environmental assessment in their history-taking. Clues that an illness is caused, in part or wholly, by an environmental factor include:

  • The patient suspects it
  • Local epidemiology: for example, the pattern of illness is atypical; the patient is not in the usual age group; the common non-environmental risk factors are absent; and if the environmental hazard persists the symptoms may not respond to the usual treatments.
  • The temporal pattern of the illness suggests it (for example, symptoms improve when the patient goes on holiday and worsen on returning home, or they worsen when the patient is at work and improve at home).
  • There is no obvious other cause for the illness
  • The signs and symptoms suggest specific toxic substances, such as lead or mercury poisoning.

Simultaneously, physicians must be aware of how climate change can impact the health of their patients and communities. While climate change is not a specific hazard that may be removed from a patient’s environment, physicians are well-placed to provide advice on adaptive measures to lessen the effects of climate on their patients. Many physicians also choose to participate in research and in political action to combat the health effects of climate change.

Hazards and risks

Hazard is the inherent capability of an agent or a situation to have an adverse effect. A hazard is a factor or exposure that may adversely affect health: the thing that may do damage. Hazard events can be characterized by their magnitude or intensity, speed of onset, duration, and the area they cover. All of these influence their health impacts, which may be loosely categorized into emergencies and disasters.1

Emergencies are unexpected events that necessitate immediate action to protect people’s welfare and/or to limit property or environmental damage. Emergencies can typically be handled using existing resources.

Disasters, on the other hand, are hazardous situations that exceed the capacity of communities to cope using their existing resources.2

Risk is the probability that a damaging health effect will occur.

Threat refers to how severe will be the damage that may occur.

Health risk = hazard x exposure x susceptibility.

For there to be a risk, a susceptible individual or population (the receiver) must be exposed (via a path) to a hazard (the source – see Figure 10.3). If there is no exposure, there is no risk. If there is exposure, but no susceptibility, there is no risk. The same idea is used in fire prevention: use a non-flammable material (i.e., reduce susceptibility) or reduce its exposure to heat (block the path), or remove the source of heat.

Risk mitigation refers to technological interventions to control or remove a risk; adaptation refers to personal approaches to managing the damage (e.g., wearing sunscreen, protective clothing, etc.).

Once an environmental cause is suspected, the physician should take a detailed environmental history to identify potentially pertinent hazards the patient may have been exposed to, as shown in the box “Taking an environmental history”. All of the patient’s activities and environments should be explored. The chronology of events, patient’s proximity to the presumed source, and whether or not other people are affected should be explored for evidence that supports or discounts the hypothesis of an environmental cause (i.e., establishing Time, Place, and Person).

Once the physician has established that the problem is likely related to a given environment, they should further consider how to engage public health authorities to address their concerns and to ensure that other people are protected. The physician can consult with their colleagues in occupational medicine or in public health and preventive medicine for advice on how to manage a health problem linked to the environment. Indeed, some provinces require physicians to notify their local public health department of particular environmental illnesses or possible outbreaks. In the case of a hazard that is likely to affect the population at large, the public health department is responsible for controlling the problem. The roles of the public health department may include conducting investigations, surveillance and public education; remediation may require intervention or support from other parties. At times, public health departments my proactively advise on the possible health impacts of projects proposed by industry or governments, known as Health Impact Assessment.

In the case of a hazard related to a workplace, employers and workplace health and safety representatives bear a responsibility to investigate and address concerns brought forward by workers. Where this fails, provincial regulatory authorities for workplace health and safety may need to get involved, as described in Chapter 12. In an emergency, as with a case of carbon monoxide poisoning, public security services (fire and police) would coordinate control efforts.

Taking an environmental history3

The following topics cover the basic elements of an environmental history. Asking scanning questions about these different topics using the CH2OPD2 mnemonic (see below) may clue you in to something that warrants further discussion.

  • Community or neighbourhood sources of hazard: pollution; industry; waste storage
  • Home: year of construction, renovations; materials used in construction and decoration; moulds; garden and house plants; use of cleaning products, pesticides, herbicides
  • Hobbies and leisure: exposure to chemicals, heavy metals, dusts, or micro-organisms
  • Occupation: current and previous occupations; work with known hazards; air quality
  • Personal habits: hygiene products; smoking
  • Diet: sources of food and water; cooking methods; food fads
  • Drugs: prescription, non-prescription, and alternative medications; health practices.

If a scanning question reveals a possible hazard, ask detailed questions to find out as much as possible about the nature and level of the hazard and then check Time, Place and Person:

  • Time: When did symptoms begin? When did the exposure begin? When do symptoms get worse? When do they improve?
  • Place: Where is the patient when symptoms get worse? Where is the likely hazard? What is the route of exposure through which the hazard reaches the patient?
  • Person: Does anyone else have similar symptoms? Who? When? Where?

Look beyond the smoking gun!

Ask questions about all the environments that the patient inhabits—even if the patient suspects one in particular or if your first few scanning questions point to a specific environment. If you stop enquiring as soon as you find your first hazard, you might miss others to which the patient is also exposed. The real cause of the patient’s problems may not be the first one your history uncovers.

Julie’s eye trouble

Dr. Rao asks Julie a bit more about her activities around the time her eye problems began. She said she was cleaning out the basement, which was very dusty. She also used a cleaning product that she hadn’t used before and because it was cold outside she didn’t open the window. The day before cleaning the basement she had gone for a walk; it had been a windy day and some dust had blown into her eyes.

Right now her eyes are normal. Dr. Rao advises Julie to make sure that there is adequate ventilation when using a cleaning product. He also suggests that she have a look at the Canada Mortgage and Housing website for advice on home maintenance. As this is not the first time that a patient has asked about radon gas, Dr. Rao advises Julie that although radon is a concern that may require attention and action, it is unlikely to have caused the symptoms she is most concerned about. He asks his practice manager to contact the local public health department for information on radon that he could pass on to his patients.

Climate Change and Health

From the population health perspective, the World Health Organization ranks ranks climate change as the top global health threat, projected to cause an estimated 250,000 additional deaths annually from 2030. Depending on the patient’s presenting complaint, physicians may also  consider how climate change is contributing. Extreme weather events may lead to an increase in injuries, exacerbations of underlying cardiovascular or respiratory diseases, heat-related illnesses, or enteric diseases if electrical or water infrastructure is damaged.4 Longer, warmer, and drier seasons may influence the food security of patients. Physicians may also encounter changing patterns of vector-borne diseases, such as Lyme disease, due to longer and warmer seasons that extend the natural habitats of vectors such as tics.5  Physicians should also recognize that some of their patients will be disproportionately impacted, such as those who are medically vulnerable or socially marginalized. As with other environmental hazards, physicians should help patients identify ways to reduce their risk of adverse health effects due to climate change. Figure 10.1 illustrates the multiple routes through which climate change may affect human health.

Figure 10.1: Routes through which climate change affects health (adapted from Mobilizing Public Health Action on Climate Change in Canada, Figure 3.

Wildfires and the climate crisis

Canada’s 2023 wildfire season was the most destructive on record. More than six thousand fires burned a staggering 16.5 million hectares of land, far more than the average 2.5 million hectares typically affected each year. Unlike previous years, fires were widespread in 2023, from the West Coast to the Atlantic and extending into the North. By mid-July, there were 29 mega-fires, each exceeding 100,000 hectares.

Wildfires impact the air quality and health of the population, effects that extend beyond the border. New York City experienced an increase in ED visits due to asthma syndrome complaints as a direct result of the wildfires burning in Quebec.

Public Health Approaches to the Climate Crisis

Climate change is an important public health priority. The public health response involves a two-pronged approach of mitigation to address the immediate impacts of climate change, and adaptation to build long-term resilience against future climate-related challenges (see Figure 10.2).

Mitigation involves efforts to slow, stabilize, or reverse climate change primarily by reducing greenhouse gas emissions: a form of primary prevention. Mitigation strategies involve two key actions: reducing the sources of greenhouse gases and enhancing the natural sinks that absorb and store these gases, such as the lake, wooded areas, and soil.

Adaptation focuses on anticipating and preparing for the effects of climate change, representing secondary and tertiary prevention strategies. Climate change adaptation seeks to reduce vulnerability to the detrimental effects of climate change and to seize any potential benefits. This may  involve conducting health vulnerability and adaptation assessments to identify at-risk populations and to evaluate the resilience of health systems. These assessments help to understand the health impacts of hazards such as heatwaves and infectious diseases, and to develop strategies to enhance infrastructure, to improve disease surveillance, and to promote community resilience.

This combined approach will guide targeted actions to minimize adverse health impacts and improve preparedness for a changing climate. This should provide ecosystems with the time they need to adapt to a changing climate. Mitigation includes ensuring that food production and economic development proceed in a sustainable manner. Policies must maintain a balance between addressing current needs and preserving the health of our planet for future generations.

Figure 10.2: Illustration of strategies for climate change mitigation and adaptation (adapted from Sandink & MacLeod (7))

Toronto’s climate change mitigation plan

In 2019, Toronto City Council declared a climate emergency. They subsequently developed an action plan, called TransformTO Net Zero Strategy, which sets out a plan to reduce community-wide greenhouse gas emissions to net zero by 2040. The strategy focuses on five key areas:
• Establishing a carbon budget for its operations
• Reducing natural gas use
• Creating and monitoring performance targets for city buildings
• Promoting environmentally-friendly transportation options, such as walking, biking, and public transit, and
• Increasing local renewable energy sources.

This net zero plan illustrates how a community can devise and implement ways to mitigate the adverse health effects of climate change.

Disasters and disaster preparedness

The Medical Council defines a disaster as “a serious disruption of the functioning of a society, causing widespread human, material, or environmental losses that exceed the ability of the affected society to cope using only its own resources.” While disasters often follow natural hazards, not all natural hazards cause disasters. For example, flash flooding of unfarmed land is not considered a disaster – it’s just weather. But if it occurs in a low-income neighbourhood without flood resilient housing and impacts thousands of inhabitants, it would be a disaster. Disaster exposure is usually quantified as number of people or assets affected. When complete prevention of exposure is not possible, it can be mitigated through the implementation of early detection systems and disaster preparedness programs.

Common categories of hazard that may lead to a disaster include:

  1. Natural hazards
    1. Weather & climate change (including anthropogenic): extreme weather events, droughts, wildfires, flooding; earthquakes
    2. Infectious disease outbreaks and pandemics
  2. Hazards deriving from human systems
    1. Technological hazards: industrial or structural failures; infrastructure disruption; electricity or water system failures
    2. Chemical, biological, radiological, nuclear hazards (unintentional or intentional); food contamination
    3. Social: civil unrest; cybersecurity; weapons; armed conflict; terrorism
  3. Multi-Hazard: combinations of the above.

Disasters are multifactorial

In 2013, eight communities along the Bow River in the Siksika Nation were devastated by flooding, displacing over 1000 people from their homes. While climate change increases the frequency and severity of flooding, other factors such as inadequate housing infrastructure, deficiencies in emergency management practices, and a lack of self-determination in disaster response also play significant roles. These factors affect disaster exposure and vulnerability. Attributing natural disasters solely to climate change risks absolving policymakers from responsibility for establishing climate-resilient infrastructure.

Responding to Disasters

Disasters could be thought of as potentially recurring events and managing disasters is generally presented as a cycle of phases that include:

  • Prevention: actions taken to stop a potential emergency or disaster from occurring (e.g., efforts to combat climate change; diplomacy to prevent wars; food and water safety standards; hazardous material safety standards).
  • Mitigation: based on risk assessment, actions taken to lessen the cause or the impact of a disaster that cannot reasonably be prevented (early warning systems; creating fire breaks in forests; adequate drainage; earthquake proofing buildings).
  • Preparedness: planning, training, and educational activities to ensure appropriate actions are taken within the components of prevention and mitigation, and where necessary, ensure an effective response to, and recovery from disasters (e.g., a tabletop exercise simulating roles in the event of a widespread fire).
  • Response: activities before, during and immediately after a disaster when regular operations are suspended (e.g., search and rescue missions). The goal is to mount a coordinated and effective response at the outset of the emergency to prevent loss of life, injury or other health impacts, property damage, loss of services, social and economic disruption, environmental damage.
  •  Recovery: restoration activities that occur alongside a return to regular operations, such as rebuilding damaged structures (building back better), provision of financial, physical and emotional support.

These are commonly shown in a circular diagram in which recovery feeds back into improving preparedness and future mitigation plans.8 Effective public health systems continuously anticipate and prepare for potential hazards, so are always in some phase of the disaster management cycle. Ontario Public Health, for example, publishes guidelines for assessing risks from infectious diseases and other potential hazards.

The emergency response cycle in practice

Several practical components and tools are typically involved in an emergency response. For example, a Hazard Identification and Risk Assessment (HIRA) system. This assesses the probability and impact of  hazards, and may identify high-level planning implications for data collection or surveillance. Ontario Public Health, for example, publishes guidance on completing a HIRA.

As part of preparedness, and before mounting a response, organizations may develop an Emergency Response Plan (ERP), which is a document that outlines the policies, procedures, roles and responsibilities of agencies, to coordinate action. For example, the Ontario provincial emergency response plan describes the multiple ministries and other organizations involved. It outlines an organizational structure, legislated responsibilities, and lines of communication.

Several tools or approaches may be utilized during the response phase. For example, once a disaster is declared, an Incident Management System (IMS) provides guidelines for standardizing responses to an incident, covering personnel, facilities, equipment, financing, procedures, and public information communications. An Emergency Operations Centre (EOC) is a centralized facility for the overall coordination of a response, including information exchange and coordination. A Continuity of Operations Plan (COOP) outlines how the continued delivery of critical functions and services will be maintained in the event of a disaster. Most disasters are managed at the local or provincial levels, but due to the extraordinary authority that may be required to mount a large-scale response to an emergency, two federal laws may be invoked:

  1. The Emergency Management Act delineates the roles and responsibilities of federal Ministries, such as those of the Ministry of Public Safety and Emergency Preparedness, which include coordinating emergency response activities between provincial/territorial actors and governments.
  2. The Emergencies Act is used during national emergencies to allow the federal government extra temporary powers only when necessary to protect the health and safety of Canadians. In this way, the Emergencies Act may conflict with the Charter of Rights & Freedoms.

The Incident Command System

This originated from fighting wildfires in the 1970s. It is called an ‘all-hazard’ system because it can be adapted to nearly any type of disaster, from natural disasters like floods and tornadoes, to human-made disasters, such as terrorism events. In many settings, incident command systems have been expanded to Incident Management Systems (IMS) to enhance collaboration across sectors.

The ICS divides the personnel involved in a disaster response into five core management teams:

  • Incident Command: Provides direction and specific objectives for the disaster response. The appointed Incident Commander typically assumes responsibility for overall incident management
  • Operations team: Conducts activities to carry out the planned disaster response
  • Planning: Responsible for preparing the Incident Action Plan; collecting, analyzing, and disseminating intelligence related to the disaster; and documenting the overall disaster response
  • Logistics: Provides the necessary support and resources needed for the disaster response, such as obtaining and maintaining needed equipment and supplies
  • Finance: Monitors and documents all costs related to disaster response.

Reducing Risk

The three main activities in addressing health problems possibly linked to environmental hazards are risk assessment, risk management, and risk communication. The clinician addresses these when discussing environmental disease with a patient; a public health officer applies them in responding to community wide problems.

Risk assessment

Risk assessment involves a series of steps in evaluating the likelihood of occurrence and probable severity of health effects due to a hazard. Please note that ‘Risk assessment’ for the purpose of environmental or occupational hazards is a different approach than the ‘Hazard Identification and Risk Assessment’ discussed above in the context of emergency preparedness. Various agencies assess hazards, including occupational health agencies, environmental protection agencies, and public health authorities. Clinicians confronted with a case of disease with possible environmental links might use some of the following risk assessment steps to arrive at a diagnosis.

Steps in risk assessment for clinicians and public health officers 9

  1. Hazard identification: Are environmental or occupational hazards involved? What are they? How likely are people to be exposed and what will the effects be?
  2. Dose – Response assessment: Given the patient’s level of exposure, is the hazard likely to cause these types of symptoms in this type of patient? What are the dose response curves for different routes of exposure (inhalation, ingestion, etc.)?  
  3. Exposure assessment: to what extent is the patient or population exposed? Is the exposure to the hazard sufficient to cause these symptoms? Which population groups are likely to be at most risk of health effects?
  4. Risk characterization: How much has the hazard contributed to the patient’s condition? What is the risk from this hazard for this specific population?

Risk assessment, Step 1: Hazard identification

The first step identifies the agents possibly responsible for the problem. Each hazard is defined by its ability to cause adverse effect, under what conditions and to which population groups. Hazards are classified as biological, chemical, physical, ergonomic, psychosocial, or related to safety. Table 10.1 gives examples of the various types of hazard and their possible health effects.

Table 10.1: Examples of the various types of environmental agents and their associated health effects

Type of hazard Examples Health effects
Biological Bacteria, viruses Specific syndromes associated with different agents e.g., salmonella food poisoning, hepatitis A, infection with Methicillin resistant staphylococcus (MRSA)
  Moulds Allergies, cancers
  Animals Allergies, zoonoses
Chemical Heavy metal (the risk may depend on its physical state) Specific syndromes e.g., lead poisoning, mercury poisoning
  Benzene Acute myeloid leukemia with prolonged exposure
  Carbon monoxide Chemical asphyxiation
  Asbestos Asbestosis, carcinoma of the lung, mesothelioma
Physical Noise Hearing loss
  Radiation DNA damage leading to cancers
  Ultraviolet light Skin damage, vision loss
  Temperature extremes Hypo- or hyperthermia, frost bite
  Kinetic energy Falls and collisions leading to bone and soft tissue injury
Ergonomic Poorly designed work station Back pain
  Physically repetitive activity Repetitive strain injuries
Psychosocial Job stress Non-specific physical and psychological manifestations
  Poor social support Psychological problems
Difficulty in coping

When we think of exposure to environmental hazards, we can consider the different media that hazards can exist in, such as air, water, soil and in food. It is through consumption, inhalation and or contact with environmental media that exposure to hazardous substances occurs. Hazards may affect health directly, or indirectly when they produce a change that puts a person or population at risk, as seen with climate change. Table 10.2 lists some of the common hazards.

Table 10.2: Examples of hazards in the environment

Hazards in: Examples
Air Carbon monoxide
Smog
Particulate matter
Water Fecal contamination
Cryptosporidia
E. Coli
Blue-green algae
Soil Heavy metals
Petroleum by-products
Food Listeria
Salmonella
Mercury in fish

Indoor hazards that cause health problems include household chemical products, carbon monoxide, radon, mould, lead, and consumer products (cosmetics, perfumes, hygiene products). Second hand smoke is still a problem in some households.

The clinical picture may indicate what kind of hazard to assess for. Airborne irritants can cause itchy or sore eyes, runny nose or coughing. Irritants that come into direct contact with the skin can cause dermatitis. Allergens can cause numerous manifestations of allergy including dermatitis, asthma, allergic rhinitis. Asphyxiants cause different respiratory problems depending on the type of asphyxiant. For instance, as a chemical asphyxiant, carbon monoxide blocks oxygen transport. Other inert gases can still accumulate in high concentrations displacing oxygen in the air. Certain ingested or absorbed substances may damage organ systems in pathognomonic ways. For instance, severe lead poisoning causes neurological changes, abdominal pain, or anaemia, whereas poisoning with mercury typically produces tremors, among other neurological symptoms. Mesothelioma is linked to exposure to asbestos.

The effects of a hazard may be delayed, sometimes for years. This is especially true of cancer-causing agents. Because of the time-lag, identifying hazards of this type and proving the effect can be difficult. Identifying this type of hazard and evaluating claims about it can be difficult. Furthermore people can be exposed to more than one hazard, each contributing to their health problem. For instance, in the case of a person who works in construction and who smokes, it can be difficult to assess the relative contributions of occupation and smoking to his chronic lung disease.

If an outbreak of a disease of environmental origin is suspected, public health officials will collect initial information on the possible sources. Once a case definition (see CASE DEFINITION in Glossary) is established, cases are sought and information is collected on when and where they were exposed, when they started showing effects, and demographic characteristics and predisposing factors (Time, Place and Person). Information from all cases is then collated to produce a picture of the distribution of cases in time and place (see Chapter 11: Detection and control of outbreaks).

Risk assessment, Step 2: Dose-response assessment

This step describes the potential health effects of a hazard at different levels of exposure. As far as possible, effects on molecular, biochemical, cellular and organ systems are described. A chemical hazard may only cause health problems when in a specific form: small amounts of ingested elemental liquid mercury are unlikely to cause adverse health effects, although mercury vapor and organic and inorganic mercury compounds have known adverse health effects. The route of entry into the body may also be an important determinant of the damage caused: the risk of toxic effects from the ingestion of asbestos is considered to be low,10 whereas inhaled asbestos causes asbestosis, mesothelioma and other cancers.11  Furthermore, a person’s response to a hazard is mediated by the factors that influence the hazard’s toxicokinetics and toxicodynamics (See Definitions: Kinetics and dynamics). The individual’s genetic makeup and metabolic state as well as environmental factors moderate the toxicokinetics and toxicodynamics, so susceptibility to damage by a hazard varies from one person to another; malaria offers an example.

Differences in susceptibility

Malaria is an example of a hazard from which the risk is modified by the genetic makeup of at-risk people. The sickle cell trait confers some resistance to malaria, and this could explain why the trait has persisted in African populations. One study showed that, compared to children without the trait, those with the sickle cell trait had a relative risk of all cause mortality of 0.45 (95% CI 0.24–0.84) from the ages of 2 to 16 months.12 This is the peak age for severe malaria. There was no difference in mortality before the age of 2 months, probably because of maternal immunity, or after the age of 16 months, probably because those who survive to 16 months develop some immunity from repeated exposures to small infectious loads.

Kinetics and dynamics

Toxicokinetics is the study of what the body does to a toxic substance, including the processes of absorption, distribution, localization in tissues, biotransformation, and excretion.13

Kinetics comes from the Greek word that means movement. Cinema (moving pictures) and kinesiology are derived from the same word.

Toxicodynamics is the study of what the substance does to the body: the biochemical and physiological effects of toxins and the mechanisms of their actions, including the correlation of actions and effect of toxins with their chemical structure. It includes the effects of a toxin on the actions of other toxins.

Dynamics comes from the Greek word meaning force or power.

Toxicokinetics and toxicodynamics are analogous to pharmacokinetics and pharmacodynamics.

A low dose of some substances may be beneficial for a person, yet a higher dose is toxic. For instance, fat soluble vitamins, such as A and D, are essential for health, but too much of either is toxic (see ‘Hormesis’). Sunlight in small doses increases the production of Vitamin D, while in high doses it can cause skin cancer. Some hazards, such as heat and noise, must reach a threshold level before damage occurs. Others, including many cancer-causing agents, are presumed to cause damage even at the lowest measurable levels. The chronic effects of some agents, such as X-rays, are cumulative over a lifetime, while the acute effects of other agents, such as anesthetics, may only be temporary without ongoing exposure.

Hormesis

Hormesis refers to a biphasic dose response to an environmental agent characterized by stimulation or a beneficial effect at moderate doses and an inhibitory or toxic effect at high doses.

Toxicokinetics of stress

Toxicokinetics and the varying dose-impact of different toxic substances have a parallel in the relationship between psychological stress and resulting strain or distress. Personality mediates the impact of psychological stress on the resulting mental strain, producing characteristic stress-strain responses. Different people react to stresses in characteristic ways reminiscent of the stress-strain curves described by Young’s modulus http://en.wikipedia.org/wiki/Stress-strain_curve.

For information on hazardous substances, clinicians can look to the scientific literature, check with the local public health department or call the toxicology or poison centre. If the probable source of the hazard is an industrial product, information is likely to be available via the Workplace Hazardous Materials Information System (WHMIS5), which sets out the labelling requirements for the hazards shown in Table 10.3. The product label also indicates if a ‘Safety Data Sheet’ is available for the product. This sheet contains further details about the hazard, how to handle it safely and what to do in an emergency.14

Table 10.3: The Workplace Hazardous Materials Information System Symbols 15

Acute toxicity, skin corrosion, eye or respiratory damage, and specific organ toxicity

Gas or chemicals under pressure
Flammable gases, aerosols, flammable liquids & solids, etc.
Oxidizing gases, liquids, or solids
Respiratory or skin sensitization, mutagenicity, carcinogenicity, reproductive toxicity and target organ toxicity and aspiration hazard
A general warning covering several of the previous hazards:
Acute toxicity, skin corrosion, eye or respiratory damage, and specific organ toxicity
Biohazardous infectious materials
Corrosive materials; agents causing skin corrosion or eye damage
Self-reactive substances & organic peroxides

Risk assessment, Step 3: Exposure assessment

Exposure assessment is the step that quantifies the exposure of a person or population to a hazard. The levels of some hazards can be directly measured, either in the environment or in the people exposed. More often, however, exposure must be estimated from a careful history of the patient’s activities, as well as an inspection of the environment. Details of activities, working practices, and processes during which a person is likely to be exposed must be examined to determine how and how much the person was exposed to the hazard.

When the problem may have been caused by an agent that produces delayed effects, such as a carcinogen, the exposure history should trace exposures back twenty years or more. Occupational disease can occur in retired people; in workers, it can be caused by previous employment.

Risk assessment, Step 4: Risk characterization

Risk characterization describes the likelihood that a hazard will affect a specific person or population; it also estimates the size or severity of the effect. In this step, the information obtained during the previous steps is summarized and collated. The epidemiological triad (see Chapter 2, Figure 2.8) can be used to assemble the information on what the hazard is, where it comes from, how the environment allows it to come into contact with the host, and the host’s susceptibility to the hazard in order to arrive at a conclusion on who is at what level of risk. Table 10.4 illustrates what needs to be considered in this step.

Table 10.4: Examples of various host, agent, and environmental risk factors for selected categories of health problems

Problem type Health problem Host Agent Environment
Infectious disease Hepatitis C virus infection among people who inject drugs Co infection with HIV RNA virus (Flaviviridae family) Lack of sterile drug preparation and injection equipment (e.g., syringes)
Environmental health problem Asthma Genetic susceptibility Allergen Carpets; pets in household; inefficient ventilation
Occupational health problem Back injuries in manufacturing facilities Posture Mechanical forces Lack of equipment necessitates human lifting.

Following the risk assessment process, risk management should be considered. The risks for an individual and for a population should be balanced against the costs and risks of intervening. In individuals it might be a choice between the risk of asthma and the loss of a beloved pet or, if the risk is work-related, it could be a choice between staying healthy or staying employed. For the population as a whole, risk management includes a balanced look at all of the benefits and harms associated with a given hazard. Some benefits of the presence/use of the hazard, assuming it is appropriately controlled, may include consumer products that are essential and employment for those who are part of production, while the risks may include adverse health effects in workers and for those in the community who may be inadvertently exposed to that given hazard due to a failure of controls

Risk and the precautionary principle 16

The four steps of risk assessment described in the text fall into a quantitative risk assessment paradigm. The steps assess probable risks and benefits, allowing people to choose the option with least risk. However, the paradigm has been criticised for not taking into account the complexities and uncertainties of risks and risk assessment. When there are uncertainties or a lack of evidence regarding potential risks, the precautionary principle may be considered. This principle states that a complete scientific understanding of a risk is not absolutely necessary before taking adaptive or mitigating actions; or, more simply, “better be safe than sorry”. It is generally used in situations where there is adequate evidence of causation, the potential harms are severe, and the mitigating actions are acceptable.17
Ontario Public Health offers guidelines on applying the precautionary principle. A criticism of this approach is that it tends to be based on the assessment of only one option and may ignore the risks and benefits of the others.

Occupational Hazards

Most people spend a substantial part of their life at work, and encounter a variety of hazards depending on the work that they do, often over a period of years. In some occupations, specific hazardous agents must be used, putting workers at risk of occupational diseases associated with them. In taking an exposure history, physicians could use a mnemonic such as WHACS.18  Ask four simple questions:

  • What sort of work do you do?”
  • How do you do it?”
  • Are you concerned about any of your exposures on or off the job?”
  • Co-workers or others exposed?”
  • Satisfied with your job?”

Occupational injuries and diseases

The vocabulary of work-related health problems is governed by provincial legislation on health and safety at work, and workers’ compensation. As a result, precise definitions of key words may vary. However, the underlying concepts remain the same.
An occupational injury may be due to an occupational disease or a work accident. It arises out of employment and in the course of employment, resulting from one of the following

  • a willful and intentional act, not being the act of the worker who suffers the accident
  • a chance event or incident occasioned by a physical or natural cause
  • a disablement caused by an occupational disease
  • a disablement or disabling condition caused by employment.

Even though the legislation refers to ‘accidents’, the term is to be eschewed. This is because most accidents are preventable, yet accident implies something unpredictable.

Injury is used in its broad sense to mean any kind of harm occurring to the worker. It can also refer to aggravation of a pre-existing condition.

Occupational disease: a disease peculiar to or characteristic of an industrial process, trade, or occupation, or a disease that arises out of and in the course of employment.

The Mad Hatter

The Mad Hatter in Alice in Wonderland illustrates mercury poisoning as an occupational disease. At the time the book was written, mercury was used in the process of felting, one of the steps in making a hat out of wool. The Hatter exhibits the neurological effects of mercury exposure: irritability, excitability and anxiety – a syndrome known as erethism.

Common, non-specific work-related diseases include dermatitis, asthma, and musculoskeletal disorders. It is also accepted that mental health can be influenced by excessive work demands, lack of decision latitude, concerns with lack of support, workplace harassment and workplace violence among other things.

Table 10.5: Some examples of occupational disease

Condition Agent Example of occupations at risk
Berylliosis Beryllium Aerospace industry
Byssinosis Cotton dust (numerous agents) Cotton industry
Farmer’s lung Mould in hay Farming
Asbestosis, Mesothelioma Asbestos Demolition work; ship-building
Hepatitis A Hepatitis A virus Sewer workers
Silicosis Silica dust Stone workers
Lymphoma Pentachlorophenol
Silica dust
Toluene
Asbestos
Pesticides
Lumber yard workers
Foundry workers; stone cutters
Painters
Foundry workers; demolition
Farming

Injuries do not occur randomly; groups at particular risk of occupational injury include:

    • New and young workers lacking in work experience or safety training—particularly those in temporary or summer jobs;
    • Workers obliged to work long hours at a fast pace. This could include piece-workers or those working on production lines;
    • Workers given work responsibility without the authority or control necessary to meet that responsibility; and
    • Workers in certain high-risk industries such as construction and forestry.

According to Canadian federal and provincial laws, specific services must be provided for the protection of workers (see Chapter 12, Occupational Health Services) and for compensating those who are harmed as a result of work.

Risk Management

Derived from energy engineering, the Source-Path-Receiver model outlines approaches to controlling risks. The source refers to the equipment or process that is directly responsible for a hazard. The hazard could be a form of energy (acoustic, thermal, etc.), or it could be a substance such as toxic fumes or dusts. The path is the conveying medium (air, water, etc.), while the receiver is the human being, the worker. Strategies to reduce risk can target the source of the hazard, the path, or the receiver, whether the risk involves a person or a population.

.

Figure 10.3: Source-path-receiver: a model to identify ways of reducing environmental risks
Figure 10.3: Source-path-receiver: a model to identify ways of reducing environmental risks

As complete elimination of risk is generally not possible, risk management aims to reduce the risk from a hazard without causing another problem. The ‘Hierarchy of Controls’ lists approaches from the most effective to the least, generally working from the source toward the receiver. The most effective approach is Elimination, followed by Substitution, then Engineering controls, Administrative or legislative controls and, finally, Personal Protective Equipment.19

Upstream strategies aimed at the source are especially relevant for climate change; examples include education on how to reduce one’s carbon footprint, green energy production, or regulations to decrease industrial greenhouse gas emissions. Other strategies aimed at the source can modify or substitute the hazard (for example, replacing asbestos with other materials). Engineering strategies include enclosing the source if it cannot be removed.

Modifications to the path include environmental changes: closing windows to prevent smog from entering the home, or using bed nets to prevent transmission of malaria. Community level interventions may include cooling centres during extreme heat events or climate resilient building codes.

Strategies aimed at the receiver alter individual (or population) susceptibility to the risks of hazards. Examples include immunization against infectious disease, improving the nutritional status of disadvantaged children, and counselling for behaviour change. Personal safety equipment is mandated in many occupations.

Nurse Jennings interviews Mr. White

Shortly after Nurse Jennings counselled David on his health behaviours in Chapter 8, she happened to meet Mr. White, a contractor for whom David occasionally works. She began by asking Mr. White what he thought of his workers’ safety habits and if there had been many injuries on his work sites….

A First Nations environmental hazard

In October 2005, 450 people from the Kashechewan First Nation were evacuated from their community because of problems with their drinking water. The community had been under a “boil water” advisory for two years. For five years there had been continuing problems with the supply; there was persistent E. Coli contamination and the chlorine used to reduce this was aggravating skin problems. The Ontario Ministry of the Environment found several problems with the water quality monitoring and with the treatment of drinking water. There were also a number of problems with the sewage system, including the fact that the sewage system outlet was upstream of the drinking water intake, which increased the risk of drinking water contamination.20

This incident prompted calls for improved standards for the drinking water supply in First Nations communities. It was noted that the regulatory framework in First Nations communities did not ensure that water quality was as high as that in other Canadian communities. By 2008, no new legislation on water quality had been developed.21  In 2016, concerns over water quality still remained (see http://www.cbc.ca/news/canada/sudbury/kashechewan-water-health-skin-rash-update-1.3500631)

Haddon’s matrix and injury prevention

Dr. William Haddon combined the epidemiological triad (see Chapter 2, Figure 2.8) with a time dimension to create Haddon’s matrix, which sets out the factors that determine the level of risk associated with a hazard and the severity of its effects, in order to identify modifiable risk factors for injury.22 It is commonly applied to the analysis of road traffic collisions, as illustrated in Table 10.6. In this example the host is the person injured (driver or other), while the agent is the equipment that determines how much energy (mechanical or thermal) is transmitted to the host. The environment refers to the physical and social environments in which the injury occurs. The time axis distinguishes factors that operate before the injury (e.g., recent snow that made the road slippery) from those that operate at the moment of injury (e.g., the driver was wearing a seat belt). Other factors operate following the collision (e.g., bystanders knew CPR).

Table 10.6: Illustration of Haddon’s matrix applied to a motor vehicle collision

Host Agent Environment
Physical Social
Pre-event Driver in a hurry Car recently serviced Road design Enforcement of speed limits
Event Wearing seat belt Air bags working Icy patch Number of people standing nearby who may get hurt
Post-event Has cell phone to call for help Technology to automatically alert emergency services after a collision Emergency vehicle access Level of assistance provided by bystanders

The matrix is now being used in other situations, including the assessment of medical errors. The matrix has the advantage of giving the full picture of the problem instead of focussing blame on individuals; it leads to a more constructive consideration of ways to reduce this type of error. Table 10.7 illustrates a situation in which potassium was used instead of saline for dissolving a drug that was then administered intravenously, causing severe cardiac arrhythmia, leading to the collapse of the patient.

Table 10.7: Illustration of Haddon’s matrix applied to an incident of erroneous intravenous administration of potassium

Host
(patient)
Agent Environment
Physical Social
Pre-event Unwell, co-morbidity Inexperienced nurse;
medications packaged in similar containers
Only one drawer in which to store both potassium and saline Rushed doctor preoccupied by another patient;
senior nurse on break
Event Too sick to enquire what medication he is being given Nurse hurriedly mixes medication;
monitors patient’s pulse while injecting
Night time;
ward lighting low, patient’s bed lamp not working.
Nurse being called to other patients;
must hurry
Post-event Immediate signs of arrhythmia Calls cardiac team Cardiac trolley was left at the far end of the corridor after an earlier call Cardiac team responds quickly

 As a way to enhance patient safety, completing the matrix identifies hazards as well as protective factors. The protective factors, such as nurses monitoring patients while they administer injections, calling promptly for help, and quick response of the cardiac team should be reinforced, while the risk factors—storage and packaging of solutions, poor lighting, inadequate supervision, and harassment by other team members—can be rectified. (To prevent this type of mistake, most hospitals do not store potassium on the ward.)

Active versus passive interventions

Interventions to reduce risks are categorised according to the participation required of the person at risk. Active interventions rely on continued compliance by the person at risk, whereas passive interventions are applied once only, or else their effects last for some time. In general, passive interventions are more effective because people do not have to remember to use them. For instance, administration of influenza vaccine (passive) confers immunity for the whole influenza season, whereas hand-washing (active) must be repeated several times a day. An airbag (passive), once installed in a car, stays there until it is needed, whereas seat belts (active) must be put on every time. Even in well-managed workplaces, people’s compliance with the use of personal safety equipment can be poor. For example, ear protectors can be hot and uncomfortable, and may mask auditory danger signals, so that reducing environmental noise levels is preferable, where possible. Safety harnesses can impede mobility, but in some situations they can be replaced by guard rails or safety cages.

Risk Communication

Once a risk has been identified and quantified and methods of reducing it have been found, the information has to be communicated to people at risk to allow them to understand their risk and take steps to mitigate it. Good communication exchanges information in a way that the recipient understands what the sender intends. A useful model of interpersonal communication is shown in Figure 10.4. It distinguishes six elements in the communication process: the message, the messenger, the encoding, the channel, the decoding, and the recipient.

Figure 10.4: The communication process showing the relationships between the elements of communication
Figure 10.4: The communication process showing the relationships between the elements of communication

The message

How risk is perceived depends on factors beyond the simple statistical level of risk; perception varies according to the nature of the hazard (the exposure) and according to its possible effects (the outcome). Factors that increase the perception of danger are listed in Table 10.8.

Table 10.8: Factors that increase public perception of danger23, 24
Exposure characteristics
  • Involuntary
  • Not under personal control
  • Unnatural (e.g., terrorist attack)
  • Unfamiliar
  • Mismatch between risk and benefit (people who suffer the consequences experience no gain from the activity)
  • No trust in the institutions involved
  • Media attention
Outcome characteristics
  • Catastrophic (instead of chronic)
  • Affects children or future generations
  • Unknown or uncertain outcome
  • Affects identifiable people, not statistics
  • Dreaded outcomes (e.g., cancer)
  • Immediate (vs. delayed)
  • Irreversible
  • Media attention.

These characteristics can transform a statistically minor risk into a major perceived risk. For example, in the U.S., the risk of death per mile travelled in a car is about 10 times the risk of death per mile travelled in a commercial airplane. Despite this, people overestimate the risk of death from an airplane crash (confusing case fatality with overall risk). News of an airplane crash is widely publicized, whereas car crashes are much less newsworthy. From Table 10.8, the difference in reaction reflects the unfamiliarity of the event and the fact that it is beyond the traveller’s control, and the death toll from an airline crash is generally in the hundreds. By contrast, road traffic fatalities are frequent, under the control of road users, and each only affects a few people. The table also offers some insight into why some people may be concerned about small environmental risks and yet underestimate the risk of behaviours such as smoking. Similarly, one may consider items from Table 10.8 to discuss why the risks of climate change may be underestimated.

Finally, the message may be obscured by indirect language and resulting uncertainty. Clinicians should be as precise as possible when giving information:

  • Words can be ambiguous and their meaning can vary: terms such as high or low risk are unclear. Clinicians should make certain that their patients understand the precise meaning of the possible outcome and the course of action suggested.
  • However, if numbers are used instead of words, be aware of potential misunderstandings. Expressing a risk should always include a time frame. A 10% chance of death from a lung cancer over a lifetime is not the same as a 10% chance in the next five years. A 20% chance of loss of function could be interpreted as a 20% reduction in function, or that 20% of people will have complete loss of function, or that 20% of people will have some loss of function.
  • Furthermore, be aware of the biases inherent in a positive versus a negative framing of statistics (see the next section).

Framing the message

In relation to communication and decision-making, framing refers to the way in which information on risk is presented. Crucially, minor variations in the way options are presented can have a major impact on a person’s choice.25

Emphasis on gain versus loss

People tend to be averse to loss and will do more to avert a perceived loss than they will to achieve a gain: see the Nerd’s corner.

The default option

The option that is presented as the usual choice is more likely to be chosen than one presented as the alternative.

Numbers versus proportions

Data expressed as proportions tend to be seen as relatively benign, whereas data expressed as a frequency tend to engage people much more. (This is the relative versus absolute presentation mentioned in Chapter 2).

Framing the information

Treatment A or B?
A well-known psychology experiment contrasts the framing of two options for tackling an imaginary disease. Six hundred people are affected by a fatal illness, and we must evaluate two forms of treatment:25

  • Treatment A will save 200 people.
  • Treatment B has a one-third possibility of saving all 600 people, and a two-thirds probability of saving no one.

Purely mathematically, the options are equivalent—saving 200 versus a one-third chance of saving 600. But most people opt for Treatment A because the certainty of saving 200 lives overrides the two-thirds risk of losing 600. However, things change when Treatment A is expressed as a loss:

  • Treatment A will allow 400 people to die.
  • Treatment B has a one-third possibility of saving everyone and a two-thirds probability that all 600 will die.

Most people now opt for Treatment B because the one-third possibility of saving everyone is more attractive than the certainty of losing 400: loss aversion affects the choice.
The way a choice is formulated is called the ‘frame’ and, to ensure informed choice, a clinician should communicate the information using several alternative frames.

Glass half full or glass half empty
Emily and Ian are psychology students. In the last exam, both answered all the questions: Emily got 74% correct while Ian got 26% wrong. Which is the better student? It is usually found that positive framing leads to positive feelings and negative framing leads to negative ones, so Emily is usually judged to be better than Ian. In discussing the risk of Alzheimer’s disease, dwelling on the 8% of people over sixty-five years old who have it makes the situation seem worse than focusing on the 92% of people who don’t.

What is the risk?
In one experiment, the case of a mentally disturbed patient was presented to physicians. They were told that 20 out of 100 patients similar to this one were likely to commit an act of violence. They were then asked if they would discharge the patient, and 41% said they would not. A similar group of physicians was presented with the same scenario, but told that the patient had a 20% chance of committing an act of violence: only 21% of these physician refused discharge.26

The messenger

People respond more to the attitude of the messenger than to their status as a professional or authority. People tend to disregard information given by a recognized expert if they show a lack of caring or empathy (Figure 10.5). Therefore, to get a message across to a patient, a clinician needs to show a caring attitude rather than trying to impress with science.

Figure 10.5: Personal qualities of the messenger and their relative effect on how the message is received
Figure 10.5: Personal qualities of the messenger and their relative effect on how the message is received

The recipient

The recipient is an active participant in communication. The recipient’s prior knowledge, beliefs, attitudes and experience affect their understanding of the message (see Nerd’s corner People and their perceptions). When communicating with patients, a clinician needs to assess the patient’s state and adapt the message accordingly.

People and their perceptions

General disposition: Optimistic people tend to feel at low risk. Pessimistic people, and those who are anxious or depressed, tend to overestimate risk. Nonetheless, defence mechanisms that reduce feelings of threat may lead them to deny the risk entirely.

Affective forecasting: People tend to be unrealistically pessimistic about how they will cope with situations they have not experienced. A person who, while still healthy, declares that she would prefer not to be resuscitated if it seems likely that survival might result in serious disability, may have a change of attitude once the disability occurs when she realizes that she is better able to cope than she thought; this is also called response shift.

Perception of threat: Most people feel that they have a lower-than-average chance of getting a severe illness. This perception is more pronounced when the health problem is seen as controllable, is likely to occur in the distant future, and occurs in a type of person that the patient considers different from himself.

Confirmatory bias: People are more inclined to retain information that supports their prior beliefs than dissonant information. Even the most objective researcher has a tendency to focus on information that supports his hypothesis. A patient who believes his risk of cancer is low may minimise the significance of cancer symptoms. Clinicians are inclined to retain their preliminary diagnoses, even in the presence of contrary evidence.

Reduction of vulnerability: The need to feel invulnerable can make people deny or forget information about personal risk. When told of the risk, people may counter by questioning the validity or reliability the information. A patient receiving bad news is more likely to request a second opinion than a patient receiving good news. People also tend to find contrary examples to corroborate their denial, for example when someone who smokes remembers their grandfather who smoked twenty cigarettes a day and died in full health in old age.

The channel

The usual channel for clinical communication is the spoken word: clinician and patient talk to each other. However, words can be supplemented with visual aids, such as posters, leaflets, and, occasionally, videos. The recipient must have access to the channel of communication: written materials may not reach people who have difficulty reading.

Encoding and decoding

Information must be coded before it can be passed on. For communication to be successful, the messenger and the recipient must share a common understanding of the code. Even though a clinician speaks the same language as the patient, differences in socio-economic milieu, education and experience can limit their shared understanding of terms. When a physician discusses an appendectomy with a patient, the physician is talking about a routine procedure that the patient is likely to recover from in a few days. The patient, on the other hand, is hearing about an alarming and unique experience that is likely to be painful, will leave a permanent scar, and will disrupt life for, at the very least, several days.

When communicating with their patients, clinicians should:

  • Use words and concepts that their patients can understand;
  • Speak directly: say “I recommend that you do this…” rather than “You may consider doing this…”. The former is unambiguous whereas the latter uses ‘mitigation’ or softening of the instruction, perhaps out of politeness. But this is harder for the patient to interpret: is my doctor telling me something important, or is it just a passing comment?
  • Remember that clinicians are familiar with medical conditions and procedures, whereas their patients are not and that the patient’s perception is clouded by apprehension;
  • Modify their tone and body language to conform to the common code, bearing in mind that gestures may mean different things in different cultures. Some people feel that it is polite to look an interlocutor in the eye, others find it threatening.

Risk information is often presented as numbers or graphs. Most people can grasp the information in these forms, but there are a number of points to remember when using numbers to communicate information:

  • People don’t come in halves
    People are more at ease with whole numbers, so fractions and decimal places should be avoided. Few estimates of risk or of therapeutic benefit are so precise that they merit decimals.
  • Numerator and denominator
    People tend to focus on the numerator and ignore the denominator. A disease that afflicts ten people in a hundred tends to be seen as less common than one that afflicts a hundred people in a thousand. When discussing a single risk with a patient it can be helpful to express it in several ways: 10%, or one in ten, or ten in a hundred. However, when asking people to compare risks of different outcomes, one should keep the denominator constant. It is difficult for most people to understand the difference between one in five risk of one outcome and a 25% risk of another outcome. They will find it easier if a 20% risk is compared to a 25% one or if a one in five risk is compared with a one in four risk.
  • Relative and absolute risk
    Relative risks may be particularly difficult to interpret because people rarely know the context. Although hormone replacement therapy doubles the risk of breast cancer, it causes only eight additional cases of breast cancer in 10,000 woman-years. For an individual woman, doubling the risk does not greatly increase her absolute risk because the baseline risk is so small. But on a population level, a doubling of the risk may be significant. It is advisable to use only absolute risks when communicating with individuals, because proportional changes may often obscure a lack of substantive importance.27 (See Chapter 5 for a discussion of relative and absolute risk).

When discussing risk with a patient, the information should be communicated in different ways, using both positive and negative framing, to help the patient arrive at a fully informed decision.

An effective message contains more than simple information; it also implies what the recipient should do with the information. For example, after discussing the risks and benefits of exercise with a patient, a clinician should conclude by relating this information to the patient’s personal situation and making it clear that the patient should take more exercise.

Self-test Questions

1. A patient is complaining of a skin rash, which you think looks like contact dermatitis. What should you question her about?

Contact dermatitis, along with many other skin diseases, is generally not due to intrinsic factors, but is it likely to be caused by occupational or environmental factors? Questions should cover all spheres of the patient’s life, following the mnemonic CH2OPD2:

  • Community acquired? In this case an unlikely source although contact with plants, or use of herbicides or insecticides in the neighbourhood should be considered
  • Home: consider contact with garden or house plants; use of cleaning products, pesticides, herbicides, construction or decorative materials
  • Hobbies and leisure: exposure to chemicals, dusts, or micro-organisms, or to particular clothing necessary for the activity – wet suits for surfing, gloves for gardening – depending on which part of the body is affected
  • Occupation: irritant contact dermatitis in health care workers due to wet work is among the most common occupational diseases in Canada. You may need to ask about previous occupations; don’t forget voluntary work; work with known hazards; the protective clothing that is used for protection, such as latex gloves
  • Personal habits: personal care products such as hair dyes and preservatives found in shampoos and skin cleansers are common causes of skin irritation. Also consider products used for washing clothes and bedding.
  • Diet: an unlikely source of contact dermatitis
  • Drugs: prescription, non-prescription, and alternative medications, particularly medications applied to the skin – nicotine or hormone patches.

A good source of information on contact dermatitis is available. You should question the patient particularly about changes in the period prior to the onset of symptoms. Where you find a possible source, make sure you get precise information about the period of exposure, how great the exposure is, the variation of symptoms in relation to episodes of exposure, whether other people were exposed and if they have similar symptoms.

2. Name and briefly describe the stages of risk assessment.

Hazard identification: : inquire about occupational and environmental exposures to identify possible sources of hazard. In the clinical setting, a good history usually identifies possible sources.

Risk characterization: describe the effects of the hazard. The local public health department will usually be able to advise on the effects of different hazards and about populations at particular risk.

Exposure assessment: describe the duration of exposure and the levels of the hazard. In the  clinical setting a good history should include precise details on the level of hazard to which the patient is exposed, the length of time of an exposure, how often the exposure occurs, and since when has this been happening, in other words to gauge the dose to which the patient is exposed. Tests may be available to measure the dose the patient has had. Public health inspectors may also be able to measure the level of hazard in the patient’s environment.

Risk estimation: integrate and analyse the information from the three previous steps to judge how much the hazard contributes to patient’s problem.

3. List the psychological influences on interpretation of quantitative data.

In relation to the person who is at risk,

General disposition: optimistic people believe themselves to be less at risk than pessimistic people.

Confirmatory bias: people pay more attention to information that confirms what they already believe.

Affective forecasting: people find it difficult to assess how they will react in future possible situations.

In relation to the hazard,

Perception of threat: people generally believe that they are at less than the average risk, particularly when they have control over their exposure to the hazard.

Reduction of vulnerability: people wish not to feel vulnerable to a perceived threat and may therefore deny their risk.

In relation to how the risk is communicated,

Loss aversion: people will avoid a choice that is presented as a loss.

Default option: people will choose the option that they think is the usual or ‘normal’ one.

Number versus proportion and numerator versus denominator: people pay attention to whole numbers that can represent whole people. They can misunderstand proportions, and pay little attention to denominators.

Glass half full or glass half empty: people will focus on the number that is presented, not on the one that is understood. If a disease incidence is presented as such, they will magnify the risk of becoming ill, rather than the risk of staying well.

Relative vs absolute risk: people interpret a high relative risk as almost equivalent to a high absolute risk, even if the underlying absolute risk in the ‘high risk’ group is small.

4. A noisy machine is causing some workers to complain of deafness. What could you suggest to alleviate the problem?

Using the source-path-receiver model,

Source – modify or re-design the machine to reduce the noise at its source, use a different type of machine or process that doesn’t produce noise, relocate it away from the workers or enclose it to confine the noise produced.

Path – use acoustic barriers to absorb or block the noise reaching the workers.

Receiver – enclose or relocate the workers away from the machine, supply workers with ear protectors and ensure that exposure to the noise in infrequent and for very short periods.

Reflection Questions

1.   A 42-year-old female patient living a kilometre away from overhead, high tension power lines is very worried of the lines’ effect on her health. How do you approach this case?
2.   You find her risk from the high tension lines is negligible. How do you reassure her?
3.   The same patient is not very worried about smoking ten cigarettes a day. How do you explain this?

References

  1. United Nations Office for Disaster Risk Reduction. Understanding disaster risk: hazard. Geneva: UNDRR; 2017 [Available from: https://www.preventionweb.net/understanding-disaster-risk/component-risk/hazard.]
  2. World Health Organization. A strategic framework for emergency preparedness Geneva: WHO; 2017 [Available from: https://iris.who.int/bitstream/handle/10665/254883/9789241511827-eng.pdf?sequence=1.]
  3. Marshall L, Weir E, Abelsohn A, Sanborn MD. Identifying and managing adverse environmental health effects: 1. Taking an exposure history. Canadian Medical Association journal. 2002;166(8):1049-55.
  4. Government of Canada. From climate hazards to health impacts: the health risks of climate change in Canada. Ottawa: Public Health Agency of Canada; 2022 [Available from: https://www.canada.ca/en/public-health/corporate/publications/chief-public-health-officer-reports-state-public-health-canada/state-public-health-canada-2022/report.html#sec13.]
  5. Bouchard C, Dibernardo A, Koffi J, Wood H, Leighton PA, Lindsay LR. Increased risk of tick-borne diseases with climate change. Ottawa: Public Health Agency of Canada; 2019 [Available from: https://www.canada.ca/en/public-health/services/reports-publications/canada-communicable-disease-report-ccdr/monthly-issue/2019-45/issue-4-april-4-2019/article-2-increased-risk-tick-borne-diseases-climate-change.html.]
  6. Chen K, Ma Y, L. BM, Yang W. Canadian wildfire smoke and asthma syndrome emergency department visits in New York City. JAMA. 2023;330(14):1385-7.
  7. Sandink D, MacLeod D. Municipal climate change adaptation reference collection. Toronto, 2009 [Available from: https://www.iclr.org/wp-content/uploads/PDFS/climate-change-adaptation-reference-collection-municipal-world.pdf.]
  8. Ministry of the Solicitor General of Ontario. Emergency management Ontario. Toronto: Government of Ontario; 2021 [Available from: https://files.ontario.ca/books/solgen-emo-emergency-management-framework-2021-en-2021-12-30.pdf.]
  9. Environmental Protection Agency. Conducting a human health risk assessment. Washington, DC: US EPA; 2022 [Available from: https://www.epa.gov/risk/conducting-human-health-risk-assessment.]
  10. World Health Organization. Asbestos in drinking water. Geneva: World Health Organization; 2021.Contract No.: WHO/HEP/ECH/WSH/2021.4.
  11. World Health Organization. Asbestos in drinking-water: background document for development of WHO guidelines for drinking-water quality 2003 [Available from: http://www.who.int/water_sanitation_health/dwq/chemicals/asbestos/en/.]
  12. Aidoo M, Terlouw DJ, Kolczak MS, McElroy PD, ter Kuile FO, Kariuki S, et al. Protective effects of the sickle cell gene against malaria morbidity and mortality. Lancet. 2002;359(9314):1311-2.
  13. Dorland WAN. Dorland’s illustrated medical dictionary. 37th ed. Philadelphia, PA.: Saunders Elsevier; 2007.
  14. Government of Canada. WHMIS – Safety Data Sheet (SDS). Ottawa: CCOHS: Canadian Centre for Occupational Health and Safety; 2023 [Available from: https://www.ccohs.ca/oshanswers/chemicals/whmis_ghs/sds.html.]
  15. Government of Canda. WHMIS – Pictograms. Ottawa: CCOHS: Canadian Centre for Occupational Health and Safety; 2023 [Available from: https://www.ccohs.ca/oshanswers/chemicals/whmis_ghs/pictograms.html.]
  16. Cox LA, Jr. Does concern-driven risk management provide a viable alternative to QRA? Risk Analysis. 2007;27(1):27-43.
  17. Weir E, Schabas R, Wilson KA, Mackie C. A Canadian framework for applying the precautionary principle to public health issues. Can J Public Health. 2010;101(5):396-8.
  18. Schuman SH, Simpson WM. WHACS your patients. J Occup Environ Med. 1999;41(10):829.
  19. Canadian Centre for Occupational Health and Safety. Hazaard and risk — hierarchy of controls. Ottawa: Government of Canada; 2023 [Available from: https://www.ccohs.ca/oshanswers/hsprograms/hazard/hierarchy_controls.html.]
  20. Ontario Ministry of the Environment. Drinking water system at the Kashechewan First Nation: Technical Report. Toronto, Ontario: Ontario Ministry of the Environment; 2005.
  21. Eggertson L. Despite federal promises, First Nations’ water problems persist. Canadian Medical Association journal. 2008;178(8):985.
  22. Haddon W, Jr. A logical framework for categorizing highway safety phenomena and activity. Journal of Trauma-Injury Infection & Critical Care. 1972;12(3):193-207.
  23. Slovic P. Perception of risk. Science. 1987;236(4799):280-5.
  24. Covello VT, Peters RG, Wojtecki JG, Hyde RC. Risk communication, the West Nile virus epidemic, and bioterrorism: responding to the communication challenges posed by the intentional or unintentional release of a pathogen in an urban setting. Journal of Urban Health. 2001;78(2):382-91.
  25. Tversky A, Kahneman D. The framing of decisions and the psychology of choice. Science. 1981;211(4481):453-8.
  26. Slovic P, Monahan J, MacGregor DM. Violence risk assessment and risk communication: the effects of using actual cases and employing probablility vs. frequency formats. Law and Human Behavior. 2000;24(3):271-96.
  27. Spasoff RA. Epidemiologic methods for health policy. New York: Oxford University Press; 1999.
Print Friendly, PDF & Email

Français (French)